Project Disclaimer by cwk80254


More Info
									Using Six Sigma in Infection
Brandi Cavegn MSN, RN – Green Belt
Personal Background

•   Who am I?
•   And what is my background?
•   Greenbelt- Certified, part time
•   Other Belts? White, Yellow, Green, Black,
    Master Black
What is Six Sigma

• Six Sigma is a problem solving methodology.
• Six Sigma minimizes mistakes and maximizes
• Six Sigma originated in Manufacturing (much like
  LEAN) but can be used in healthcare successfully.
• Six Sigma performance is the statistical term for a
  process that produces fewer than 3.4 defects (or
  errors) per million opportunities for defects. (think
  bell curve).
• Six Sigma is often the goal but rarely reached
• Six Sigma decreases the “normal variation” in a
Sigma Scale

Sigma     Percent      Defects per
          Defective    Million
1         69%          691,462
2         31%          308,538
3         6.7%         66,807
4         0.62%        6,210
5         0.023%       233
6         0.00034%     3.4
7         0.0000019%   0.019
So what does that mean?

3.8 Sigma (99% good)        6 Sigma (99.99966%
5000 incorrect surgical     1.7 incorrect surgical
operations per week         operations per week
200,000 incorrect drug      68 incorrect drug
prescriptions each year     prescriptions each year
Unsafe drinking water for   One unsafe minute of
almost 15 minutes per       drinking water every
day                         seven months
48,000 to 96,000 deaths     17 to 34 deaths attributed
attributed to hospital      to hospital errors each
errors each year            year.
How Six Sigma tools can be useful to

• Variety of tools to be used
• Focus is on decreasing variation
• Full variety of tools can be used without
  initiating entire project.
• DMAIC Methodology
  –   D- Define
  –   M- Measure
  –   A- Analyze
  –   I- Improve
  –   C- Control
Case Study

• NICU CA-BSI project
• Use Six Sigma methodology to reduce
  variation in the insertion and maintenance
  of Central line catheters in the NICU.
• Overall goal was to reduce the infection
  rate, but this was not the goal of the project.
• Disclaimer
Start with a Charter (Any template
will do)
Team Charter                                                                D M A   I   C
Project : ? Prevention of Surgical site infections
Business Case:                                         Opportunity Statement

Goal Statement                                         Project Scope
                                                              Process :

                                                            Start Point :

                                                            End Point :

Project Plan                                           Team Members
  Task/Phase   Start Date    End Date     Actual End       Champion :
                                                       Process Owner :
                                                           Master BB :
                                                            Black Belt :
                                                             Member :
                                                             Member :
    D-Business Case (Use Evidence)
•    An opportunity exists within CHW to reduce the number of blood stream infections
     associated with catheters in the NICU. It is important to address this issue now because it
     impacts not only patient safety but key business drivers related to organizational success.
•    The Agency for Healthcare Research and Quality (AHRQ) and the Centers for Disease
     Control and Prevention (CDC) have acknowledged that central venous lines are critical
     components of medical care for many patients, and their use can lead to catheter-
     associated blood stream infections.
•    Bloodstream infections account for 30% of all health care associated infections in
     pediatrics according to the CDC’s National Nosocomial Infection Surveillance System
     (NNIS). Although the association between bloodstream infections and death is somewhat
     controversial, AHRQ concluded that findings in the literature are consistent with a 10-20%
     increase in mortality.
•    The CDC has reported an average of 2.8 to 12.8 infections per 1000 catheter-days.
•    Directly aligned to the CHW strategic goal to provide the Best and Safest care
•    The mean cost of a bloodstream infection has been estimated at $46,133 due to the
     longer length of stay and additional ancillary utilization (Slonim et al), making it the most
     expensive of all nosocomial infections.
•    The financial impact may be greater for CHW because of the NICU population and the
     possible impact on Neurodevelopment
•    Line infections can also be categorized as “never events” which are errors in medical care
     that are clearly identifiable, preventable and serious in their consequences for patients.
     Never events are not reimbursable under many insurance plans.
•    Results of the project such as standardized processes or new staff knowledge regarding
     line insertion, maintenance and infection risks should improve employee satisfaction
     scores and increase staffs comfort level dealing with catheters
•    Preventing infection will be a positive driver for patient satisfaction
D- Goal Statement

