Creating Culture of Safety

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					Prevention of Central Line Associated
Bloodstream Infections (CLABs)


    Quality and Patient Safety
    Effectiveness and Outcomes

    Beth Israel Medical Center
    Petrie and Kings Highway Divisions
             CLABs Myths
   Our infection rates are below national
    benchmarks - which is good enough.
   CLABs are inevitable. It is the price we pay
    for sophisticated, complex care of severely
    ill patients.
   CLABs are benign and readily treated with
    antibiotics.
   CLABs are a common accompaniment of
    complex care and covered by outlier
    payments.
           Lessons Learned

   We can come surprisingly close to
    eliminating    hospital     acquired
    infections with determination as
    opposed to resources
   Our data must not only be reportable
    but actionable
       Save lives
       Reduce costs
       Reduce error and waste
             How We Did It

   Make data actionable
   Observe variations in work practices
   Real time problem solving of origins of
    CLABs
   Implement and test practice changes
        Make Data Actionable
   Start small
   Use and monitoring of evidence based
    patient care practices or “bundles” with
    reporting back of data to end users
   Counter measures generated by the people
    who do the work
       Process that generates sustainable fixes
       Avoid “workarounds” that are constantly
        repeated
       Set a time to achieve goal
   Plan-Do-Study Act (PDSA) methodology
              Beth Israel Medical Center

   Petrie Division
   Kings Highway Division

   94 ICU beds
       3,000 discharges
   824 non-ICU beds
       43,000 discharges

   1,200 central lines placed annually
       40% of patients in ICU with central line
       Average length of stay for patients with central line = 5 days
       Average length of stay for patients with CLAB = 10 days
       CLABs rate of 9 per 1,000 device days or 3.8% in 2004
            Beth Israel Medical Center
                CLABs Prevention
   June 2005
       ICU
       MICU, SICU

   August 2005
       CCU and CSICU

   December 2005
       Emergency Departments

   January 2006
       General Medical Surgical Units

   April 2006
       Operating Room

   August 2006
       NICU and PICU
                    Multi-disciplinary CLABs
                        Team Members
Physicians                                  Patient Care Services
 Chief Medical Officer                      Vice President
 Associate Chairman, Department of          Director
   Medicine                                  Nurse Manager
 Director                                          ICU, MICU, SICU
        ICU, MICU, SICU                            Emergency Room
        Emergency Room                        Nurse Education Manager
        Medical and Emergency Department
         Residency Programs
                                            Other
   Intensivist
                                             Director
   Critical Care Fellow                            Materials Management
                                                    Housekeeping
Infection Control                                   Respiratory Therapy
 Hospital Epidemiologist                           Quality Improvement
 Manager                                      Pharmacist
 Practitioner                                 Dietician
             Multi-disciplinary CLABs Team
                        Principles


   It is not good enough that our infection rates
    are below national benchmarks.

   CLABs are preventable, they are not an
    inevitable consequence of sophisticated,
    complex care that we provide to our severely
    ill patients.
           Multi-disciplinary CLABs Team
                      Principles


 CLABs can be eliminated by determination as
  opposed to additional resources.
 Strict adherence to evidence based patient
  care practices, called “bundles” that will
  improve patient safety and reduce adverse
  patient outcomes is required.
             Multi-disciplinary CLABs Team
                        Principles

   Patient hospital length of stay, morbidity and
    mortality can be reduced through prevention
    of CLABs.

   We can reduce the Medical Center’s costs
    incurred for the care of patients with CLABs.
    CLABs

                       BIMC   USA       Mortality = 18%
Patients in ICU with   40%    48%       ICU risk 8x >non-ICU
Central Line
                                        Additional $40,000 to
CLABs Rate             3.8%   4%
                                         hospital costs
Increase LOS           5d     14 d          Hospitals absorb the
                                             costs!


