1. Preventing Central Line Infections Saving 100,000 Lives with IHI Presented by Brenda Hackett, MT, CIC, MPH

2. The New Healthcare Mission 2006 & Beyond IHI (& Others) Healthcare Campaign - Goal = Save 100,000 lives per year - Proven intervention “bundles” - Quick, Adaptive PDCA - Measure and share success **www.ihi.org – info/materials

3. What is the Goal ? P revent catheter-related bloodstream infections WHY? * 60-80% BSI caused by cvcs 1 * 14,000-28,000 associated deaths/yr. * LOS mean of 7 d * Cost $3700-29,000 2 1 Wisplinghoff et al. Clin Infect Dis 36:1103, 2003 2 Soufir et al. Infection Control Hosp Epi. 20(6) 1999

4. The Central Line Bundle 5 Evidence Based Components * IHI CR-BSI bundle - *Shocking reductions in CR-BSI rates Hand Hygiene Maximal Barrier Precautions Chlorhexidine skin antisepsis Optimal catheter site selection -subclavian preferred for non-tunneled Daily review line necessity -prompt removal if unnecessary

5. Hand Hygiene Hand hygiene for Central Line Care: - Before/after palpating insertion site - Before/after inserting, accessing, dressing an intravascular catheter - Suspect or obviously soiled hands - Between patients - Before donning/after removing gloves - After using restroom

6. Maximal Barrier Precautions **Applies to Everyone involved in Line Insertion Includes: -Hand Hygiene -Cap, Mask, Sterile gown, Gloves For Patient: -Large sterile drape – small opening insertion site * 2 Studies – Raad and Mermel et al. – CR-BSI reduced with maximal barriers

7. Chlorhexidine antisepsis Chlorhexidine antisepsis – prep central line insertion site *Studies support better skin antisepsis than other antiseptic agents (if not contraindicated) * Beware: patient safety- alcohol pooling + cautery = potential danger

8. Optimal Catheter Site Selection Many infections develop at insertion site Subclavian Preferred Site Recent study = site didn’t matter (*if controlled environment for insertion/care) *Other site OK if Documented rationale

9. Daily Review Line Necessity- Prompt Removal Remove Unnecessary lines Increased time line in = Increased risk of infection

10. Getting Started…?? PLAN *Gather Team – stakeholders Define the Problem - Pilot one area? - spread the change Develop Aim Statement -what, how, by when? Plan data collection -baseline bundle compliance –insertion checklist -baseline CR-BSI infection rates - Definition Cr-BSI? - (NHSN: Central Line = tip terminates in a great vessel)

11. Collect Baseline Compliance Data– (observation/questionnaire) Observer: Date: Unit: Insertion or Exchange 'I' or 'E' Circle line site: Subclavian/Jugular/Femoral/Other Hand Hygiene before? 'Y' or 'N' Line reviewed for necessity? ‘Y’ or ‘N’ Hand Hygiene after? 'Y' or 'N' Skin prep - Chloroprep, Hibiclens, Betadine ( Circle)- 'Cl', 'Hi', 'B' Skin prep allowed to dry? 'Y' or 'N' Maximal barrier used ? 'Y' or 'N' if no, note what was missing? sterile full drape used? 'Y' or 'N' sterile gowns used? 'Y' or 'N' sterile gloves used? 'Y' or 'N' mask used? 'Y' or 'N' Cap used? 'Y' or 'N' Inserted by (Circle) MD, Midlevel, RN 'MD', 'Mid', or 'RN'

12. Analyze Baseline Data

13. Act Develop “Plan of Attack” -Feedback baseline results -Get input – “current state” (what are we doing?/why?/obstacles to change) - Standardize -Develop/implement educational plan -Develop safety checklist - cvc insertion -Pilot safety checklist

14. CVC Insertion Safety Checklist E nsure the R ight Way - All the Time:  Educate Staff  Engineer for Safety -Reduce opportunity for error  Empower Staff

15. CVC Safety Checklist - Date: Reason For Insertion: Malfunction ___ New indication ____ Other ____ Insertion Site: Subclavian_____Jug _____ Fem _____ Other_____ Consent completed Preparation Patient equipment Patient Positioned Time-Out (right patient/right site) Central Line Insertion Bundle hand hygiene full body barrier implemented chlorhexidine prep (if not contraindicated) catheter secured in place Post Procedure Sterile/ appropriate dressing applied Documentation insertion/exchange Safety check for sharps/guide wire M.D. order – Post procedure x-ray if appropriate M.D. post procedure note EXAMPLE

16. Measure Trends Trend Bundle Compliance Trend CR-BSI Infection Rates -Share Feedback - Solicit input - Patient/Family Fact sheet – involve them - Share success

17. The GOAL Intervention CR-BSI Rate per 1000 cvc days Compliance with CVC Bundle

18. The GOAL *Measure # of Days Until Next Infection

19. The GOAL  SAVE Patient Lives  Reduce Morbidity  Be Healthcare Customer of Choice  SAVE Healthcare $$

20. THANK YOU! Your Patients and their Families Thank You Your Hospitals Thank You