Download Slides CLI B Young June 3 - Canadian Patient Safety Institute

Whose Line is It Anyway?
Preventing Central Line Blood Stream
Infection
Winnie Lee RN
Nurse Champion Central Line project ICU/CCU
Barb Young, BScPhm
Quality Facilitator, Quality and Risk Management
Credit Valley Hospital
Safer Health Care Now! Teleconference
June 2008
Background
• The Credit Valley Hospital
is a 383 bed community
hospital in Mississauga,
Ontario with a 16 bed
ICU/CCU.
• ICU/CCU patients include
a mix of general medicine,
cardiology and surgical
patients.
• The Central Line team
includes the members of
the ICU/CCU
multidisciplinary team in
addition to members from
Quality and Risk
Management, Health
Records, Microbiology and
Senior Management.
How we are doing?
Central Line Blood Stream Infection
CLBSI rate/1000 central line days
2006-2008
6
5
4
3
--------------------CLBSI GOAL - 3.2 (National Noscocomial Infection US average for Medical-Surgical ICUs)------------------
2
1
0
Dec-06
Feb-07
Apr-07
Jun-07
Aug-07
CLBSI rate
Oct-07
Dec-07
Feb-08
Apr-08
The Numbers
• Tracking Lines: calendar in CN binder, CN on
nights enters # of lines, # of new lines
Important to define:
Time frame: midnight to midnight, 0700 – 0700,
Take into account workload of CN, what time is
best for them
Engage them with defining the time parameters,
how to promote communication
Can this be entered on line?
Insertion Bundle
• Caps
• Sterile drapes
• Chlorhexidine products:
Asking what is available, what to keep, who is affected if you
remove a product, what to remove from ward stock
Out of sight = Out of mind
Engage users into deciding what product they prefer
We knew:
Chlorhexidine 2% with 70% Alcohol for
Insertion
User Input is Key!
Users were looking for:
•Individual patient use
•Tinted (to know where you had
cleaned)
•To have only this product available
so they could get it quickly!
•This needs sterile gauze to be
available to clean skin
This is the preference of one of our
users
•Eliminates the need for gauze
•Not tinted
• Can be used by RRT’s to cleanse
skin prior to arterial stabs
•Unique packaging makes teaching
fun
Cart
•Safer
•Portable
•One Stop Shopping
“Buy in” is important
Changed a system in place
“since the beginning of time”
Provide opportunity for
feedback/discussion
Labeling: increase
awareness of materials in
cart and #
Critical Care Central Line Insertion Checklist – Draft Feb 6, 2006
Purpose: to work as a team to decrease patient harm from catheter-related bloodstream infections.
When: for all central venous line insertions and central line rewire. Use one form for each new site attempted
per line.
Who: by bedside nurse.
1.Today’s date
_____ / _____ / _____
year month day
1.Bedspot number ___________________
2. Procedure
□ New Line
□ Line Rewire
3.Is the procedure
□ Elective
□ Emergent
4.Site of insertion □ Subclavian □ Jugular
□ Femoral
(if NOT subclavian, write reason below)
Please answer these questions
1.
Did the physician complete a two minute hand wash before
commencing the procedure?
2.
Is the physician wearing mask, sterile gown and sterile
gloves?
3.
Is the insertion site prepared with 2% chlorhexidine
solution?
4.
Is the patient covered with sterile drape?
5.
After procedure, was sterile dressing immediately applied
to site?
6.
After procedure, were sterile caps placed on all lumens?
7.
Was a correction required to ensure compliance with
above infection control practices? (explain below)
8.
Did you wipe down the procedure cart before and after the
procedure?
Yes
Yes, after
prompting
by nurse
The Insertion
Checklist
•Have no fear
•Corrections can be
made
•Using forms will
guide your direction
Yes
No
Comments:
****Please place completed checklist in envelope in bottom drawer of cart****
•Feedback is
important
Critical Care Central Line Insertion Checklist – Draft Feb 13, 2006
Purpose: to work as a team to decrease patient harm from catheter-related blood stream infections.
When: for all central venous line insertions and central line rewire (avoid if possible). Use one form for each new site attempted per line.
Who: by bedside nurse.
1.Today’s date
_____ / _____ / _____
year month day
1.Unit number ___________________
2. Procedure:
□ New Line □ Line Rewire (not recommended, if needed include reason under comments)
1.Is the procedure
□ Elective
□ Emergent
2.Site of insertion:
□ Subclavian □ Jugular □ Femoral (not recommended, if needed include reason under comments)
Please answer these questions
1.
Did you wipe down the bedside table before and after the
procedure?
2.
Did the physician complete a two minute hand wash before
commencing the procedure?
3.
Is the physician wearing mask, sterile gown and sterile
gloves?
4.
Is the insertion site prepared with 2% chlorhexidine in 70%
isopropyl alcohol?
5.
Is the patient covered with sterile drape?