•   To reduce bloodstream infections associated with catheters to
    1.5 per 1,000 catheter days in the NICU population by year end
•   Double the number of days between bloodstream infection
•   100% of patients receive the insertion central line bundle (hand
    hygiene, maximal barrier precautions (sterile gown, sterile
    gloves, cap, mask, insertion site toweled off with sterile towels,
    daily review of line necessity, optimal catheter site selection,
    chlorhexidine skin antisepsis for patients over 2 months of age)
•   95% of patients with a CVL were assessed daily for necessity of
    retaining the CVL.
•   95% of patients receive the line maintenance bundle
•   Improved communication among staff and standardized work
    processes regarding the insertion and maintenance of CV lines.
•   Sigma level 4.47 (1.5 per 1000) Six Sigma would be (.005 per
D-Team Members
  Team Member Name                         Responsibility Areas*

  Dr Uhing – NICU Medical Director         Executive sponsor

  Brandi Cavegn (Clinical Transformation   Project Managers / Greenbelts
      Project Mgr)
  Amy Stecker (Patient Care Regulatory
      Compliance Mgr. )
  Tia Luangrath                            Liaison to project manager, Team
  Carla Clemens (NICU)                     Team Member

  Kari Fixel (NICU)                        Team Member

  Kimberly Tritz (NNP)                     Team Member

  Amanda Kazda (CAT)                       Team Member

  Mary Firary (Pharmacy)                   Team Member

  Mary Rotar (Infection Control)           Team Member

  Sunita Hermon (NICU leadership)          Team Member

  Ann Grippe (APN)                         Team Member
D-Project Scope

•   The scope of the project includes lines placed in the NICU at CHW.
•   Central Venous Lines (CVL) include: Broviac, Peripherally Inserted
    Central Catheter (PICC), Umbilical Arterial Catheter (UAC),
    Umbilical Venous Catheter (UVC)
•   The team will focus on the process boundaries of line insertion and
    line maintenance.
•   The definition of Blood Stream Infections (BSI) as defined by NHSN
    will be used for data collection purposes.
•   Catheter Associated –Blood Stream Infection (CA-BSI) Insertion
    Bundle compliance in the NICU
•   The project begins in May 2008 and will conclude at the end of
    December 2008

      Decision made to
                         Line is inserted   Line is maintained   Line is removed
         place line
D-Alignment and Authority
•   Does this project align with any other business initiatives currently underway? How will we
    coordinate with the people leading these initiatives?
•   Infection control
•   Interventional Radiology
•   Pharmacy
•   CAT
•   Anesthesia
•   PICU initiatives
•   What authority do we have to make decisions and implement changes? Include here the
    authorities we must approach for decisions and approvals beyond our team’s scope. Is there
    anything that is outside the team’s boundaries?
•   Product Committee – must evaluate any recommendations on equipment
•   Infection Control – approval required for any changes to surveillance data
•   JCPC – review of any new policies
•   OR – stakeholder involved in patient care process– Rob Omelina is contact person
•   Purchasing – approval required on recommendation to purchase new supplies
•   Sterile Processing – approval required on recommendations for cleaning equipment and supplies
•   Environmental – stakeholder in process and impact patient care environment
•   Respiratory Care – stakeholder providing care to patient and would need training on any process
    changes or expectations regarding line insertion and maintenance
•   Radiology - stakeholder providing care to patient and would need training on any process changes or
    expectations regarding line insertion and maintenance
M- Data Measurement Plan

                                                                                    Other Data
                               Data                         When                       that
                                        Samp    Who Will                 Will
Performanc     Operational    Source                       Will Data                Should be
                                          le     Collect                Data be
 e Measure      Definition     and                            be                     Collected
                                         Size   the Data                Collect
                             Location                      Collected                  at the
                                                                                    Same Time

How will data be used?                                How will data be displayed?
M-Insertion vs. Maintenance
Insertion   Onset Date   # of days until   Insertion vs.
   date                      onset            Maintenance

