Transcript Evidence Based Approach to the Maintenance Bundle

An Evidence-Based
Approach to the
Maintenance Bundle
Julie M. Weldon, MSN, RN
Education Coordinator
Mercy Medical Center
Adjunct Faculty – Mercy College of Health Sciences
Des Moines, Iowa
[email protected]
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Learning Objectives
• Describe the elements of the insertion
bundle, in efforts to reduce risk of CLABSI.
• Describe the elements of the maintenance
bundle, in efforts to reduce risk of CLABSI
• Compare CDC and INS standards of practice
for central line care.
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18
network
hospitals
Iowa population = 3.1 million
Des Moines Metro Area = 569,633
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Mercy Medical Center ~ Des Moines
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649 staffed for 802 licensed beds, daily census > 500
2 campuses (downtown & west)
About 1500 nurses
4 adult intensive care units (62 beds)
9 bed PICU, 22 bed Peds unit
64 room level 4 NICU
80 bed, 2 floor, maternal child unit
Women's Services with 5137 deliveries in FY 2014
12 medical / surgical & telemetry units
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Mercy Medical Center ~ Des Moines
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FY 2014 total discharges = 35,475
FY 2014 ED visits ~ 75,000 (30% admitted)
FY 2014 Surgical Cases ~ 20,000
No Infusion Team; PICC Insertion Team – 3 full
time nurses
• Average of 3000 PICC
insertions per year
• Additional Central Line
insertions by physicians
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Central Venous Access Devices
• Central Venous Access Devices (CVADs) are
also known as central venous catheters or
central lines.
• Over 7 million lines are placed a year for short or
long term use:
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Medications, solutions
Chemotherapy
Blood, blood products
Parenteral nutrition
Ongoing therapy at home
(CDC, 2011)
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A Patient’s Perspective
“I have survived for the past 10 years by
infusion nutrition at home. This therapy
is what sustains me, and requires central
venous access. Catheter infections and
other complications threaten my
existence. Since I am unable to care for
myself, I must rely on YOU for the best
care possible, especially with regard to
my central line.”
Short cuts taken by healthcare providers may result in infusion
complications, loss of the line, or loss of quality of life. 7
International Campaign
• Infusion complications are a global problem
affecting all patient and healthcare
demographics.
• Complications must be addressed globally in
all settings in order to reduce mortality,
especially from Central Line Associated
Bloodstream Infections (CLABSI).
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Infections, Just One Example
• In 2009 alone, an estimated 25,000 fewer
CLABSIs occurred in the US ICUs than in
2001, a 58% reduction.
• In 2011, the CDC reported “12-25% mortality
from CLABSIs.
• This represents 6,000 lives saved and
excess health care costs. A substantial
number of CLABSIs continue to occur…”
(CDC, 2011)
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Evidence-Based Infusion Care
INS Standard of Practice 8
•“The nurse shall use research findings and
current best evidence to expand nursing
knowledge in infusion therapy, to validate and
improve practice, to advance professional
accountability, and enhance evidence-based
decision making.”
(INS, 2011)
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It Starts with You!
• As leaders in vascular access, we
need to be concerned this
widespread risk exists.
• Promotion and education of basic
principles for vascular catheter
management is our responsibility
to address.
• Use memorable tools like AVA’s
“ I SAVE That Line!” or Oley’s
“Save My Line – Save My Life!” 11
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Patient Care Education
Patient education available
from the OLEY Foundation.
Found on their website:
www.oley.org
S = scrupulous hand hygiene
A = aseptic technique
V = vein preservation
E = ensure patency
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I Am Accountable for My
Patient’s Care!
• Safety starts with me!
• What I permit, I promote!
• Many of the harms patients experience in
healthcare are preventable.
• Quality may be defined as,
“what happens when no one is watching”.
• Deviance from best practice must not be
tolerated!
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Implement Insertion Bundle
We participated in the Keystone ICU Initiative, 100K Lives & 5M Campaigns.
• Hand Hygiene
• Maximum Barrier
Precautions
• Optimum Site Selection
• Daily Review of the
Necessity of the Line
(CDC, 2011 & INS, 2011)
Insertion Bundle
• Thanks to the science behind the Insertion
Bundle, the number of infections possible related
to insertion technique has dropped.
• For example, only about 30% of the CLABSIs in
our organization are identified within the first five
days of insertion.
