1. creating an integrated clabsi prevention program
Presented by:
Tracy Shamburger, RN, MSN and Karen Bailey, RN

2. objectives
Identify The Joint Commission (TJC) National Patient Safety Goal Elements of Performance
Cite the Mike Denton Infection Reporting Act (2009)
Define CLABSI and Central Lines per CDC Guidelines
Identify National Healthcare Safety Network (NHSN): ADPH HAI Reporting Requirements
Understand that the Comprehensive Unit-based Safety Program (CUSP) is a process for creating a culture of patient safety
HAIs remain a …..and are a topic of great interest …….We have been challenged as IPs to sort through all of the demands for monitoring, reporting, and preventing HAIs. During this presentation we will discuss central line associated Bloodstream infections and show how the TJC guidelines, CDC’s NHSN and CUSP prevention strategies are related and provide an example of how one facility has …….

3. Institute for Healthcare
The Joint Commission
NPSG
Institute for Healthcare
Improvement (IHI)
Monitoring;
Evidence Into
Practice
Standards;
Regulatory
Compliance;
& Reporting
CLABSI
Prevention
Comprehensive
Unit-based
Safety Program
(CUSP)
Patient
Safety
Evaluation
& PI
National Healthcare
Safety Network
(NHSN);
CMS; ADPH

4. Let’s begin with The Joint Commission National Patient Safety Goal 07
Let’s begin with The Joint Commission National Patient Safety Goal (CLABSI Prevention). How many of you have conducted a periodic hospital-wide risk assessment addressing this NPSG? Are there any gaps in your compliance with these elements of performance?

5. EVALUATING COMPLIANCE WITH TJC NPSG.07.04.01
Conduct periodic hospital-wide risk assessments for CLABSI; monitor compliance with evidence- based practices; and evaluate the effectiveness of prevention efforts.
After conducting your risk assessment, do you have gaps in compliance or process improvement opportunities? If so, what are the gaps; are you conducting process reviews; and are your developing action plans to achieve compliance?

6. MONITORING AND REPORTING COMPLIANCE RATES
Compliance with evidence-based practices should be measured weekly or monthly and reported/charted to show progress towards goal of 100% compliance.
Compliance rate must be calculated with the whole bundle, not just parts.

7. CALCULATING COMPLIANCE RATES
# of pts with CVC during monitoring period who received all 5 elements of bundle (with documentation)
# of pts with CVC audited during the monitoring period
X 100 = Compliance Rate (%)
Do you have a process for evaluating and reporting compliance rates with documentation? CLABSI rates?

8. SAMPLE COMPLIANCE RATES AND CLABSI REPORTING SCORECARD
July
Aug
Sept
Oct
How often did we harm (CLABSI)? Goal: <1CLABSI/1000 CL DAYS
0.11/1000
0.09/1000
0.08/1000
Compliance Rate? Goal: 90% or greater
43%
82%
88%
Are we improving based on data monitoring?
Yes
Where are we failing based on data monitoring? Non-compliance Rate:
57%
18%
12%
a. Non-compliance with insertion documentation: Nurses
24%
10%
3 nurses did not document CVC insertion; Infusa Ports not consistently documented in the insertion screen as POA 9%
2 M/S and 1 ICU nurse did not document insertion screens; M/S staff are not consistently documenting the insertion screen for Infusa Ports POA
b. Non-compliance with barrier precautions: Physicians
19% 8%
3 MD failed to wear full barrier precautions 3%
1 MD failed to use full barrier precautions
c. System implementation issues:
**Processes exist for ER and OR staff to document data; however, the data is not flowing between modules for M/S and ICU
14%
**0%
The scorecard is designed to report as rate based measures only those interventions that can be validly measured as rates. In the Keystone Project, we had rates for CLABSI and rates for VAP processes of care (how often do we do what we should?).
In the scorecard, we also captured important improvements that can’t be measured as rates. Though we would love to understand how well and how often teams learn from mistakes, there is no way to quantify that. We say hundreds to acknowledge that once teams develop a lens to see patient safety issues, learning from mistakes becomes a unit norm. The LFD form is used to quantify significant or common mistakes but on a daily basis many units find a way to capture and record mistakes and how they’ve been resolved.
In Keystone ICU, we were able to quantify the rate of culture improvement using the SAQ scores. In this national project, we will be using HSOPS to assess improvements in culture (teamwork and communication).
Finally, you likely notice that the first two items on the scorecard, relate to measures on TRiP and the second two items reflect components or interventions that are part of CUSP.