1/8/07      1/11/07      3                 ?I
1/31/07     2/22/07      22                M
2/26/07     3/2/07       4                 ?I
5/12/07     8/21/07      100               M
6/14/07     10/31/07     139               M
6/22/07     7/20/07      28                M
9/26/07     11/8/07      43                M
12/6/07     12/13/07     7                 M
12/6/07     12/13/07     7                 M
12/18/07    12/26/07     8                 M
M-Days Between Infection

      Rolling # of days
      1/11/07             0
      2/22/07             42
      3/2/07              8
      7/20/07             139
      8/21/07             31
      10/31/07            41
      11/8/07             8
      12/13/07            43
      12/13/07            0
      12/26/07            13
M-Preliminary Data on CA-BSI

10 infections in 2007 = 1.65 infections per 1000 line days
8/10 were identified as maintenance related
2/10 were undetermined (3 and 4 days after insertion)
2007 Average days between infections- 36.1
Goal for 2008 is 72.2 (double last year)

                                                Rolling # of Days
                                                Between infections,
100                                             Higher is Better
                                                Current Average

A-Opportunity/ Problem Statement

• 10 Catheter Related Blood stream Infections were
  reported in the NICU for 2007
   – $46,133 per infection x 10 infections = $461,133 in
     additional costs
• Infections can occur during the line insertion or
  maintenance period
   – Insertion Bundle Compliance- evidence based
     interventions that should be implemented together
     (hand hygiene, maximal barrier precautions, daily
     review of line necessity, optimal catheter site
     selection, chlorhexidine skin antisepsis for patients
     over 2 months of age)
   – Maintenance include dressing and tubing changes
• 1.65 infections per 1000 line days
• Sigma of 4.44
M- Process Maps or Flow charts
• A graphic model of the flow of activities, material,
  and/or information that occurs during a process.
• Sets your baseline.
PICC & Broviac Line Maintance – process if no complications / everything normal

                            Determine                                                                          Check IV fluid
 Assess Line                                                           Assess date         Assess date                             Secure line
                          location of tip            Check line                                                   rate &                                   Transfer           Document
  (intact leaking,                                                     for dressing         for tubing                                (frequent
                               (central /           connections                                                 expiration           monitoring)
                                                                                                                                                            patient            hourly
 redness of skin)
                                                                         change              change

                                                  Not everyone

PICC & Broviac Line Maintance – change dressing

 Determine dressing                                          Get                                                                                                                                                                            Remove old
 change is required                 Get second                                                                                  Open kit, 1st & 2nd              Other supplies
                                                          equipment            Scan            Wash              Prepare                                                                           Put sterile             Open              dressing
   (dressing is occlusive,           person to                                                                                   person put on                  gathered & added                                                                                A
                                                         from supply          supplies         hands              baby                                                                             glove on             supplies in kit      (helper holding
leaking, skin red* or heart /         assist                                                                                    mask, pull curtain                to sterile field                                                            baby & line)
    disk under tegaderm                                     room

                     Use decision criteria to                                                                                   I.D. supplies, where you       Getting tegaderm into           Trash – disposal
                     determine if physicain should be                                                                           need to go & where to          tray, need smaller              issue, maintainging
                     contacted about redness. Do                                                                                set up                         tegaderm for little babies,     sterile evnironment if
                     not change dressing if physician                                                                                                          no sterile scissor, swab &      you “hit hand” no new
                     requests culuter                                                                                                                          H2O2 in kit                     gloves in kit

                                       Sterile person
                                                                                 Assess line        Apply H2O2                                      Repeat with
              Change to             hands sterile Q tip                                            (swab in a circular                                                                                   No      Proceed
                                                                 Count hash          and                                   Wipe off line             Betadine                    Betadine still                                 Wipe off       Recount
   A          new sterile              to helper and                                               motion moving out                                                                                               with                                         B
                                                                   marks          insertion         from line – do 3
                                                                                                                           with H2O2               (wait 2 minutes with              wet                                         saline       hashmarks
                gloves              placed on insertion                                                                                             betadine in place)
                                                                                     site                times)