  Nationally:
  80,000 CLABs in ICUs per year
  14,500 CLABs deaths
                 Costs Incurred
         For Care of Patients with CLABs

                                             Incremental               Annual
              Discharges    CLAB               Cost Per              Incremental
               Per Year    Patients         CLAB Patient                Costs


94 ICU Beds     3,000        24                $40,000                $960,000


824 Non-ICU
               43,000        22                $25,000                $550,000
Beds


                 Total Incremental CLAB Costs                        $1,510,000




                             Used BI BSI information and discharge
                                     information from 2004
            Multi-disciplinary CLABs Team
                    Aims and Goals

   Process that generates sustainable fixes
   Avoid “workarounds” that are constantly
    repeated
   Collaborative process
   Knowledge gained from this process is shared
    with all
   Our data must not only be reportable but
    actionable
            Beth Israel Medical Center
                CLABs Prevention

   Physician and Nurse reeducation and
    recertification on central line insertion
    technique and maintenance practices

   Standardization of practices to ensure
       Maximal barrier protection utilized
       Skin prep with chlorhexidine
       Preference for subclavian site        unless
        medically contraindicated
            Beth Israel Medical Center
                CLABs Prevention

   Nursing     empowerment       to     monitor
    practices
       Nursing permitted to ask and stop other
        persons who do not follow appropriate
        practices
       Hand hygiene compliance
            Beth Israel Medical Center
                CLABs Prevention

   Daily review of line necessity

   Root cause analysis performed in real
    time for every CLAB

   Development of a central line insertion kit
       Barrier precaution components
       Insertion components
       Maintenance components
Beth Israel Medical Center
CLABs Prevention
Education and Recertification


Standardization of Practices and Documentation
but also:
  HospitalSpecific
  Department Specific

  Unit Specific
             2005 Infection Control Policy
       for Prevention of Intravascular Infection

                             BETH ISRAEL MEDICAL CENTER                                                DISTRIBUTION All Manual Holders
                              INFECTION CONTROL POLICY
                                                                                                       PURPOSE        To provide the Registered Nurse with the guidelines for dressing and cap change
                                            MANUAL CODE:                                                              on a central venous access device (includes single/double lumen catheters,
SUBJECT:              Guidelines for Prevention of Intravascular Infection                                            implanted venous access ports, triple lumen catheters and PICC lines.)
EFFECTIVE:            February 2005
                                                                                                       POLICY         This procedure may be performed by a Registered Nurse whose competence
DISTRIBUTION:         Nursing Units, Nursing Administration/Education Clinical Department                             has been demonstrated.

                                                                                                                      Central Venous Access Device dressings are changed at least every 7 days or if
Reviewed                                                                                                              they become damp, soiled, loose or if inspection of the site or catheter change is
Revised      8/05                                                                                                     necessary. In addition, dressings on implanted ports must be changed when the
                                                                                                                      non-coring needle is changed once every five days. Caps must be changed
                                                                                                                      whenever the integrity of the cap has been compromised but not less than once
I.     Handwashing                                                                                                    a week on Mondays.

       A.     Wash hands with soap and water or use alcohol based hand rub solution prior to           EQUIPMENT
              starting the procedure.                                                                  A Dressing Change Tray (sterile) containing:
       B.     Verify the patient’s identity by name and birth, explain the procedure and obtain          powder-free vinyl gloves (one pair)    towel
              informed consent.                                                                          dressing                               tape
                                                                                                         ChloraPrep One-Step                   mask (optional)
II.    Surveillance for Catheter-Related Infection                                                       Biopatch® chlorhexidine foam pad       cotton tip applicator (optional)
                                                                                                         clean gloves (one pair)
       A.     Palpate the catheter insertion site for tenderness daily through the intact dressing.
                                                                                                                      PROCEDURE                                           KEY PONTS
       B.     Visually inspect the catheter site if the patient develops tenderness at the insertion      1. Verify the patient’s identity by name
                                                                                                             and date of birth.
              site, fever without obvious source, or symptoms of local or blood stream
              infection.
                                                                                                          2. Wash hands and don clean gloves.
III.   Barrier Precautions During Catheter Insertion & Care                                               3. Carefully remove the old dressing           Touch only the outer layer of the dressing to
                                                                                                             completely and discard.                     avoid contamination
       A.     Wear clean gloves when inserting a peripheral venous catheter and during
              catheter dressing site changes required by the Occupational Safety and Health               4. Inspect the insertion site for color,       Look for leakage, swelling. bruising,
              Administration (OSHA). Bloodborn Pathogens standard. Sterile Gloves are not                    tenderness, swelling or any discharge.      tenderness, redness and general skin
              required.                                                                                                                                  condition. Notify physician of any changes.
                                                                                                          5. Remove gloves and wash hands
       B.     Use sterile technique, including the use of a sterile gown and gloves, a mask, cap,
              and a large sterile drape (i.e., maximal barrier precautions) for the insertion of          6. Open the Dressing Change Tray and           Strict aseptic technique is essential when
              central venous lines including PICCs and guidewire exchanges. Use these                        don the sterile gloves                      carrying out any procedure involving central
              precautions, even if the catheter is inserted in the operating room.                                                                       venous access catheter
                                                                                                          7. Prep the skin with ChloraPrep One-
       C.     During central line catheter dressing site care, use a mask and sterile gloves.                Step
                                                                                                          a. Pinch the wings on the applicator to        Do not touch the sponge
IV.    Selection of Catheter Insertion Site                                                                  break the ampule and release the
                                                                                                             antiseptic
                 Beth Israel Medical Center
                    CLABs Prevention
                Education and Recertification

