Prevention of Central Line Associated Bloodstream Infections (CLABs)

1. Prevention of Central Line Associated Bloodstream Infections (CLABs) Quality and Patient Safety Effectiveness and Outcomes Beth Israel Medical Center Petrie and Kings Highway Divisions

2. CLABs Myths • Our infection rates are below national benchmarks - which is good enough. • CLABs are inevitable. It is the price we pay for sophisticated, complex care of severely ill patients. • CLABs are benign and readily treated with antibiotics. • CLABs are a common accompaniment of complex care and covered by outlier payments.

3. Lessons Learned • We can come surprisingly close to eliminating hospital acquired infections with determination as opposed to resources • Our data must not only be reportable but actionable • Save lives • Reduce costs • Reduce error and waste

4. How We Did It • Make data actionable • Observe variations in work practices • Real time problem solving of origins of CLABs • Implement and test practice changes

5. Make Data Actionable • Start small • Use and monitoring of evidence based patient care practices or “bundles” with reporting back of data to end users • Counter measures generated by the people who do the work • Process that generates sustainable fixes • Avoid “workarounds” that are constantly repeated • Set a time to achieve goal • Plan-Do-Study Act (PDSA) methodology

6. Beth Israel Medical Center • Petrie Division • Kings Highway Division • 94 ICU beds • 3,000 discharges • 824 non-ICU beds • 43,000 discharges • 1,200 central lines placed annually • 40% of patients in ICU with central line • Average length of stay for patients with central line = 5 days • Average length of stay for patients with CLAB = 10 days • CLABs rate of 9 per 1,000 device days or 3.8% in 2004

7. Beth Israel Medical CenterCLABs Prevention • June 2005 • ICU • MICU, SICU • August 2005 • CCU and CSICU • December 2005 • Emergency Departments • January 2006 • General Medical Surgical Units • April 2006 • Operating Room • August 2006 • NICU and PICU

8. Physicians Chief Medical Officer Associate Chairman, Department of Medicine Director ICU, MICU, SICU Emergency Room Medical and Emergency Department Residency Programs Intensivist Critical Care Fellow Infection Control Hospital Epidemiologist Manager Practitioner Patient Care Services Vice President Director Nurse Manager ICU, MICU, SICU Emergency Room Nurse Education Manager Other Director Materials Management Housekeeping Respiratory Therapy Quality Improvement Pharmacist Dietician Multi-disciplinary CLABs Team Members

9. Multi-disciplinary CLABs TeamPrinciples • It is not good enough that our infection rates are below national benchmarks. • CLABs are preventable, they are not an inevitable consequence of sophisticated, complex care that we provide to our severely ill patients.

10. Multi-disciplinary CLABs TeamPrinciples • CLABs can be eliminated by determination as opposed to additional resources. • Strict adherence to evidence based patient care practices, called “bundles” that will improve patient safety and reduce adverse patient outcomes is required.

11. Multi-disciplinary CLABs TeamPrinciples • Patient hospital length of stay, morbidity and mortality can be reduced through prevention of CLABs. • We can reduce the Medical Center’s costs incurred for the care of patients with CLABs.

12. CLABs • Mortality = 18% • ICU risk 8x >non-ICU • Additional $40,000 to hospital costs • Hospitals absorb the costs! Nationally: 80,000 CLABs in ICUs per year 14,500 CLABs deaths

13. $1,510,000 Total Incremental CLAB Costs Costs Incurred For Care of Patients with CLABs Discharges Per Year CLAB Patients Incremental Cost Per CLAB Patient Annual Incremental Costs $40,000 $960,000 94 ICU Beds 3,000 24 $25,000 $550,000 824 Non-ICU Beds 43,000 22 Used BI BSI information and discharge information from 2004

14. Multi-disciplinary CLABs TeamAims and Goals • Process that generates sustainable fixes • Avoid “workarounds” that are constantly repeated • Collaborative process • Knowledge gained from this process is shared with all • Our data must not only be reportable but actionable

15. Beth Israel Medical CenterCLABs Prevention • Physician and Nurse reeducation and recertification on central line insertion technique and maintenance practices • Standardization of practices to ensure • Maximal barrier protection utilized • Skin prep with chlorhexidine • Preference for subclavian site unless medically contraindicated

16. Beth Israel Medical CenterCLABs Prevention • Nursing empowerment to monitor practices • Nursing permitted to ask and stop other persons who do not follow appropriate practices • Hand hygiene compliance

17. Beth Israel Medical CenterCLABs Prevention • Daily review of line necessity • Root cause analysis performed in real time for every CLAB • Development of a central line insertion kit • Barrier precaution components • Insertion components • Maintenance components

18. Beth Israel Medical CenterCLABs PreventionEducation and Recertification Standardization of Practices and Documentation but also: Hospital Specific Department Specific Unit Specific

19. 2005 Infection Control Policyfor Prevention of Intravascular Infection

20. Beth Israel Medical CenterCLABs PreventionEducation and Recertification • Indications • Anatomy • Procedure • “Time Out” • Universal Protocol • Patient Position • Skin Preparation • Maximal Barrier Precautions • Anesthesia • Approach • Dressing • Additional Expectations • Clean up • Monitor for complications

