The Title Slide opens up the presentation and provides the main headline. Insert a maximum of five lines.

Why Maintenance is so High Maintenance: How to Achieve SuccessTamara Johnson RNDirector Clinical IntegrationIvera Medical CorporationObjectivesUnderstand why CABSI and CLABSI are importantTop 10 Reasons Maintenance is High MaintenanceUnderstand the dynamics associated with Port Protection and compliance and their role in the maintenance bundleOvercoming Port Protection challenges (Process Changes)

2Clabsi timeline2001 Beginning of the term Never Events

32012 Updated CLABSI Definitions from CDC

2008 CMS releases reimbursement guidelines which include Vascular Catheter Related BSIs (no CL modifier)

2011 National Healthcare Safety Network begins monitoring mandatory surveillance reporting on CLABSI2013 Updated CLABSI Definitions from CDC2014 Updated CLABSI Definitions from CDC

National Quality Forum coalition of public and private healthcare sector leaders who are focused on ensuring healthcare quality and patient protection by providing measurement capabilities and public reportingCEO Ken KizerAHRQ request to reduce infections by 50% by 2013

3 From our friends at the cDC41. ) http://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdfCentral Line Associate Blood Stream Infection (CLABSI) - a laboratory confirmed bloodstream infection (LCBI) where the central line (CL) or umbilical catheter (UC) was in place for >2 calendar days on the date of the event, with day of device placement being Day1, and a CL or UC was in place on the date of event or the day before. If a CL or UC was in place for >2 calendar days and then removed, the LCBI criteria must be fully met on the day of discontinuation or the next day. If the patient is admitted or transferred into a facility with a central line in place (e.g., tunneled or implanted central line), day of first access is considered Day 1.1

4A reminder about Great Vessels1AortaPulmonary ArterySuperior Vena CavaInferior Vena CavaBrachiocephalic VeinsInternal Jugular VeinsSubclavian VeinsCommon Femoral VeinsExternal Iliac VeinsFemoral VeinsUmbilical Artery/Vein in Neonates

51. ) http://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf

A central line includes:Central Venous Catheter (CVC)Peripherally Inserted Central Catheter (PICC)Dialysis CatheterUmbilical Catheter Hickman CatheterBroviac CatheterGroshong Catheter6

Impact of CLabsi$34, 500 - $56, 000 per episode272.) Moreau N. Nursing 2009;34:14-153.) Hollenbeak CS. J Infus Nurs. 2011:3309-33134.) OGrady NP, et al. American Journal Infection Control 2011;39(4suppl 1):51-345.) Klevens RM, et al. Public Health Rep. 2007;122-160-16680,000 ICU BSIs a year leading cause of ICU nosocomial infections4250,000 CLABSIs a year230,665 deaths a year from CLABSI5$54,000 - $75,000 in adult Surgical ICU3Mechanisms leading to clabsi6 Pathogen migration along external surface typically within first 7 days86.) The Joint Commission. Preventing Central LineAssociated Bloodstream Infections: A Global Challenge, a Global Perspective. Oak Brook, IL: Joint Commission Resources, May 2012. http://www.PreventingCLABSIs.pdf.Contaminated infusionsNeedleless connector contamination leading to intraluminal colonization Established from a different sourceHub contamination leading to intraluminal colonization

Protecting our patientsImplementation of Bundles97.) http://www.ihi.org/explore/bundles/Pages/default.aspxBundle7 - a structured way of improving the processes of care and patient outcomes: a small, straightforward set of evidence-based practices generally three to five that, when performed collectively and reliably, have been proven to improve patient outcomes.

CDC Guidelines for CLABSI BundlesInstitute for Healthcare Improvement9CLABSI Bundles Central Line Insertion Practices (CLIP)8

108.) http://www.cdc.gov/nhsn/PDFs/pscManual/5psc_CLIPcurrent.pdf

Hand Hygiene

All 5 Maximal Barrier PrecautionsSterile GlovesSterile GownCapMask WornSterile drape covering entire patient

Chlorhexidene gluconate (CHG)

Insertion Site

Daily assessment to determine need

10Extraluminal vs IntraluminalCLIP = happens one time on a patientMaintenance = happens all day long by a lot of different people (#1)

