1. Deborah R. Campbell, RN-BC, CCRN, MSN Pediatric Cardiovascular CNS Kentucky Hospital Association Children’s Hospital Association QTN faculty

2.  Clinical Consultant for Carefusion ◦ Work to be presented was completed without commercial support

3.  Review current bundle concept  Discuss chasing “0”: How low can we go?  Discuss policy change v. reliable implementation  Discuss other interventions, looking at outliers  Share new “Clot Prevention” bundle

4.  How few is few enough?  How long without a CA-BSI is long enough?  Sustain the Gain- how? ◦ Kits and carts ◦ Incorporate checklists into electronic documentation ◦ Make part of orientation/cross-training for all disciplines (credentialing for MDs) ◦ Incorporate goal attainment into performance appraisals/pay for performance ◦ Celebrate success often and enthusiasticallyj

5.  Insertion Bundle- very familiar to everyone involved in HEN ◦ Where are we with this in our units? Hospitals? ◦ Kits and Carts ◦ How about “Stop the Line?  Everyone has a policy on this, but Policy change is not = to practice change ◦ Reliably implemented? ◦ Audits- frequency, accuracy, duration

6.  Maintenance Bundle ◦ Where are we with creation of policies with specific bundle elements? ◦ Kits and supplies to support the practices available? ◦ Just the ICU or is this concept accepted, practiced housewide? Radiology, OR

7. ◦ VATs ◦ CHG sponge dressings ◦ CHG impregnated transparent dressings ◦ CVL securement devices v. suturing ◦ CHG baths ◦ Antibiotic/ethanol locks ◦ Antibiotic coated catheters (even 5FU) ◦ Continuous passive disinfection caps ◦ Staffing models

8.  Children’s Hospital Association, formerly NACHRI ◦ CLUE (Central Line Utilization and Entries) and Clot ◦ Part of “chasing zero”  Why clot? ◦ Simultaneously attacked 2 problems that were universal- occlusions and infections

9.  Randolph, et al Chest, 1998, 113 p165-71: Benefit of Heparin in Central Venous and Pulmonary Artery Catheters: A Meta-analysis of Randomized Controlled Trials ◦ 12 CVC studies, one pediatric ◦ Variability in definition of infection ◦ Prophylactic heparin decreases catheter-related venous thrombosis (relative risk [RR], 0.43; 95% confidence interval [CI], 0.23, 0.78) and bacterial colonization (RR, 0.18; 95% CI,0.06, 0.60) of central venous catheters and may decrease catheter- related bacteremia (RR, 0.26;95% CI, 0.07, 1.03)

10.  Timsett et al, (CHEST 1998; 114:207-213): Central Vein Catheter-Related Thrombosis in Intensive Care Patients: Incidence, Risks Factors, and Relationship With Catheter- Related Sepsis ◦ Observational Prospective Multi-institutional Study ◦ Adult ◦ The risk of catheter related sepsis was 2.62-fold higher when thrombosis occurred (p=0.011)

11.  Thornburg et al, Thrombosis Research (2008) 122, 782–785: Association between thrombosis and bloodstream infection in neonates with peripherally inserted catheters ◦ Cohort study of 1540 PICC neonates ◦ 212 removed for thrombosis; 142 removed for infection ◦ Positive association of thrombosis and BSI  INS and AVA guidelines

12.  Prescriptive Surveillance ◦ Check for blood return every 12 hours if line has an infusion that can be safely interrupted ◦ For lumens that are locked and not being entered for any purpose, check for blood return when lumen is flushed at least every 24 hours

13. Prevention Multiple attempts at same site avoided if possible Blood waste not returned unless self contained blood conservation system in use Flush line with preservative free 0.9% saline before and after each use

14. Positive fluid displacement should be maintained Either by using a positive displacement device per manufacturer directions By employing the "flush-clamp" technique (clamping while still in the process of flushing) which prevents reflux of blood into the line Lock line with heparin at least 10 units/ml Frequency for flushing locked lines at least every 24 hrs if not accessing for any other purpose.

15.  Thrombosis Suspected If line sluggish when flushed and/or if blood return absent or sluggish, TPA administered Consider ultrasound of line, if available If clot visualized and/or TPA unsuccessful, line removed if possible Document lines not removed and reason

16.  Is there a “magic bullet?  Are there certain, specific items?  1+1=3 Synergy?  Pathogen dose v. immune response  Bundles act as checklists  Bundles act as curriculum  Recipe v. culture

17.  Is there a best way? ◦ Direct Observation  Peers  Supervisors, educators, CNSs ◦ Self-audits ◦ Secret Shoppers  Sampling ◦ Include weekends, nights ◦ Attempt randomness by setting specific days, times  Met your goals consistently, decrease frequency-BUT never less than quarterly.

18.  Make the right action the default ◦ Opt-outs v. necessity to overtly choose (products) ◦ Standardization (kits, carts) AND across units ◦ Redundant processes ◦ From the IHI- Everyone chooses (or is assigned) a focus area for which they provide input  5 audits per day per person (on HAPU, CLABSI, CAUTI, SSI or VAP)

19.  Videos, e.g. Josie King  Think of patient in front of you being your mother, grandfather, child  VA campaign ◦ “Have you ever killed someone with your bare hands?”