- Email: [email protected]
Sustained Reduction of Central Line-Associated Bloodstream Infections (CLABSI) in a NICU
S96
Poster Abstracts / American Journal of Infection Control 41 (2013) S25-S145
Presentation Number 9-378 Assessing Central Line Utilization in the Journey to Decrease CLABSI Rates in an Academic Tertiary Care Facility Kerri Adams RN, MSN, Infection Control Practitioner, Johns Hopkins Bayview Medical Center; Zeina Khouri-Stevens, Director of Surgical Nursing, Johns Hopkins Bayview; Carol Sylvester, Senior Director of Care Management, Johns Hopkins Bayview; Geeta Sood, Hospital Epidemiologist, Johns Hopkins Bayview ISSUE: Central Line Associated Blood Stream Infection (CLABSI) has become a focus of health care professionals, regulatory agencies, payers, and the public over the past few years. Our hospital has spent the last 3 years working with our teams to create a culture of safety around insertion and maintenance of central lines, resulting in a reduction in CLABSI rates. However, as we have not reached our goal of zero, we decided to take a closer look at our line utilization. There are data to support an increased risk of CLABSI associated with central line utilization and duration of line placement. PROJECT: A prospective 30 day audit of all central line prevalence was conducted on our adult inpatient units. A daily central line report generated by electronic medical record and a review of documentation were used to obtain patient name, medical record number, unit, date of admission, date of line insertion, type of line, and current patient/line disposition. Line duration was calculated for each patient who had a central line during this time period. The same report was used to calculate central line days per unit and a patient census report provided by the billing department was used to calculate central line utilization rates for comparison to the 2010 National Healthcare Safety Network (N.H.S.N.) benchmarks. RESULTS: Our tertiary academic facility consists of 5 adult intensive care units (ICU’s), 3 ICU step-down units, and 7 floor status medical, surgical, and specialty units. Of the 15 total units, only 2 of our floor status medical/surgical units were above the N.H.S.N. pooled mean for device utilization. Data regarding utilization by device type, duration and patient acuity are listed in tables below.
Device utilization by unit type Total Central Lines Triple Lumen Central Lines Intensive Care Unit Step Down Unit Med/Surg Floor Duration of device Mean (range) Median Modes
42.6% 11.8% 45.6%
72.7% 3.6% 23.6% Triple Lumen Catheters 10.4 (1-33) 9.5 6,9
LESSON LEARNED: Although only 43% of our total central lines are in the ICU’s, the majority of triple lumen catheters are used in this setting. Literature supports not only an increased risk of CLABSI with triple lumen catheters but also that the risk more than doubles when lines exceed 7 days and doubles yet again after 15 days. Although our overall line utilization rates were below NHSN benchmarks, our findings show that our selection of line type and average duration of line placement placed our patients at high risk to develop a CLABSI. Institutions should evaluate not only total line
days or line utilization ratios, but also type and duration of line placement in assessing risk factors for CLABSI’s.
