Prevention of Central Line Infections Safer Healthcare Now Prevention of Central Line Infections The LHSC experience Feb.5, 2008 Deb McAuslan

CLI Prevention Teams at LHSC Oncology and Interventional Radiology Team CCTC Team ICU Team Oncology and Interventional radiology team at our Victoria Hospital campus CCTC or Critical Care Trauma Unit Intensive Care Unit at University Hospital.

Prevention of Central Line Infections Insertion Hand hygiene Maximal barrier Chlorhexidine 2%/70% alcohol Optimal placement Maintenance Daily review Dedicated TPN line Chlorhexidine prep Check for inflammation with drsg changes The Central Line package is divided into Insertion and Maintenance components.

PICC Line Dressing Procedure-RN to RN Check List Equipment Dressing tray or sterile towel Sterile gloves- 1 pair Non sterile gloves- 1 pair 2% Chlorhexidine/ 70% alcohol swabs- 2 or more Steri strips- 2 pkgs Sterile transparent dressing Primed Injection port caps Hand sanitizer Essential Steps Wash Hands Y N Position Patient appropriately to allow good visualization and access Using non-sterile gloves remove dressing with care, observe site for catheter migration. Discard dressing and gloves Assess insertion site for inflammation, redness & exudates Assess integrity of skin beneath dressing Wash/ Sanitize hands Cleanse site with swabs in back/forth, up/down scrubbing motion with friction Allow site to dry for at least one minute With sterile gloves apply steri strips Apply sterile transparent dressing to cover site, leaving the connection hub(s) Change caps Connect tubing or lock as indicated Document procedure and observations on appropriate record On our oncology unit we implemented a central line dressing procedure check list . Spot audits were done with dressing changes at the bedside. This allowed us to gather information that could isolate problems with technique, knowledge and compliance. We found that some staff were not familiar with the new technique of scrubbing with friction, the chlorhexidine with added alcohol. Posters were placed on the unit to give quick reference as to “What’s Hot & What’s Not in Central Lines” Data was collected for a minimum of 5 dressing changes per month- the audits covered all four units on our floor – new and senior staff were all audited Hickman/Perm catheters had separate checklist

Oncology/Radiology CLI Infections It was our Oncology team that felt they had a problem with infection rates and because their population is at such high risk, they wanted to improve. The Coordinator of this area, Kate Fournie approached me and asked if they could be involved. Almost exclusively their central lines are started in Interventional radiology. She connected with her counterpart in Interventional Radiology, Mary Jayne Bambury who agreed to be part of the team. This was our only team to have control over both components.

CCTC Central line infections 2006-2007 When we approached the critical care units, they were concerned that they were not able to control the insertion component and they felt most of their central lines were started outside their unit. They also felt they would not get good compliance from the ever changing resident pool that work there. They also felt they did not have time to do the audits. Plus, they did not feel that this was a big problem in their areas and they were meeting the NIS average in Canada and that they had multiple bigger practice issues that needed their attention that they had teams working on. We looked at CCTC and where lines were being started. From Oct-Dec/05 – approx. 56% of lines were inserted in CCTC, 15% in the OR, 9% in Radiology, 9% in ER, 7% in other hospitals, some unknown. They agreed to implement the bundles, but not participate in auditing.

UH ICU CLI - 2006 ICU at UH were already had incredibly low rates and it took me awhile to realize they truly had very low rates. They felt that this intervention would not benefit them much for all the effort of implementation, but did agree to implement the protocols.

What helped? LHSC Senior leadership stated their support Communication to leadership Resource support It is essential to have Senior Leadership stand and announce that this project is supported. This is an acute care teaching hospital. Our teams are continually working on best practice initiatives. The difficulty is which ones can areas support as all this work demands resources, either in people or supplies. Getting the message out. Having this project presented at our Leadership Forum for all to hear by our Trailblazer, Project Lead made sure people were aware of it. We are fortunate at LHSC to have a lot of resources to help with data - Our infection control team collected the infection rates. Our Quality Performance people collected the no. of pts per month per area and identified those under 18. What has been the most difficult was counting line days. This fell to the Coordinators and was a grueling daily task to count. We have moved to adding this to our Workload measurement data sheet, but are now concerned that we may have lack of compliance in completion of this data.

What helped… SHN Trailblazer support Toolkit, fact sheet, bibliography Communities of practice Audit tools Mary Anne Davies, our Trailblazer has kept encouraging us and problem solving when times got tough. The Toolkit and fact sheets helped as we went to to engage teams. The bibliography was essential, as team now demand to know the research recommendations are based on. The communities of practice have been helpful in looking for solutions, but most of all, to reassure me that we were not the only ones struggling to find our way. The audit tools were a helpful starting place to develop tools for our teams.

Key Learning's Engagement - Compelling reason Champions - Passion Engage your resources Encouragement Don’t give up – keep momentum Teams have multiple demands on their time – all want to give good care. There are lots of best practices to be worked on. Why should they choose this initiative now? Need to see this as a priority to be motivated – must make the case if not their idea One passionate person to lead the charge makes all the difference. Kate was that passionate person. The Oncology population are so immunosuppressed, it was obvious what devastation sepsis can impact outcomes. Multiple departments pulling together to make this happen Infection Control Professional Practice Management and leadership Quality Performance Risk Management Front line nurse and physician teams