                                                                                                  Person holding picks                                                                                                                       not always
                                                                                                  up Q tip
                                                                                                                                                                             Dry with dry sterile                 2 types

                                      Skin prep           Apply         Chevron                                                                                              Variance- wipe all off or
               Loop the                                                                  Secure       dressing                                                               leave some, what to you
   B                                   avoiding         tegaderm          line
                 line                                                                     line        change &                                                               use to clean it
                                     line let dry       over heart
                                                                                                                                                                                 Respiratory bullets
                                                        Line might

PICC & Broviac Line Maintance – tip location
  Tip is not                                      MD
 where it’s                  Call             determines if           Xray                                                                                                                                                                 = potential failure mode
 suppose to                Physician             xray is             ordered
     be                                         needed

              Rev 7/9/08
        Line Maintance – PICC & Broviac Tubing Change

    RN gathers
     supplies                  Get fluids            Check                                               Yes                                               Hook to
   (Syringes, tubing,          (pharmacy or          against      Gloves on               Syringe?                     MUL             Get Air Out      syringe tubing
extensions, connectors,                             computer                                                                                             (med tubing)

                                                                                                No                                                                                                    Prime
                                                                                                                                            Opening it up,
                                                                                                                   Multiple times
                                                                                                                                            foam over need                                        Connections (Hx/        Add filter   A
                                                                                                                   because multiple
                                                                                                                                            cleaning                                                  Quad/Bi/T-Com)

                                                                                                               Alchohol             Spike the        Prime
                                                                                                               the port               bag            tubing

                                     Place                        Purge                                 Yes     Clamp patient                                                     No   Use saline
            Cut clamps                             Program                           Immediately                                          Alcohol                                                            Connect
  A                                everything                    syringe                                         line or bend                                  Low rate                 to fill air                        Unclamp     B
            with do-jab                             pumps                              infuse                                           connection                                                             line
                                   on pumps                       pump                                                line                                                               pocket

                                                                                              No                                                                       Yes

      Should we cut before prime                                                                                Bending line or a
                                                                                                                                                                                                             New gloves
                                                                                    Leave cap on                clamp risk

                                                                   People put
                                                                   blunt cap on                                                                              Use line to fill
                                                                                                                                                              air pocket

                                                                              End in sterile vol feed
                                                                                                                                                         Check lure lock – is
                                                                                                                                                        there really air
                                                                                  Secure line high in                                                   Infection possible air
                                                                                       feeder                                                           pocket drip, drip, drip

                                                                                  Tape bottle to pole

                                                                                      Run Fluids

                                                                                      Calc run time

                  Push                                         Double
   B                                Scan        check with
                  Start                                        check
                                                second RN

       Some scan then Prime some prime and scan (policy saty
       scan when hung)

Entering a line meds

 Prepare to    Syringe tubing   No
                                                                             Prime tubing     Place connector                        Scrub the
                                      Gather tubing        Wash hands                                                 Connect to                        Connect
 enter line    already hooked                                                 with normal           on line                         Hub (STH) or                        Start infusion
                                       and meds            Put gloves on                                                Clave                        tubing to clave
    med              up                                                      saline or med     (alligator clip)                        Clave

                                                                              Prime with
                                                                              med or NS

                                 Take flush off
                                                       Scrub the                               Connect
                Wash hands       of med tubing                             Drip med into
                                                      Hub (STH) of                            syringe to
                Put gloves on     and discard                                  tubing
                                                       med tubing                               tubing

Giving Med in closest Port

                                                                                                                  STH with
              Wash hands             Compatible                 Clamp          STH with                                        Administer      Disconnect
Gather Med                                                                                     Flush line          alcohol                                        Unclamp TPN
              Put gloves on           with TPN                 TPN line      alcohol wipe                                        Med             syringe

                                                                                                                                                        Repeat steps with flush
                                                                            Vigorously rub                                                              after medication
                                                         Place all four    (back and forth)
                                       STH with
                                                         corners over       for 5 seconds
                                     alcohol wipe
                                                             hub           Saying “STH” 3

