CLABSI Prevention: Resources & Best Practices Laurie Reyen MSN, RN March 3, 2016 1
CLABSI Prevention:
Resources & Best Practices Laurie Reyen MSN, RN
March 3, 2016
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Why CLABSI Prevention?
• Nurse Sensitive Indicator:
• AANC EO for Magnet Accreditation
• Hospital Acquired Condition Reportable at the State and National Level
• JC Patient Safety Goal
• Impact on the patient:
• Morbidity and Mortality
• Increase LOS : 7 to 21 days
• Increases cost of care: $ 35,000 – $45,000
• Impact on the organization:
• Decreased reimbursements from CMS
• Publically available- impacts the public’s trust and confidence
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CLABSI Prevention:Best Practices
Bundle Time
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CLABSI Prevention:Best Practices
CLIP Bundle
• Central Line Insertion Practices:
• Practice hand hygiene before and after device insertion
• Use maximal sterile barrier precautions (mask, large drape, cap, sterile gloves) for CVC insertion
• Prep skin with appropriate antiseptic: CHG, unless contraindicated
• Allow skin prep agent to dry before puncture
• Avoid using the femoral vein for central venous access in adult patients whenever possible
• Document compliance with CLIP bundle
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CLABSI Prevention: Best Practices
CVC Maintenance Bundle
• CVC Maintenance:
• Daily assessment of line necessity
• Critical assessment and decision making about condition of site/dressing
• Sterile CVC dressing change
• Access – 15 second scrub before entering line
• Standardized Cap change
• Curos cap
• 2% CHG Bathing
• Patient/family education about risk of CLABSI.
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CLABSI Prevention: Best Practices
Active Daily Management
• Active Daily Management
• Talk the Line
• LNQIT
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Indicator Symbol on
Tool
Interpretati
on of
Symbol
Action Required based on
Symbol
CHG
Date
Date reflects
last
documented
CHG treatment
If CHG treatment date is >24hrs
communicate with RN and CP as to the
importance of compliance with CHG
treatment. Follow up with those that
missed the treatment.
Foley CAUTION
SIGN
Indicates that
the patient has
an active Foley
catheter
Communicate with RN and discuss
clinical indication and CAUTI
prevention strategies. Discuss Nurse
Driven Protocol that allows for removal
of Foley without an MD order if clinical
indication is no longer met.
Central
Line,
Porta
Caths,
Dialysis
CAUTION
SIGN
Indicates the
patient has an
active Central
line, Dialysis
Catheter or
Porta-cath.
Communicate with RN clinical necessity
and CLABSI prevention strategies.
Enforce removal of line as soon as
indication is no longer being met.
Ensure dressing changes are up to
date. Review infection prevention
strategies including utilization of Curos
Caps.
CLABSI Prevention Resources: Policies
• Two major policies guide nursing practice:
• Central Line Policy 104
• Prevention of CVC Related Bloodstream Infections HS 1401
• Evidence Based Guidelines and Standards:
• CDC Guidelines for Prevention of Intravascular Catheter Related Infections
• INS - Infusion Nursing Standards of Practice, 2016
• Joint Commission Patient Safety Goal NPSG .07.04.01
• Use proven guidelines to prevent infection of the blood from central lines.
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CLABSI Prevention Resources:People
• Laurie Reyen, Subject Matter Expert
• PICC Team
• Clinical Epidemiologists
• Unit Specific
• Unit Champions
• CNS/Educators
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CLABSI Prevention Resources:
Surveillance Data
• Unit Specific Data is sent out monthly by Epidemiology, includes:
• CLABSI Rates
• CLABSI SIR
• CLIP Compliance
• Unit specific data is also available on unit dashboards.