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Maintenance Bundle
“SAVE” principles:
•S = Scrupulous Hand Hygiene
•A = Always Disinfect Every Needleless
Connector (evidence demonstrates scrub at
least 15 seconds or use passive disinfection)
•V = Vein Preservation
•E = Ensure Patency
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Maintenance Bundle
• Standard of practice for tubing changes
• Standard of practice for changing needleless
connectors and flushing
• Standard of practice for dressing changes
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Skin antisepsis
Dressing change time frame
Securement device
Chlorhexidine dressing
(CDC, 2011 & INS, 2011)
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Stages of CLABSI Interventions
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Prior to 2006
2006 – 06/2007
07/2007 – 2008
2009
06/2010
07/2011
2012
07/2013
9. 03/2014
= maximum barrier and insertion checklist
= Six Sigma Green Belt Project
= Project Improvements Implemented
= PICC Catheter Conversion
= changes to dressing change processes
= “scrub the hub” and Huber needles
= group chart review on all CLABSIs
= tubing / dressing change work and CHG
baths in adult critical care, TVU, PICU, 8S
= IJ dressing application changes
Vascular Access Stabilization
INS Standard of Practice 36
•Practice Criteria C & D
 “The use of alternative methods of vascular
access device stabilization in lieu of sutures
should be considered to mitigate the risk of
needle stick injury…”
 Use of any stabilization method should be based
on evidence, as well as analysis of risks vs.
benefits.”
(INS, 2011)
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Vascular Access Stabilization
• In 2008, we introduced a PICC and central line
dressing change kit to reduce variation in
practice.
• From about 2008 – 2010, our PICC team was
using one of the first stabilization devices out on
the market.
• Our catheter dislodgement rate was 25%,
causing us to re-evaluate our choice and review
the evidence.
(Marschall et al, 2008) 23
Vascular Access Stabilization
• After several months of trial, in June of 2010 we
changed our PICC dressing change kit with new
securement to reduce our rate of accidental
dislodgment.
• Within the first month, our accidental
dislodgment rate for PICCs dropped to 0. It
remains here today.
• Our physicians are slow to accept, and still
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suture other central lines.
(Wood, et al, 1997)
Vascular Access Stabilization
• In January of 2013, we participated in the 3M
vascular access stabilization and dressing trial.
• Our PICC nurses completed head to head
comparison of our current stabilization and the
3M stabilization.
• Also hoped to move
physicians away from
sutures.
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Stabilization Trial Results
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No loss of line during the trial.
No catheter migration during the trial.
Wear time comparable.
No skin integrity issues.
Higher nurse satisfaction with ease of
application & ease of removal.
• Higher patient satisfaction regarding comfort.
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Vascular Access Device Site
Care and Dressing Changes
INS Standard of Practice 46
•Practice Criteria B
 “Central vascular access device site care and
dressing changes should include the following:
removal of the existing dressing, cleansing of the
catheter-skin junction with appropriate antiseptic
solution, replacement of stabilization device, and
application of a sterile dressing.”
(INS, 2011)
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Vascular Access Device Site
Care and Dressing Changes
INS Standard of Practice 46
•Practice Criteria C
 “Chlorhexidine solution is preferred for skin
antisepsis”… “not recommended for infants under
2 months of age.”
•Practice Criteria E
 “Transparent semipermeable dressings should be
changed every 5-7 days, gauze dressings every 2
days.”
(INS, 2011)
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Vascular Access Device Site
Care and Dressing Changes
INS Standard of Practice 46
•Practice Criteria G
 “Use of a Chlorhexidine-impregnated dressing
with short-term CVADs should be considered in
patients older than 2 months of age as an
additional catheter-related bloodstream infection
measure.”
(INS, 2011)
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Vascular Access Device Site
Care and Dressing Changes
• In 2010 while changing our stabilization
device, we evaluated the various
Chlorhexidine-impregnated dressings on the
market.
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Vascular Access Device
Dressing Changes
• Review of the literature for studies with
Chlorhexidine-impregnated dressings
demonstrated similar efficacy when reducing
bacterial counts at the insertion site.
• Compliance audits also play a factor.
(Garland et al, 2001)
(Ho et al, 2006)
(Levy, et al, 2005)
(Timsit, et al, 2009)
(Yong-Gang et al, 2009)
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Vascular Access Device
Dressing Changes
• At the time, we were inserting an average of
300 PICCs per month and averaged about 700
total PICC dressing changes per month.
• We have difficulty tracking how many
physician inserted central lines averaged per
month.
• We knew we used an average of 60 central
line dressing change kits per month.
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Change Management and
Process Improvement
• Patient in the center of the process.
• Implement a structured, systematic approach to
achieve operational excellence.
• Understand a defect-free process results from
breakthrough improvement.
• Standardization eliminates variability in the
process.
• Variability in the process results in errors.
(Eyberg, et al 2008)
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(INS, 2010)
Perseverance and Resilience
“Opportunity is missed by most people because it
is dressed in overalls and looks like work.”
~ Thomas Edison
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Financial Implications
• When comparing two different dressing change
approaches and all things are clinically
comparable, it is time to look at the initiative
from the financial perspective.
$ + $$ = $$$ vs. $ = $
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Our Decision
1. Clinical results similar according to the
evidence.
2. Application of the dressing is “mistake proof”.
3. Price ~ given our volume, it was a $10,000
difference annually.
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Our Volume
• CHG Dressing implementation in June 2010
• Usage audit revealed 100% compliance of
using dressing on all central lines during spot
checks.