                                                                                                                                        = Possible failure mode
Prepare medications

                   Prepare                                                                                                                                 Draw NS                         Cap syringe
                                                                                                            Wash        Needle on
  Need to           in the                                Wipe prep                    Gather                                           Alcohol NS        off vial into    Mix med            with            Gloves          Take to
                                           Go to Hood                  Get med                            hands put       med
Obtain Meds       Pharmacy                                  area                      supplies                                             Vial               new         and Saline        needeless           off           bedside
                                                                                                          on gloves      syringe
                                                                                                                                                            syringe                          needle

                                                                                                                                                                          Difference in
                                                                                                                                         Use of spray                       practice
                Get med from                                                                                                                bottle                         NS to Med
                 drawer at                                                                                                                                                 Med to NS

Bedside Process (Amp as example)

  Get sterile        Gather                                                                                                                        Alcohol tops of
                                                        Wipe down        Gather                                   Put all                                                                                     Shake or roll
  water from        syringes,               Go to                                       Wash hands,                                               sterile water and       Draw up          Inject water
                                                         counter or     med from                               supplies on       Pop tops                                                                      vial to mix         A
    above         needles, and             bedside                                      put on gloves                                             amp vials, leave         water          into amp vial
                                                        bedside cart     drawer                               clean surface                                                                                    medication
  computers       alcohol wipes                                                                                                                     wipe on vial

                 Leave for 10
                                                                Draw up amp
                   minutes to                                                      Mix med with                               Connect syringe
                                             Alcohol top of       with new                                    Remove
      A          dissolve with                                                     normal saline                              to tubing or give
                                                 amp             syringe and                                  needle
                alcohol wipe on                                                     for dilution                               in closest port

                                                                                 Difference in Practice
                Precipitate & clot lines                                                NS-Med
                                                                                       Med - NS

                                                                                                                                                                                    = Possible failure mode
Draw Blood (UAC)

                                          Carefully open
 Know the amt to                                                 Enter baby’s            Silence
                                          gauze, wipes                                                       Turn          Scrub the          Take off         STH and          Put on waste
  be drawn and        Wash hands                                 area, prepare        monitor (this
                                            syringes                                                     stopcock off      stopcock         syringe and     clean off dries     syringe and                A
 gather supplies      Put gloves on                                 area on           is only good
                                           2 wipes for                                                    to patient      connection         discard it         blood            draw waste
   accordingly                                                    baby’s bed         for 3 minutes)
                                          every syringe

                                      *What is P&P
                                                                 *Patient can move                                                        Place back on
                                      *What is literature on
                                                                 & contaminate                                                            sterile field
                                      “scrub the hub” before &
                                      after syringe
                                                                 *Can cantaminate
                                      *Next to diaper change
                                                                 enering isolett

               Place waste
                syringe on                            Turn          Repeat for         Hit silence       Place all full                  Give back                         Place new
                                                                                                                                                          Take waste                                             Clean
    A         sterile field or    STH               Stopcock          each             button as         syringes on       STH           waste and                        flush on line         Flush
                                                                                                                                                              off                                              stopcock
                  back n                              back           syringe           nessecary         sterile field                     STH                              and STH

                                                                                     *Silence button –
                                                                                                                                       *Get air out
                                                                                     not clear
                                                                                     *Hand going in &
                                                                                     out of isolette
                                                                                     handing off

                                                                                                                                                                                          = Possible failure mode

A- Use Your Tools
  Top-Down: the breaking down of a system to gin insight into
  its compositional sub-systems
 System: Placement and Care of Central Line in the NICU

Insertion of     Maintain         Medication          Hand               General
Line             Line             preparation         Washing            Infection
                                  and                                    Control
Obtain sterile   Knowledge of     Hand washing        Removal of         Keep insertion
supplies and     line                                 Jewelry and nail   site dry, intact,
cart                                                  accessories        and covered
Set up tray      Asses line       Obtain aseptic      Roll-up sleeves    Follow
                 integrity        medications         or remove lab      medication
                                  from pharmacy       coat               administration
Position and     Identification   Dilution and        Get scrub brush    Scrub the Hub
restrain         and              reconstitution of   and turn on
patient          Intervention     medication at       water
                 of               bedside
  Line           Maintenance       Medication     Hand washing         IP practices