11CLIP vs maintenance

1 vs ???Bloodstream infections related to long-term CVC use are almost always a result of intraluminal biofilm development. - James Davis, RN, CICSenior Infection Prevention AnalystPennsylvania Patient Safety AuthorityHand hygiene compliance Scrub access port or hub immediately prior to each use with appropriate antiseptic (70% IPA, CHG, provodine iodine) Access catheters with only sterile devices Dressing care. Replace wet, soiled or dislodged (using aseptic technique with clean or sterile gloves) Replacement of administration sets and needleless connectors Perform daily assessments to determine need for CVL

129.) http://www.cdc.gov/hicpac/BSI/BSI-guidelines-2011.html

Central Line Maintenance GUIDELINES

#2Needleless connector disinfection13

2007 Java Vol 12, No 3, 140-142Scrub the HuB15 seconds

14

Is 15 sec every single time, every single access a practical expectation today?Ideal web page load time 3.5 seconds(2010 PhoCusWright/Akamai Study)15

#3And the survey says16

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Challenges with claBSIsMany Ports of Entry into the bloodstream18

#419

Culture from a patients needleless connector. Wendy Kaler, MT, MPH, CICChallenges with ClabsiCannot See Microorganisms blessing and curse

#520Challenges with ClabsiNo Immediate Accountability Patient doesnt yell OUCH!

#6

Challenges with ClabsiDynamic Bedside environment nurse gets interrupted every two minutes

#721

PORT PROTECTIONWhat is a Port Protector?70% IPA in a capMedical grade foam pad To be placed on any swab-able, luer-activated device To disinfect and act as a physical barrier between accesses when not in use22How a port protector works23Passive DisinfectionChemical agent 70% Isopropyl AlcoholTime of exposure 3 - 5 minutes (per DFU)Physical barrier up to 4 - 7 days if not removed (per DFU)No scrubbing necessary (for first access)FDA 510(k)Single use

Types of Port Protectors24

Advantages to port protectionMinimizes riskDisinfected and protected vs. exposed and contaminatedConsistent disinfectionNo user variability #8Saves time*Hub Scrub not necessary for first access if port protector in place for specified timeVisible tool for managing complianceAllow for complete compliance with TJC NPSG 07.04.01Peer Reviewed DataStudies have demonstrated reduction in CLABSI, Contaminated Blood Cultures, and Intraluminal contaminationWhats next?

25Port protector CLINICAL studyObservational before-after study in adult oncology nursing unit (Sweet, 2012)Control period manual cleaning with alcohol wipes, retrospective CLABSI data1 year, 472 patients, 6851 central line days16 CLABSIs, 2.3 infections/1000 catheter daysIntervention period using port protectors on neutral mechanical valve NC6 months, 282 patients, 3005 central line days1 CLABSI, 0.3 infections/1000 catheter daysReduction of contaminated blood cultures taken from catheters

26Possible reduction in CLABSICost savingsLength of stay decreaseReadmission decreaseIncrease in Patient SatisfactionSAVED LIVESPossible reduction in contaminated or false positive blood culturesCost savingsReduction in unnecessary antibiotic usage

26Port protector CLINICAL STUDYCase-crossover study with PICCs indwelling for 5 or more days, 3 hospitals (Wright, 2012)1.5 mLs of blood drawn from PICC for culture on days 5, 6, 7 and twice weekly thereafter3 phases 799 patients enrolledManual scrubbing 32/252 (12.7%) contaminated. 4 cfu/mL medianUse of port protector 20/364 (5.5%) contaminated, p=0.002, 1 cfu/mL medianReturn to manual scrubbing 22/183 (12%) contaminated, 2 cfu/mL medianAvoid 21 CLABSI, 4 fewer deaths, 13 new admissions

27Possible reduction in CLABSICost savingsLength of stay decreaseReadmission decreaseIncrease in Patient SatisfactionSAVED LIVESPossible reduction in contaminated or false positive blood culturesCost savingsReduction in unnecessary antibiotic usage

27Port protector CLINICAL STUDYObservational before-after study in 2 adult ICUs (Ramirez, 2012)Control period manual disinfection with alcohol pad for 15 seconds, normal surveillance data4 CLABSIs, 1.9 infections/1000 catheter daysIntervention period application of port protectors on all NCs1 CLABSI, 0.5 infections/1000 catheter days