9. COMMUNICATE AND REPORT COMPLIANCE AND INFECTION RATES
TJC requires that you report CLABSI rate data and prevention outcome measures to key stakeholders, including leaders, nursing staff, and other clinicians
Regulatory guidelines require reporting CLABSI rates to the National Healthcare Safety Network (NHSN)

10. Institute for Healthcare
The Joint Commission
NPSG
Institute for Healthcare
Improvement (IHI)
Monitoring;
Evidence Into
Practice
Standards;
Regulatory
Compliance;
& Reporting
CLABSI
Prevention
Comprehensive
Unit-based
Safety Program
(CUSP)
Patient
Safety
Evaluation
& PI
National Healthcare
Safety Network
(NHSN);
CMS; ADPH

11. CDC’s National Healthcare Safety Network (NHSN): CENTRAL LINE definition
An intravascular catheter that terminates at or close to the heart or in one of the great vessels which is used for infusion, withdrawal of blood, or hemodynamic monitoring.
-The Great Vessels Include the following:
Aorta
Superior Vena Cava
Pulmonary Artery
Brachiocephalic Veins
Internal Jugular Veins
Subclavian Veins
Inferior Vena Cava
External Iliac Veins
Common Femoral Veins
Umbilical Artery in neonates

12. Infusion Defined
Introduction of a solution through a blood vessel via a catheter lumen. Includes:
Continuous Infusions such as nutritional fluids,
medications, or
Intermittent infusions such as flushes or IV
antimicrobial administration, or
Administration of blood or blood products in the
case of transfusion or hemodialysis.

13. CDC’s National Healthcare Safety Network (NHSN): Central Line Blood Stream Infection
A Central Line Blood Stream(CLABSI) is a primary bloodstream infection (BSI) in a patient that had a Central line within the 48 hour period before the development of the BSI.

15. CDC’s National Healthcare Safety Network (NHSN): AL HAI Reporting
Mike Denton Infection Reporting Act (2009; Rules and Regulations Released-August 2010)
-Requires Critical Access hospitals in Alabama to begin reporting
certain HAIs using CDC’s NHSN.
HAI Reporting Requirement
Denominator Requirement
Locations
CLABSIs
Central Line Days
Medical CCUs
Surgical CCUs
Medical Surgical CCUs
Pediatric CCUs
CAUTIs
Catheter Days
Medical Wards
Surgical Wards
Medical Surgical Wards
SSIs for Colon Surgeries and Abdominal Hysterectomies (inpatient)
All inpatient procedures for Colon Surgeries and Abdominal Hysterectomies
Any

16. ALABAMA CENTRAL LINE/CLABSI DATA ENTRY REQUIREMENTS
NHSN monthly reporting:
Report central line device days
Report CLABSI events
**You must have a monitoring plan for each month that you plan to report.
Reporting Deadline for Alabama
-All data must be entered into NHSN no later than the last day of the subsequent month. Ex. January data is due by 28February).

17. National Healthcare Safety Network (NHSN): CMS HAI Reporting
CMS Final Rule Passed (July 2010)
-Requires hospitals accepting Medicaid across the Nation to
begin reporting certain HAIs using CDC’s NHSN January, 2011
HAI Reporting Requirement
Denominator Requirement
Locations
CLABSIs
Central Line Days
All CCU locations
SSIs (2012) ?

19. Extended to
28 Feb 2011

20. Considerations: Are staff informed of their role in reporting HAIs?
Have you evaluated all the different central lines utilized in your facility that fit the definition of a central line?
Do you have a Device Days Report?
Do you consistently collect device day information at the
same time each day?
If the patient is in CC/ICU, how do you capture positive blood
cultures that return after the patient is transferred to a
regular floor?
Have you updated your NHSN monthly monitoring plan to include
both CMS, and Alabama Central line/CLABSI reporting mandates?
Are your Locations Correctly Mapped?
Are staff informed of their role in reporting HAIs?

21. ALABAMA HAI REPORTING AWARENESS CAMPAIGN
Resources:

22. Surveillance tipS
Periodically check the accuracy of line day data by visiting units and comparing reported catheter days with actual number of patient lines.
Remember….
–Internal validation of central line data is critical!!
-when counting central line days, only count one
central line day for patients with multiple central lines.
-Under reporting line days will artificially increase
CLABSI rates.

23. Institute for Healthcare
The Joint Commission
NPSG
Institute for Healthcare
Improvement (IHI)
Monitoring;
Evidence Into
Practice
Standards;
Regulatory
Compliance;
& Reporting
CLABSI
Prevention
Comprehensive
Unit-based
Safety Program
(CUSP)
Patient
Safety
Evaluation
& PI
National Healthcare
Safety Network
(NHSN);
CMS; ADPH

24. COMPREHENSIVE UNIT-BASED SAFETY PROGRAM (cusp)
NHSN and CUSP Participation
The main focus of the two year “On the CUSP: Stop BSI” project is to improve our culture of safety, thereby decreasing CLABSIs. Furthermore, participation in the project facilitates standards compliance, measurement, and reporting of CLABSI, along with other HAI data, to the CDC/NHSN

25. HOW DOES CUSP WORK? “CUSP IS A PROCESS”
CUSP comprises five fundamental steps and is a continuous process.
CUSP guides you on a journey of education and communication; implementation and evaluation; review and transparency.
It starts with one high risk unit but provides a scalable intervention program that can be implemented throughout your organization.