Time out         Protect form      Preparation    Wet hands and     Follow line tubing
                 manipulating or   of line and    scrub brush       policy
                 pulling           hook up

Use of PPE-      Dressing          Scrub the      Scrub hands for   Follow isolation
Sterile          change            Hub            2 minutes up to   protocols

Draping and      Tubing/cap/tree   Flush before   Clean Nails       Wear clean gloves
prepping         change            and after                        and change them
patient/area                       medication                       when needed

Line insertion   Medication                       Rinse and Dry     Hand Hygiene

x-ray to check   Blood draws                                        Only direct patient
placement                                                           care handle lines

Line             Documentation                                      No ties, long
adjustment                                                          sleeves, or lab coats

                 Family                                             No food in patient
                 education                                          care areas

                 x-rays (weekly)

• Identifies the Voice of the Customer (VOC)
• S- Suppliers
   – Systems, people, organizations, or other sources of the
     materials, information, or other resources that are
     consumed or transformed in the process
• I- Inputs
   – Materials, information, and other resources provided by the
     suppliers that are consumed or transformed in the process
• P- Process
   – The set of actions and activities that transform the inputs
     into outputs
• O-Outputs
   – The products or services produced by the process and
     used by the customer
• C- Customer
   – Persons, groups of people, companies, systems, and
     downstream processes that receive the output of the

       Supplier                               Input                       Process                              Output                          Customer

                                       * Hand washing policy                                                 * Decrease line                      * Babies
      * Distribution
                                           * Scrub Brush                                                         infection                       * Families
    *Central Supply
                                               * Water                                                    *Minimized transfer                   * CHW staff
                                           * Paper towels            Hand Washing                           *Healthy Patient                   * Community
                                           * Type of Sink                                                  * Decrease germs                       * Payers
                                             * Nail Sticks                                                    * Clean hands                * Regulatory agencies
    * Environmental
                                                   *                                                    * Maintain skin integrity                  * Peers

  Removal of                                                                        Scrub hands for 2
                       Roll-up sleeves or      Get scrub brush    Wet hands and
jewlery and nail                                                                      minutes up to               Clean Nails       Rinse and Dry
                        remove lab coat       and turn on water    scrub brush
  accessories                                                                            elbows

     Supplier                              Input                    Process                          Output                           Customer

                                                                                                   * Decrease line
    * Distribution                 * CVL bundle literature                                             infection
   *Sterile Supply                      * CVL orderset                                                                                    * Infant
                                                                                                  *Appropriate Line
    *Purchasing                       *Pharmacy orders                                                                                   * Family
   *Supply Techs                       * Assistant / Staff      Line Insertion                       *Appropriate
                                                                                                                                      * Caregivers
     *NICU staff                                                                                                                        * Hospital
                                                                                              securement / Dressing
     *Pharmacy                                                                                                                           * Payers
                                                                                                 *No Complications
       * X-Ray                                                                                 *Patient Skin Integrity
                                                                                              * Staff safety (ie needle

                                                                                                                          Line insertion and
Obtain Supplies                              Position and                                             Drape and prep                             Line adjustment and
                     Set up tray                               Time out          Use of PPE                                    x-ray for
   and Cart                                 restrain patient                                              patient                                    securement

                     Supplier                             Input                       Process                          Output                       Customer

                                                 * Policy and Procedures                                            * 0 Infections
                    * Distribution                      * Order sets                                            * Time limited use of                  * Babies
                    * Purchasing                    * Med/Fluid Orders                                                    line                        * Families
                     * Pharmacy                  * CVL Dressing Change                                               * Decrease                      * CHW staff
                       * Peers
                         * Lab
                                                              Kit                   Maintain Line              complications to patient             * Community
                                                       * Tubing/Caps                                              * decrease in line                   * Payers
                      * Finance                      * Stickers/Labels                                                breakage                  * Regulatory agencies
                     * Physician                       * New IV bags                                               * Decrease line                      * Peers
                       * X-Ray                         *Med Syringes                                                complications
                                                         * Lab Vials
                                                      * Alcohol Wipes
                                                      * Sterile Gauze
                                                          * Flushes

