- Email: [email protected]
Reduction of Indwelling Urinary Catheter-associated Urinary Tract Infections (CAUTI) through System-wide Interventions
www.ajicjournal.org Vol. 38 No. 5
E35
Presentation Number 4-034
Reduction in Central Line-related Bloodstream Infection (CLBSI) as a Result of Multiple Process Improvement Changes Renee L. Smith, MT(ASCP), Infection Control Coordinator; Kimberly Rivera, MT(ASCP), Supervisor, Infection Control; Lisa Snedeker, MT(ASCP); Jana Wolfgang, RN BS, Infection Control Coordinator; Lisa Rose, MT(ASCP); Haley Hardenstine, RN BS, Infection Control Coordinator, Pinnacle Health System, Harrisburg, PA Issue: In the United States, approximately 80,000 central line-related bloodstream infections (CLBSI) occur in Intensive Care Units (ICUs) each year. Project: PinnacleHealth System is a 600-bed hospital system consisting of two acute care hospitals in South Central Pennsylvania. Baseline CLBSI rates for the four adult ICUs (two Medical/Surgical Units, one Cardio-Thoracic Unit, and one Coronary Care Unit consisting of a total of 51 beds) indicated a need for multiple process improvement changes. In May 2005 the Health Care System began participation in the Institute for Healthcare Improvement 100,000 Lives Campaign. This campaign focused on using a ‘‘bundle’’ for the prevention of CLBSI. The bundle includes utilization of a maximal sterile barrier during insertion, chlorhexidine skin antisepsis, proper site selection, and daily review of line necessity. Root Cause Analyses conducted on CLBSI showed inconsistent use of the bundle components. Since then, various interventions have been put in place to increase compliance and reduce the rate of CLBSI. In July 2006, a kit that includes all necessary items for use during insertion was created to improve compliance. The Central Line Insertion Pre-Procedure Checklist and Progress Note was implemented for use during all central line insertions in October 2008. In January 2009 the IV Team began observing all central line insertions and in addition, educated staff system-wide with the ‘‘SAVE that Line’’ campaign. Sponsored by the Association for Vascular Access, this campaign seeks to educate and remind all clinicians about the most important principles that must be observed when inserting, accessing or maintaining any vascular access device. The implementation of these measures increased both awareness and compliance when inserting central lines, which in turn, resulted in a significant decrease in CLBSI. Results: The baseline CLBSI rate (per 1,000 catheter days) in the four adult critical care units was 1.8 (16/8,833) for January 2005-December 2005. The current post intervention CLBSI rate for January 2009-June 2009 is 0.0 (0/3,855) P 5 0.0030. Lessons Learned: Education of staff responsible for line placement and maintenance, making items necessary for line insertion readily available in one central location, in addition to using the Pre-Procedure Checklist and direct observation of central line insertions have all contributed to a significant decrease in CLBSI.
Presentation Number 4-035
Reduction of Indwelling Urinary Catheter-associated Urinary Tract Infections (CAUTI) through System-wide Interventions Haley Hardenstine, RN, BS, Infection Control Coordinator; Kimberly Rivera, MT (ASCP), Infection Control Supervisor; Kimberly Fowler, MSN, RN, Clinical Nurse Specialist; Jana Wolfgang, RN, BS, Infection Control Coordinator, Pinnacle Health System, Harrisburg, PA Issue: CAUTI is the most common preventable hospital-acquired infection and leads to increased morbidity and cost. According to the SHEA/ Infectious Diseases Society of America (IDSA) Practice Recommendations, the use of indwelling urinary catheters (catheters) contributes to 80% of urinary tract infections. SHEA/IDSA recommends properly securing catheters after insertion. Project: A multi-disciplinary CAUTI Prevention Task Force was created when our health-care system began participation in the VHA Rapid Adoption Network - Reduction of CAUTI in September 2008. Data indicated a high use of catheters in our system compared to other systems in the network. The goals of the task force were to decrease
E36
American Journal of Infection Control June 2010
catheter days and improve compliance with catheter tubing securement devices. In March 2009, a CAUTI prevention video and post-test were distributed to staff that provide care for patients with catheters. Random audits for securement device compliance began in March 2009, and feedback is reported to nursing leadership. In May 2009, an electronic workflow was implemented for physicians to verify necessity of the catheters. The task force promotes ongoing staff education and resources including: 1) monthly UTI Prevention Tips Sheets, 2) CAUTI prevention materials available on the Infection Control website, 3) interactive nursing education regarding catheter care and insertion techniques, and 4) a CAUTI Risk nursing plan of care that electronically sends reminders to the staff. Results: The first post-intervention period indicated a significant decrease in the use of catheters and a significant increase in the use of catheter securement devices. The CAUTI rate in the first post-intervention period shows a 43% reduction in infections.