Presentation Number 9-379 Sustained Reduction of Central Line-Associated Bloodstream Infections (CLABSI) in a NICU Vicki H. Riddle RN, BSN, CIC, Infection Preventionist, WakeMed Health & Hospitals; Jessica M. Dixon RN, BSN, MHA, CCRN, CIC, Infection Prevention Project Specialist, WakeMed Health & Hospitals; Thomas E. Young MD, Medical Director, Nurseries/ Professor of Pediatrics, WakeMed Faculty Physicians Neonatology/University of North Carolina at Chapel Hill; Vickie Brown RN, MPH, CIC, Infection Prevention Director, WakeMed Health & Hospitals; Susan Gutierrez BSN, RNC-NIC, Nurse Manager, Neonatal Intensive Care Unit, WakeMed ISSUE: Our 36 bed NICU had an unacceptable rate of CLABSI. In 2007, a collaborative team was formed to review relevant scientific studies, investigate each CLABSI event, and implement process improvement changes to eliminate CLABSIs. PROJECT: In 2007, the NICU CLABSI rate was 10.1/1000 device days. We created a multidisciplinary workgroup that included NICU doctors, nurse practitioners, nurses, and the Infection Preventionist to focus on reducing CLABSIs. Staff education started with emphasis on hand hygiene, utilizing posters in every bed space and empowering staff to confront hand hygiene offenders. Bed space cleanliness was emphasized, with all surfaces and patient care items in each bed space cleaned at the beginning of every shift. A 2% chlorhexidine gluconate (CHG)/70% isopropyl alcohol product was instituted for skin antisepsis prior to all IV insertions. Staff was educated to use a central line bundle checklist for insertion and maintenance of central lines. Central line dressings were assessed daily, changing as needed. Neutral displacement connectors were introduced for all access ports, and staff was educated to “scrub the hub” for 15 seconds with alcohol and allow to dry before access. In 2008, mandatory gloving was required for all direct patient care. In 2008, the CLABSI rate dropped to 5.0/1000 device days. In 2009, the rate increased to 7.3/1000 device days. We joined a statewide multicenter perinatal quality collaborative to reduce CLABSIs to compare our processes with other NICUs. We trialed a silver alginate patch for 3 months with no improvement. In 2010, we began to use 3.15% CHG/70% isopropyl alcohol skin prep pads for disinfection of needleless connectors on all IV access ports. Staff was educated to “scrub the hub for 30 seconds” and allow to dry. The CLABSI rate declined dramatically. RESULTS: The CLABSI rate from 2007 to 2012 has decreased by 85% (Figure 1, Table 1). After introduction of the 3.15% CHG/70% isopropyl alcohol skin prep pads for disinfection of all access ports, the NICU had zero CLABSI for 6 months and has sustained a rate below 2.0/1000 device days. LESSON LEARNED: Continued vigilance to infection control measures by front line staff can dramatically decrease CLABSIs. Monthly infection reports help keep staff motivated and engaged. It is important not to become discouraged and to continue to evaluate new interventions. It is important to review the published literature to identify innovative use of infection prevention products, such as CHG/alcohol skin prep pads for disinfection of IV access ports.
APIC 40th Annual Conference j Ft Lauderdale, FL j June 8-10, 2013
Poster Abstracts / American Journal of Infection Control 41 (2013) S25-S145
Presentation Number 9-378 Assessing Central Line Utilization in the Journey to Decrease CLABSI Rates in an Academic Tertiary Care Facility Kerri Adams RN, MSN, Infection Control Practitioner, Johns Hopkins Bayview Medical Center; Zeina Khouri-Stevens, Director of Surgical Nursing, Johns Hopkins Bayview; Carol Sylvester, Senior Director of Care Management, Johns Hopkins Bayview; Geeta Sood, Hospital Epidemiologist, Johns Hopkins Bayview ISSUE: Central Line Associated Blood Stream Infection (CLABSI) has become a focus of health care professionals, regulatory agencies, payers, and the public over the past few years. Our hospital has spent the last 3 years working with our teams to create a culture of safety around insertion and maintenance of central lines, resulting in a reduction in CLABSI rates. However, as we have not reached our goal of zero, we decided to take a closer look at our line utilization. There are data to support an increased risk of CLABSI associated with central line utilization and duration of line placement. PROJECT: A prospective 30 day audit of all central line prevalence was conducted on our adult inpatient units. A daily central line report generated by electronic medical record and a review of documentation were used to obtain patient name, medical record number, unit, date of admission, date of line insertion, type of line, and current patient/line disposition. Line duration was calculated for each patient who had a central line during this time period. The same report was used to calculate central line days per unit and a patient census report provided by the billing department was used to calculate central line utilization rates for comparison to the 2010 National Healthcare Safety Network (N.H.S.N.) benchmarks. RESULTS: Our tertiary academic facility consists of 5 adult intensive care units (ICU’s), 3 ICU step-down units, and 7 floor status medical, surgical, and specialty units. Of the 15 total units, only 2 of our floor status medical/surgical units were above the N.H.S.N. pooled mean for device utilization. Data regarding utilization by device type, duration and patient acuity are listed in tables below.
