1. Reducing Central Line Infections (CLI) National Call September 5, 2007

2. 2 Purpose By the end of this call, participants will have: –Updated information on the SHN Campaign, Getting Started Kits and reporting worksheets –Heard successes and learnings from Improvement Teams –Answers to your team’s questions about intervention-specific changes and measurement –An understanding of benefits and expectations of enrolling in the Canadian ICU Collaborative

3. September 5, 20073 Campaign Structure Partner Network Peer Support Network CAPHC Measurement Working Group & CMT Education & Resource Working Group Clinical Support Canadian ICU Collaborative ISMP Canada Operations Teams Other Canadian Faculty Communication Working Group Atlantic Node Ontario Node Western Node Campaign Support SHN National Steering Committee Secretariat - CPSI Patients CCHSA CIHI Quebec Campaign IHI

4. September 5, 20074 Teams Continue to Enroll Updated August 21, 2007

5. September 5, 20075 Safer Healthcare Now! Enrollment by Intervention InterventionNumber of Teams Deploy Rapid Response Teams52 Improve Care for Acute Myocardial Infarction111 Prevent Adverse Drug Events through Medication Reconciliation 282 Prevent Central Line-Associated Bloodstream Infection66 Prevent Surgical Site Infection129 Prevent Ventilator-Associated Pneumonia94 Total734 As at August 21, 2007

6. September 5, 20076 Safer Healthcare Now! Enrollment by Province & Territory Province/TerritoryNumber of Teams New Brunswick24 Newfoundland & Labrador16 Nova Scotia56 Prince Edward Island11 Quebec22 Ontario278 Alberta63 British Columbia118 Manitoba55 Northwest Territories1 Saskatchewan22 Yukon1 Total669 As at May, 2007

7. September 5, 20077 WestOntarioAtlanticQuebecTotal Healthcare Delivery Organizations [includes hospitals, agencies, services and regions (with one or more hospitals participating)] 531152517210* *Total at August 21, 2007 Enrollment Update

8. September 5, 20078 CLI Rate

9. September 5, 20079 Insertion Bundle Compliance

10. September 5, 200710 Maintenance Bundle Compliance

11. September 5, 200711 Updates to GSK Essentially unchanged since previous edition Suggestions for implementation: –Begin with insertion bundle –Standardize policies, equipment and cleaning agents Suggestions for measurement: –Deviation from bundle components will assist with strategizing for improvement

12. September 5, 200712 Updates to Measurement Worksheets Three worksheets for each measure: chart, data entry and submitted by Compliance to individual bundle components Instructions for new section

13. September 5, 200713 Resources CLI Getting Started Kit & Worksheets http://www.saferhealthcarenow.ca/Default.aspx?fold erId=82&contentId=180 Communities of Practice http://www.saferhealthcarenow.ca/Default.aspx?fold erId=124 Canadian ICU Collaborative Improvement Guide Available when enrolled in the Collaborative

14. Questions

15. September 5, 200715 Success Stories Pediatric ICU’s Centre Hospitalier Régional de Lanaudière

16. T. Northway, RN, MSN, & A. Robin, RN, BScN, BC Children’s Hospital; E. Folz, RN, BScN, Alberta Children’s Hospital; M. Golberg, RN, BScN, NP, Stollery Children’s Hospital; J. Plouffe, RN, BScN, NP, Winnipeg Children’s Hospital Reduction of Catheter Related Blood Stream Infections A Canadian National PICU Collaborative Experience October 2004 to October 2005

17. September 5, 200717 Incidence of CRBSI Comparatively high rate of CRBSI in PICU (NNIS 6.6/1000 CVC line days) CDC reports 5.3/1000 CVC line days adult ICU Attributable cost approximately $34,500-$56,000 US Increased LOS (3 weeks) Estimated mortality rate 13% - 19% (child) & 12% - 25% (adult) o Elward, A et al. (2005). Pediatrics 115(4), 868-872. o (2007) http://www.edwards.com/Products/CentralVenous/VantexInservice.htm?http://www.edwards.com/Products/CentralVenous/VantexInservice.htm wbc_purpose=Basic&WBCMODE=PresentationUnpublished o Slonim, A et. Al (2001). Pediatric Critical Care Medicine 2, 170-174. o Yogaraj, J. et al. (2002). Pediatrics 110(3), 481-485.

18. September 5, 200718 Aim and Goals/Objectives Aim: To reduce the incidence of catheter related blood stream infections (CRBSI) within Canadian PICUs Goals/Objectives: To reduce the incidence of CRBSIs by 20% to 50% within 12 months (October 2005)

19. September 5, 200719 Teams

20. September 5, 200720 CRBSI Improvement Bundles Insertion Bundle Hand Hygiene Maximum Barrier Precautions (Inserter & Patient) Chlorhexidine for Skin Prep Site selection Maintenance Bundle Hand Hygiene Standardized Hub Antisepsis Standardized Accessing of Line –Line set-up –Accessing hubs –Dressing & tubing changes Daily Reviewing of Line Necessity

21. September 5, 200721 Changes Tested A P S D A P S D A P S D D S P A A P S D A P S D A P S D D S P A Specific Test Cycles Baseline Stream Education Stream Establish current reality Adoption of insertion & maintenance bundles Adoption of CDC definition Handwashing campaign Moving to a culture of safety Celebrating successes! Developing staff clinical champions Increased understanding of ICU Collaborative & process Awareness of current reality Awareness of importance Of CVC infections Creating controversy through transparency!

