cardiff and vale nhs trust ymddiriedolaeth gig caerdydd ar fro central line infections avoidable?...

Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro

Central Line Infections

Avoidable? Preventable?


• What is a CLC-RBSI?

• Can we avoid them?

• The IHI tools

• The UHW experience


What is a CLC-RBSI?(Central Line Catheter–Related Blood Stream Infection)

Agree a definition


HELICS(Hospital in Europe Link for Infection Control through

Surveillance)

• CLC-RBSI– The patient has a positive blood culture with

a recognised pathogenOr

– 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


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


What can cause the infection?

• Poor insertion hygiene• Poor insertion technique• Lack of appropriate skills• Poor line maintenance• Lines remaining in place for an

inappropriate length of time• Use of 3 way taps.......


What is the cost to the patient?

• CLC-RBSI’s are a major cause of morbidity

• A 2006 prevalence survey found that 42.3% of bloodstream infections in England are central line-related

• National Audit Office (2000) estimated the additional cost of a bloodstream infection to be £6,209 per patient


How to avoid/prevent Line Infections

• Standardise practicePractice variation is the enemy of quality

• Measure our practice and outcomesKnow the extent of the problem in order to show

improvement over time

• Develop a checklist model...... Care BundleIt makes the right thing to do the easy thing to do


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


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


What else is a bundle?

• Methodology to spread the use of generally accepted science




• Provide a “pressure” for teamwork




• Provide a “pressure” for teamwork• Simple, memorable checklist




• Provide a “pressure” for teamwork• Simple, memorable checklist• Audit tool




• Provide a “pressure” for teamwork• Simple, memorable checklist• Audit tool• All aspects should be done to get the

maximum benefit


Bundles bridge the “Guideline Gap”

Evidence Guidelines Practice

Bundle


What makes a bundle so special?

• The power of a bundle

– science behind it

– method of execution: with complete consistency

• The changes in a bundle are not new; they’re well established best practices, but they’re often not performed uniformly, making treatment unreliable

• A bundle ties the changes together into a package of interventions that people know must be followed for:

– every patient

– every single time


Types of Care Bundles

• Ventilator Care Bundle

• Sepsis Care Bundle

• Central Line Care Bundle


CLC Bundle.....insertion• 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 Alchohol)

• 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


CLC Bundle....maintenance• 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


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 � �

Cen

tral

Lin

e C

are

Bun

dle


Results

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

outcome


Structure

• Staff• Equipment• Documentation


Process MeasureCompliance with all elements of the

CLC Care Bundle (insertion and maintenance)


Outcome Measure

Avoid / reduce Central Line Catheter-Related Blood Stream Infections

(CLC-RBSI)


S + P = O


How do we achieve reliable improvements to our systems?• Implementing evidence-based

changes to improve patient outcomes

• Set time frames......how much, by when?

• Getting the data to show what impact the changes are having

• Spread


The Three Fundamental Questions for Improvement

• What are we trying to accomplish?

• How will we know that a change is an improvement?

• What changes can we make that will result in improvement?

Source, API The Improvement Guide, p. 10


What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make that will result in improvement?

The Model for Improvement

Act Plan

Study Do

When you combine

the 3 questions with the…

PDSA cycle, you

get…

…the Model for

Improvement.


The PDSA Cycle for Learning and Improvement

Act

• What changes are to be made?

• Next cycle?

Plan• Objective• Questions & predications (why)• Plan to carry out the cycle (who, what, where, when)• Plan for data collection

Study• Complete the analysis of the data

•Compare data to predictions

•Summarize what was learned

Do• Carry out the plan• Document problems and unexpected observations• Begin analysis of the data


Use the PDSA Cycle for :

• Testing or adapting an improvement change

• Implementing the change

• Spreading the change to the rest of your system


Repeated Use of the PDSA Cycle

Hunches, theories,

best practices

Changes That Result in

Improvement

A P

S D

APS

D

A P

S D

D SP A

DATA

Very Small Scale Test

Follow-up Tests

Wide-Scale Tests of Change

Implementation of Change

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Sequential building of knowledge under a

wide range of conditions


Use a PDSA form to organize, standardize and document your tests!

Worksheet for Testing Change – Critical Care

Aim: Primary: To reduce mortality and adverse effects Secondary:

Every goal will require multiple smaller tests of change

Describe your first (or next) test of change Person Responsible

When to be done

Where to be done

Plan List the tasks needed to set up this test of change Person

Responsible When to be done

Where to be done

Predict what will happen when the test is carried out Measures to determine if prediction succeeds

Do Describe what actually happened when you ran the test

Study Describe the measured results and how they compared to the predictions

Act Describe what modifications to the plan will be made for the next cycle from what you learned


Plan

• Clear objective• State predictions• Who, what, where, when?• Describe data collection plan


Do

• Attempt to carry out plan• Document any problems or

unexpected events• Collect planned data• Capture feedback or observations

from those conducting the plan• Suggestions to improve in the DO

phase of the PDSA


Study

• Complete the analysis of the data• Analyse feedback or observations• Compare data/feedback to

predictions & summarise what was learned

• Suggestions


Act

• What will happen in the next PDSA cycle?

• Develop change further?• Test?• Implement?


PDSA example: CLC Care Bundle

CLC Bundle

Routine use of CLC Bundle

A P

S D

APS

D

A PS D

D SP A

DATA

Cycle 1: 1 Doctor/1 Nurse / 1 patient/1 day use of Chlorhexedine 2%

Cycle 2: Repeat using 2 patients and 2 doctors/nursesfor 2 days

Cycle 3: Repeat using 2 patients, doctors/nurses for 1 week

Cycle 4: Repeat using 6 patients


Multiple PDSA Cycles Running on Parallel Ramps with Multiple Aims

Testin

g and

adap

tatio

n

A P

S D

A PS D

A P

S D

D S

P A

A P

S D

A PS D

A P

S D

D S

P A

A P

S D

A PS D

A P

S D

D S

P A

A P

S D

A PS D

A P

S D

D S

P A

Alcohol gel each bed area

Coloured aprons

Use of Chlorhexedine

2%

Stricter visiting times

Change Concepts


AIM

Change Concepts, Theories, Ideas

Concept B

Concept C

Concept A

Concept D

Multiple PDSA Cycles Directed Toward a Single Aim


Whatcan you accomplish

by Tuesday?It all depends on the size and scope of the planned change!

1 patient, 1 nurse, 1 doctor, 1 day

Start small


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.


UHW experience


Structure and Process

Compliance with CLC Bundle


1 doctor non-compliant

Dressing packs

introduced

Lines Trolleys

introduced

Start small

Compliance tick-box stickers


Outcome

Zero CLC infections


No agreed

definition

HELICS agreed

National surveillance

in Wales


A fundamental tenet of improvement in any industry is that if you want to

improve you must develop a system to evaluate performance


Future challenges

Spread


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.

cardiff and vale nhs trust ymddiriedolaeth gig caerdydd ar fro central line infections avoidable?...

Documents

practice slide

patient slide

teamwork slide

clc bundle

bundle science

definition slide

compliance slide

accepted science slide