Central Line Education: Focus on CLABSI 2009

UC Campus Rates Comparison UC BSI Rate Fall 2008 Q1 FY 2008-2009 (July,Aug, Sept 2008) Q1 FY 2008-2009 (July, Aug, Sep 2008) Q2 FY 2008-2009 (Oct, Nov, Dec 2008) Q2 FY 2008-2009 (Oct, Nov, Dec 2009) Q3 FY 2008-2009 (Jan, Feb, March 2009) Q3 FY 2008-2009 (Jan, Feb, March 2009) (adult ICUS excluding burns) Rate/1000 Line Days Rate/ 1000 Line Days change from 2008 Average UCD 3.99 3.06 -23% 7.27 82% 2.46 -38% UCI 4.3 6.05 41% -7% 3.94 -8% UCLA RR 1.55 1.44 0.54 -65% 0.14 -91% UCLA SM 3.04 3.58 18% 4.73 56% 5.91 95% UCSD 3.05 0.85 -72% 2.01 -34% 1.53 -50% UCSF 4.48 1.72 -62% 2.53 -43% 1.77 -60% Total 3.1 2.26 -27% 2.83 -9% -45% One way we know we need to improve is by comparing our CLABSI rates to other benchmarks For example, the University of California medical campuses compare rates among certain ICU units. Rates are compared quarter to quarter As seen on this slide, UC Irvine has remained higher than several other campuses for multiple quarters One of the organization-wide goals for UC Irvine Healthcare is to reduce our CLABSI rates.

Dressing Change Procedure Steps of dressing change procedure

Open kit to Inner Level

Central Line Associated Blood Stream Infections (CLABSI) Central line infections are associated with high morbidity, mortality, prolonged length of stay, and significant costs Skin flora can colonize central lines and migrate along the catheter to the intravenous space. Inflamed skin or wounds at the insertion site increase the risk for catheter associated colonization, biofilm formation, and infection.

Current Challenges in Central Line Insertion Site Assessment Nursing (RN) documentation options for describing line insertion site appearance do not offer a way to communicate problematic central line insertion sites Physicians (MD) must open nursing documentation to see line insertion site assessments RN and MD communication on concerning insertion site findings is inconsistent Once symptomatic insertion site is identified, there is no directive on what actions should be taken

Central Line Insertion Site Assessment (CLISA) Score The CLISA score was developed to: Improve the quality of insertion site documentation Improve RN-MD communication of line site appearance Facilitate early recognition of localized insertion site inflammation/wounds Facilitate removal of high risk central lines

CLISA Score 0: Normal appearance Description: The skin directly around the insertion site is flesh-colored. There is no erythema, no localized swelling or drainage. Actions: RN documents CLISA Score 0 and serial assessments continue per usual.

CLISA Score 1: Minimal Erythema Description: The skin directly around the insertion site has minimal erythema, < 3mm radius. There is no focal swelling at the site There is no purulence. If drainage or crusting is present, it is non-cloudy and serosanguineous. Note: the catheter diameter of peripherally inserted or multi-lumen central venous catheters is almost 3mm. This can be used to gauge the size of the erythema. Actions: RN communicates with next shift MD acknowledges the CLISA Score of 1 in the progress note.

CLISA Score 2: Advancing Erythema Description: The skin directly around the insertion site has increased erythema, 3-6 mm radius. There may be focal swelling at the site There is no purulence. If drainage or crusting is present, it is non-cloudy and serosanguineous. Note: the catheter diameter of peripherally inserted or multi-lumen central venous catheters is almost 3mm. Doubling this size can help gauge progression up to 6mm. Actions: RN verbally communicates with MD CLISA 2 strongly consider line removal. If unable to remove, physician documents reason and plan

CLISA Score 3: Severe Erythema or Purulence Description: The skin directly around the insertion site has rapidly worsening erythema, or is >6 mm radius. OR There is any amount of purulence or cloudy crusting, with or without erythema. Focal edema may accompany erythema Note: the catheter diameter of peripherally inserted or multi-lumen central venous catheters is almost 3mm. Doubling this size can help gauge progression past 6mm. Actions: RN pages MD CLISA 3 immediate line removal. If unable to remove, physician documents reason and plan.

Additional Details If skin around insertion site is not visible for any reason (e.g., gauze or excess blood making skin difficult to visualize), then the RN will document “NV = insertion site not visible”. Findings of erythema or edema should relate solely to that which is organized around the insertion site. Clinical parameters of CLISA do not apply to generalized erythema or edema (as may be found in anasarca or acute thrombus). Purulence can be present without erythema and may indicate a tunnel infection Physicians have the option to change the CLISA score if their exam of the insertion site differs from nursing assessment CLISA scoring will not apply to port-a-caths or the neonatal ICU

EPIC Nursing Documentation Assess and document site according to policy

CLABSI Rate UCI Q2 2017 Q3 2017 Q4 2017 Q1 2018 # INFECTIONS 5 0.6 2 0.3 0.7

Optimize patient safety, remove lines at the earliest opportunity. Summary Prevention is key. Optimize patient safety, remove lines at the earliest opportunity.