Central Line Infections Avoidable

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Central Line InfectionsAvoidable?
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• What is a CLC-RBSI?
• Can we avoid them?
• The IHI tools
• Critical Care experience - UHW

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What is a CLC-RBSI?(Central Line
CatheterRelated Blood Stream Infection)

• Agree a definition

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HELICS(Hospital in Europe Link for Infection
Control through Surveillance)

• CLC-RBSI
• The patient has a positive blood culture with a
  recognised pathogen
• Or
• 2 positive blood cultures drawn within 48 hours
  for a common skin contaminant
• And
• Clinical evidence of infection (fever/
  hypotension)
• And
• A culture positive line tip

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HELICS(Hospital in Europe Link for Infection
Control through Surveillance)

• CLC infection
• Clinical signs of infection (fever/ hypotension)
• A positive line tip culture
• Symptoms resolve within 48 hours of line removal

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What can cause the infection?

• Poor insertion hygiene
• Poor insertion technique
• Lack of appropriate skills
• Poor line maintenance
• Use of 3 way taps.......
• Lines remaining in place for an inappropriate
  length of time

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What is the cost to the patient?

• CLC-RBSIs are a major cause of morbidity
• National Audit Office (2000) estimated the
  additional cost of a bloodstream infection to be
  6,209 per patient
• A 2006 prevalence survey found that 42.3 of
  bloodstream infections in England are central
  line-related

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How to avoid/prevent Line Infections

• Standardise practice
• Practice variation is the enemy of quality
• Measure our practice and outcomes
• Know the extent of the problem in order to show
  improvement over time
• Develop a checklist model...... Care Bundle
• It makes the right thing to do the easy thing to
  do

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Care bundles explained

• A global standard of care management
• A group of interventions related to a disease
  process that when implemented together result in
  better outcomes than when implemented
  individually
• Bundle components can easily be measured as
  completed or not completed all-or-none
  compliance

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Bundle Aim

• To eliminate the piecemeal application of
  evidence-based guidelines that characterises the
  majority of clinical environments today
• To make it easier for clinicians to bring
  guidelines into practice

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Bundles bridge the Guideline Gap
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What makes a bundle so special?

• science behind it
• method of execution with complete consistency 
• every patient, every time

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Types of Care Bundles

• Ventilator Care Bundle
• Sepsis Care Bundle
• Central Line Care Bundle

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CLC Bundle.....insertion (4 main elements)

• Hand hygiene
• Decontaminate hands before and after each patient
  contact
• Use correct hand hygiene procedure
• Maximal barrier precautions
• PPE
• Single use gloves
• Eye/face protection
• Aseptic technique
• Sterile gown, gloves and full body drape
• Chlorhexidine skin antisepsis (2 Chlorhexidine
  Gluconate in 70 Isopropyl Alcohol)
• Catheter
• Optimal catheter site selection, with subclavian
  vein as the preferred site for non-tunnelled
  catheters
• Single lumen unless indicated otherwise
• Consider antimicrobial impregnated catheter if
  duration of 1-3 weeks and risk of CLC-RBSI high

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CLC Bundle....maintenance(6 main elements)

• Hand hygiene
• Decontaminate hands before and after each patient
  contact
• Use correct hand hygiene procedure
• Catheter site inspection
• Regular observation for signs of infection ie.
  leakage, inflammation etc AT LEAST DAILY
• Dressing
• A sterile, transparent, semi-permeable dressing
  should be in place
• Ensure dressing is intact and dry
• Catheter access
• Aseptic technique swabbing ports/hubs with 2
  Chlorhexedine prior to access
• Administration set replacement
• Following administration of blood/blood products
  immediately
• Following TPN after 24 hours or 72 hours if no
  lipids
• All other fluid sets after 72 hours
• TPN should be infused via dedicated lumen
• Daily review of line necessity with prompt
  removal of unnecessary lines

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How to measure

• 1. Hand hygiene Yes No
• (hands washed alcohol gel used)
• 2. Maximal barrier precautions on insertion Yes
  No
• (user cap, mask, sterile gown, sterile
  gloves
• patient covered with large sterile drape)
• 3. Chlorhexidine skin antisepsis Yes No
  
• 4. Optimal catheter site selection Yes No
  
• (document site in notes reason for site
  selection)
• 5. Daily review documentation of line
  necessity Yes No
• (To be documented in patients notes)
• 6. Ultra sound used for insertion Yes No
  

Central Line Care Bundle
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To be successful.....

• Structure in place
• Process in place
• ........... will result in the desired outcome

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Structure

• Staff
• Equipment
• Documentation

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Process Measure

• Compliance with all elements of the CLC Care
  Bundle
• (insertion and maintenance)

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Outcome Measure

• Reduction in line related infections

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• S P O

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Use a PDSA form to organize, standardize and
document your tests!
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PDSA example CLC Care Bundle
Routine use of CLC Bundle
DATA
Cycle 4 Repeat using 6 patients
Cycle 3 Repeat using 2 patients, doctors/nurses
for 1 week
Cycle 2 Repeat using 2 patients and 2
doctors/nurses for 2 days
CLC Bundle
Cycle 1 1 Doctor/1 Nurse / 1 patient/1 day use
of Chlorhexedine 2
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Multiple PDSA Cycles Running on Parallel Ramps
with Multiple Aims
Testing and adaptation
Coloured aprons
Use of Chlorhexedine 2
Stricter visiting times
Alcohol gel each bed area
Change Concepts
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Multiple PDSA Cycles Directed Toward a Single Aim
AIM
Concept C
Concept D
Concept B
Concept A
Change Concepts, Theories, Ideas
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What can you accomplish by tomorrow? It all
depends on the size and scope of the planned
change!
Start small
1 patient, 1 nurse, 1 doctor, 1 day
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Critical Care UHW results
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Start small
1 doctor non-compliant
Lines Trolleys introduced
Dressing packs introduced
Compliance tick-box stickers
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No agreed definition
National surveillance in Wales
HELICS agreed
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• If you want to improve, you need to develop a
  system to evaluate performance

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Future challenges
Spread
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References on Measurement and Improvement

• Brook, R. et. al. Health System Reform and
  Quality. Journal of the American Medical
  Association 276, no. 6 (1996) 476-480.
• Carey, R. and Lloyd, R. Measuring Quality
  Improvement in healthcare A Guide to Statistical
  Process Control Applications. ASQ Press,
  Milwaukee, WI, 2001.
• Langley, G. et. al. The Improvement Guide.
  Jossey-Bass Publishers, San Francisco, 1996.
• Lloyd, R. Quality Health Care A Guide to
  Developing and Using Indicators. Jones and
  Bartlett Publishers, Sudbury, MA, 2004.
• Nelson, E. et al, Report Cards or Instrument
  Panels Who Needs What? Journal of Quality
  Improvement, Volume 21, Number 4, April, 1995.
• Solberg. L. et. al. The Three Faces of
  Performance Improvement Improvement,
  Accountability and Research. Journal of Quality
  Improvement 23, no.3 (1997) 135-147.\
• Associate in Process Improvement. The Improvement
  Handbook Models, Methods and Tools for
  Improvement, Austin, TX, January 2005.

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