21. Procedure Competency Form

22. Beth Israel Medical Center CLABs PreventionEducation and Recertification

23. Beth Israel Medical CenterCLABs PreventionStandardization of Practices Enforcement of Policy and Procedure Procedure Note Insertion Kit Nursing Empowerment

25. Central Line Insertion Kit

26. Compliance - Central Line Bundle

27. ResultsData from PDSA Cycles Incremental cost per episode of CLAB ranges from $25,000 to $56,000 (CDC data: Burke 2003)

28. ResultsData from PDSA Cycles Attributable morbidity and mortality: 12 – 25% (Wenzel 2001)

29. ResultsData from PDSA Cycles • Significant reduction in CLABs • 95% reduction for institution • Achievement of zero CLABs on a variety of units • Reduction in morbidity and mortality • Daily review of need for line necessity • 20% decrease in central line days • Reduction in costs incurred in caring for patients with CLABs • $1,500,000 costs avoided • 90% reduction in costs from 2004 • Costs to implement • Additional $15 per line inserted • Total additional costs $30,000

30. Beth Israel Medical CenterCLABs Prevention

31. Beth Israel Medical CenterCLABs Prevention ICUs

32. BETH ISRAEL MEDICAL CENTER CLABs Prevention CCU

33. Beth Israel Medical CenterCLABs PreventionRoot Cause Analyses Within 24 hours of a CLAB All involved patient care staff 4 – 12 persons ED, ICU, non-ICU 20 – 45 minutes Collaborative, non-punitive process

34. Beth Israel Medical CenterCLABs PreventionRoot Cause Analyses Process that generates sustainable fixes Avoid “workarounds” that are constantly repeated Knowledge gained from this process is shared with all

35. Beth Israel Medical CenterCLABs PreventionRoot Cause Analysis – August 2005 • 84 year old female with a history of hypertension, CHF, cardiac arrhythmia with pacer, insulin dependent diabetes • Admitted to ICU with CHF exacerbation, pleural effusion • Developed acute renal failure requiring dialysis • Nephrologist places Shiley catheter • Groin site chosen • Difficult procedure requiring multiple attempts • Maximal barrier precautions not fully utilized • Nursing staff attempt to assist • Call intensivist to place line • Blood cultures positive for C. albicans 48 hours later

36. Beth Israel Medical CenterCLABs PreventionRoot Cause Analysis – August 2005 • Nephrologist conducts RCA • Credentialed • Central line indicated • Urgent not emergent • Supplies available and easily obtainable but not fully utilized for maximal barrier precautions • Need to ask for assistance sooner rather than later • Corrective Actions • Central line insertion kit • Nursing staff empowered and more comfortable with role • Reeducation and recertification of nephrologist

37. Beth Israel Medical CenterCLABs PreventionRoot Cause Analyses 2005 • Central Line Care • Dressings • Access • Insertion Practices • Maximal barrier precautions • Supplies never an issue • Certification of physicians

38. Results - Data from PDSA CyclesICU CLABs

39. Beth Israel Medical CenterCLABs PreventionRoot Cause Analyses 2006 • Central Line Care • Dressings • Access • Maintaining the momentum

40. Results - Data from PDSA CyclesICU CLABs

41. Beth Israel Medical CenterCLABs Prevention • Use and monitoring of evidence based patient care practices or “bundles” with reporting back of data to end users resulted in the rapid and sustained elimination or decreased incidence of CLABs on many units • Limited additional resources were necessary for the success of this initiative • Efforts were effective for all areas of the hospital where central lines are inserted • As compliance with insertion bundle improves, line maintenance has assumed a greater role in the prevention of CLABs • Culture change regarding goal of zero CLABs infections is applicable for all hospital acquired infections and patient safety issues

42. Beth Israel Medical Center Bronx-Lebanon Hospital Center Brookdale Hospital Medical Center Cabrini Medical Center Good Samaritan Hospital Medical Center Interfaith Medical Center Kingsbrook Jewish Medical Center* Kingston Hospital* Lenox Hill Hospital Long Beach Medical Center Long Island College Hospital Lutheran Medical Center Montefiore Medical Center Mount Sinai Hospital Mount Sinai Hospital of Queens New York Downtown Hospital New York Hospital Queens* New York Methodist Hospital New York-Presbyterian Hospital New York University Medical Center North General Hospital Our Lady of Mercy Medical Center North Shore-Long Island Jewish Health System, including: Forest Hills Hospital Franklin Hospital Glen Cove Hospital Huntington Hospital Long Island Jewish Medical Center North Shore University Hospital Plainview Hospital Southside Hospital Staten Island University Hospital Syosset Hospital Peninsula Hospital Center Richmond University Medical Center* Sound Shore Medical Center of Westchester St. Catherine of Siena Medical St. Charles Hospital St. Joseph’s Medical Center, Yonkers* St. Luke’s - Roosevelt Hospital Center St. Luke's Cornwall Hospital St. Vincent’s Medical Center, Manhattan* Stamford Hospital The Parkway Hospital* Trinitas Hospital Winthrop University Hospital* Wyckoff Heights Medical Center GNYHA/UHF CLABs CollaborativeParticipating Hospitals *Hospitals that joined the CLABs Collaborative in the second round of participation (i.e., in August/September 2006).

