1 / 38

The 5 Million Lives Campaign: “Preventing Central Line Infections”

The 5 Million Lives Campaign: “Preventing Central Line Infections”. Institute for Healthcare Improvement. The Central Line Bundle. Do Central Lines Cause Blood Stream Infections?.

margo
Download Presentation

The 5 Million Lives Campaign: “Preventing Central Line Infections”

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. The 5 Million Lives Campaign: “Preventing Central Line Infections” Institute for Healthcare Improvement

  2. The Central Line Bundle

  3. Do Central Lines Cause Blood Stream Infections? • Central venous catheters (CVCs) disrupt the integrity of the skin, making infection with bacteria and/or fungi possible. • Infection may spread to the blood stream (bacteremia) and hemodynamic changes and organ dysfunction (sepsis) may ensue. • Approximately 90% of the catheter-related blood stream infections (BSIs) occur with CVCs. Maki DG. Infections due to infusion therapy. In: Hospital Infections, Third Edition, Bennett JV, Brachman PS (eds), Little, Brown, Boston 1992.

  4. Incidence & Risk: • 48% of ICU patients have central venous catheters, accounting for 15 million central venous catheter-days per year in ICUs. • The case fatality rate for catheter-related blood stream infections approaches 20%. • Attributable mortality ranges from 12-25% but was 3% in one meta-analysis. Mermel LA. Ann Int Med 2000;132: 391-402 Soufir L et al. Infect Control Hosp Epidemiol 1999 Jun;20(6):396-401.

  5. Incidence & Risk: • Studies that control for underlying illness severity give lower estimates of attributable mortality. • These data suggest that attributable mortality is between 4 and 20%. • Thus, between 500-4000 U.S. patients die annually due to blood stream infections. Pittet D, Tarara D, Wenzel RP. Jama. May 25 1994;271(20):1598-1601 Soufir L et al. Infect Control Hosp Epidemiol 1999 Jun;20(6):396-401.

  6. BSI is Costly & Prolongs Care • Attributable cost per blood stream infection is estimated to be $3,700 to $29,000. • Nosocomial blood stream infections prolong hospitalization by a mean of 7 days. Pittet D, Tarara D, Wenzel RP. Jama. May 25 1994;271(20):1598-1601 Soufir L et al. Infect Control Hosp Epidemiol 1999 Jun;20(6):396-401.

  7. BSI Risk Factors Risk Factors with Percutaneous or Tunneled Catheters: • Site of insertion: Subclavian vein less risky than internal jugular or femoral vein. • Multiple ports/hubs: More manipulation and contamination. • Parenteral feeding: TPN and/or lipids • Infection elsewhere: Remote, e.g. UTI or wound. Mermel LA, Am J Med. Sep 16 1991;91(3B):197S-205S McCarthy MC, J Parenter Enteral Nutr 1987; 11:259.

  8. BSI Risk Factors Risk Factors with a Central Venous Access Device (C-VAD): • Lower infection rates: 0.1 to 0.2 per 100 catheter days. • Subcutaneous ports: 10-12 fold lower rate of infection compared with tunneled catheters. • Some risks remain: • Colonization of catheter with organisms • IV catheterization longer than 72 hours • Inexperience of personnel inserting the C-VAD Groeger JS, et al. Ann Intern Med 1993; 119:1168.

  9. CDC Guidelines Major areas of emphasis: • Education and training of providers who insert lines • Maximal sterile barrier precautions • Use of 2% chlorhexidine for skin antisepsis • Avoiding routine replacement • Consider antiseptic/antibiotic impregnated catheters if rate of infection remains high O’Grady NP. MMWR Aug 9, 2002; 51: RR10, 1-29

  10. AHRQ-Sponsored Evidence Summary • Attributable mortality 4-20% • Analyses of costs very variable • Routine replacement does not reduce risk • Maximum barrier precautions reduce risk • CVCs coated with antiseptics or antibiotics might reduce risk but are expensive • Use of chlorhexidine skin prep reduces risk more than povidone-iodine Saint S. http://www.ahrq.gov/clinic/evrptfiles.htm#ptsafety

  11. Opportunity Knocks • What if a series of interventions could markedly reduce the risk of BSI? • What if those interventions were already readily available in hospitals? • What if all of those interventions were done all of the time on each patient?

  12. Benefits of Reducing BSI • Better patient outcomes • Reduced mortality • Improved satisfaction • Nursing • Physician • Patients and families • Financial benefits

  13. The Central Line Bundle …is a group of interventions related to patients with intravascular central catheters that, when implemented together, result in better outcomes than when implemented individually.

  14. What is a Bundle? • A grouping of best practices with respect to a disease process that individually improve care, but when applied together result in substantially greater improvement. • The science behind the bundle is so well established that it should be considered standard of care. • Bundle elements are dichotomous and compliance can be measured: yes/no answers. • Bundles eschew the piecemeal application of proven therapies in favor of an “all or none” approach.

  15. Central Line Bundle Elements • Hand hygiene • Maximal barrier precautions • Chlorhexidine skin antisepsis • Appropriate catheter site and administration system • Avoidance of routine replacement

  16. But, Does it Work? ICUs that have implemented multifaceted interventions similar to the central-line bundle have nearly eliminated CR-BSIs. Berenholtz SM, Pronovost PJ, Lipset PA, et al. Eliminating catheter related bloodstream infection in the intensive care unit. Critical Care Medicine. 2004; 32:2014-2020.