• House wide spot checks continued for 3
months.
• Using CY 2013 as our example…
 31,713 “Central Line Days” by definition
 13,177 dressings used
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Maintenance Bundle
• For Mercy – Des Moines, following the
evidence-based Maintenance Bundle is more
is critical in comparison the evidence-based
insertion bundle.
• Why???
 70 % of our CLABSI in CY 2013 & 2014 had a
dwell time of greater than 5 days.
• Introduced extended dwell midline and
dressing change kit in October 2014.
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IJ Dressing Issues
• Recent review of the literature
revealed few interventions
specific to patients with
jugular central lines.
• Jugular lines are at higher risk
than other insertion sites due
to location near challenging
care areas and patient
anatomy.
• CLA-BSI patients in CSICU
from calendar year 2013 with
10 CLABSI, 7 with IJ line.
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IJ Dressing Improvements
• Multidisciplinary team included anesthesia,
surgery nurses, CSICU nurses, nursing
education coordinator and infection prevention.
Team identified problems with central line
dressing adherence for the jugular site.
• Nursing Education Coordinator re-educated
staff on proper dressing application, including
trial of skin prep prior to application.
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Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
per 1000 cath days
IJ Dressing Improvements
• Patients with both jugular
central line and CLABSI
decreased from 7 (CY13)
to 0 IJ infections
(CY14 + year to date).
CLABSI in CSICU
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8
7
6
5
4
3
2
1
0
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Stages of CLABSI Interventions
1.
2.
3.
4.
5.
6.
7.
8.
Prior to 2006
2006 – 06/2007
07/2007 – 2008
2009
06/2010
07/2011
2012
07/2013
9. 01 - 03/2014
= maximum barrier and insertion checklist
= Six Sigma Green Belt Project
= Project Improvements Implemented
= PICC Catheter Conversion, StatLock
= changes to dressing change processes
= “scrub the hub” and Huber needles
= group chart review on all CLABSIs
= tubing / dressing change work and CHG
baths in adult critical care, TVU, PICU, 8S
= IJ dressing application changes, extended
dwell midline implementation
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An Evidence-Based
Approach to the
Maintenance Bundle
Julie M. Weldon, MSN, RN
Mercy Medical Center
Des Moines, Iowa
Education Coordinator
Adjunct Faculty – Mercy College of Health Sciences
[email protected]
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References
• Centers for Disease Control and Prevention. (2011) Guidelines for the prevention of
intravascular catheter-related infections. MMWR, Vol. 51, 1-30.
• Centers for Disease Control and Prevention. (2011). Vital Signs: Central Line–Associated
Blood Stream Infections — United States, 2001, 2008, and 2009. MMWR , March 4, 2011.
Vol. 60, No. 8 .
• Doellman, D. Pettit, J. Catudal, P. Buckner, J. Burns, D. Frey, AM. Runde, D. (2009).
Pediatric CVC Maintenance Bundles. Pedivan.
• Eyberg, C.I…….
• Garland, J.S. Alex, C.P. Uhing, M.R. Peterside, I.E Rentz, A. Harris, M.C. (2001)
Randomized trial comparing providone-iodine to chlorhexidine gluconate impregnated
dressing for prevention of central venous catheter infections in neonates. Pediatrics, 107,
6, 1431-1436.
• Ho, K.M. …..
• Infusion Nurses Society (2010). Infusion Nursing: An Evidence-Based Approach. Saunders
Elsevier, St. Louis, 3rd edition, p. 395.
• Infusion Nurses Society (2011). Infusion Standards of Practice. Journal of Infusion
Nursing. Supplement to January/February, vol. 34, n. 1S.
• Infusion Nurses Society (2011). Policies and Procedures of Infusion Nursing. 4th edition.
• Joint Commission (2013). National Patient Safety Goals. www.jointcommission.org
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References
• Levy, I. Katz, J. Solter, E. et al. (2005) Chlorhexidine-impregnated dressings for
prevention of colonization of central venous catheters in infants and children: a
randomized controlled study. Pediatrics Infection Journal, 24, 8, 676-679.
• Marschall, J. Mermel, L.A. Classen D. (2008) Strategies to prevent central line –
associated blood stream infections in acute care hospitals. Infection Control Hospital
Epidemiology, v. 29, S22-S30.
• Oley Foundation (2013). Save My Line, Save My Life. www.oley.org
• Timsit, J.F. Bouadma, L. Ruckly, S. et al. (2012) Dressing disruption is a major risk
factor for catheter-related infections. Critical Care Medicine, 40, 6, 1707-1714.
• Wood, D. And Bowe-Geddes, L. (1997). A Comparative Retrospective Analysis of Two
Securement Techniques for Peripherally Inserted Central Catheters (PICC) and
Midlines in the Home Care Setting. Journal of Association of Vascular Access, v 2, n 3.
• Yong-Gang, L….
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