Journey to Improvement

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Presentation transcript:

Journey to Improvement Central Line Associated Blood Stream Infections (CLABSI)

NHSN Methodology National Healthcare Safety Network (2005) All + blood cultures reviewed Line Present Known pathogen No other source of infection Common skin contaminant 2 or more Cultures Signs/Symptoms

CLA-BSI Surveillance Time Period: Sept 2009-Jan 2010 February 2010 One Patient (2-1-10) PICC 7 days to infection Yeast + TPN

NCH Overall

Opportunities ICU and Floors PICCs Candida (TPN/Propofol) Enteric Organisms (Lines, dressings) Endogenous (preps)

January 2011 CLABSI Report Infection Prevention Department

NCH CLABSI

NCH Healthcare System CLABSI Jan 2010 thru Jul 2011

Critical Care CLABSI Rate

NCH CLABSI: Critical Care/DNH

NCH CLABSI: Critical Care/NNH

NCH CLABSI: Jan 2010 – July 2011

NCH CLABSI: Critical Care

CLABSI: Non-ICU’s Only

CLABSI: NCH System

Critical Care CLABSI Utilization Central line utilization above NHSN 50th percentile for both hospitals. Higher risk for infection Doing great job but it’s a matter of time….. Assess need for line daily.

NCH CLABSI Costs

CLABSI Analysis Number of months WITHOUT a CLABSI in Critical Care Units: ICU-N > 9 months PCU > 12 months (closed for part of time) SICU > 14 months ICU-DTN > 23 months CVRU > 2 years! Number of months WITHOUT a CLABSI in all of NCH Healthcare: 2 Months in 2011 (May/Nov)

CLABSI Action Plan Non-ICU units have significantly decreased CLABSIs Swab Cap trials at NNH successful and now implemented at DNH NSG education and compliance monitoring continues to reinforce best practice New insertion and dressing change kits implemented High utilization requires daily assessment for lines

Critical Care CLABSI/Quarter Sep 2009 – Jun 2011

NCH CLABSI: Critical Care versus Non-Critical Care Jan 2010 – Mar 2011

Hard Work The results have been through the ongoing efforts of the CLABSI Team, a multidisciplinary group lead by Dr. Doug Harrington including expertise from: Critical Care, Infection Prevention, Education, Clinical Nurse Specialists and the IV Team.

Action Plans Relentless execution of the following actions has resulted in significant improvements: Monthly data feedback to the system and individual units for # of infections, causative organisms and types of lines. The use of RCA forms to assist units with understanding the opportunities for improvement.

Action Plans Standardization of policies and education for insertion and ongoing line care. Education for all who care for patients with central lines. Monitoring compliance with these policies to insure consistent execution. Weekly feedback to the units regarding their compliance to recognize excellence and encourage improvement.