1

Four “C’s” to Conquer CLI:

An Integrated Approach to Performance Enhancement

Elaine C. Killough, RN, MSN, CCRN, CSSturdy Memorial HospitalAttleboro, MA

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www.cdc.gov/nicdod/dhqp/images/Fig_CLABSI_ICU accessed 05/31/08

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Sturdy Memorial Hospital

128-bed community hospital

14 bed medical-surgical ICU

Open unit with primary intensivist coverage

Admits ~700 patients/year

Mean LOS 4.8 days

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Central Lines (2007)

265 lines managed 74.9% Multi-lumen catheters 14.3% Dialysis catheters 10.9% SwanGanz catheters

73.6% placed in the ICU 93.3% placed by intensivist

Site Selection 46.7% IJ 45.0% SC 8.3% Femoral

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Frequency: Line Placement 2004 - 2007

Year

Patients with

Lines

(# of Lines)

Total ICU

Admissions

Pts with Lines/ Total ICU Pts

(%)

2004 264

(294)

708 37.3

2005 245

(278)

710 34.5

2006 225

(247)

686 32.8

2007 232

(255)

812 28.5

6

ICU Line Days 2004 - 2007

Year # of Lines Total Line Days

Line Days/

Line

(mean)

2004 294 4777 16.2

2005 278 3904 14.0

2006 247 2114 8.6

2007 255 2225 8.7

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CLI: SMH ICU 2002 - 2007

ICU Primary Central Line BSI 2002-2007

0 0 0 0 0

2.5

0

3.5

3.42.1

0.8

1.41.2

2.5

1.81.3

0

5.1

0 0 0

1.5 1.7

0.2

0

1

2

3

4

5

6

J an-Mar02

Apr-J un02

J ul-Sept02

Oct-Dec02

J an-Mar03

Apr-J un03

J ul-Sept03

Oct-Dec03

J an-Mar04

Apr-J un04

J ul-Sept04

Oct-Dec04

J an-Mar05

Apr-J une05

J ul-Sept05

Oct-Dec05

J an -Mar06

Apr-J une

06

J uly-Sept06

Oct -Dec06

J an-Mar07

Apr-J un07

J ul-Sept07

Oct-Dec07

Quarter/Year

Rat

e/10

00 L

ine

Day

s

8

Sturdy Excellence Program

Integrated quality and service improvement goals Validity supported by evidence Measurable outcomes

Unit/department-based Regular reporting to Quality and Service

Enhancement Committee Review and feedback from administrative

and multidisciplinary resources High emphasis on progress and

accountability

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An Integrated Approach

Senior and Risk Management/

Quality Improvement

Unit Management

ICUNursing

InfectionControlPhysicians

PreventCLI

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SMH ICU: CLI Prevention Practices: 2004

Developed a formalized program of daily surveillance

Established system for auditing related documentation and dressing changes per existing protocol (record review)

Provided parameters for identification of suspect lines and clarified expectations for physician response

Worked on development of comprehensive program for 2005

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SMH ICU CLI Prevention Program: 2005 - 2007

Adopted evidence-based interventions as standard of care

Developed total management program:

ComprehensiveCollaborative

Current Partnering with QSEC to review and

evaluate program effectiveness Goal: To remain at or below the CDC

median occurrence rate

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A Comprehensive Approach Prior to placement: Conservative decision-

making as to appropriateness of intervention. Inclusive documentation tool:

Identifies accountable personnel. Validates implementation of evidence-based

standards at insertion. Describes line maintenance per hospital standard,

including description of insertion site, documentation of dressing changes.

Documents problems identified and resolution. Documents analysis and review if line is suspect.

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A Comprehensive Approach Line maintenance documented each

shift in the electronic record. Daily assessment/data collection by

CNS or unit leadership staff: Insertion site Intactness/quality of the dressing

All program elements are reviewed and reinforced in orientation for all new staff including temporary personnel.

14

A Collaborative Approach

Proactive, facilitative approach with MDs not familiar with standards

Problem-solving related to difficult sites or persistent patient problems

Regular review of documentation tools by IC RN

CNS/IC RN analysis of occurrences Dissemination of findings to staff Collaborative problem-solving

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A Collaborative Approach

Nursing education involvement in all changes in program/protocol

QSEC review of documented performance progress and goal achievement; dialogue to provide feedback, identify problems, and suggest solutions.

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Keeping Things Current Problems identified are addressed

immediately. Bi-weekly reporting to management on all

process elements. Monthly reporting of process compliance

and outcomes in staff meetings and through e-mail.

Reports to QSEC available on unit; feedback shared as it is received.

Annual review of program.

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CLI: SMH ICU 2002 - 2007

ICU Primary Central Line BSI 2002-2007

0 0 0 0 0

2.5

0

3.5

3.42.1

0.8

1.41.2

2.5

1.81.3

0

5.1

0 0 0

1.5 1.7

0.2

0

1

2

3

4

5

6

J an-Mar02

Apr-J un02

J ul-Sept02

Oct-Dec02

J an-Mar03

Apr-J un03

J ul-Sept03

Oct-Dec03

J an-Mar04

Apr-J un04

J ul-Sept04

Oct-Dec04

J an-Mar05

Apr-J une05

J ul-Sept05

Oct-Dec05

J an -Mar06

Apr-J une

06

J uly-Sept06

Oct -Dec06

J an-Mar07

Apr-J un07

J ul-Sept07

Oct-Dec07

Quarter/Year

Rat

e/10

00 L

ine

Day

s

18

CLI: SMH ICU

Cases of CLI in 20 Months!(Since September, 2006)

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SMH ICU: CLI Prevention Practices: 2008

Incorporated a“Zero Tolerance”Approach into Our

2008 CLI Prevention

Sturdy Excellence

Goal

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The Fourth “C”……..

Continued excellent performance.

Consistent goal-achievement.

Commitment to improving patient outcomes.