6.
After procedure, was sterile dressing immediately applied
to site?
7.
After procedure, were sterile caps/lines placed on all
lumens?
8.
Was there any identifiable contamination during the
procedure? If yes, explain under Comments.
Yes
Yes, after
prompting
by nurse
The Edits
Yes
No
Comments:
****Please place completed checklist in envelope in bottom drawer of cart****
Critical Care Central Line Insertion Checklist – Draft Feb 20, 2006
Purpose: to work as a team to decrease patient harm from catheter-related blood stream infections.
When: for all central venous line insertions and central line rewire (avoid if possible). Use one form for each new site attempted per line.
Who: by bedside nurse.
1.Today’s date
_____ / _____ / _____
year month day
1.Unit number ___________________
2. Procedure: □ New Line
□ Line Rewire (not recommended, please comment below)
3.Is the procedure □ Elective
□ Emergent
4.Site of insertion:
□ Subclavian □ Jugular □ Femoral (not recommended, please comment below)
Please complete the check list
1.
Check
RN – bedside table disinfected before procedure, hands washed and mask worn
2.
MD(s) – hands washed
3.
MD(s) – mask, sterile gown, sterile gloves, cap worn
4.
Insertion site - prepared with 2% chlorhexidine in 70% isopropyl alcohol
5.
Sterile drape – covered patient
6.
Caps/lines – attached using sterile technique
7.
RN – bedside table disinfected after procedure
8. Identifiable contamination occurred; if yes, explain under comments
9. MD – documented insertion with date on Admission record
Comments:
***Please return the completed checklist to the bag on the Special Procedures Cart***
The
Edits
Grouping and Colour
• Viewing other hospital’s checklists (Virginia
Mason Medical Center)
• ICU Collaborative: Conference Calls
• Look outside your initiative to see what may
apply to you
• Jonas Shultz, M.Sc. Human Factors
Consultant. Calgary Health Region
• Spoke on Human Factors in Healthcare: used
examples related to medication safety
The Final Edition
Critical Care Central Line Insertion Checklist
Purpose:
When:
Who:
To work as a team to decrease patient harm from catheter-related blood stream infections.
For all central venous line insertions and central line rewire (avoid if possible).
Use one form for each new site attempted per line.
By bedside nurse
(include name to win Tim Horton’s gift certificate)______________
Today’s date
(Month/day/year)
Patient Unit Number
Procedure
□ New Line
□ Line Rewire (not recommended, please comment below)
Is the procedure?
□ Elective
□ Emergent
Site of insertion:
□ Subclavian
□ Jugular
□ Femoral (not recommended, please comment below)
Please complete the check list
1.RN – bedside table disinfected before procedure, hands washed and mask worn
2, MD(s) – hands washed
3, MD(s) – mask, sterile gown, sterile gloves, cap worn
4. Insertion site - prepared with 2% chlorhexidine in 70% isopropyl alcohol
5. Sterile drape – covered patient
6. Caps/lines – attached using sterile technique
7. RN – bedside table disinfected after procedure
8. Identifiable contamination occurred; if yes, explain under comments
9. MD – documented insertion with date on Admission record

Location, Location, Location!
• Checklists placed on all central lines
• Extras placed where lines are stored
• Return location is in the same place
Contest
To promote use of checklists!!
Whose Line is it Anyway?
So how are we doing?
Things to Celebrate
• Use of the bundle has become the standard
• Consider when to stop using checklists (or
change frequency of use)
• Intensivists, Nephrologists, Cardiologists are
all willing to comply with the bundle
• Taking to the ER (use of insertion checklist),
RACE team
One Stop Shopping for One Line
Link with key stakeholders in each
area
Education
• RN champion allows for education to occur on
all shifts
• ICU rounds: present to multidisciplinary team,
introduction of audit tools
• Skills Day: Halloween theme – RN champion
dressed as MD ready to insert a line, all
supplies available for RN’s to see
• One to One: slow process, promotes
discussion, discover/dispel myths
Maintenance List
• Policies and
Procedures currently
in place reflecting
SHN! Maintenance
bundle
• Focus placed on
Insertion bundle
initially
• Create audit tool and
go!!
Daily Evaluation Form
** Please fill in/initial every WHITE box, every
shift as applicable
**Use 1 sheet per central line per 7 days/remove from chart on D/C or
when line removed
**Return ALL sheets to the envelope at the UCA desk area in
both ICU and CCU
**THIS IS NOT A CHART FORM, chart all necessary actions or findings in
the patient's chart
Site:________________
Line In
DATE:
D
CL(s) reviewed in Rounds
Dedicated lumen for TPN
(indicate NA if not applicable)
Chlorhexidine used when
lumens opened (tubing
changes or capping off)
Entry site examined (Also
indicate when dressing
change done q6-7days or
PRN)
Comments:
N
D
N
D
N
D
N
D
N
D
N
D
N
What went wrong?
