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VASCULAR ACCESS Specialist team. Ownership of the Bundle. April VanDerSlik BSN RN CIC Infection Prevention Manager November, 2013. Bronson Healthcare System. Regional, not-for-profit health system Recognized for workplace excellence National leader in healthcare quality

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vascular access specialist team
VASCULAR ACCESS Specialist team

Ownership of the Bundle

April VanDerSlik BSN RN CIC

Infection Prevention Manager

November, 2013

bronson healthcare system
Bronson Healthcare System
  • Regional, not-for-profit health system
  • Recognized for workplace excellence
  • National leader in healthcare quality
    • Keystone, including CUSP
bronson methodist hospital
Bronson Methodist Hospital
  • 434 bed tertiary teaching hospital
  • 11 VAST nurses (7 full-time, 2 part-time, 2 on-call)
  • 642 Acute CVCs / year
  • Approximately 1,000 PICCs / year
    • ~ 50% PICCs are placed in critical care units
history
History
  • Team Beginnings: Hyperal Initiation
    • Formed 1978
    • Dr. James Heersink, General Surgeon
    • Hyperalimention Team (doctors, nurses, pharmacist, and dieticians)
    • Duties
      • Assisted with CVC inserts
      • Education of staff and patients
      • Improved patient outcomes
      • Decreased infection rate
    • Team name change in 2009 (VAST)
vast team responsibilities
VAST: Team Responsibilities
  • Education
    • Develop policies and procedures according to INS standards, CDC & Joint Commission guidelines
    • Teach IV & Infusion Management class
    • Patient, family and staff education
    • Manage Champion program
    • Clinical resource to community
  • Placement
    • Assist providers with CVC insertions
    • Insertion of PICCs at bedside
  • Post Placement
    • PICC daily surveillance
    • PICC dressing changes
central line associated blood stream infections clabsis adult population only
Central Line Associated Blood Stream Infections (CLABSIs) Adult Population Only

All TPN Dressing

low clabsi national recognition
Low CLABSI National Recognition
  • Healthgrades, 2013
    • Better than average
  • Consumer Reports, Jun 2011
    • reported zero
    • received highest score
  • Commonwealth Fund, Dec 2011
    • reported zero
methodology
Methodology

Guidance

  • CDC & Joint Commission guidelines
  • Keystone: CVC bundle
  • PICC bundle (Bronson specific protocol)

Practice

  • Daily PICC and TPN surveillance
  • Dressing change protocols
  • Hand hygiene program with auditors
  • Ultrasound guided CVAD placement
  • Blood sampling protocols
  • Education
  • Scrub the hub
  • Chlorhexidine disc
keystone cvc bundle
Keystone CVC Bundle

Before procedure

  • Hand hygiene, chlorhexidine prep

During Procedure

  • Full Barrier Pre-cautions: Hat, mask, sterile gown, sterile gloves
  • Assist physicians and residents with insertion – avoid femoral site
  • Monitor sterility
  • Empowered to stop procedure
  • Monitor traffic pattern
  • Use of checklist

After procedure

  • Sterile dressing applied
  • Removing unnecessary catheters
bronson picc bundle at the bedside
Bronson PICC Bundleat the Bedside
  • Hand hygiene
  • Max barrier precautions
    • pre-packaged insertion kit
  • Chlorhexidine prep
  • Ultrasound guided PICCinsertion
  • Neutral connector system
  • Connector disinfection
  • Flushing protocol
  • Daily monitoring of all PICCs by VAST
scrub the hub 1
Scrub the Hub1
  • Wash hands or use hand sanitizer
  • Wear gloves
  • Scrub the hub for 30 seconds each and every time with chlorhexidine

1Centers for Disease Control, Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011

patient ownership
Patient Ownership

Goal: Patient Empowerment of their VAD

  • Inpatient
    • Permission to say “no” to care beinggiven (i.e. change your gloves, wash your hands, scrub for 30 seconds)
    • Basic care & maintenance education
  • Discharge
    • Care & maintenance instructions
    • Emergency contact information
    • All CVAD types
checklist and nurse empowerment
Checklist and Nurse Empowerment