                                                                                                       Entering and
                         Identification and   Protect line from
Assess Line (Type                                                                   Tubing/Cap/Tree   accessing line
                           Intervention of    manipulating or     Dressing Change                                          Documentation   Family Education       Weekly X- rays
  and Integrity)                                                                        change        (Medication or
                           Complications           pulling
                                                                                                       Blood draws)

   Supplier                              Input                        Process                               Output                         Customer

                                  * Med administration                                                                                       * Babies
    * Pharmacist                            Policy                                                                                          * Families
    *Med Select                      * Syringe Pump              Medication                                * Aseptic drug
                                                                                                                                           * CHW staff
   * Refrigerator                      * Lexi- Drugs           Preparation and                           * 0 Infection rate
                                                                                                                                          * Community
* Med Supply Room                 * Staffing Pharmacist                                                                                      * Payers
   * Med Drawer                          * C-Admin              Administration                        * 0 Transfer of Germs
                                                                                                                                      * Regulatory agencies
                                          * Sunrise                                                                                           * Peers

                                                              Dilution and
                                          Obtain aseptic
                                                            reconstitution of   Preparation of line                           Flush before and
                    Handwashing          medications from                                                    Scrub the Hub
                                                             medication at          hook up                                   after medication

 Supplier                                 Input                   Process                        Output                Customer

                                         * Line policy                                         * Decrease line
                                             * Pump                                                infection
                                                                                             *No Complications               * Infant
 * Distribution                            * Flushes
                                                                                                 *Clean Hub                 * Family
*Sterile Supply                             *Alcohol
                                                                                                                         * Caregivers
*Supply Techs                          * Sterile Gauze       Scrub the Hub                    * decrease germs
                                                                                                                           * Hospital
  *Pharmacy                                 * Gloves
                                                                                                                            * Payers
 *Med-Select                        * Needle less system
                                                                                                                    * regulatory agencies
                                          * Syringes
                                          * Betadine

                                                                                                    Scrub while
                                                           Follow hand
                  Gather supplies           Prepare Area                     Open Supplies       repeating phrase
                                                                                                    three times

• Failure Mode Effects Analysis
• A procedure used to identify, assess, and
  mitigate risks associated with potential
  failure modes in a product, system, or
A- FMEA- Dressing Change
   Item Process Steps          Potential Failure Mode          Potential Effects of        Potential Cause's) of
                                                                    Failure                       Failure

           Text                           Text                        Text                          Text

Determine Dressing Change     Not changed                   Moist Contamination         Knowledge deficit (KD),
is required                                                                             lazy, it's not Tuesday, failure
                                                                                        to look, assumptions, in a

                              What is literature on 7 day                               No clear decisions criteria
                              dressing change? What's                                   (occlusive non occlusive,
                              reinforced?                                               red, etc)

                              Drsg may get changed twice                                KD - RN can get cx before
                              if cx is needed                                           new dressing placed on

Get second person to assist   Not getting 2nd person        Contamination, loose line   Too busy, staffing, needs to
                                                                                        be changed immediately.
A- FMEA Dressing Change
Failure Mode                  Severity   Frequency   Costs and Ease

# 1 Changing dressing         H          H           L
when due, & when it is
#3, #8 Having proper          H          H           M
# 11 Removing old             H          H           M-L
Dressing, no sterile field
under arm/leg
#12 Not Changing to new       H          M           L
sterile gloves
# 13 Q-Tip contamination      H          H           L

# 16 Using Solutions out of   H          H           L
# 18 Not letting Betadine     H          H           L
dry for 2 minutes

# 23 Looping the Line         H          H           L

# 25 Correct placement and    H          H           M
use of Tegaderm
A- FMEA Tubing Change
 Failure Mode             Severity   Frequency   Costs and

 #1 Bedside/              H          H           H
 Prep area not Clean
 #5 Priming               H          H           M
 Connection/ Tubing
 #6 Alcohol Ports/        H          H           L
 “Scrub the Hub”
 # 7, #8 Spiking Bag,     H          H-M         L
 Priming Tubing
 #13 Priming into Volu-   H          H           M
 Feed/ and in areas
 where visitors are