• Kept on patient’s chart
• To be returned to central spot on discharge did not happen
• Allow for daily auditing of individual patient
• Addition to workload – another piece of paper
Needed new plan
Date
Days/Nights
Please circle
Patient
U#
New
Line
Yes/No/
Rewire
Chlorhexidine used
when lumens
opened (tubing
changes or
capping off)
Yes/No
If not,
why?
Dedicated Lumen for
TPN
Yes/No
or N/A
If not,
why?
Entry Site Examined
(Dressing change q.
6-7 days or prn)
Yes/No
If not,
why?
CL(s) Reviewed in
rounds
(to be completed by
day shift only)
Yes/No
If not,
why?
How well are we doing?
Central Line Blood Stream Infection
Compliance - Insertion and Maintenance Bundle (%)
2006-2007
____________ Goal 100% ____________
100
90
80
Audit tool revised
70
60
50
40
30
20
10
0
Mar-06
Apr-06
May-06
Jun-06
Jul-06
% compliance w ith use of insertion check list
Aug-06
Sep-06
Oct-06
% compliance w ith insertion bundle
Nov-06
Dec-06
Jan-07
Feb-07
% compliance w ith maintenance bundle
So how are we doing?
Central Line Blood Stream Infection
Compliance - Insertion and Maintenance Bundle %
2006-2008
100
-------------------------------------------------------------------GOAL 100%----------------------------------------------------------------
90
80
70
60
50
40
30
20
10
0
Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08
% compliance with insertion bundle
% compliance with maintenance bundle
Patient
U#
New
Line
Yes/N
o/
Rewire
Chlorhexidine used when lumens
opened (tubing changes or capping
off)
¨Yes
¨No
¨tubings not changed
Dedicated Lumen for TPN
¨Yes
Entry Site Examined
CL(s)/site reviewed in rounds/with
MD (to be completed by day shift
only)
¨No
¨Yes
¨No
¨Yes
¨No
¨No
¨Yes
¨No
¨Yes
¨No
¨No
¨Yes
¨No
¨Yes
¨No
¨No
¨Yes
¨No
¨Yes
¨No
¨No
¨Yes
¨No
¨Yes
¨No
¨No
¨Yes
¨No
¨Yes
¨No
¨No TPN
¨lines not capped
¨Yes
¨No
¨tubings not changed
¨Yes
¨No TPN
¨lines not capped
¨Yes
¨No
¨tubings not changed
¨Yes
¨No TPN
¨lines not capped
¨Yes
¨No
¨tubings not changed
¨Yes
¨No TPN
¨lines not capped
¨Yes
¨No
¨tubings not changed
¨Yes
¨No TPN
¨lines not capped
¨Yes
¨tubings not changed
¨lines not capped
¨No
¨Yes
¨No TPN
Perfec
t Care
Yes/No
Patient Information Sheet
CVH is committed to improving patient care by participating in a nationwide initiative called Safer
Healthcare Now. One project being led by the Critical Care staff is aimed at reducing Central Line
Bloodstream Infections.
What is a Central Line Bloodstream Infection?
It is an infection of the bloodstream that occurs in patients who have
a central line or central venous catheter. Central lines are necessary
for patients who need frequent intravenous (IV) medications, blood,
fluid replacement, dialysis and/or nutrition.
What causes Central Line Bloodstream Infections?
Sometimes bacteria on the skin start growing in the central line and
can then spread to the patient’s bloodstream. This is a very serious
infection which requires treatment with antibiotics and removal of the line.
What are we doing to prevent Central Line Bloodstream Infections?
We will take the following steps whenever possible for all patients who have central lines:
Use proper hand hygiene. Everyone who touches the central line must wash their hands with soap and water or an alcohol
cleanser.
Use maximal barrier precautions. The person who inserts the line should be in sterile clothing – wearing a mask, gloves, and
cap. The patient should be fully covered with a sterile drape, except for a very small hole where the line goes in.
Clean the patient’s skin with “chlorhexidine” (a type of soap) when the line is put in.
Use the best vein to insert the line. Often, this is the subclavian (chest) or jugular vein (neck) which is not as likely to get an
infection as veins in the arm or leg.
Check the line for infection each day. The line will be taken out when no longer needed.
How patients and family members can help:
• Wash your hands or use the hand sanitizer before entering and after leaving the patient’s room.
Keys to success
• Keeping it fun
• Sometimes, it doesn’t work, use feedback to
improve
• Actively involved RN champion (teaching,
generating ideas, seeking feedback)
• Frequent meetings (weekly to biweekly to
monthly, special meetings to help with
implementation)
• Communication
• Involve all members of team
• Support of all levels of administration
Future Steps
• Expanding maintenance to all inpatient units
(work with who will work with you)
• Continue to promote use of cart/kits for
insertions in those units
• Explore possibility of evaluating the patient
information sheet
• Celebrate the success thus far!!