26. FIVE FUNDAMENTAL STEPS TO CUSP
Engage Senior Leadership
Open lines of communication between frontline staff and administration
Educate leadership about clinical issues and safety hazards
Improve providers attitudes about leadership
Enlist administration in obtaining necessary resources to improve patient safety
Have you formed a CUSP team? Do you have an executive leader on your team? If not, get one in order to open lines of communication between frontline staff and administration; educate leadership about safety issues and obtain resources as necessary.

27. FIVE FUNDAMENTAL STEPS TO CUSP
Educate Staff on Science of Safety
Ensure all current staff have viewed the Science of Safety video and incorporate the video into new hire orientation (consider adding the video to annual review)
Evaluate HSOPS results; identify safety needs and develop a plan of action. Form a team to assist with these goals and monitor for improvement.

28. FIVE FUNDAMENTAL STEPS TO CUSP
Implement Teamwork Tools
Engage staff to be active team players, not passive players
Breakdown physician – nurse barriers
Provide tools to facilitate teamwork and communication (ex: daily goals sheet)
Incorporate morning briefings and observing rounds

29. FIVE FUNDAMENTAL STEPS TO CUSP
Identify Defects
Use incident reports, liability claims, or sentinel events
Survey staff and ask, “How will the next patient be harmed?”

30. FIVE FUNDAMENTAL STEPS TO CUSP
Learn From Defects
Incorporate a practical tool to address what happened, why it happened, what you did to reduce future risk, and how to measure for reduced risk
Use resources such as the “Learning from Defect Tool” and “Investigating a CLABSI Tool” found on the CUSP: Stop BSI website
Plan to learn from at least one defect a month

31. APPLYING CUSP TO CLABSI PREVENTION
Begin by reviewing your TJC NPSG risk assessment:
Sounds a lot like everything we already discussed Joint Commission Compliance

32. Let’s begin with The Joint Commission National Patient Safety Goal 07
Let’s begin with The Joint Commission National Patient Safety Goal (CLABSI Prevention). How many of you have conducted a periodic hospital-wide risk assessment addressing this NPSG? Are there any gaps in your compliance with these elements of performance?

33. APPLYING CUSP TO CLABSI PREVENTION
If you’ve already conducted a TJC risk assessment for NPSG , then you’ve already identified gaps, deficiencies, and/or process improvement opportunities
Now develop actionable plans to improve processes
Monitor compliance with evidence-based practices
Evaluate effectiveness of prevention efforts
Sounds a lot like everything we already discussed Joint Commission Compliance

34. APPLYING CUSP TO CLABSI PREVENTION
Educate staff, patients, and family about CLABSIs and prevention
Implement policies aimed at reducing the risk of central line infections
Adhere to the CLABSI Prevention Bundle:
Strict and consistent hand hygiene
Maximum use of barrier precautions, including full patient drape
Site prep with Chlorhexidine
Optimal site selection (avoid femoral insertions when possible)
Scrub the hub before accessing ports
Remove catheters when no longer necessary; assess daily need

35. APPLYING CUSP TO CLABSI PREVENTION
Create a Central Line Insertion Kit or Cart
Devise and consistently use a Central Line Insertion Checklist
Empower nurses to stop the procedure if guidelines are not followed
Post the # of patients infected per month and your quarterly infection rates
Participate in monthly CUSP calls, enter data into MHA Care Counts, and complete the Monthly Team Check-up Tool

36. EVALUATING PROCESSES
If your CLABSI rate is NOT going down, evaluate your processes!
Determine if processes are breaking down and if so, develop a plan of action to correct the deficiencies!
Finally, CUSP is not exclusive to CLABSI prevention. It is a process to address your overall culture of patient safety. Once you understand the process, CUSP can be applied to any process improvement program i.e., other TJC National Patient Safety Goals:

37. (CUSP) The Joint Commission NPSG.07.05.01 Comprehensive Unit-based
Monitoring;
Evidence Into
Practice
Standards;
Regulatory
Compliance;
& Reporting
SSI
Prevention
Comprehensive
Unit-based
Safety Program
(CUSP)
Patient
Safety
Evaluation
& PI
National Healthcare
Safety Network
(NHSN);
CMS; ADPH

38. (CUSP) The Joint Commission NPSG.07.07.01 Comprehensive Unit-based
Monitoring;
Evidence Into
Practice
Standards;
Regulatory
Compliance;
& Reporting
CAUTI
Prevention
Comprehensive
Unit-based
Safety Program
(CUSP)
Patient
Safety
Evaluation
& PI
National Healthcare
Safety Network
(NHSN);
CMS; ADPH

39. CONCLUSION
Creating an integrated CLABSI Prevention program is about evaluating your TJC compliance; understanding how to define and report CLABSI to NHSN; and implementing CUSP processes that sustain a culture of patient safety!
The Alabama Department of Public Health and the Alabama Hospital Association truly wish every IP great success in this new venture! Odds are, now that you understand how all these elements are inter-related, you will probably discover that you’ve done more with the CUSP project than you thought.
The challenge, use CUSP processes to raise the bar with CLABSI prevention – take it to the next level: implement daily goal sheets; begin daily rounding with physicians; conduct AM briefings.
And remember to always ask, “How will the next patient be harmed; how can I prevent it from happening?”

40. QUESTIONS?