creating an integrated clabsi prevention program

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 07.04.01 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

3
The Joint Commission NPSG.07.04.01 Institute for
Healthcare Improvement (IHI)
Standards Regulatory Compliance Reporting
Monitoring Evidence Into Practice
CLABSI Prevention
Comprehensive Unit-based Safety Program (CUSP)
Patient Safety Evaluation PI
National Healthcare Safety Network (NHSN) CMS
ADPH
4
(No Transcript)
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 lt1CLABSI/1000 CL DAYS 0.11/1000 0.09/1000 0.09/1000 0.08/1000
Compliance Rate? Goal 90 or greater 43 82 82 88
Are we improving based on data monitoring? Yes Yes Yes Yes
Where are we failing based on data monitoring? Non-compliance Rate 57 18 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 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 9 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 0 0
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
The Joint Commission NPSG.07.04.01 Institute for
Healthcare Improvement (IHI)
Standards Regulatory Compliance Reporting
Monitoring Evidence Into Practice
CLABSI Prevention
Comprehensive Unit-based Safety Program (CUSP)
Patient Safety Evaluation PI
National Healthcare Safety Network (NHSN) CMS
ADPH
11
CDCs 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
CDCs 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.

14
(No Transcript)
15
CDCs 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 CDCs 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
CDCs NHSN January, 2011
HAI Reporting Requirement Denominator Requirement Locations
CLABSIs Central Line Days All CCU locations
SSIs (2012) ?
18
(No Transcript)
19

Extended to 28 Feb 2011
20
Considerations

• 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 http//www.adph.org/hai/

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
The Joint Commission NPSG.07.04.01 Institute for
Healthcare Improvement (IHI)
Standards Regulatory Compliance Reporting
Monitoring Evidence Into Practice
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

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 07.04.01 risk
  assessment

32
(No Transcript)
33
APPLYING CUSP TO CLABSI PREVENTION

• If youve already conducted a TJC risk assessment
  for NPSG.07.04.01, then youve 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

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
The Joint Commission NPSG.07.05.01
Standards Regulatory Compliance Reporting
Monitoring Evidence Into Practice
SSI Prevention
Comprehensive Unit-based Safety Program (CUSP)
Patient Safety Evaluation PI
National Healthcare Safety Network (NHSN) CMS
ADPH
38
The Joint Commission NPSG.07.07.01
Standards Regulatory Compliance Reporting
Monitoring Evidence Into Practice
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
  youve 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?