   Indications
   Anatomy
   Procedure
       “Time Out”
       Universal Protocol
       Patient Position
       Skin Preparation
       Maximal Barrier Precautions
       Anesthesia
       Approach
       Dressing
       Additional Expectations
           Clean up
           Monitor for complications
        Procedure Competency Form
                                                                                                                            Assessment of Procedure

                                                                                             ______ Informs patient of procedure including risks and benefits and obtains consent (if
Procedure Competency Form:                                                                            appropriate for circumstances)
Central Line /Transvenous Pacemaker
                                                                                             ______ Observes universal precautions
                                                        Patient Addressograph
                                                                                             ______ Positions patient properly

                                                                                             ______ Maintains proper sterile technique
Resident: ____________________ Observing Faculty: _______________________
                                                                                             ______ Uses ultrasound appropriately to identify vessel/patency
Date: _______________________              Line Site:       IJ              R      L
                                                            Subclavian      R      L         ______ Central line flushed if appropriate
Procedure:    Central Line                                 Femoral         R      L
                                                                                             ______ Skin prep appropriate for procedure
              Transvenous Pacemaker                        if femoral, reason for choice
                                                            _____________________            ______ Appropriate local anesthesia

Indication: ____________________________                    # or Attempts _________          ______ Needle aimed at proper angle and direction

Time Out @ ___________AM/PM                                                                  ______ Resident able to analyze and correct potential reasons for unsuccessful procedure
Verified Correct (all must be verified):   Patient   Procedure Site/Side                  ______ Venous blood obtained
                            Position            Supplies       Equipment
                                                                                             ______ Wire introduced and syringe removed
_________________________ RN/MD              ________________________RN/MD
                                                                                             ______ Skin cut made prior to inserting catheter dilator
Consent Signed and In Chart
                                                                                             ______ Wire withdrawn as catheter advanced
Sterile Technique & Order of Procedure                     Operator / Sup    Check          ______ Confirmation of port function
      1. All equipment at bedside                           __________/______  
                                                                                             ______ Catheter secured in place
      2. Wash hands (before procedure)                      __________/______  
      3. Prep with Chlo-prep x 3                            __________/______               ______ Patient cleaned up and proper dressing applied ( Bio-Patch placed )
      4. Gown                                               __________/______               ______ Sharps disposed of in appropriate container
      5. Gloves                                             __________/______  
      6. Cap                                                __________/______               ______ Confirmatory x-ray ordered and reviewed as necessary

      7. Drape                                              __________/______  
      8. Time-out                                           __________/______               Assessment: Unsatisfactory            Proficient           Mastered

      9. Procedure with sterile technique                   __________/______               Comments:
      10. Place Bio-patch                                   __________/______  
      11. Dressing with date                                __________/______  
      12. Dispose sharps                                    __________/______  
      13. Wash hands (after procedure)                      __________/______               Faculty Signature:________________________                 Date: __________________


________________________________________________________________
                                                                                             Resident Signature: _______________________                Date: __________________
                                Continued on Reverse Side
Beth Israel Medical Center CLABs Prevention
        Education and Recertification

Generated By:                     Beth Israel GME & Residency                  05/03/06 05:40
                                            Manager

                                  Procedure Report: Summary

Medical Resident KM                              Review Status                Medicine

                                                                  No
          Procedure                Logged Acc. Rej. Pend.               Req. Exp. Compliance
                                                                 Rev.

