CLABSI REDUCTION - AAMN · CLABSI REDUCTION UTILIZATION OF ... intervention is paramount for preventing the occurrence of CLABSI (Chai Koh, Robertson, ... ACE Star Model of Knowledge

CLABSI REDUCTIONUTILIZATION OF POLICY DRIVEN EDUCATION PROGRAM THAT IMPLEMENTS

THE USE OF CHLORHEXADINE DURING INSERTION AND SUBSEQUENT SITE CLEANSING TO REDUCE INFECTION RATES

Dustin Williams, DNP, APRN, FNP-C, ENP-BC

Why this project is important

Question…..

•In your facility, what site cleansing preparation is used prior to PICC or central line insertion?

What is CLABSI

• Central Line Associated Blood Stream Infection

• Fever and leukocytosis with a leukocyte count greater than 13,500 without apparent cause or infectious diagnosis (i.e. pneumonia, meningitis, cellulitis) along with at least one of the following; discharge from the insertion site, pain at the insertion site or erythema at the insertion site

Project Objectives• Implement a Evidence Based Policy and Protocol for site

cleansing at insertion and at dressing changes for central venous catheters and peripherally inserted central catheters

• Provide staff education focusing on CLABSI reduction by utilizing appropriate site cleansing at insertion and dressing changes by policy and protocol adherence

• Compare the rate of CLABSI before and after implementation of an staff educational program, policy and protocol on site cleansing and care with chlorhexidine

Background

• Hospital Acquired Infections (HAI’s) affect 5% of all Hospitalized patient in the US (CDC, 2004)

• Central Line Associated Blood Stream Infections (CLABSI’s) are among these, with a mortality rate of 15-25% (CDC, 2004)

Background

• Evidence based policies and protocols to care for central catheters will reduce infection rates (CDC, 2004; Marschall, et al., 2008; Munoz-Price, et al., 2012; Young, Commisky, & Wilson, 2006)

• Appropriate cleansing of the central line insertion site intervention is paramount for preventing the occurrence of CLABSI (Chai Koh, Robertson, Watts, & Davies, 2012; Marschall, et al., 2008; Munoz-Price, et al., 2012; Young, Commisky, & Wilson, 2006; & CDC, 2011).

Facility

• Facility has minimal policies / practice standards for central catheters

• 2006 – implemented standardized policies for PICC insertions, however NO standardized site cleansing

• 2012, facility joined On the CUSP program with lack of accepted change by staff (KHC, 2012)

Review of LiteratureCLABSI Reduction

Review of Literature

• PubMed, EBSCo, CINAHL, Google Scholar

• Search Terms• Central line, CLABSI, Chlorhexadine, provodine, iodine, infection

site prevention, PICC, central venous catheter, systems based approach, staff education

• 12 year time span• Small amount of research in the past five years

ROL - Site Cleansing Preparations

• No consensus on efficacy of chlorhexidine versus PI however, the literature supports its use at the time of insertion and at dressing changes

• Some evidence suggest there is no difference in efficacy (Girard, Comby, & Jacques, 2012; Ishizuka, Nagata, Takagi, & Kubota, 2009; & Humar, et al., 2000)

• Greater evidence suggests that chlorhexidine is superior in reducing CLABSI when compared to other solutions (Valles, et al., 2008; Mimoz, et al., 2007; Chalyakunapruk, Veenstra, Lipsky, & Saint, 2002; Nishihara, Kajiura, Yokota, Kobayashi, & Okubo, 2012; & Marschall, et al., 2008)

ROL - Chlorhexidine Concentration

• Varying concentrations of Chlorhexidine have been used

• Chalyakunapruk, Veenstra, Lipsky, & Saint, (2002), evaluated eight research studies that used various concentrations of chlorhexidine, finding that site preparation with any concentration of chlorhexidine reduced infection

• The combined evidence suggests that concentrations of greater than 0.5% of Chlorhexidine should be utilized for CLABSI reduction.