 #16 Alcohol connection   H          H           L
 point to patient

 # 18 Wearing gloves to   H          H           L
 connect line
A-Staff Survey
 1) A Clave (Blue end cap) needs to be primed before attaching it to a med line or bifuse.
    TRUE/FALSE           Answer: TRUE
 2) You should always wear gloves when hanging a med or flush and when hanging new IVF.
    TRUE/FALSE          Answer: TRUE
 3) How often do you need to change your med tubing?
    a) with every med
    b) every 24 hours     Answer: b

    c) every 48 hours
    d) every 72 hours
 4) What should you use to clean your patient's PICC LINE during a sterile dressing change?
    a) Betadine             Answer: a
    b) Alcohol
    c) Sali wipes
    d) None of the above
 5) Alcohol is used to clean your Broviac Line during a sterile CVL dressing change.
   TRUE/FALSE               Answer:TRUE
 6) How long should "Scrub the hub" take before breaking into a line?
   a) 1 second
   b) 3 seconds
   c) 5 seconds            Answer: c
   d) 10 seconds
 7) A small circle of Betadine should be left at the insertion site of your PICC/Broviac during a dressing change.
   TRUE/FALSE             Answer: FALSE
 8) How often should you change the dead ender/blue clave on the end of a capped CVL or UVC lumen?
   a) After any blood draw
   b) After giving blood products
   c) Every 7 days
   d) All of the above      Answer: d
 9) When doing a PICC line dressing change, where should your heart/disc be located?
   a) Underneath the tegaderm
   b) Outside of the tegaderm
   c) Underneath the tegaderm with a chevron. Answer: c
   d) Outside the tegaderm with a chevron.
 10) Who should you contact if your patient has impaired skin integrity related to the tegaderm dressing on a central line?
    a) the MD only
    b) the Charge nurse
    c) the CAT team (Central Access Team)
    d) Both a and c                   Answer: d
Survey Results
                                                                     Incorrect Responses
                                                                     Correct Responses














                 1   2   3   4     5         6      7   8   9   10
                                 Question Num ber
I- Improve

• Use of improvement tools, project
  management tools, and designing
• We chose PDSA (Plan, Do, Study, Act)
  –   Ran small scale experiments
  –   Captured data
  –   Reported back to group
  –   Used for full scale decision making
I-So what did we do?

• Staff education was #1
• Observation Data Collection Tools Created
• Using the FMEA, we identified those areas that could be
  changed quickly at little cost.
• Performed small scale experiments (IV fluids in pharmacy)
• Decreased variation by sharing proper techniques and
  monitoring with audits
• Changed out dressing change kits to help decrease need for
  obtaining supplies outside of the sterile field
• Established a partnership with the CAT and infection
• Maintenance and Insertion Checklists implemented and
• Measured reduction in defects
Parking lot
•   Track/follow CVL care in OR, how          •   New claves/posiflows, impregnated
    handled and if events occur                   lines, caths etc
•   Review NICU infection control policy      •   Hand washing in pharmacy
•   General Infection control-OR’s scrub      •   Med. Prep in pharmacy and at bedside
    routine vs. current NICU scrub            •   TPN/IL/meds under the hood
•   Update CVL P&P if changes identified      •   Patient handling and lines- Rad, PT,
•   Follow/track why CVLs discontinued            OT, RT
•   Drsg changes, how done, by whom,          •   Mechanism that assists with switching
    when done, migration rate and infection       from IV to PO meds
    occurrence                                •   Order set re; above and for line
•   Chlorohexadine for line changes               maintenance
•   Tubing change documentation, sticker      •   NICU CVL dressing team- core group
    use                                           vs. whole unit – “super user”
•   Electronic documentation                  •   Vanco Hep flushes
•   Medication Tubing change every 72         •   Hub care
    hours vs. every 24 hours                  •   Awareness Education on data/stats
•   Closest port to baby                      •   Utilize on the pot educational sheets
•   Reduce amount of times lines are
C-Awareness Board

• Ongoing Meetings
• Created public board that showcases:
  – Number of days since last infection
  – Tip of the week that is determined at prior

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