22. September 5, 200722 A P S D A P S D A P S D D S P A A P S D A P S D A P S D D S P A Specific Test Cycles Insertion Stream Maintenance Stream Creation of insertion bundle Hand hygiene Full barrier precautions Site selection Cleansing solution change Standardize equipment: Creation of vascular access tray Standardize equipment: Creation of line insertion cart Create line insertion checklist Culture shift: RNs halting insertion if insertion bundle violated Let’s make it easy to do the right thing & difficult to do the wrong thing! Daily Goal Sheet to review line necessity Standardized data collection CVC Maintenance Bundle: Hand hygiene Line set-up (closed system) Dressing & tubing changes Standardized cleansing solution CVC maintenance OSCE station at annual RN competency validation days Changes Tested

23. September 5, 200723 Total line days 9030 Total CRBSI 29 Group 3.2 CRBSI/1000 line days Collaborative Results

24. September 5, 200724 NNIS Benchmark 6.6 per 1000 Line Days June to Dec 2005: Period with existing 6 teams contributing data Collaborative Results Initial Learning Session (LS) for CRBSI Collaborative

25. Preventing central line infections at the CSSSNL Jean Levasseur MD

26. September 5, 200726 CSSSNL Large regional, community hospital 275 acute care beds 12 beds 8 ICU and 4 CCU beds Closed Unit Working on Collaborative projects since 2003

27. September 5, 200727 Aims and objectives Eliminating C.L. infections Implementing the insertion bundle Initiate the maintenance bundle

28. September 5, 200728 Results 9 months of surveillance (insertion bundle) –Hand washing –Strict sterile technique –Chlorhéxidine –Insertion site

29. September 5, 200729 Results Data collection sheets –Insertion technique –Insertion protocol

30. September 5, 200730 Results Insertion

31. September 5, 200731 Results Technique

32. September 5, 200732

33. September 5, 200733

34. September 5, 200734 Results

35. September 5, 200735 Results

36. September 5, 200736 Results

37. September 5, 200737 Results

38. September 5, 200738 Results

39. September 5, 200739 Results

40. September 5, 200740 Results

41. September 5, 200741 Results During the last year : NO line infections for lines inserted on the unit BUT, 4 line infections during the 24 months of provincial surveillance for lines cared for on the unit.

42. September 5, 200742 Results Common points to infected lines : Site “Emergent” insertions

43. September 5, 200743 Results DxLOSGerm Site (days) Outcome 1 2005 VC Paralysis67Staph C-Fem. (2)Survived 2 2005 MVR12CandidaFem. (8)Died 3 2006 AAA22Staph C-IJ (6)Survived 4 2006 Urosepsis16Staph C-Fem. (3)Survived

44. September 5, 200744 Changes tested Dedicated cart

45. September 5, 200745 Changes tested Withdrawal of other products

46. September 5, 200746 Reminders... Technique

47. September 5, 200747 Patient Perspective Results are posted

48. September 5, 200748 Lessons Learned Small changes can bring big results The maintenance bundle has to be implemented as soon as possible…

49. September 5, 200749 Remerciements Thanks to the fantastic and hard working CSSSNL ICU quality team.

50. About the Canadian ICU Collaborative

51. September 5, 200751 Benefits of Participating Faster learning and quicker gains

52. September 5, 200752 Benefits of Participating (continued) Face-to-face Learning Sessions Evidence-based changes, ready to test and implement Coaching from experienced Faculty on application of changes Education and training on tools for improvement and measurement Advice on targeted strategies to overcome resistance and address barriers Monthly feedback on progress from the Collaborative Faculty Monthly conference calls specific to challenges your team is facing A List-Serve that provides real-time sharing of information, direct to your email Inbox A website for storing and sharing your documents with others A comprehensive Improvement Guide with examples, checklists, tools No cost to join!

53. September 5, 200753 Expectations for Participating Teams Commitment of a team sponsor Full participation of a multidisciplinary team Development of measures Regular reporting of progress to the Faculty Willingness and commitment to implement rapid and widespread changes Desire to innovate Regular access to email and Internet

54. September 5, 200754 Collaborative Resources To Enroll http://www.saferhealthcarenow.ca/Default.aspx?fold erId=104&contentId=420 About the ICU Collaborative http://www.improvementassociates.com/dnn/Default.aspx?tabid=190 About Breakthrough Series Collaboratives (general) http://www.ihi.org/IHI/Results/WhitePapers/TheBrea kthroughSeriesIHIsCollaborativeModelforAchieving %20BreakthroughImprovement.htm http://www.ihi.org/IHI/Results/WhitePapers/TheBrea kthroughSeriesIHIsCollaborativeModelforAchieving %20BreakthroughImprovement.htm

55. Questions

56. September 5, 200756 Contacts Bruce Harries, Collaborative Director bharries@telus.net