1. Central Line Associated Bloodstream Infection Prevention is Primary! Tennessee Collaborative Reducing Healthcare Associated Infections Erlanger Health System Implementation

2. Erlanger Health System Level 1 Trauma Center Level 1 Trauma Center 4 Inpatient Campuses 4 Inpatient Campuses 564 Inpatient Beds - Adult and Pediatrics 564 Inpatient Beds - Adult and Pediatrics –7 Adult ICUs with 66 beds –50 bed Neonatal ICU –8 bed Pediatric ICU – expanding to 12 beds

3. CLA-BSI Prevention “Erlanger Timeline” 1999 Implemented CHG skin prep for CVL insertions and site care and use of antimicrobial impregnated CVL in TICU 1999 Implemented CHG skin prep for CVL insertions and site care and use of antimicrobial impregnated CVL in TICU 2000- 2001 Implemented use of CHG skin prep and antimicrobial impregnated CVL in other ICUs 2000- 2001 Implemented use of CHG skin prep and antimicrobial impregnated CVL in other ICUs 2002 Standardized central line dressing change kit and site care 2002 Standardized central line dressing change kit and site care 2003 Implemented new central line insertion kits to include all items for the procedure including; 2003 Implemented new central line insertion kits to include all items for the procedure including;  Full Sheet drape  Chloraprep™  Safety devices

4. CLA-BSI Prevention “Erlanger Timeline” 2006 Central Line checklist implemented 2006 Central Line checklist implemented 2007 Development of poster to show the major points related to CVL insertion and placed on all patient care units 2007 Development of poster to show the major points related to CVL insertion and placed on all patient care units 2008-09 Participation in the statewide initiative to reduce healthcare associated infections 2008-09 Participation in the statewide initiative to reduce healthcare associated infections

5. “Bundle Components” Hand Hygiene Hand Hygiene Maximal sterile barriers Maximal sterile barriers CHG skin antisepsis- Chloraprep® CHG skin antisepsis- Chloraprep® Optimal site selection- avoid femoral line Optimal site selection- avoid femoral line Daily review of line necessity Daily review of line necessity Line maintenance- dressing changes, disinfection of access ports, limit number of times it is accessed! Line maintenance- dressing changes, disinfection of access ports, limit number of times it is accessed!

6. Elements of Implementation #1 Education Multidisciplinary Team formed with members from; IC Executive Management, leaders from Critical Care, Med/Surg, Anesthesia, Children’s, and frontline staff. Education ;  Barrier : Large facility  Solution: Developed a computerized comprehensive education program/s which is required by all who manage CVLsDeveloped a computerized comprehensive education program/s which is required by all who manage CVLs Visual education- picture is worth a thousand words!Visual education- picture is worth a thousand words!

7. ICU Nurse’s Hands Pre-hand hygiene Normal skin flora carried by the healthcare provider puts susceptible patients at risk

8. Clave Cultures Before Alcohol Swab After alcohol Swab (10 reps) Swab it every time. Make it safe for your patient.

9. Elements of Implementation #2 Standardize Barrier: Barrier: –Bundle Checklist: Initially taped on top of each CVL kit- Misplaced, torn off, missing Solution: Solution: –Developed custom kit that included checklist placed inside the kit and placed checklist on intranet –IV team responsible for dressing changes for all CVLs

10. Elements of Implementation #2 Standardize  Barrier :  Issue’s with Daily Maintenance – Different dressing change protocols  Solutions:  IV team responsible for dressing changes for all patients with CVLs

11. Elements of Implementation #2 Standardize  Barrier : “Daily Review of Line Necessity”  Solutions: Added an area for documentation of “daily review of line necessity” to the nursing flow-sheetAdded an area for documentation of “daily review of line necessity” to the nursing flow-sheet Developed an electronic report of all patients with CVLs -automatically forwarded to the nurse managersDeveloped an electronic report of all patients with CVLs -automatically forwarded to the nurse managers

12. Elements of Implementation #3 Feedback of Data Unit specific infection data is forwarded monthly to nurse managers and physician leaders. Information is shared with frontline staffUnit specific infection data is forwarded monthly to nurse managers and physician leaders. Information is shared with frontline staff Monthly compliance data is placed on each area’s “report card” and posted in the areaMonthly compliance data is placed on each area’s “report card” and posted in the area This data is shared with frontline staff at staff meetings and monthly credentialing classesThis data is shared with frontline staff at staff meetings and monthly credentialing classes Celebrate success!Celebrate success!

13. Outcome Measure: BSIs per 1,000 Line Days

14. Success Stories CSICU & NNICU