Goal: Assist providers with CVC insertion

  • Checklist to delineate, guide and document completion of each step
  • Source of data collection to verify adherence to protocol
  • Taught to speak up and “stop the line”
  • Patient safety strong backing by RN, MD and management
vascular access infusion training who do we educate
Vascular Access Infusion Training(Who do we educate?)
  • Physician and residents
  • Clinical staff (more than 800 FTEs)
  • Management
  • Patients and families
post insertion care
Post Insertion Care

Goal: Dressing Change and Line Surveillance

  • Daily: PICC & TPN lines –VAST Team
  • Daily: Acute CVC – Staff Nurses
  • Check bag & tubing–labeled with time/date/initials
  • Lab values
  • Fever
  • Line Necessity
staff engagement activities
Staff Engagement Activities

Traveling Story Board

Updated according to unit specific educational needs

»Transferred from unit to unit»

champion program selection
Champion Program Selection

Clinician empowerment of insertion procedure, care & maintenance and training of staff

  • RN for two years at Bronson
  • VAST and management approval needed
  • Attends Champion class done by VAST
  • Specially trained in high risk central line skills
  • Ability to sign off other RN’s on certain procedures
  • Yearly peer review
champion program duties skills
Champion Program: Duties / Skills
  • Champion Duties
    • Sign off floor staff
    • Removal PICC / CVC
    • Dressing Changes (CVC)
    • Catheter Clearance - Thrombolytic
    • Continuing Education
  • Champion Sign off Staff (Procedures)
    • Hanging TPN
    • Blood draws
    • Dressing Change (CVC)
    • Port Access
champion program competency
Champion Program: Competency

Goal: Proficiency Demonstration

VAST or unit champion to sign RN off on procedure

  • RN observation
  • RN practicum / performance of procedure with assistance
  • RN demonstrated competency without assistance
new hire employee infusion training
New Hire Employee: Infusion Training

Computer Based Learning (CBL) class

  • IV insertion and infusion management
  • Practicum for hands on demonstration in classroom setting
new initiative community education
New Initiative: Community Education

Goal: Initiative to decrease readmits from community due to CLABSIs w/ outside staff training

  • Local Nursing homes
  • Home Health Agencies
  • Local Hospice – policies only
obstacles to overcome
Obstacles to Overcome
  • Hospital Administration support of empowerment
  • Finding a Physician(s) Champion
  • A hospital wide culture change
lessons learned
Lessons Learned
  • Participate in infection prevention collaboratives to share your challenges and best practices with other hospitals.
  • Involve physician champions and multidisciplinary teams.
  • Use checklists.
  • Employ small, specially trained teams and individuals (including intensivists in the ICUs) to conduct and/or oversee line insertion and maintenance throughout the hospital.
  • Sustain best practices with ongoing education, monitoring, and adjustments and provide performance data to staff to keep them focused on outcomes.
references
References
  • Carroll SS (December 2011) Eliminating Central Line Infections and Spreading Success at High-performing Hospitals Synthesis Report December 2011 Commonwealth Fund publication 1559 Volk 21
  • Ending Health Care-Associated Infections Agency for Healthcare Research and Quality (2009) www.ahrq.gov/research/findings/factsheets/errors-safety/haicusp/index
  • Lowes R (2011) High Central-Line Infection Rates at Many Teaching Hospitals New Consumer Reports Study Gives Poor Marks to 67 Institutions Medscape Medical News June 7,2011 www.medscape.com/viewarticle/744131
  • O’Grady NP et al (2011). CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections
  • Sardone F (2010) Celebrating Nursing Excellence Bronsonhealth.com
  • www.commonwealthfund.org
  • www.bronsonhealth.com/about
  • www.healthgrades.com/quality/top-hospitals-2013