Central Venous Line Placement
                                      2      0     0    0         2      5         NC (40%)
- Femoral Line Insertion
Central Venous Line Placement
                                      1      0     0    0         1      5         NC (20%)
- Internal Jugular Insertion
Central Venous Line Placement -
                                      6      6     0    0         6      5        C (100%+)
Subclavian Insertion
Beth Israel Medical Center
CLABs Prevention
Standardization of Practices


 Enforcement   of Policy and Procedure
 Procedure Note

 Insertion Kit

 Nursing Empowerment
                 BETH ISRAEL MEDICAL CENTER
              VASCULAR ACCESS PROCEDURE NOTE

Date: _________________
Time Out at _______ AM/PM
Verified Correct (all must be verified):   Patient   Procedure         Site/Side
Position             Supplies            Equipment

_________________________ RN/MD               ________________________RN/MD

Central vein:                 R L
Pulmonary artery:             R L
Transvenous pacemaker         R L
subclavian internal jugular femoral (if femoral, reason for choice)
________________________________________________________________

Arterial:     R     L             radial       femoral other_______________

Indication(s):
_________________________________________________________

Consent in chart      Operator(s): _______________________________________

Central Line Check List :
1-all equipments at bedside                     8-Time-out
2-Wash hands                                    9-Mask
3-Chlor- prep                                  10-procedure with sterile technique
4-Gown                                         11-Bio-Patch
5-Gloves                                       12-Dressing with date
6-Cap                                          13-Dispose sharps
7-Drape                                        14-wash hands

Anesthesia: _________________________________________________________

Technique: _________________________________________________________

Comments: ________________________________________________________

Complications: ______________________________________________________


__________________________________________________________________
Signature/Title
Time:_______
Central Line Insertion Kit
   Compliance - Central Line Bundle

         100
          90
          80
          70
          60
Rate (%) 50
          40
          30
          20
          10
           0
               Aug   Oct   Dec   Feb    Apr   Jun   Aug

                                 Time
                 Results
         Data from PDSA Cycles

                          Number of             Costs of
                           CLABS                 CLABS
2004                         46                $1,510,000

2005                            18              $705,000

2006                             7              $392,000

2007                             2              $112,000

Incremental cost per episode of CLAB ranges from $25,000 to $56,000
(CDC data: Burke 2003)
                  Results
          Data from PDSA Cycles

                          Number of               Attributable
                           CLABS                   Morbidity
                                                 and Mortality
  2004                          46                      9
  2005                          18                    4
  2006                           7                    2
  2007                           2                    0

Attributable morbidity and mortality: 12 – 25%
(Wenzel 2001)
                    Results
            Data from PDSA Cycles
   Significant reduction in CLABs
       95% reduction for institution
       Achievement of zero CLABs on a variety of units
       Reduction in morbidity and mortality
   Daily review of need for line necessity
       20% decrease in central line days
   Reduction in costs incurred in caring for
    patients with CLABs
       $1,500,000 costs avoided
       90% reduction in costs from 2004
       Costs to implement
           Additional $15 per line inserted
           Total additional costs $30,000
Beth Israel Medical Center
CLABs Prevention
       Unit       Longest Duration of Days
                       Without CLAB
CCU                         644
ICU                         601
ED                          547
SICU                        483
PICU                        396
non-ICU                     345
MICU                        344
CSICU                       300
Beth Israel Medical Center
CLABs Prevention ICUs

       5

       4

       3
Rate




       2

       1

       0
           2004         2005          2006         2007

           Rate per 1,000 Line Days   Rate per 100 Patients
BETH ISRAEL MEDICAL CENTER
CLABs Prevention CCU
Rate per 1,000 line days




                           10
                           8
                           6
                           4
                           2
                           0
                                 Q4   Q1   Q2   Q3   Q4   Q1   Q2   Q3
                                2005 2006 2006 2006 2006 2007 2007 2007
                                                 YEAR
                                           CCU    NHSN     NYS
 Beth Israel Medical Center
 CLABs Prevention
 Root Cause Analyses


Within  24 hours of a CLAB
All involved patient care staff
   4– 12 persons
   ED, ICU, non-ICU

   20 – 45 minutes

   Collaborative, non-punitive process
Beth Israel Medical Center
CLABs Prevention
Root Cause Analyses