ROL - Education

• Implementation of a stepwise, systems based interventions along with education, policies and protocols reduce CLABSI rates

• Education program for staff that include feedback focused on corrective efforts will reduce infection rates (Coopersmith, et al., 2002 and Rosenthal,

Guzman, Pezzotto, and Crinch, 2003)

• Central catheters inserted within facilities that have CLABSI reduction bundles within nursing departments have decreased rates of complications (Krishniaih, Soothill, Wade, Mok, & Ramnarayan,2012; Munoz-Price, et al., 2012 & Young, Commisky, & Wilson, 2006)

Project ImplementationCLABSI Reduction

Theoretical Framework

• ACE Star Model of Knowledge Transformation

• Knowledge Discovery

• Evidence Summary

• Transition Into Practice Recommendations

• Integration Into Practice

• Evaluation of Implementation (Stevens, 2004)

Project Description• Implement an evidence based infection control policy,

protocol and formal educational program • Nursing Staff & Practitioners

• Evidence based infection control protocol and policy using chlorhexidine as the lone skin disinfectant

• CLABSI rates were obtained through retrospective chart audit and compared to rates after the implementation of policy, protocol, and educational program

Project Design

• Retrospective Review of CVC and PICC placements within facility for CLABSI

• Approve & Implement Policy

• Staff Education

• Data Collection

• Evaluation

Retrospective Chart Review

• 12 Month period

• CVC or PICC

• Insertions by Physician, CRNA, APRN

• Data includes – next slide

Data Obtained

• Patient Demographics

• Catheter Type

• Hospital Unit

• Type of Practitioner

• Site Prep Used

• Central Line Days

• CLABSI Days

Data

• 102 Patients

• 1580 Catheter Days

• 9 CLABSI Days

• CLABSI Rate 5.72 / 1000 Catheter Days

Policy Approval / Implementation

• IRB Approval – Facility and University

• Policy Change / Approval (Intervention)

• Education Implementation

Staff Education

• Dressing Change Frequency

• Site Cleansing Solution

• Identification/Definition of CLABSI

• Terminal Tip Location

• Site Inspection for CLABSI

Pre and Post Test ComparisonMake a Graph

Pre Test % Post Test % Improvement %

Dressing Change

68 97 29

Solution 78 100 22ID CLABSI 59 100 41Terminal Tip 53 97 44Site Inspection 44 100 56

Intervention

• John Hopkin’s University Hospital CVC and PICC policy bundle • Pre-defined order sets

• CLABSI Monitoring Form

• Nursing Standing Orders

• Nursing / Facility Policies for Insertions

• Revisions only made for facility size and department changes

• All Insertion Trays will have only Chlorhexadine available

Data Collection

• Six Month time period

• Data Collected• Location in Facility

• Site Location

• Type of Use

• Catheter Days

• S&S of CLABSI

• Cleansing Solution

• Patient Disposition

Evaluation

• Retrospective Chart Review

• Utilization of Health Information Management

• Charts isolated by CPT codes for central catheterization

• Data compared utilizing Excel and SPSS

• Results are provided in CLABSI rates per 1000 catheter days

Group Comparison

Pre Intervention Post Intervention

Insertion Provider MD-13 / CRNA-41 / NP-45

MD-12 /CRNA-20 / NP-67

PICC / CVC 87 / 13 90 / 10Gender 67.6 Male 62.7 MaleMean Age 65 61Outpatient / Inpatient

47 /53 49 / 51

Post InterventionGender

Male Female

Type of Cath

CVC PICC

Inserting Provider

Physician CRNA APRN

Pre and Post Comparison

Pre Intervention Post Intervention

Patients 102 59

Catheter Days 1580 917

CLABSI Days 9 1

CLABSI Rate 5.72 1.09

Findings

• Implementation of an educational program covering topics associated with CLABSI and CLABSI reduction, showed statistical significance in improving participant knowledge.

• Data collected from the pre and post intervention groups found associations between the use of chlorhexidine solution for site cleansing at the time of CVC and PICC insertion and decreased rate of CLABSI per one thousand catheter days

Limitations

• Short length of study period for the post-intervention group versus pre-intervention group

• Time restriction on educational intervention presentations that lacked psychomotor demonstration or evaluation

References

• AHRQ. (2011). Eliminating CLABSI: A National Patient Safety Imperative. Rockville: AHRQ.

• Alaska Medical Library. (2012). Alaska Medical Library . Retrieved July 10, 2012, from Evidence Based Ractice: www.consortiumlibrary.org

• CDC. (2004). National Nosocomial Infections Survillence system report. American Journal of Infection Control, 470-485.

• CDC. (2011). Guidelines for the prevention of intravascular catheter-related infections. Atlanta, GA: CDC.

• Chai Koh, D., Robertson, I., Watts, M., & Davies, A. (2012). Density of microbial colonization on external and internal surgaces of concurrently placed intravascular devices. American Journal of Critical Care, 21(3), 162-171.

