Issue: It is the objective of every health care facility to achieve and maintain a zero Central Line Associated Bloodstream Infection Rate (CLABSI). This facility achieved the goal by applying evidence based and critical thinking enhancements to the Central Line Bundle. An essential component of this is a dedicated IV Team. An important aspect of any improvement program is introducing innovations to improve care; however, the plan will not be as successful without staff education in outstanding care of the patient.

Project: Prospective surveillance and enhanced central line care has been implemented through a dedicated IV Team (IVT) for the last 6 ½ years. The team’s interventions to reduce infection included many innovations, a few in order of appearance: vigorous insertion and site care education, a swabable positive displacement valve, chlorhexidine patch, and switching to a clear version of the same valve. Prospective BSI surveillance and case findings were the responsibility of the IV Team and infection control team. Infection rates were tracked every 6 months using the NNIS and then the NHSN definitions. Data were tracked from January 2003 through July 2009.

Results: There were over 13,000 central line catheter days of prospective surveillance per year. Rates were calculated for the Intensive Care Units, Medical-Surgical units, Spinal Cord Injury Unit, and Transitional Care. An increase in the CLABSI rate occurred with poor compliance to the central line bundle. Since June 2006 the facility saw a steady reduction in CLABSIs after implementing the CHG patch, increased use of PICCs, instituting clear swabable valves, and vigorous maintenance education of CVCs. The facility achieved a zero CLABSI rate in the year 2008 (p <0.05) which was maintained through July 2009. This is clinically significant.

Lessons Learned: The innovations introduced into the facility coupled with an IV Team for implementation along with vigorous staff education, daily site assessment and surveillance, has shown to have the best success in sustaining a zero CLABSI rate. Innovations need a well planned educational program.

ABSTRACT CLABSI REDUCTION PROGRAM TIMELINE

ISSUE

RESULTS

PROJECT

It is the objective of every health care facility to achieve and maintain a zero Central Line Associated Bloodstream Infection Rate (CLABSI). This facility achieved the goal by applying evidence based and critical thinking enhancements to the Central Line Bundle. An essential component of this is a dedicated IV Team. An important aspect of any improvement program is introducing innovations to improve care; however, the plan will not be as successful without staff education in outstanding care of the patient.

Educational Posters #1 and #2 are an example of the education program that was implemented at this facility. When a new technology was implemented, the staff education program was augmented to include training on proper use of the technology per the manufacturer’s instructions and best nursing practices, such as the INS Guidelines.4Prospective surveillance and enhanced central line care has been implemented

through a dedicated IV Team (IVT) for the last 6 ½ years. The team’s interventions to reduce infection included many innovations, a few in order of appearance: vigorous insertion and site care education, a swabable positive displacement valve, chlorhexidine patch, and switching to a clear version of the same valve. Prospective BSI surveillance and case findings were the responsibility of the IV Team and infection control team. Infection rates were tracked every 6 months using the NNIS and then the NHSN definitions. Data were tracked from January 2003 through July 2009.

There were over 13,000 central line catheter days of prospective surveillance per year. Rates were calculated for the Intensive Care Units, Medical-Surgical units, Spinal Cord Injury Unit, and Transitional Care. An increase in the CLABSI rate occurred with poor compliance to the central line bundle. Since June 2006 the facility saw a steady reduction in CLABSIs after implementing the CHG patch, increased use of PICCs, instituting clear swabable valves, and vigorous maintenance education of CVCs. The facility achieved a zero CLABSI rate in the year 2008 (p <0.05) which was maintained through July 2009. This is clinically significant.

• Over 13,000 of in-patient central line days per year

– 78,000 days total over 6 years – Includes CICVCs and PICCs – Rates were calculated for the whole Medical Center • Intensive Care Units (ICUs) • Medical Surgical Units • Spinal Cord Injury Unit • Transitional Care Unit

LESSONS LEARNED

The innovations introduced into the facility coupled with an IV Team for implementation, vigorous staff education, daily site assessment and surveillance has shown to have the best success in sustaining a zero CLABSI rate. Innovations need a well planned educational program.

4. Infusion Nurses Society: Infusion Nursing Standards of Practice J Infus Nurs. 2006;29(1S): S44.5. Costello JM, et. al. Systematic Intervention to Reduce Central Line–Associated Bloodstream Infection

Rates in a Pediatric Cardiac Intensive Care Unit. Pediatrics. 2008;121;(5):915-923.6. Shanks, Robert M. Q. et al Heparin Stimulates Staphylococcus aureus Biofilm Formation Infection and

Immunity August 2005;73:8;4596-4606.