Process that generates sustainable fixes
Avoid “workarounds” that are constantly
repeated
Knowledge gained from this process is
shared with all
            Beth Israel Medical Center
                CLABs Prevention
        Root Cause Analysis – August 2005
   84 year old female with a history of hypertension, CHF,
    cardiac arrhythmia with pacer, insulin dependent diabetes
   Admitted to ICU with CHF exacerbation, pleural effusion
   Developed acute renal failure requiring dialysis
       Nephrologist places Shiley catheter
       Groin site chosen
       Difficult procedure requiring multiple attempts
       Maximal barrier precautions not fully utilized

   Nursing staff attempt to assist
       Call intensivist to place line

   Blood cultures positive for C. albicans 48 hours later
            Beth Israel Medical Center
                CLABs Prevention
        Root Cause Analysis – August 2005

   Nephrologist conducts RCA
       Credentialed
       Central line indicated
       Urgent not emergent
       Supplies available and easily obtainable but not fully
        utilized for maximal barrier precautions
       Need to ask for assistance sooner rather than later
   Corrective Actions
       Central line insertion kit
       Nursing staff empowered and more comfortable with role
       Reeducation and recertification of nephrologist
             Beth Israel Medical Center
                 CLABs Prevention
               Root Cause Analyses

2005
 Central Line Care
       Dressings
       Access
   Insertion Practices
       Maximal barrier precautions
       Supplies never an issue
       Certification of physicians
                                Results - Data from PDSA Cycles
Rate per 1,000 line days
                                           ICU CLABs


                           10
                           8
                           6
                           4
                           2
                           0
                                 2004    Q1     Q2     Q3     Q4     Q1
                                        2005   2005   2005   2005   2006
                                                 YEAR
                                               ICU    NHSN
            Beth Israel Medical Center
                CLABs Prevention
              Root Cause Analyses

2006
 Central Line Care
       Dressings
       Access


   Maintaining the momentum
                  Rate per 1,000 line days




                          0
                              2
                                  4
                                      6
                                          8
                                              10
                  20
              Q
                1 04
                  2
              Q 00
                2     5
                  20
              Q
                3 05
                  2
              Q 00
                4     5
                  20
              Q
                1 05
                  2
              Q 00
                2     6




ICU
                  20
              Q
                3 06
                  2

       YEAR
              Q 00
                4     6
                  20
                                                              ICU CLABs




              Q

NHSN
                1 06
                  20
              Q
                2 07
                  20
              Q
                3 07
                  20
                     07
                                                   Results - Data from PDSA Cycles
             Beth Israel Medical Center
                 CLABs Prevention
   Use and monitoring of evidence based patient care practices
    or “bundles” with reporting back of data to end users
    resulted in the rapid and sustained elimination or decreased
    incidence of CLABs on many units
   Limited additional resources were necessary for the success
    of this initiative
   Efforts were effective for all areas of the hospital where
    central lines are inserted
   As compliance with insertion bundle improves, line
    maintenance has assumed a greater role in the prevention
    of CLABs
   Culture change regarding goal of zero CLABs infections is
    applicable for all hospital acquired infections and patient
    safety issues
                     GNYHA/UHF CLABs
                          Collaborative
                     Participating Hospitals
•    Beth Israel Medical Center                                •   North Shore-Long Island Jewish Health
•    Bronx-Lebanon Hospital Center                                 System, including:
•    Brookdale Hospital Medical Center                              –   Forest Hills Hospital
                                                                    –   Franklin Hospital
•    Cabrini Medical Center                                         –   Glen Cove Hospital
•    Good Samaritan Hospital Medical Center                         –   Huntington Hospital
•    Interfaith Medical Center                                      –   Long Island Jewish Medical Center
•    Kingsbrook Jewish Medical Center*                              –   North Shore University Hospital
•    Kingston Hospital*                                             –   Plainview Hospital
•    Lenox Hill Hospital                                            –   Southside Hospital
                                                                    –   Staten Island University Hospital
•    Long Beach Medical Center                                      –   Syosset Hospital
•    Long Island College Hospital                              •   Peninsula Hospital Center
•    Lutheran Medical Center                                   •   Richmond University Medical Center*
•    Montefiore Medical Center                                 •   Sound Shore Medical Center of
•    Mount Sinai Hospital                                          Westchester
•    Mount Sinai Hospital of Queens                            •   St. Catherine of Siena Medical
•    New York Downtown Hospital                                •   St. Charles Hospital
•    New York Hospital Queens*                                 •   St. Joseph’s Medical Center, Yonkers*
•    New York Methodist Hospital                               •   St. Luke’s - Roosevelt Hospital Center
•    New York-Presbyterian Hospital                            •   St. Luke's Cornwall Hospital
•    New York University Medical Center                        •   St. Vincent’s Medical Center, Manhattan*
•    North General Hospital                                    •   Stamford Hospital
•    Our Lady of Mercy Medical Center                          •   The Parkway Hospital*
                                                               •   Trinitas Hospital
*Hospitals that joined the CLABs Collaborative in the second   •   Winthrop University Hospital*
round of participation (i.e., in August/September 2006).
                                                               •   Wyckoff Heights Medical Center
       GNYHA-UHF CLABs Collaborative
        Characteristics of Participating
                  Hospitals
• 38 hospitals participating, 56 ICUs*
• At inception of Collaborative, hospital practice was widely
  variable across participants:

