1 Four “C’s” to Conquer CLI: An Integrated Approach to Performance Enhancement Elaine C. Killough, RN, MSN, CCRN, CS Sturdy Memorial Hospital Attleboro, MA

2 accessed 05/31/08

3 Sturdy Memorial Hospital  128-bed community hospital  14 bed medical- surgical ICU  Open unit with primary intensivist coverage  Admits ~700 patients/year  Mean LOS 4.8 days

4 Central Lines (2007)  265 lines managed 74.9% Multi-lumen catheters 14.3% Dialysis catheters 10.9% SwanGanz catheters  73.6% placed in the ICU 93.3% placed by intensivist  Site Selection 46.7% IJ 45.0% SC 8.3% Femoral

5 Frequency: Line Placement Year Patients with Lines (# of Lines) Total ICU Admissions Pts with Lines/ Total ICU Pts (%) (294) (278) (247) (255)

6 ICU Line Days Year# of LinesTotal Line Days Line Days/ Line (mean)

7 CLI: SMH ICU

8 Sturdy Excellence Program  Integrated quality and service improvement goals Validity supported by evidence Measurable outcomes  Unit/department-based  Regular reporting to Quality and Service Enhancement Committee  Review and feedback from administrative and multidisciplinary resources  High emphasis on progress and accountability

9 An Integrated Approach Senior and Risk Management/ Quality Improvement Unit Management ICU Nursing Infection Control Physicians Prevent CLI

10 SMH ICU: CLI Prevention Practices: 2004  Developed a formalized program of daily surveillance  Established system for auditing related documentation and dressing changes per existing protocol (record review)  Provided parameters for identification of suspect lines and clarified expectations for physician response  Worked on development of comprehensive program for 2005

11 SMH ICU CLI Prevention Program:  Adopted evidence-based interventions as standard of care  Developed total management program: Comprehensive Collaborative Current  Partnering with QSEC to review and evaluate program effectiveness  Goal: To remain at or below the CDC median occurrence rate

12 A Comprehensive Approach  Prior to placement: Conservative decision- making as to appropriateness of intervention.  Inclusive documentation tool: Identifies accountable personnel. Validates implementation of evidence-based standards at insertion. Describes line maintenance per hospital standard, including description of insertion site, documentation of dressing changes. Documents problems identified and resolution. Documents analysis and review if line is suspect.

13 A Comprehensive Approach  Line maintenance documented each shift in the electronic record.  Daily assessment/data collection by CNS or unit leadership staff: Insertion site Intactness/quality of the dressing  All program elements are reviewed and reinforced in orientation for all new staff including temporary personnel.

14 A Collaborative Approach  Proactive, facilitative approach with MDs not familiar with standards  Problem-solving related to difficult sites or persistent patient problems  Regular review of documentation tools by IC RN  CNS/IC RN analysis of occurrences Dissemination of findings to staff Collaborative problem-solving

15 A Collaborative Approach  Nursing education involvement in all changes in program/protocol  QSEC review of documented performance progress and goal achievement; dialogue to provide feedback, identify problems, and suggest solutions.

16 Keeping Things Current  Problems identified are addressed immediately.  Bi-weekly reporting to management on all process elements.  Monthly reporting of process compliance and outcomes in staff meetings and through .  Reports to QSEC available on unit; feedback shared as it is received.  Annual review of program.

17 CLI: SMH ICU

18 CLI: SMH ICU Cases of CLI in 20 Months! (Since September, 2006)

19 SMH ICU: CLI Prevention Practices: 2008 Incorporated a “Zero Tolerance” Approach into Our 2008 CLI Prevention Sturdy Excellence Goal

20 The Fourth “C”……..  Continued excellent performance.  Consistent goal- achievement.  Commitment to improving patient outcomes.