Download Chapter 7: Appendix F Performance Monitoring Plan for CLABSI

Chapter 7: Appendix F
The NC Quality Center and its Collaborative Partners are not responsible for any reprinted materials and
encourage all facilities to evaluate the adequacy of sample policies, tools, and forms provided before using.
Performance Monitoring Plan for CLABSI Prevention Measures (EXAMPLE ONLY)
XYZ Healthcare Facility and
Unit
Population to be monitored: All patients on
Measure
unit who have a central venous catheter in at any time during stay on unit.
Operational
Definition
Source of
Definition
Method and Frequency of
Data Collection
Who will
collect?
1. Central
lineassociated
bloodstream
infection
(CLABSI)
Criteria to be
applied are found in
the NHSN Deviceassociated HAI
module at
http://www.cdc.gov/
nhsn/PDFs/pscMan
ual/4PSC_CLABSc
urrent.pdf
Calculation used is:
Total number of
CLABSIs per
month per unit
divided by the total
number of central
line days multiplied
by 1,000.
National
Healthcare
Safety
Network
(NHSN)
database
Daily of all positive blood
cultures and chart review by
Infection Preventionist
<Name of
IP>
1a. CLABSI
denominator:
Central line
days
Central line days:
number of patients
per day with a
central line in.
Follow the NHSN
NHSN
At midnight every night, the unit
charge nurse will count the
number of patients on the unit
with a central line. He/she will
record on the data tool located
Unit
Charge
RN
Who will
analyze and
report?
<Name of
person >
Unit
Secretary will
total each
day and
Infection
What will be reported, to whom,
and when?
1. Individual cases will be
reported immediately upon
discovery to unit manager
to facilitate rapid defect
analysis.
2. Case data and
denominator data to be
entered into NHSN
monthly by <date>.
3. Rates to be reported
monthly to unit manager
who will share with staff
and unit medical director
by <date>.
4. Rates to be reported to the
medical staff at monthly
quality meeting by <date>.
5. Rates to be reported
quarterly to the Board on
dashboard report by
<date>.
6. Rates to be reported
monthly to CNO and
VPMA by <date>.
Chapter 7: Appendix F
The NC Quality Center and its Collaborative Partners are not responsible for any reprinted materials and
encourage all facilities to evaluate the adequacy of sample policies, tools, and forms provided before using.
Measure
Operational
Definition
Source of
Definition
criteria for counting
device days.
2. Central
Line Device
Utilization
Ratio
2a. CL DUR
denominator:
Patient Days
3. CL
Insertion
Practices
4a. CL
Maintenance
Practices:
Routine
review for
necessity
Numerator:
Presence of
documentation in
the medical record
for assessment by
a physician at
least <defined by
facility> for a
temporary CL and
<defined by
facility> for a PICC
or tunneled CL or
port-a-cath.
Denominator: # of
patients reviewed.
Method and Frequency of
Data Collection
Who will
collect?
Who will
analyze and
report?
Preventionist
will check
and use for
CLABSI and
DUR
calculations.
What will be reported, to whom,
and when?
A member
of the
CLABSI
PI Team
assigned
to each
date listed
on the
calendar
in
Appendix
G.a.
Project Team
Data
Coordinator
will be
responsible
for ensuring
data are
aggregated
and reported.
Data are to be entered into the NC
SHIM database by the 20th of the
following month. (E.g. November
2011 data should be entered no
later than 12/20/11.)
on the charge nurse clip-board.
Each tool will contain one
month’s worth of data. On the
first day of the following month,
the unit secretary will total the
days at the bottom of each day,
then fax to the Infection
Prevention office.
CLABSI
Prevention
PI Team
and
Infection
Control
Committee
At least five charts per week of
patients with CLs will be
assessed for this
documentation. If there are not
5 patients with CLs in on
designated days of review,
100% of the patients with CLs
will be reviewed and this is to
be recorded on data tool.
Reviews will be conducted on
random days of the week
outlined in Appendix G.a.
(based on sampling methods
described in the NCQC
document “Random
Permutations for Sampling
In addition, any non-compliance
will be shared with the unit
manager on a case-by-case basis
to support defect analysis as soon
as recognized.
Compliance rates per month will
be shared with the Project Team.
Chapter 7: Appendix F
The NC Quality Center and its Collaborative Partners are not responsible for any reprinted materials and
encourage all facilities to evaluate the adequacy of sample policies, tools, and forms provided before using.
Measure
4b. Hand
hygiene
4c.
Standardized
dressing
changes
Operational
Definition
Numerator: The
number of times
appropriate hand
hygiene by hand
washing or alcohol
foam is performed
prior to each port
access.
Denominator: The
number of hand
hygiene
observations
performed prior to
CL port access.