Area of Focus                      Consistently Use               Inconsistently       Do Not Use
                                                                       Use
Daily Goals Sheet                             21                         7                26
Interdisciplinary Rounds                      45                         9                 2
Central Line Bundle                           11                        27                17
Ventilator Bundle                             16                        30                10


             GREAT OPPORTUNITIES FOR IMPROVEMENT!
   Responses obtained from ICUs within participating hospitals.
   *Note that these were responses from the original group of 38 CLABs Collaborative
   participating hospitals.
GNYHA-UHF CLABs Collaborative
          Design
• Systematic model for change that would

  – Meet needs of hospitals within the
    region
  – Use existing staffing and financial
    resources
      GNYHA/UHF CLABs Collaborative
                Design
•    Hospital leadership involvement and commitment
•    Interdisciplinary teams / Physician and Nurse champions
•    Evidence-based interventions: Implemented “Central Line Bundle”
•    3 learning sessions: Reviewed key interventions for eliminating CLAB infections,
     guidelines for inserting central line, materials needed, maintaining central lines,
     hospital best practices, and approaches to sustaining improvements.
•    Bi-weekly conference calls: Shared information / tools specific to reducing CLAB
     infections.
 •   Collaborative web site for information-sharing: http://jeny.ipro.org/clabs
 •   “Expert on Call” clinical consultant
 •   Reinforcement of “zero tolerance” for CLAB infections
•    Standardized Materials: Teams developed and used standardized data collection
     and definitions
•    Root Cause Analysis (RCA): Real time RCAs encouraged to identify reasons for
     CLABs and develop solutions for prevention
•    Tracking Success: Aggregate and hospital-specific results reported monthly and
     site visits made by Collaborative sponsors to identify areas in need of support
       Central Line Bundle: Hospital teams identified the “central line bundle” as a strategy to prevent infection
          during central line insertion. Components include: hand hygiene, use of maximal barrier precautions,
                       chlorhexidine skin use, site of line placement, and review of line necessity.
      All necessary supplies should be available at the patient’s bedside when needed (creation of central line insertion kit).
CLABs Collaborative Website: http://jeny.ipro.org/clabs
           Examples of Findings from
             Root Cause Analyses
Line                       Technique              Lack of Education
Maintenance                not adequate           and Staffing

  Line not changed            Not compliant with            Inexperienced
  on timely basis             hand hygiene                  residents and clinicians
    Line in for too long           Line inserted w/o           Clinicians not
                                   sterile technique           knowledgeable about
       Dressing not                                            Central Line Bundle
                                      Inadequate use of
       changed using
                                      maximal barrier              Nurses do not properly
       aseptic techniques
                                      precautions                  know how to change
           IV tubing not labeled         Inadequate prep           dressings
           properly to change            before insertion
                                                                        MD does not get
              Line not manipulated          Femoral line                someone to assist with
              appropriately                 chosen instead of           line insertion
                                            subclavian
                                                                          Nurses too busy to check
                                                                          & change dressings

