Preventing Central Line

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Preventing Central Line Blood Stream Infection

• Winnie Lee RN, BN
• Nurse Champion Central Line project ICU/CCU
• Barb Young, BScPhm
• Quality Facilitator, Quality and Risk Management
• Credit Valley Hospital
• Quality Healthcare Network/Safer Healthcare Now
• June 17, 2008 Workshop

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Background

• The Credit Valley Hospital is a 383 bed community
  hospital in Mississauga, Ontario with a 16 bed
  ICU/CCU.
• ICU/CCU patients include a mix of general
  medicine, cardiology and surgical patients.

• The Central Line team includes the members of the
  ICU/CCU multidisciplinary team in addition to
  members from Quality and Risk Management, Health
  Records, Infection Control, Microbiology and
  Senior Management.

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Diagnosis of Central Line Infection

• Patient with a laboratory confirmed Blood Stream
  Infection (BSI) who has a central line in place
  within the 48 hour period before development of
  the BSI.
• Reference Getting Started Kit, page 28

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Rollout of Project

• Team leads decided by Senior Management for all
  Safer Healthcare Now projects
• Decision to have central line project led by
  ICU/CCU
• First phase insertion bundle, tracking data
• Second phase implementation of maintenance
  bundle
• Third phase spread to rest of hospital

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Data Collection

• MD makes diagnosis and writes on front sheet of
  patient chart
• Unit clerk collects information from patient
  charts and enters in Excel shared file
• Coordinating Nurse enters central line days in
  Excel shared file (time frame)
• Quality Facilitator pulls data to create graphs
  and reports

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--------------------CLBSI GOAL - 3.2 (National
Noscocomial Infection US average for
Medical-Surgical ICUs)------------------
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Education

• RN champion allows for education to occur on all
  shifts
• ICU rounds present to multidisciplinary team,
  introduction of audit tools
• Skills Day Halloween theme RN champion dressed
  as MD ready to insert a line, all supplies
  available for RNs to see
• One to One slow process, promotes discussion,
  discover/dispel myths

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Insertion Bundle

• Caps
• Sterile drapes
• Chlorhexidine products
• Asking what is available, what to keep, who is
  affected if you remove a product, what to remove
  from ward stock
• Out of sight Out of mind
• Engage users into deciding what product they
  prefer

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• We knew
• Chlorhexidine 2 with 70 Alcohol for Insertion
• User Input is Key!
• Users were looking for
• Individual patient use
• Tinted (to know where you had cleaned)
• To have only this product available so they could
  get it quickly!
• This needs sterile gauze to be available to clean
  skin

• This is the preference of one of our users
• Eliminates the need for gauze
• Not tinted
• Can be used by RRTs to cleanse skin prior to
  arterial stabs
• Unique packaging makes teaching fun

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Cart

• Safer
• Portable
• One Stop Shopping

Buy in is important Changed a system in place
since the beginning of time Provide
opportunity for feedback/discussion Labeling
increase awareness of materials in cart and
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The Insertion Checklist

• Critical Care Central Line
  Insertion Checklist Draft Feb 6, 2006
• Purpose to work as a team to decrease patient
  harm from catheter-related bloodstream
  infections.
• When for all central venous line insertions and
  central line rewire. Use one form for each new
  site attempted per line.
• Who by bedside nurse.
• Todays date _____ / _____ / _____
• 
  year month day
• Bedspot number ___________________
• Procedure ? New Line ? Line Rewire
• Is the procedure ? Elective ? Emergent
• Site of insertion ? Subclavian ? Jugular ?
  Femoral
• (if
  NOT subclavian, write reason below)

• Have no fear
• Corrections can be made
• Using forms will guide your direction
• Feedback is important

Comments Please place completed checklist in
envelope in bottom drawer of cart
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The Edits

• Critical Care Central Line Insertion Checklist
  Draft Feb 13, 2006
• Purpose to work as a team to decrease patient
  harm from catheter-related blood stream
  infections.
• When for all central venous line insertions and
  central line rewire (avoid if possible). Use one
  form for each new site attempted per line.
• Who by bedside nurse.
• Todays date _____ / _____ / _____
• 
  year month day
• Unit number ___________________
• Procedure
• ? New Line ? Line Rewire (not recommended,
  if needed include reason under comments)
• Is the procedure ? Elective ? Emergent
• Site of insertion
• ? Subclavian ? Jugular ? Femoral (not
  recommended, if needed include reason under
  comments)

