1. VASCULAR ACCESS Specialist team
Ownership of the Bundle
April VanDerSlik BSN RN CIC
Infection Prevention Manager
November, 2013

3. Bronson Healthcare System
Regional, not-for-profit health system
Recognized for workplace excellence
National leader in healthcare quality
Keystone, including CUSP

4. Bronson Methodist Hospital
434 bed tertiary teaching hospital
11 VAST nurses (7 full-time, 2 part-time, 2 on-call)
642 Acute CVCs / year
Approximately 1,000 PICCs / year
~ 50% PICCs are placed in critical care units

6. The Bronson Story

7. History Team Beginnings: Hyperal Initiation Formed 1978
Dr. James Heersink, General Surgeon
Hyperalimention Team (doctors, nurses, pharmacist, and dieticians)
Duties
Assisted with CVC inserts
Education of staff and patients
Improved patient outcomes
Decreased infection rate
Team name change in 2009 (VAST)

8. VAST: Team Responsibilities
Education
Develop policies and procedures according to INS standards, CDC & Joint Commission guidelines
Teach IV & Infusion Management class
Patient, family and staff education
Manage Champion program
Clinical resource to community
Placement
Assist providers with CVC insertions
Insertion of PICCs at bedside
Post Placement
PICC daily surveillance
PICC dressing changes

9. Central Line Associated Blood Stream Infections (CLABSIs) Adult Population Only
All TPN Dressing

10. Low CLABSI National Recognition
Healthgrades, 2013
Better than average
Consumer Reports, Jun 2011
reported zero
received highest score
Commonwealth Fund, Dec 2011

11. Bronson’s Implementation Plan
Reduce CLABSI

12. Methodology Guidance Practice CDC & Joint Commission guidelines
Keystone: CVC bundle
PICC bundle (Bronson specific protocol)
Practice
Daily PICC and TPN surveillance
Dressing change protocols
Hand hygiene program with auditors
Ultrasound guided CVAD placement
Blood sampling protocols
Education
Scrub the hub
Chlorhexidine disc

13. Actual Practice Example

14. Keystone CVC Bundle Before procedure During Procedure After procedure
Hand hygiene, chlorhexidine prep
During Procedure
Full Barrier Pre-cautions: Hat, mask, sterile gown, sterile gloves
Assist physicians and residents with insertion – avoid femoral site
Monitor sterility
Empowered to stop procedure
Monitor traffic pattern
Use of checklist
After procedure
Sterile dressing applied
Removing unnecessary catheters

15. Bronson PICC Bundle at the Bedside
Hand hygiene
Max barrier precautions
pre-packaged insertion kit
Chlorhexidine prep
Ultrasound guided PICC insertion
Neutral connector system
Connector disinfection
Flushing protocol
Daily monitoring of all PICCs by VAST

16. Scrub the Hub1 Wash hands or use hand sanitizer Wear gloves
Scrub the hub for 30 seconds each and every time with chlorhexidine
1Centers for Disease Control, Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011

17. Patient Ownership Goal: Patient Empowerment of their VAD Inpatient
Permission to say “no” to care being given (i.e. change your gloves, wash your hands, scrub for 30 seconds)
Basic care & maintenance education
Discharge
Care & maintenance instructions
Emergency contact information
All CVAD types

18. Checklist and Nurse Empowerment
Goal: Assist providers with CVC insertion
Checklist to delineate, guide and document completion of each step
Source of data collection to verify adherence to protocol
Taught to speak up and “stop the line”
Patient safety strong backing by RN, MD and management

19. Vascular Access Infusion Training (Who do we educate?)
Physician and residents
Clinical staff (more than 800 FTEs)
Management
Patients and families

20. Post Insertion Care Goal: Dressing Change and Line Surveillance
Daily: PICC & TPN lines –VAST Team
Daily: Acute CVC – Staff Nurses
Check bag & tubing–labeled with time/date/initials
Lab values
Fever
Line Necessity

21. Staff Engagement Activities
Traveling Story Board
Updated according to unit specific educational needs
»Transferred from unit to unit»

22. Champion Program Selection
Clinician empowerment of insertion procedure, care & maintenance and training of staff
RN for two years at Bronson
VAST and management approval needed
Attends Champion class done by VAST
Specially trained in high risk central line skills
Ability to sign off other RN’s on certain procedures
Yearly peer review

23. Champion Program: Duties / Skills
Champion Duties
Sign off floor staff
Removal PICC / CVC
Dressing Changes (CVC)
Catheter Clearance - Thrombolytic
Continuing Education
Champion Sign off Staff (Procedures)
Hanging TPN
Blood draws
Dressing Change (CVC)
Port Access

24. Champion Program: Competency
Goal: Proficiency Demonstration
VAST or unit champion to sign RN off on procedure
RN observation
RN practicum / performance of procedure with assistance
RN demonstrated competency without assistance

25. New Hire Employee: Infusion Training
Computer Based Learning (CBL) class
IV insertion and infusion management
Practicum for hands on demonstration in classroom setting

26. New Initiative: Community Education
Goal: Initiative to decrease readmits from community due to CLABSIs w/ outside staff training
Local Nursing homes
Home Health Agencies
Local Hospice – policies only

27. Central Line Infection Rate History (Adult Population Only)
All TPN Dressing

28. Obstacles to Overcome Hospital Administration support of empowerment
Finding a Physician(s) Champion
A hospital wide culture change

29. Lessons Learned
Participate in infection prevention collaboratives to share your challenges and best practices with other hospitals.
Involve physician champions and multidisciplinary teams.
Use checklists.
Employ small, specially trained teams and individuals (including intensivists in the ICUs) to conduct and/or oversee line insertion and maintenance throughout the hospital.
Sustain best practices with ongoing education, monitoring, and adjustments and provide performance data to staff to keep them focused on outcomes.

30. References
Carroll SS (December 2011) Eliminating Central Line Infections and Spreading Success at High-performing Hospitals Synthesis Report December 2011 Commonwealth Fund publication 1559 Volk 21
Ending Health Care-Associated Infections Agency for Healthcare Research and Quality (2009)
Lowes R (2011) High Central-Line Infection Rates at Many Teaching Hospitals New Consumer Reports Study Gives Poor Marks to 67 Institutions Medscape Medical News June 7,2011
O’Grady NP et al (2011). CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections
Sardone F (2010) Celebrating Nursing Excellence Bronsonhealth.com