1. CLABSI: Working Toward Zero Trinity Regional Health System Infection Prevention and Control Presented by: Patricia Herath, BSN, RNC Infection Preventionist April 20, 2010

2. Central Line Associated Bloodstream Infection (CLABSI) History  2006: 45 CLABSI = Rate of 7.7 per 1000 line days  2007: 9 CLABSI = Rate of 1.0 per 1000 line days Developed Central Line Insertion Bundle  2008: 15 CLABSI = Rate of 1.9 per 1000 line days Developed Central Line Maintenance Bundle  2009: 3 CLABSI = Rate of 0.4 per 1000 line days

3. Aim  Launched a focused initiative to reduce CLABSI  Zero rate was targeted using the IHI bundle check list

4. Initial Action Plan  Formed multidisciplinary team to track and evaluate central lines from insertion to discharge  Tracked insertion bundle compliance for Central Lines Physician champions Use of Chlorhexidine Gluconate (CHG)– prep and biopatch Audited insertion bundle check sheets  Central lines  Included PICC lines  Ramped up Hand Hygiene education

5. Identified Issues Concerns related to:  Although insertion bundle was followed, additional cases were noted o Observed non-standardized approach to line maintenance o Identified documentation issues o Identified issues relating to maintenance (daily care)

6. Additional Action Plan  In-serviced oncology office staff regarding standardized evidence based practice care Standardizing dialysis catheter dressing changes  Developed an evidence based daily maintenance bundle for care of Central lines (April 2009)

7. Additional Action Plan (cont.)  Staff Education  Documentation  Observation of sites, daily care and discontinuance  PICC nurses started evaluation of daily care by direct observation

8. Lessons learned  TMC went 9 months with out a HAI – CLABSI One in February 2010  Real time reporting to CL team with each finding Identified possible competency issue with care of line Manager to review care with the unit’s staff  2010 Rate First Quarter=.05  Continued commitment on Director level Disseminated throughout the entire team

9. Outcome  Average cost of CLABSI = $20,000  2006 – 2009 = 72 x $20,000 = $1,440,000  Reduction of costs with 0 rate

10. Future Direction  Evidence based standardized approach to central line blood draws  Implement program to identify patients at high risk with strategies to mitigate risk  Develop analytic committee Preventative vs. reactive

11. Acknowledgements  A special thanks is extended to the CLABSI team for their dedicated efforts to launch this project!

12. VAP: Maintaining Zero Trinity Regional Health System Infection Prevention and Control Presented by Patricia Herath, BSN, RNC Infection Preventionist April 20, 2010

13. Ventilator Associate Pneumonia – (VAP) History  In first 9 months of 2006 – 13 VAPs  Developed ventilator bundle

14. Cost of VAPs to TRHS  Average cost of VAP: $33,887*  13 VAPs in 2006 = $440,531  Cost of product for oral care: $30.30 for 24 hours  Avoiding VAP saves $$$ *Source: CDC, Consumer Price Index (CPI) 2007 average cost

15. Aim  Launched facility- wide initiative to reduce VAPs  Zero rate was targeted using IHI VAP bundle

16. Action Plan  Formulated multidisciplinary team to reduce VAP: Unit mgr, RN staff, RT, MD champion  Initiated VAP bundle  Meticulous hand hygiene  HOB 30-45 degrees unless contraindicated  Peptic ulcer prophylaxis  Daily readiness to extubate  Oral care q 2H and prn (with product at head of the bed) and deep suctioning q 8H  Also: anti embolism stockings and DVT prophylaxis (e.g. meds, TEDS stockings)

17. Action Plan (cont.)  Issues identified: Received commitment from staff to provide:  oral care every 2 hours  competency education in-services on protocol and rationale target audience: physicians and nursing staff  Documentation of compliance to bundle on check list Identified need to improve charting

18. Results  Since October, 2006 Trinity Regional Health System has had two VAPs  Currently 26 months without a VAP 2009 – 2010: rate = 0  Staff response: great “buy in” when positive results noted  Received resistance due to cost of product used for oral care  Any suspected cases are reviewed in real time  Huddles with Managers and unit staff  Charts reviewed with Infectious Disease physician

19. Results of increasing HH compliance and HAI outcomes

20. Acknowledgements  A special thanks is extended to the VAP team for their dedication to launch and maintain this project!

21. Resources  Institute for Healthcare Improvements (IHI) Improvement Project IHI is a reliable source of energy, knowledge, and support for a never-ending campaign to improve health care worldwide. The Institute helps accelerate change in health care by cultivating promising concepts for improving patient care and turning those ideas into action.  CDC. www.cdc.orgwww.cdc.org  Scott II, R.D. (March 2009). The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention. Retrieved from http://www.cdc.gov/ncidod/dhqp/pdf/Sco tt_CostPaper.pdf (2010) http://www.cdc.gov/ncidod/dhqp/pdf/Sco tt_CostPaper.pdf