Comments Please place completed checklist in
envelope in bottom drawer of cart
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The Edits

• Critical Care Central Line Insertion Checklist
  Draft Feb 20, 2006
• Purpose to work as a team to decrease patient
  harm from catheter-related blood stream
  infections.
• When for all central venous line insertions and
  central line rewire (avoid if possible). Use one
  form for each new site attempted per line.
• Who by bedside nurse.
• Todays date _____ / _____ / _____
• 
  year month day
• Unit number ___________________
• Procedure ? New Line ? Line Rewire
  (not recommended, please comment below)
• Is the procedure ? Elective ? Emergent
• Site of insertion
• ? Subclavian ? Jugular ? Femoral (not
  recommended, please comment below)

Comments Please return the completed
checklist to the bag on the Special Procedures
Cart
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The Final Edition
Critical Care Central Line Insertion Checklist
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Location, Location, Location!

• Checklists placed on all central lines
• Extras placed where lines are stored
• Return location is in the same place

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ContestWhose Line is it Anyway?

• To promote use of checklists!!

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So how are we doing?
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Reaching our Goal
--------------------CLBSI GOAL - 3.2 (National
Noscocomial Infection US average for
Medical-Surgical ICUs)--------------
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Things to Celebrate

• Use of the bundle has become the standard
• Consider when to stop using checklists (or
  change frequency of use)
• Intensivists, Nephrologists, Cardiologists are
  all willing to comply with the bundle
• Ready for next phase maintenance bundle

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Maintenance Bundle

• Policies and Procedures currently in place
  reflecting SHN! Maintenance bundle
• Create audit tool and go!!

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Daily Evaluation Form
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What went wrong?

• Kept on patients chart
• To be returned to central spot on discharge -did
  not happen
• Allow for daily auditing of individual patient
• Addition to workload another piece of paper
• Needed new plan

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How well are we doing?
revised maintenance bundle tool
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Patient Information Sheet
CVH is committed to improving patient care by
participating in a nationwide initiative called
Safer Healthcare Now. One project being led by
the Critical Care staff is aimed at reducing
Central Line Bloodstream Infections.

• What is a Central Line Bloodstream Infection?
• It is an infection of the bloodstream that occurs
  in patients who have
• a central line or central venous catheter.
  Central lines are necessary
• for patients who need frequent intravenous (IV)
  medications, blood,
• fluid replacement, dialysis and/or nutrition.
• What causes Central Line Bloodstream Infections?
• Sometimes bacteria on the skin start growing in
  the central line and
• can then spread to the patients bloodstream.
  This is a very serious
• infection which requires treatment with
  antibiotics and removal of the line.
• What are we doing to prevent Central Line
  Bloodstream Infections?
• We will take the following steps whenever
  possible for all patients who have central lines
  
• Use proper hand hygiene. Everyone who touches the
  central line must wash their hands with soap and
  water or an alcohol cleanser.
• Use maximal barrier precautions. The person who
  inserts the line should be in sterile clothing
  wearing a mask, gloves, and cap. The patient
  should be fully covered with a sterile drape,
  except for a very small hole where the line goes
  in.
• Clean the patients skin with chlorhexidine (a
  type of soap) when the line is put in.

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One Stop Shopping for One Line Link with key
stakeholders in each area
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Spreading the Message

• Race team
• Presentation to Nurse educators
• (insertion kit added in ER)
• Diagnostic Imaging
• Renal - developing team

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Keys to success

• Keeping it fun
• Sometimes, it doesnt work, use feedback to
  improve
• Actively involved RN champion (teaching,
  generating ideas, seeking feedback)
• Frequent meetings (weekly to biweekly to monthly,
  special meetings to help with implementation)
• Communication
• Involve all members of team
• Support of all levels of administration

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Future Steps

• Expanding maintenance bundle to all inpatient
  units (work with nurse educators)
• Continue to promote use of cart/kits for
  insertions in those units
• Explore possibility of evaluating the patient
  information sheet
• Celebrate the success thus far!!

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Customize to each area!