• Chalyakunapruk, N., Veenstra, D., Lipsky, B., & Saint, S. (2002). Chlorhezadine compared with provodine-iodine solution for vascular catheter-site care: A Meta-analysis. Annals of Internal Medicine, 792-801.

• Coopersmith, C., Rebmann, T., Zack, J., Ward, M., Corcoran, R., Schallom, M., . . . Fraser, V. (2002). Effect of an educational program on decreasing catheter-related bloodstream infections in the surgical intensive care unit. Critical Care Medicine, 30(1), 59-64.

• Girard, R., Comby, C., & Jacques, D. (2012). Alcoholic provodine-iodine or chlorhexadine-based antiseptic for the prefention of central venous catheter-related infections: In-use comparison. Journal of Infections Control and Public Health(5), 35-42.

• Humar, A., Ostromecki, A., Direnfeld, J., Marshall, P., Lazar, N., Houston, P., . . . Conly, J. (2000). Prospective randomized trial of 10% provodine-iodine versus 0/5 tincture of chlorhexidine as cutaneous antisepsos for prevention of central venous catheter infection. Clinical Infections Disease(31), 1001-1007.

• Ishizuka, M., Nagata, H., Takagi, K., & Kubota, K. (2009). Comparison of 0.05% Chlorhexadine and 10% Provodine-Iodine as cutaneous disenfectant for prevention of central cenous catheter-related bloodstream infection: A Comparitave Study. European Surgical Research(43), 286-290.

• Kansas Health Collaborative. (2012). KHC. Retrieved from CAUTI, CLABSI, SSI, & VAP: www.khconline.org

References

• Krishniaih, A., Soothill, J., Wade, A., Mok, Q., & Ramnarayan, P. (2012). Central venous catheter associated bloodstream infections in a pediatric intensive care unit : Effect of the location of insertion. Pediatric Critical Care Medicine, 13(3), 176-180.

• Marschall, J., Mermel, L., Classen, D., Arias, K., Podgorney, K., Anderson, D., . . . Yoke, D. (2008). Stratigies to prevent central line associated bloodstream infestions in acute care hospitals. Infection ControlHospital Medicine(29), 22-30.

• Merriam-Webster. (2012). Merriam Webster Medical Dictionary. Retrieved 28 2012, July, from www.merriam-webster.com

• Mimoz, O., Villeminey, S., Ragot, S., Dahyot-Fiezlier, C., Laksiri, L., Petitpas, F., & Debaene, B. (2007). Chlorhexadine-based antiseptic solution versus alcohol-based providone-iodine for central venous catheter care. Archives of Internal Medicine, 167(19), 2066-2072.

• Munoz-Price, L., Dezfulian, C., Wyckoff, M., Lenchus, J., Rosalsky, M., Birnbach, D., & Arheart, K. (2012). Effectiveness of stepwise interventions targeted to decrease central catheter associated blood stream infections. Critical Care Medicine, 40(5), 1464-1469.

• Nishihara, Y., Kajiura, T., Yokota, K., Kobayashi, H., & Okubo, T. (2012). A comparative clinical study focusing on the antimicrobial efficacies of chlorhexadine gluconatealcohol for patient skin preperations. Journal of Infusion Nursing, 35(1), 44-50.

• Rosenthal, V., Guzman, S., Pezzotto, S., & Crinch, C. (2003). Effect of an infection control progrm using education and performance feedback on rate os intervascular device-associated bloodstream infections in intensive care units in Argentina. American Journal of Infection Control, 31(7), 405-409.

• Stevens, K. R. (2004). ACE Star Model of EBP: Knowledge Transformation. Retrieved July 21, 2012, from Academic Center for Evicence-based Practice ath the UTHSC: www.acestar.uthscsa.edu

• Valles, J., Fernandez, I., Alcarza, D., Chacon, E., Cazorla, A., Canals, M., . . . Moron, A. (2008). Prospective randomized trial of 3 antiseptic solutions for prevention of catheter colonization in an intersive care unit for adult patients. Infection Control and Hospital Epidemiology, 29(9), 843-853.

• Young, E., Commisky, M., & Wilson, S. (2006). Translating evidence into practice to prevent central venous catheter associated blood stream infections: A systems based intervention. American Journal of Infection Control, 34(8), 503-506.

Questions?