28Possible reduction in CLABSICost savingsLength of stay decreaseReadmission decreaseIncrease in Patient SatisfactionSAVED LIVESPossible reduction in contaminated or false positive blood culturesCost savingsReduction in unnecessary antibiotic usage

2829SIX SIGMA PROJECT TX HOSPITAL

1. Open MAR

2. Scan Medication

3. Prepare Medication

4. Open Alcohol Pad

5. Scrub Hub for 15 sec

6. Dry for 15 sec

7. Administer Medication= 66 secper injection(Avg. time spent in 12hr shifts giving IV injections)Advantages to Port Protection30

1. Open MAR2. Scan Patient

3. Scan Medication4. Prepare Medication5. Remove Port Protector

6. Administer Medication

64 % reduction!7. Replace with new port protector= 23.7 secper injectionEven simple solutions have challengesThe Silver Bullet SyndromeHand HygieneClean, Dry, Intact DressingsConfusing ProtocolForced Compliance vs. Non-Forced Compliance31complianceForced Compliance

Car keysNeed them to drive car

Non-forced Compliance

Seat BeatCar drives fine without seatbeltNeed for HARD WIRED habit

32#932Main Challenge?IT ONLY TAKES

EXPOSURE33ONE#10Thank You!

Questions?34

Challenge acceptedProduct LocationEasy access grab and goEducation reinforce the WHYProcess vs. ProductSimple ProtocolsAll Patients, All Lines, All the TimeEliminates confusionSupports Behavioral Changes AuditingReinforcement to hardwire new process 21 DaysManagement engagementVisibility to actual practice35audit program unit basedReal time feedback/educationAccountabilityShare compliance resultsNursing leadership supportClinical ladderMagnet storyCUSPHENIP Liaisons If can not measure it, you can not improve it. Lord Kelvin36Advantages to port protection37

Allows for complete compliance with JCAHO NSPG 07.04.01Visual auditable tool (no shadowing!)Allows for documentation of standardized procedure and allows for reporting

3738The single biggest problem withCOMMUNICATIONis the illusion that it has taken place.

- George Bernard ShawREAL TIME COMMUNICATIONPost Compliance RatesStaff nurses, management, CLABSI committeeShare Success StoriesPrime tubing in med room, place PP onCelebrate VictoriesReward positiveGain more champions39WEEKLY UNIT REPORTING

4040Celebrate successes

4141

I dont have time!42ORGANIZATIONS WHERE ONE breach in process CAN IMPACT lives

43Monitoring Process ComplianceHigh reliability organizations, i.e. military, aviation, nuclear powerContinuous monitoring of critical processes# of observationsMultidisciplinary/multidepartmentalProcess examplesLine insertionLine entryProvide feedback - immediate and monthly

Monitoring & Effect on CLABSI rateBundle use alone not associated with lower CLABSI rate. Rate when process monitored & achieved > 95% compliance Furuya et al; Presentation at Fifth Decennial International Conference on HAI. March 2010, Atlanta.

44SHEA/IDSA Practice recommendationsInfection control and hospital epidemiology, vol. 35, no. 7 (july 2014) pp. 753-7712014 UpdateSection 1: Rationale and Statements of ConcernSection 2: Background Strategies to Detect CLABSISection 3: Background Strategies to Prevent CLABSISection 4: Recommended Strategies for CLABSI PreventionBasic PracticesSpecial ApproachesSection 5: Performance MeasuresInternal ReportingExternal ReportingSection 6: Examples of Implementation StrategiesEngageEducateExecuteEvaluate

45$$$ ReimbursementFYI 2015HAC Reduction Program (1%)Penalty enforced after VBP & Readmission adjustmentsDomain 1 AHRQ 35%PSI-7 CLABSIPSI-13 SepsisDomain 2 CDC Measure 65%CAUTICLABSIVBP (Zero Sum Bucket) (1.5% - 2% in 2017)Improvement (Self) current performance vs baselineAchievement (Others) how does current performance stack up to othersBoth make up your Total Performance ScoreReadmission Reduction Program (3%)

46CONCLUSIONCABSI and Central Line DefinitionsChallenges with BSI PreventionNo immediate accountabilityIt only takes ONE exposure to put a patient at riskOvercoming BSI ChallengesEducation as to WHYMonitoring maintenance careENGAGE NURSING LEADERSHIP Unit based programsImportant tools to assistPort ProtectionVisual auditing toolMeans to communicate compliance47Any questions?48