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Target Threshold Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16
UCLA Organizational Goals: Quality, Safety, & Service
Quality
Infection Prevention: Data retrieved from Epidemiology Department, Quality Dashboard, MAPS Report, Prevalence Day
Centra l Line Infections Standardized Infection Ratio (SIR)<1
<1: green; 1.01-1.5:
yellow; 1.6+: red0.00 0.00 0.00 1.78 2.07 0.00 1.59 0.00 2.02 0.00 1.79 2.20 0.00
CLABSI Mini -Root Cause Analys is Compl iance100%
>95: green; 90-94%:
yellow; <90%: red- - - 0% 100% - 100% - 100% - 100% 100% -
CAUTI Standardized Infection Ratio (SIR)<1
<1: green; 1.01-1.5:
yellow; 1.6+: red0.52 0.67 0.52 1.46 1.00 0.65 0.45 1.41 0.00 2.21 0.57 0.00 0.00
CAUTI Mini -Root Cause Analys is Compl iance100%
>95: green; 90-94%:
yellow; <90%: red0% 0% 0% 33% 50% 100% 100% 100% - 100% 100% - -
CVC Compl iance Bundle Checkl is t (ICUs only)100%
>95: green; 90-94%:
yellow; <90%: red100% 100% 96% 100% 100% 100% 99% 100% 95% 100% 100% 97% 100%
Hand Washing Between Patient Contact (MAPS)
RNs/CPs95% >95%: green; 91-94%:
yellow; <90%: red100% 100% 100% 100% 92% 96% 96% 99% 100% 98% 100% 100% 94%
CHG Treatment Performed in Last 2 Shi fts95%
>95%: green; 91-94%:
yellow; <90%: red100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
Overal l Foley Care Compl iance95%
>95%: green; 91-94%:
yellow; <90%: red99% 93% 100% 99% 95% 100% 91% 99% 96% 99% 98% 100% 99%
FY 2015RR UCLA Medical Center
Performance DashboardFY 2016
CLABSI Prevention Resources:
Surveillance Data
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CLABSI Prevention Resources:
Surveillance Data
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Target Threshold Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16
UCLA Organizational Goals: Quality, Safety, & Service
Quality
Infection Prevention: Data retrieved from Epidemiology Department, Quality Dashboard, MAPS Report, Prevalence Day
Centra l Line Infections Standardized Infection Ratio (SIR)<1
<1: green; 1.01-1.5:
yellow; 1.6+: red0.00 0.00 0.00 1.78 2.07 0.00 1.59 0.00 2.02 0.00 1.79 2.20 0.00
CLABSI Mini -Root Cause Analys is Compl iance100%
>95: green; 90-94%:
yellow; <90%: red- - - 0% 100% - 100% - 100% - 100% 100% -
CAUTI Standardized Infection Ratio (SIR)<1
<1: green; 1.01-1.5:
yellow; 1.6+: red0.52 0.67 0.52 1.46 1.00 0.65 0.45 1.41 0.00 2.21 0.57 0.00 0.00
CAUTI Mini -Root Cause Analys is Compl iance100%
>95: green; 90-94%:
yellow; <90%: red0% 0% 0% 33% 50% 100% 100% 100% - 100% 100% - -
CVC Compl iance Bundle Checkl is t (ICUs only)100%
>95: green; 90-94%:
yellow; <90%: red100% 100% 96% 100% 100% 100% 99% 100% 95% 100% 100% 97% 100%
Hand Washing Between Patient Contact (MAPS)
RNs/CPs95% >95%: green; 91-94%:
yellow; <90%: red100% 100% 100% 100% 92% 96% 96% 99% 100% 98% 100% 100% 94%
CHG Treatment Performed in Last 2 Shi fts95%
>95%: green; 91-94%:
yellow; <90%: red100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
Overal l Foley Care Compl iance95%
>95%: green; 91-94%:
yellow; <90%: red99% 93% 100% 99% 95% 100% 91% 99% 96% 99% 98% 100% 99%
FY 2015RR UCLA Medical Center
Performance DashboardFY 2016
CLABSI Prevention Resources:
Process Metrics
• Process metrics measured on prevalence day:
• CHG Compliance
• Curos Caps
• CVC Maintenance
• Learning from events:
• MRCAs provide useful information on gaps in practice, patient specific risk factors, and system failures.
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CLABSI Prevention Resources:
Process Metrics
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Unit Based Innovations
• 2 RN Dressing Change
• Standardized Dressing change days
• 8ICU CUSP Project
• Video Education- 6 East
•Good Video •Bad Video
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