1. Preventing Catheter Related Bloodstream Infections Suzanne Brungs MSN, MBA, RN Program Coordinator -VA Inpatient Evaluation Center (IPEC) March 29, 2007

2. Background Greater Cincinnati Health Council and VA GAPS (Getting at Patient Safety ) Center formed a patient safety workgroup in 2002. Set stretch goal: Get funding for patient safety project Agency for Healthcare Research and Quality (AHRQ) issued a matching federal grant solicitation for implementation of evidence-based practices that improve patient safety. Hospital CEOs agree to fund 50% of the project : Cincinnati Children’s Hospital Medical Center The Christ Hospital Fort Hamilton Hospital Jewish Hospital Mercy Mt. Airy St. Elizabeth Medical Center TriHealth University Hospital VA Medical Center

3. AHRQ Project Objectives Demonstrate successful implementation evidence- based practices by measuring –Adherence to processes and practice –Reduction of nosocomial infections in OR, ICU. –Economic impact Train leaders at each hospital in transformation strategies and methodology Share successful transformation and training strategies across Cincinnati Change elements of safety culture through learning Sustain implementation of new evidence based practices and collaborative beyond project funding.

4. Project Randomization 9 Cincinnati Hospital Systems Reduction in surgical site infections (5) Reduction in central line infections (4) Randomly assigned Reduction in surgical site infections Reduction in central line infections Year 1 Year 2

5. 1)Implementation of maximal sterile barriers will reduce catheter related blood stream infections. 2)Together, the sites can achieve goals faster than had the practice been implemented individually. 3)Systematic spread of practice within the organization can occur. 4)The methodology of change can be learned. The learning curve will be reduced the second year. The project will demonstrate that:

6. Components to the project Pre-Work Kick-off Learning sessions Data collection Dissemination Develop data to promote buy-in. Raise project profile with visible leadership support Change Theory / Methods Evidence Base reduce rework Plan Reduce work Share strategies Stimulate success Measure processes and improvement, feedback, value to project approach Spread practice approach to other organizations, cities etc

7. Catheter-Related Bloodstream Infection (CR-BSI): The Evidence 150,000 cases of CR-BSI annually in U.S. 10% to 30% attributable mortality rate Annual cost between $300 million & $2 billion Maximum sterile barriers and chlorhexidine has been shown to save lives and costs. Results of multiple studies support initiatives to prevent/reduce CRBSI

8. 150 – 200,000 people get Catheter-related blood stream infection in United States Hospitals Up to 20% die

9. Modifiable risk factors for Catheter related blood stream infections 1.Location: Infection less with Peripheral than Central; Chest or Neck preferable to Groin placement. 4. Antibiotic impregnated line Chlorohexidine-Sulfadiazine <8 day Minocycline- Rifampin >8 day 5. Time: Shorter = Better but No benefit to  Automatic line change  Over wire changes 2. Site Prep Chlorhexidine 3. Operator Prep Gown, gloves, cap, Mask, Full drape

10. Make it right Project leaders said “we have to take away what’s wrong and give them only what’s right” Central line kits included supplies not included in best practices (small drape and betadine) Infection Control Practitioners contacted major companies providing kits to their facilities. Meetings detailed desirable elements including deletion of small drape and betadine and additional safety items. Kit available for use October 2004 Dissatisfaction with drape hole size, customized drape with multiple holes proto-typed and tested here.

11. New Model - Repeated Use of the PDSA Cycle Hunches Theories Ideas Changes That Result in Improvement AP SD A P S D AP SD D S P A DATA Very Small Scale Test Follow-up Tests Wide-Scale Tests of Change Implementation of Change ©2001 Institute for Healthcare Improvement

12. Proxima Drape - Medline

13. 1. Placement matters2. Chlorhexidine Use 3. Maximal Barriers Central Line Reference Cards were handed out

14. Catheter-related septicemias are 6 times lower when maximum sterile barriers are used during central line insertion -Raad II, Hohn DC, Gilbreath J, et al. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insert. Infect Control Hosp Epidemiol. 1994; 15:231–238. The use of Chlorhexidine gluconate rather than povidone-iodine can reduce the risk for catheter-related bloodstream infection by approximately 50%. -Chaiyakunapruk, Nathorn. et al Chlorhexidine Compared with Povidone-Iodine Solution for Vascular Catheter-Site Care: A Meta- Analysis. [Article] Annals of Internal Medicine. 136(11):792-801, June 4, 2002. The use of PICC lines reduce infection and thrombotic risks -Laughran SC, Borzatta M Peripherally Inserted Central Catheters: A report of 2506 Catheter days. Journal of Parental and Enteral Nutrition 1996, 19(2) p 133-136 Central Line Reference Cards

16. 2 Minutes to Save a Life...PRICELESS Alcohol Hand Gel.. 10 seconds Maximum Sterile Barriers.........50 seconds Chloraprep..Apply..30 seconds Dry.. 30 seconds _________ 2 minutes Market Project

17. Dress for Success and Prevent Infection For all Central Lines Prep skin with Chloraprep Sterile gown Mask Cap Sterile gloves Full body sheet Please don’t forget to wash your hands.

18. Process Adherence Increased Project Month % Adherence