Catheter Use (catheter days/patient days) Baseline Oct-Dec 2008 Use of Securement Device (random observations) Baseline - March 2009 CAUTI (infections/catheter days) Baseline - Oct-Dec 2008
Baseline
Post-intervention Period I Jul-Sep 2009
Significance (P value)
34% (13,370/39,115)
30% (11,530/38,470)
P 5 0.0000
62% (41/66)
85% (53/62)
P 5 0.0154
1.6 (21/13,370)
1.0 (12/11,530)
P 5 0.1660
Lessons Learned: Teamwork and innovation contributed to a significant reduction in the use of catheters and a significant increase in the use of catheter securement devices. Implementation of methods to increase compliance with CAUTI risk reduction recommendations has decreased the number of CAUTI in our inpatient units.
Presentation Number 4-036
Reduction of Ventilator-associated Pneumonia Incidence in a 32-bed Combined Medical Surgical Intensive Care Unit After Adding Chlorhexidine Oral Care and Skin Cleansing to the Ventilator Bundle Vicki Keller, RN, BSN, PHN, CIC, Infection Prevention Manager, Northridge Hospital Medical Center, Northridge, CA Issue: Ventilator Associated Pneumonia (VAP) is a risk for any patient on a ventilator. During fiscal year 2008, our intensive care unit (ICU) had 11 VAPs with 4374 ventilator days, and a VAP rate of 2.51 per 1000 ventilator days. VAP continued to be an issue: in this 32 bed ICU, even after implementation of the ventilator bundle elements. The ventilator bundle consisted of 1) daily sedation vacation, 2) daily assessment for ventilator weaning, 3) head of the bed elevated to 30 degrees, 4) deep vein thrombosis (DVT) prophylaxis, and 5) stress bleeding prophylaxis. An oral care kit had also been implemented for use every four hours. Project: Realizing the bundle elements alone were not helping us reach our goal of zero VAP, the managers, educators, Infection Preventionist (IP), and respiratory therapists (RT) began an educational campaign. All ICU nurses attended mandatory educational sessions. The ventilator bundle elements were included in daily rounding using a rounding sheet for report. In addition to routine oral care every four hours, chlorhexidine (CHG) oral rinse was added to the kit to be delivered every twelve hours. RTs assisted by applying the first CHG oral rinse of the day during the ventilator tape change each morning. CHG cloths were also added each day, after the bath, to decrease skin colonization of bacteria. Results: As of fiscal year 2009, after an aggressive educational campaign, daily reminders of the ventilator bundle elements, and adding CHG to the oral care kit and CHG cloths after the bath, the VAP rate dropped to 2 VAP with
E35
Presentation Number 4-034
Reduction in Central Line-related Bloodstream Infection (CLBSI) as a Result of Multiple Process Improvement Changes Renee L. Smith, MT(ASCP), Infection Control Coordinator; Kimberly Rivera, MT(ASCP), Supervisor, Infection Control; Lisa Snedeker, MT(ASCP); Jana Wolfgang, RN BS, Infection Control Coordinator; Lisa Rose, MT(ASCP); Haley Hardenstine, RN BS, Infection Control Coordinator, Pinnacle Health System, Harrisburg, PA Issue: In the United States, approximately 80,000 central line-related bloodstream infections (CLBSI) occur in Intensive Care Units (ICUs) each year. Project: PinnacleHealth System is a 600-bed hospital system consisting of two acute care hospitals in South Central Pennsylvania. Baseline CLBSI rates for the four adult ICUs (two Medical/Surgical Units, one Cardio-Thoracic Unit, and one Coronary Care Unit consisting of a total of 51 beds) indicated a need for multiple process improvement changes. In May 2005 the Health Care System began participation in the Institute for Healthcare Improvement 100,000 Lives Campaign. This campaign focused on using a ‘‘bundle’’ for the prevention of CLBSI. The bundle includes utilization of a maximal sterile barrier during insertion, chlorhexidine skin antisepsis, proper site selection, and daily review of line necessity. Root Cause Analyses conducted on CLBSI showed inconsistent use of the bundle components. Since then, various interventions have been put in place to increase compliance and reduce the rate of CLBSI. In July 2006, a kit that includes all necessary items for use during insertion was created to improve compliance. The Central Line Insertion Pre-Procedure Checklist and Progress Note was implemented for use during all central line insertions in October 2008. In January 2009 the IV Team began observing all central line insertions and in addition, educated staff system-wide with the ‘‘SAVE that Line’’ campaign. Sponsored by the Association for Vascular Access, this campaign seeks to educate and remind all clinicians about the most important principles that must be observed when inserting, accessing or maintaining any vascular access device. The implementation of these measures increased both awareness and compliance when inserting central lines, which in turn, resulted in a significant decrease in CLBSI. Results: The baseline CLBSI rate (per 1,000 catheter days) in the four adult critical care units was 1.8 (16/8,833) for January 2005-December 2005. The current post intervention CLBSI rate for January 2009-June 2009 is 0.0 (0/3,855) P 5 0.0030. Lessons Learned: Education of staff responsible for line placement and maintenance, making items necessary for line insertion readily available in one central location, in addition to using the Pre-Procedure Checklist and direct observation of central line insertions have all contributed to a significant decrease in CLBSI.