REFERENCES

1. 5 Million Lives Campaign. Getting Started Kit: Prevent Central Line Infections How-to Guide. Cambridge, MA: Institute for Healthcare Improvement; 2008. (Available at www.ihi.org)

2. Brunelle D. Impact of a dedicated infusion therapy team on the reduction of catheter-related nosocomial infections Journal of Infusion Nursing 2003;26:362-6.

3. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care–associated infection and criteria for specific types of infections in the acute care setting American Journal of Infection Control 2008;36:309-32.

Maintaining a Zero Central Line Associated Bloodstream Infection Rate for 17 Months Across a Large and Diverse Adult Patient Population: What Gets the Credit?

EDUCATIONAL POSTER #1

EDUCATIONAL POSTER #2

Tim Royer, BSN, CRNI

Timothy Royer, Nurse Manager Vascular Access (Retired), is a clinical practice consultant for Bard Access Systems™, Medegen, Johnson and Johnson and a Cath�o™ Nurse trainer for Genetech™. This study was completed without commercial support.

Timothy Royer, BSN, CRNIWe2frogs@oz.net

RESULTS: KEY POINTS

1.92 to 0.63P value <0.05

0.63 to ZEROP value <0.05

Using CHG disk along with continuous vigorous education on the care of central lines reduced the CLABSI rate.

Increasing the use of PICCs in place of CICVCs, especially in the ICUs, decreased infection rates.

Impressive continued drop to zero CLABSI rate was noted with the implementation of clear positive displacement needleless connector as a cue to clean, flush, or change the valve.

6 month cost savings was calculated from January 2007 through July 2007 after implementation of the clear swabable valve.

• $241,000 cost savings realized due to a five-fold decrease in CLABSI in the ICUs alone and 60% reduction in contaminated blood cultures

• savings of $125,000 in contaminated cultures • savings of $116,000 in bloodstream infections • as calculated by the VA Puget Sound Health Care System

PROTECTING CATHETER FROM CONTAMINATIONEXTRALUMINAL PROTECTION-Starts with the catheter insertion site

• Central Line Insertion Bundle

• CHG Eluting Disk

• Catheter Securement

• Education on proper care and maintenance of the catheter insertion site

INTRALUMINAL PROTECTION - Starts with the Needleless Connector

• Flat, smooth access port for effective disinfection

• Positive Displacement for reduction of occlusions to reduce growth media for bacteria5

• Saline flushing to reduce heparin - reduce heparin associated risks and possibly reduce biofilm formation6

• Education on proper care and maintenance of the needleless connector; proper disinfection practices and complete flushing of the needleless connector until clear, or change the connector, to reduce intraluminal contamination

Clear, swabable valves serve as a visual cue reminding nurses to complete best

practice-priming,scrubbing and flushing

Changed to new PositiveDisplacement Valve withswabable hub

Inception of the CLABSI Reduction Program

Date

January 2003January 2003

1992

Intervention Implemented

PICC Insertion Team EstablishedFormation of the Vascular Access Team (VAT)Implement swabable, positive displacement connector

Implementation of the central Line Bundle (CLB) for Insertion

Date

April 2005

Intervention Implemented

Hand HygieneMaximal Barrier Precautions upon InsertionChlorhexidine Skin AntisepsisOptimal Catheter Site Selection and Avoidance of the Femoral Vein in Adult NecessityDaily Review of Line NecessityStandardized Checklist

Beyond the CLB - The Care and Maintenance Bundle

Date

January 2006

January 2006

January 2006

January 2007

January 2007

Intervention Implemented

Implement the Use of a ChlorhexidineImpregnated DiskIncreased Use of peripherally inserted central venouscatheters (PICCs) in place of centrally inserted central venous catheters (CICVCs)Daily review of central line necessity and prompt removal of unnecessary lines

Change to the same needleless connector but with a clear housing and hospital staff received continuousand rigorous catheter care education and were admonished to flush needleless connectors with 20 mlof normal saline and change needleless connectors if visible signs of debris or blood are still presentVigorous “Scrub the Hub” Connector Care and Catheter Maintenance Program

What gets the credit? CLB Insertion bundle started us on the road to reduction to decreasing our CLABSI rate. We did not see a significant and sustained reduction until additional interventions were added to the CLB. We called these additional interventions the Central Line Maintenance Bundle. This Maintenance Bundle recognized that extraluminal and intraluminal contamination are contributors to CLABSI development. When we added interventions that were aimed at reducing both extraluminal and intraluminal contamination, we realized a significant reduction in the CLABSI rate, and this reduction has been sustained.A rigorous and continuous staff education program to sustain best nursing practices for catheter insertion and maintenance, and for proper training on any new intervention introduced to the facility, is essential to any CLABSI reduction effort.