                                                                                 Central Line–
                                                                                 Associated
                                                                                 Bloodstream Infection
              Barriers and Solutions
        Barrier                              Solution
                                       Development of central line
                                      insertion & maintenance kits
                                Creation of monitoring tools to assure
    Lack of Compliance           compliance with bundle components
       •Maintenance             Empowerment of nursing staff to stop
        •Technique               procedure when bundle not followed
                               Daily rounds to assess line necessity and
                                    assure appropriate maintenance

                               Development of Department/Hospital-wide
                                       educational programs re:
                                      insertion and maintenance
Lack of Education & Staffing          Reorganization of staffing
                                  to monitor and assure compliance
                                Creation of protocols in which nursing
                                     signs off on dressing rounds

   Lack of Standardized          Adoption of CDC’s NHSN definitions
      Data Collection           Monthly data fed back (CLAB infection
                               rates) to participating hospitals and staff
              GNYHA-UHF Collaborative
               15-Month Data Results*
Bundle Implementation1:
•       88% reported full implementation; remaining 12% in process of fully implementing
•       Mean pre-bundle implementation CLAB infection rate = 4.02 infections / 1,000
        central line days
•       Mean post-bundle implementation rate = 1.79 infections / 1,000 (p Value <0.0001)
Overall Aggregate CLAB Infection Data:
•       Mean baseline rate = 4.86 infections / 1,000 central line days
•       Mean fifteen-month study period2 infection rate = 2.38 infections / 1,000
•       51% overall decrease (p Value <0.0001)
Comparison of CLAB Infection Data in 3-month Cohorts during 15-
  month Study Period2:
•       Mean first three months (July through September 2005) = 3.10 infections / 1,000
        central line days
•       Mean last three months (July through September 2006) = 1.76 infections / 1,000
•       43% decrease during the course of the study period (p Value = 0.015)
Maintaining Zero CLAB Infections during 15-month Study Period2:
•       29 hospitals (81%) maintained zero for at least 3 months
•       8 hospitals (22%) maintained zero during the last 6 months
    Notes:
    1Bundle implementation, reported by 34 of the 38 original participating hospitals through an Interventions Survey developed by Collaborative
    sponsors, April 2006.
    2 Study Period includes data collected by 36 of the 38 original participating hospitals from July 2005 through September 2006.
    *Includes data from 36 of the 38 original participating hospitals
                                                                         Monthly ICU Central Line Infection Rates for Hospitals Participating
                                                                           in the GNYHA/UHF CLABS Quality Improvement Collaborative
                                                                                                 Round 1 Hospitals
                                                      6.00
Central Line Infections per 1,000 Central Line Days




                                                      5.00 4.52
                                                                  5.01     4.26


                                                      4.00
                                                                                  3.18

                                                                                                2.70
                                                      3.00

                                                                           2.55                               2.77                               2.46                                    2.44
                                                                                                                     2.69                                                  2.37
                                                                                                                                          2.27                                                  2.21          2.04
                                                                                                       2.47                 2.15
                                                      2.00                               2.33                                                                  1.94 2.02          1.87                 1.80          2.02

                                                                                                                                   1.65                 1.68                                                           1.65
                                                                                                                                                                                                       1.33
                                                      1.00



                                                      0.00
                                                          Baseline Jul-05 Sep-05 Nov-05 Jan-06 Mar-06 May-06 Jul-06 Sep-06 Nov-06 Jan-07 Mar-07 May-07
                                                                        Monthly ICU Central Line Infection Rates for Hospitals Participating
                                                                            in GNYHA/UHF CLABS Quality Improvement Collaborative
                                                                                                Round 2 Hospitals

                                                      6.00
Central Line Infections per 1,000 Central Line Days




                                                               5.13

                                                      5.00
                                                                                                      4.75


                                                      4.00
                                                                                                                            3.31


                                                      3.00

                                                                           2.62       1.88
                                                      2.00                                                         2.45                 1.73


                                                                                                0.88
                                                      1.00

                                                                                                                                                0.68     0.81

                                                      0.00
                                                             Baseline     Oct-06   Nov-06    Dec-06      Jan-07   Feb-07   Mar-07   Apr-07     May-07   Jun-07
    Decreasing Incidence of MDROs!
                       BIMC      Petrie      KHD
MRSA                              65%        50%
VRE                               15%        25%
MDR Klebsiella                    15%        20%
MDR Acinetobacter                 45%        50%
C. difficile                      10%        35%

               Costs avoided: $1.5 million
Thank You

				
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