Presentation Number 4-035
Reduction of Indwelling Urinary Catheter-associated Urinary Tract Infections (CAUTI) through System-wide Interventions Haley Hardenstine, RN, BS, Infection Control Coordinator; Kimberly Rivera, MT (ASCP), Infection Control Supervisor; Kimberly Fowler, MSN, RN, Clinical Nurse Specialist; Jana Wolfgang, RN, BS, Infection Control Coordinator, Pinnacle Health System, Harrisburg, PA Issue: CAUTI is the most common preventable hospital-acquired infection and leads to increased morbidity and cost. According to the SHEA/ Infectious Diseases Society of America (IDSA) Practice Recommendations, the use of indwelling urinary catheters (catheters) contributes to 80% of urinary tract infections. SHEA/IDSA recommends properly securing catheters after insertion. Project: A multi-disciplinary CAUTI Prevention Task Force was created when our health-care system began participation in the VHA Rapid Adoption Network - Reduction of CAUTI in September 2008. Data indicated a high use of catheters in our system compared to other systems in the network. The goals of the task force were to decrease
E36
American Journal of Infection Control June 2010
catheter days and improve compliance with catheter tubing securement devices. In March 2009, a CAUTI prevention video and post-test were distributed to staff that provide care for patients with catheters. Random audits for securement device compliance began in March 2009, and feedback is reported to nursing leadership. In May 2009, an electronic workflow was implemented for physicians to verify necessity of the catheters. The task force promotes ongoing staff education and resources including: 1) monthly UTI Prevention Tips Sheets, 2) CAUTI prevention materials available on the Infection Control website, 3) interactive nursing education regarding catheter care and insertion techniques, and 4) a CAUTI Risk nursing plan of care that electronically sends reminders to the staff. Results: The first post-intervention period indicated a significant decrease in the use of catheters and a significant increase in the use of catheter securement devices. The CAUTI rate in the first post-intervention period shows a 43% reduction in infections.
Catheter Use (catheter days/patient days) Baseline Oct-Dec 2008 Use of Securement Device (random observations) Baseline - March 2009 CAUTI (infections/catheter days) Baseline - Oct-Dec 2008
Baseline
Post-intervention Period I Jul-Sep 2009
Significance (P value)
34% (13,370/39,115)
30% (11,530/38,470)
P 5 0.0000
62% (41/66)
85% (53/62)
P 5 0.0154
1.6 (21/13,370)
1.0 (12/11,530)
P 5 0.1660
Lessons Learned: Teamwork and innovation contributed to a significant reduction in the use of catheters and a significant increase in the use of catheter securement devices. Implementation of methods to increase compliance with CAUTI risk reduction recommendations has decreased the number of CAUTI in our inpatient units.
Presentation Number 4-036
Reduction of Ventilator-associated Pneumonia Incidence in a 32-bed Combined Medical Surgical Intensive Care Unit After Adding Chlorhexidine Oral Care and Skin Cleansing to the Ventilator Bundle Vicki Keller, RN, BSN, PHN, CIC, Infection Prevention Manager, Northridge Hospital Medical Center, Northridge, CA Issue: Ventilator Associated Pneumonia (VAP) is a risk for any patient on a ventilator. During fiscal year 2008, our intensive care unit (ICU) had 11 VAPs with 4374 ventilator days, and a VAP rate of 2.51 per 1000 ventilator days. VAP continued to be an issue: in this 32 bed ICU, even after implementation of the ventilator bundle elements. The ventilator bundle consisted of 1) daily sedation vacation, 2) daily assessment for ventilator weaning, 3) head of the bed elevated to 30 degrees, 4) deep vein thrombosis (DVT) prophylaxis, and 5) stress bleeding prophylaxis. An oral care kit had also been implemented for use every four hours. Project: Realizing the bundle elements alone were not helping us reach our goal of zero VAP, the managers, educators, Infection Preventionist (IP), and respiratory therapists (RT) began an educational campaign. All ICU nurses attended mandatory educational sessions. The ventilator bundle elements were included in daily rounding using a rounding sheet for report. In addition to routine oral care every four hours, chlorhexidine (CHG) oral rinse was added to the kit to be delivered every twelve hours. RTs assisted by applying the first CHG oral rinse of the day during the ventilator tape change each morning. CHG cloths were also added each day, after the bath, to decrease skin colonization of bacteria. Results: As of fiscal year 2009, after an aggressive educational campaign, daily reminders of the ventilator bundle elements, and adding CHG to the oral care kit and CHG cloths after the bath, the VAP rate dropped to 2 VAP with