Device utilization by unit type Total Central Lines Triple Lumen Central Lines Intensive Care Unit Step Down Unit Med/Surg Floor Duration of device Mean (range) Median Modes
42.6% 11.8% 45.6%
72.7% 3.6% 23.6% Triple Lumen Catheters 10.4 (1-33) 9.5 6,9
LESSON LEARNED: Although only 43% of our total central lines are in the ICU’s, the majority of triple lumen catheters are used in this setting. Literature supports not only an increased risk of CLABSI with triple lumen catheters but also that the risk more than doubles when lines exceed 7 days and doubles yet again after 15 days. Although our overall line utilization rates were below NHSN benchmarks, our findings show that our selection of line type and average duration of line placement placed our patients at high risk to develop a CLABSI. Institutions should evaluate not only total line
days or line utilization ratios, but also type and duration of line placement in assessing risk factors for CLABSI’s.
Presentation Number 9-379 Sustained Reduction of Central Line-Associated Bloodstream Infections (CLABSI) in a NICU Vicki H. Riddle RN, BSN, CIC, Infection Preventionist, WakeMed Health & Hospitals; Jessica M. Dixon RN, BSN, MHA, CCRN, CIC, Infection Prevention Project Specialist, WakeMed Health & Hospitals; Thomas E. Young MD, Medical Director, Nurseries/ Professor of Pediatrics, WakeMed Faculty Physicians Neonatology/University of North Carolina at Chapel Hill; Vickie Brown RN, MPH, CIC, Infection Prevention Director, WakeMed Health & Hospitals; Susan Gutierrez BSN, RNC-NIC, Nurse Manager, Neonatal Intensive Care Unit, WakeMed ISSUE: Our 36 bed NICU had an unacceptable rate of CLABSI. In 2007, a collaborative team was formed to review relevant scientific studies, investigate each CLABSI event, and implement process improvement changes to eliminate CLABSIs. PROJECT: In 2007, the NICU CLABSI rate was 10.1/1000 device days. We created a multidisciplinary workgroup that included NICU doctors, nurse practitioners, nurses, and the Infection Preventionist to focus on reducing CLABSIs. Staff education started with emphasis on hand hygiene, utilizing posters in every bed space and empowering staff to confront hand hygiene offenders. Bed space cleanliness was emphasized, with all surfaces and patient care items in each bed space cleaned at the beginning of every shift. A 2% chlorhexidine gluconate (CHG)/70% isopropyl alcohol product was instituted for skin antisepsis prior to all IV insertions. Staff was educated to use a central line bundle checklist for insertion and maintenance of central lines. Central line dressings were assessed daily, changing as needed. Neutral displacement connectors were introduced for all access ports, and staff was educated to “scrub the hub” for 15 seconds with alcohol and allow to dry before access. In 2008, mandatory gloving was required for all direct patient care. In 2008, the CLABSI rate dropped to 5.0/1000 device days. In 2009, the rate increased to 7.3/1000 device days. We joined a statewide multicenter perinatal quality collaborative to reduce CLABSIs to compare our processes with other NICUs. We trialed a silver alginate patch for 3 months with no improvement. In 2010, we began to use 3.15% CHG/70% isopropyl alcohol skin prep pads for disinfection of needleless connectors on all IV access ports. Staff was educated to “scrub the hub for 30 seconds” and allow to dry. The CLABSI rate declined dramatically. RESULTS: The CLABSI rate from 2007 to 2012 has decreased by 85% (Figure 1, Table 1). After introduction of the 3.15% CHG/70% isopropyl alcohol skin prep pads for disinfection of all access ports, the NICU had zero CLABSI for 6 months and has sustained a rate below 2.0/1000 device days. LESSON LEARNED: Continued vigilance to infection control measures by front line staff can dramatically decrease CLABSIs. Monthly infection reports help keep staff motivated and engaged. It is important not to become discouraged and to continue to evaluate new interventions. It is important to review the published literature to identify innovative use of infection prevention products, such as CHG/alcohol skin prep pads for disinfection of IV access ports.
APIC 40th Annual Conference j Ft Lauderdale, FL j June 8-10, 2013