(Facility-defined to
match evidencebased policy.)
Numerator:
Number of
observed CL
dressings that are
compliant to policy:
clean, dry, and
transparent, semipermeable dressing
is intact; dressing is
dated, and is in-
Source of
Definition
Facility
hand
hygiene
policy and
CL policy.
Same as
4b
Method and Frequency of
Data Collection
Days of the Week,” Appendix
G) The data tool to be used will
be Appendix D. When
completed, data tools are to be
faxed to the Project Team Data
Coordinator at XXX-XXXX.
On the same days of the week
that the 4a monitor is carried
out, a designated person will
unobtrusively monitor hand
hygiene prior to port access.
Same as 4b
Who will
collect?
Who will
analyze and
report?
What will be reported, to whom,
and when?
Same
member
of team
collecting
data for
4a.
Project Team
Data
Coordinator
will be
responsible
for ensuring
data are
aggregated
and reported.
Data are to be entered into the NC
SHIM database by the 20th of the
following month. (E.g. November
2011 data should be entered no
later than December 2011.)
Same as
4b
Same as 4b
In addition, any non-compliance
will be shared with the unit
manager on a case-by-case basis
to support defect analysis.
Compliance rates per month will
be shared with the Project Team
and discussed in case intervention
is needed.
Same as 4b
Chapter 7: Appendix F
The NC Quality Center and its Collaborative Partners are not responsible for any reprinted materials and
encourage all facilities to evaluate the adequacy of sample policies, tools, and forms provided before using.
Measure
Operational
Definition
Source of
Definition
Method and Frequency of
Data Collection
Who will
collect?
Who will
analyze and
report?
What will be reported, to whom,
and when?
date according to
policy. (example:
48 hours if gauze
present, every 7
days if semipermeable,
transparent
dressing is intact.)
Also, CHG sponge
is present.
4d.
Administratio
n tubing,
access ports,
etc. are
changed per
facility policy.
4e. Scrub the
hub
Denominator: Total
number of CL
dressings observed
(Facility-defined to
match evidencebased policy.)
Numerator:
Number of
observed CL tubing
sets (including IV
admixture push
lines, access ports,
stop-cocks,
manifold sets, etc.)
that are in
compliance with
policy.
Denominator: Total
number of line sets
observed.
(Facility-defined to
match evidence-
Facility CL
policy
Same as 4a.
Same as
4a.
Same as 4a
Same as 4a
Facility CL
policy.
Same as 4b
Same as
4b
Same as 4b
Same as 4b
Chapter 7: Appendix F
The NC Quality Center and its Collaborative Partners are not responsible for any reprinted materials and
encourage all facilities to evaluate the adequacy of sample policies, tools, and forms provided before using.
Measure
Operational
Definition
Source of
Definition
Method and Frequency of
Data Collection
Who will
collect?
Who will
analyze and
report?
What will be reported, to whom,
and when?
based policy.)
Numerator:
Example: Number
of hub scrubs that
are done for a
minimum of 15
seconds using a
sterile 70%
isopropyl alcohol
wipe.
Denominator:
Number of hub
scrubs observed
4f. Patients
are screened
every 24
hours for
signs/sympto
ms of
infection
5a
Observation
of real-time
CL dressing
Numerator:
Number of patients
with CL present
who have
documented
assessment for CL
infection within past
24 hours.
Denominator:
Number of patient
charts reviewed for
documentation of
assessment for CL
infection.
No
numerator/denomin
ator. This is
observation of
Facility CL
policy
Same as 4a.
Same as
4a.
Same as 4a
Same as 4a
CL policy
Periodically when collector has
time and opportunity. Initially in
project, this should be done
several times to gain ground
Unit
manager,
IP, PI
Specialist.
Person doing
observations.
Take what is learned back to the
project team to support
improvement and plan
interventions to address any
Chapter 7: Appendix F
The NC Quality Center and its Collaborative Partners are not responsible for any reprinted materials and
encourage all facilities to evaluate the adequacy of sample policies, tools, and forms provided before using.
Measure
change
5b.
Observation
of real-time
CL
tubing/port
changes.
Operational
Definition
practice to
determine if all
elements of the
policy are adhered
to and to
understand why not
if not compliant. It
is an observation
for understanding,
not for correction.
Same as 5a
Source of
Definition
Method and Frequency of
Data Collection
Who will
collect?
Who will
analyze and
report?
truth. (Part of a gemba walk)
The Unit Manager, Infection
Preventionist (IP) and PI
Specialist should consider
doing one each initially to gain
as much ground truth as
possible about actual practice.
Same as
5a
Same as 5a
What will be reported, to whom,
and when?
recognized gaps.
Same as
5a
Same as 5a
Same as 5a