  17. Outcome and Cost Impact • Rate of CR-BSIs fell from 11.3 to 0 /1000 catheter days. • Prevented annually (estimated): • 43 CR-BSIs • 8 deaths • 559 ICU days • Estimated savings to hospital: $1,824,447

  18. Baptist Memorial Hospital-Memphis, Memphis, TN • Reduced CR-BSI and ICU length of stay:

  19. Hand Hygiene 101 • Wash hands if they are obviously soiled • Wash hands or use an alcohol based waterless hand cleaner • Before and after invasive procedures • Between patients • After removing gloves • Before eating • After using the bathroom • If contamination is suspected

  20. What are Maximal Barrier Precautions? • For Provider: • Hand hygiene • Non-sterile cap and mask • All hair should be under cap • Mask should cover nose and mouth tightly • Sterile gown and gloves • For the Patient: • Cover patient’s head and body with a large sterile drape

  21. Impact of Maximal Barrier Precautions (MBR) OR=odds ratio MBR= inserter washes hands and wears mask, sterile gown, sterile gloves and patient’s head & body are covered with a large, sterile drape.

  22. Key Change: Central Line Checklist • Have the nurse document compliance with the insertion criteria at the time of insertion. • Create a culture of safety and prevention: • empower nurses to stop line placement if improper techniques are used • Instruct nurses in use of critical communication strategies to facilitate important exchanges. • e.g. “the sterile field has been contaminated,” rather than “Youcontaminated the catheter!”

  23. Checklist Elements • Before the procedure, did they: • Wash hands? • Sterilize procedure site? • Drape entire patient in a sterile fashion? • During the procedure, did they: • Use sterile gloves, mask and sterile gown? • Maintain a sterile field? • Verify: did all personnel assisting with procedure follow the above precautions?

  24. Chlorhexidine Skin Antisepsis • Prepare skin with antiseptic/detergent Chlorhexidine 2% in 70% isopropyl alcohol. • Pinch wings on the “Chloraprep” applicator to pop the ampule. Hold the applicator down to allow the solution to saturate the pad. • Press sponge against skin, apply chlorhexidine solution using a back and forth friction scrub for at least 30 seconds. Do not wipe or blot. • Allow antiseptic solution time to dry completelybefore puncturing the site ( ~ 2 minutes).

  25. Baseline Compliance With Best Practice Example: At one hospital, providers were compliant with best practice during 62% of the observed Procedures Intervention: National compliance estimated to be 30%

  26. Central Line Site Care • Use line carts and dressing change kits • Standardize site care procedures • Store all equipment in the same place

  27. To Be Successful • Set an aim: “Reduce the incidence of central line catheter-related bloodstream infections using the central line bundle.” • Set a goal: “The rate of CR-BSI will decrease by 50% in one year using the central line bundle.” • Plan well: Adopt a change methodology that accelerates improvement such as The Model for Improvement.

  28. Model 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 an improvement? Act Plan Study Do

  29. Me and What Army? • Form… a team • Include a diverse staff. • MDs, RNs, respiratory therapists. • Identify… a project champion • Someone who maintains visibility in the ICU. • Identify… a process owner • For concerns now and in the future.

  30. Engage Stakeholders • Identify stakeholders in intensive care. • 3 groups: MDs, RNs, venous access teams. • Secure representation from each. • Facilitates physician buy-in. • Generates nursing support.

  31. Role of Leadership • Committed: staff cannot improve without supportive leadership. • Set the standard: “This is how we will practice.” • Resources: make time to work on testing. • Share data: to motivate staff for change.

  32. Starting the Project • Is there a method in place now? • Know your baseline performance: • Randomly select 20 patients’ records who had central lines placed. Apply the measures to them. • Be sure to check compliance with the total bundle as well, the “all or none” goal. • Educate ICU staff (using your own data).

  33. Small Tests of Change • Small tests... 1 RN, 1 MD, 1 patient. • Move on to pilot test in one ICU: • Refine the process • Test on all shifts • Test on all patients with central lines • Measure your results to know if a change was an improvement.

  34. Supportive Interventions • Multidisciplinary Daily Rounds: • An opportunity to assess bundle related issues. • Invite and encourage the family to join in. • Daily Goal Sheets: • Maintenance of bundle items.

  35. Measure: CR-BSI per 1000 Line Days Central line-associated BSI rate per 1000 central line-days: Numerator: Number of central line-associated BSI x 1000. Denominator: Number of central line-days (total number of days of exposure to central venous catheters by all patients in the selected population during the selected time period).

  36. Measure: Central Line Bundle Compliance Central line bundle elements in place: Numerator: Number of patients with central line bundle in place. Denominator: Total number of pts on central lines per day of week of prevalence sample.

  37. Model for Improvement • What did we accomplish? • Was that change an improvement? • What further changes will lead to more improvement? Act Plan Study Do

  38. Summary: • Central line infections are common. • Proven strategies exist to decrease CR-BSI line days. • Using the Central Line Checklist, most bundle elements are implemented. • Thousands of lives and millions of dollars saved with reliable adherence and bundle execution.

More Related