43. GNYHA-UHF CLABs Collaborative Characteristics of Participating Hospitals • 38 hospitals participating, 56 ICUs* • At inception of Collaborative, hospital practice was widely variable across participants: GREAT OPPORTUNITIES FOR IMPROVEMENT! Responses obtained from ICUs within participating hospitals. *Note that these were responses from the original group of 38 CLABs Collaborative participating hospitals.

44. GNYHA-UHF CLABs Collaborative Design • Systematic model for change that would • Meet needs of hospitals within the region • Use existing staffing and financial resources

45. GNYHA/UHF CLABs Collaborative Design • Hospital leadership involvement and commitment • Interdisciplinary teams / Physician and Nurse champions • Evidence-based interventions: Implemented “Central Line Bundle” • 3 learning sessions: Reviewed key interventions for eliminating CLAB infections, guidelines for inserting central line, materials needed, maintaining central lines, hospital best practices, and approaches to sustaining improvements. • Bi-weekly conference calls: Shared information / tools specific to reducing CLAB infections. • Collaborative web site for information-sharing: http://jeny.ipro.org/clabs • “Expert on Call” clinical consultant • Reinforcement of “zero tolerance” for CLAB infections • Standardized Materials: Teams developed and used standardized data collection and definitions • Root Cause Analysis (RCA): Real time RCAs encouraged to identify reasons for CLABs and develop solutions for prevention • Tracking Success: Aggregate and hospital-specific results reported monthly and site visits made by Collaborative sponsors to identify areas in need of support Central Line Bundle: Hospital teams identified the “central line bundle” as a strategy to prevent infection during central line insertion. Components include: hand hygiene, use of maximal barrier precautions, chlorhexidine skin use, site of line placement, and review of line necessity. All necessary supplies should be available at the patient’s bedside when needed (creation of central line insertion kit).

46. CLABs Collaborative Website: http://jeny.ipro.org/clabs

47. Examples of Findings fromRoot Cause Analyses Line Maintenance Technique not adequate Lack of Education and Staffing Line not changed on timely basis Not compliant with hand hygiene Inexperienced residents and clinicians Line inserted w/o sterile technique Line in for too long Clinicians not knowledgeable about Central Line Bundle Dressing not changed using aseptic techniques Inadequate use of maximal barrier precautions Nurses do not properly know how to change dressings IV tubing not labeled properly to change Inadequate prep before insertion MD does not get someone to assist with line insertion Line not manipulated appropriately Femoral line chosen instead of subclavian Nurses too busy to check & change dressings Central Line–Associated Bloodstream Infection

48. Barriers and Solutions Barrier Solution • Lack of Compliance • Maintenance • Technique Development of central line insertion & maintenance kits Creation of monitoring tools to assure compliance with bundle components Empowerment of nursing staff to stop procedure when bundle not followed Daily rounds to assess line necessity and assure appropriate maintenance Development of Department/Hospital-wide educational programs re: insertion and maintenance Lack of Education & Staffing Reorganization of staffing to monitor and assure compliance Creation of protocols in which nursing signs off on dressing rounds Lack of Standardized Data Collection Adoption of CDC’s NHSN definitions Monthly data fed back (CLAB infection rates) to participating hospitals and staff

49. GNYHA-UHF Collaborative 15-Month Data Results* Bundle Implementation1: • 88% reported full implementation; remaining 12% in process of fully implementing • Mean pre-bundle implementation CLAB infection rate = 4.02 infections / 1,000 central line days • Mean post-bundle implementation rate = 1.79 infections / 1,000 (p Value <0.0001) Overall Aggregate CLAB Infection Data: • Mean baseline rate = 4.86 infections / 1,000 central line days • Mean fifteen-month study period2 infection rate = 2.38 infections / 1,000 • 51% overall decrease (p Value <0.0001) Comparison of CLAB Infection Data in 3-month Cohorts during 15-month Study Period2: • Mean first three months (July through September 2005) = 3.10 infections / 1,000 central line days • Mean last three months (July through September 2006) = 1.76 infections / 1,000 • 43% decrease during the course of the study period (p Value = 0.015) Maintaining Zero CLAB Infections during 15-month Study Period2: • 29 hospitals (81%) maintained zero for at least 3 months • 8 hospitals (22%) maintained zero during the last 6 months Notes: 1 Bundle implementation, reported by 34 of the 38 original participating hospitals through an Interventions Survey developed by Collaborative sponsors, April 2006. 2Study Period includes data collected by 36 of the 38 original participating hospitals from July 2005 through September 2006. *Includes data from 36 of the 38 original participating hospitals