CARE BUNDLES IN THE ACUTE AND COMMUNITY SETTING

1. CARE BUNDLES IN THE ACUTE AND COMMUNITY SETTING CENTRAL LINES AND URINARY CATHETERS Fiona Barry Infection Prevention and Control Nurse Mercy University Hospital, Cork. fbarry@muh.ie UCC 8 September 2011

5. The 5 Moments apply to any setting where health care involving direct contact with patients takes place

6. 1st principle of infection prevention at least 35-50% of all healthcare-associated infections are associated with only 5 patient care practices: Use and care of urinary catheters Use and care of vascular access lines Therapy and support of pulmonary functions Surveillance of surgical procedures Hand hygiene and standard precautions

7. Innovations in Health Care 1497 100 of 160 crew die form scurvy 1601 Lancaster gave lemon juice to the crew of one ship on the way to India. 110 of 278 sailors died on the 3 other ships. 1747 (146 yrs later) random trial proved the efficacy of citrus fruits 48 yrs later adopted by the RN 1865 Board of Trade ruling Time of implementation 264 years Lancaster was director of the East India Company� 4 ships set sail on an expedition which took 5 months to reach their destinationLancaster was director of the East India Company� 4 ships set sail on an expedition which took 5 months to reach their destination

8. Patient safety Intensive Care in the ROI suffers from �excessive diversity� in service provision Experience from high reliability organisations Need to standardise procedures / critical processes through guidelines Need a �checklist� model Patient safety is the top of the agenda��. We know that despite the aims of CG there exists diversity in practice There is evidence to support this from organisations such as NCEPOD Need to have standardised protocolsPatient safety is the top of the agenda��. We know that despite the aims of CG there exists diversity in practice There is evidence to support this from organisations such as NCEPOD Need to have standardised protocols

9. Aim Background Care Bundle definition Types of Care Bundles Care Bundles in practice � culture change

10. Bundle Aim To eliminate the piecemeal application of guidelines that characterises the majority of clinical environments today To make it easier for clinicians to bring guidelines into practice

11. Why? Rate of bacteraemia associated with CVC is increasing year on year HIQA Infection Control Standards 2008 Standard 8 Device related infections are reduced or prevented Criteria 8.1 �the implementation of a structured set of processes that have been proven to improve outcomes, (e.g. bundles) for the prevention of invasive medical devices related infections�

12. Do Central Lines Cause Bloodstream Infections? Central venous catheters (CVCs) disrupt the integrity of the skin, making infection with bacteria and/or fungi possible. Infection may spread to the bloodstream and hemodynamic changes and organ dysfunction (severe sepsis) may ensue. Approximately 90% of the catheter-related bloodstream infections (BSIs) occur with CVCs. Central venous catheters (CVCs) are increasingly used in the inpatient and outpatient setting to provide long-term venous access. The most common complication of CVCs is infection, and nosocomial infection for hospitalized patients. The principal problem is the disruption of the integrity of the skin. The consequences may include bloodstream infection, sepsis, and/or death.Central venous catheters (CVCs) are increasingly used in the inpatient and outpatient setting to provide long-term venous access. The most common complication of CVCs is infection, and nosocomial infection for hospitalized patients. The principal problem is the disruption of the integrity of the skin. The consequences may include bloodstream infection, sepsis, and/or death.

13. Healthcare workers are committed to delivering high standards of care to all patients Standards of care are generally defined by evidence based guidelines, e.g. infection control guidelines SARI guidelines CDC guidelines(USA) EPIC/NICE guidelines (UK) Standards of care

14. Dr.Peter Pronovost is accredited with developing the first Care Bundle-insertion and management of CVC�S Intensivist in a hospital in Michigan Developed a checklist for insertion and management of CVC�s to ensure that key interventions recommended by the CDC 2002 guidelines were implemented every time a CVC was inserted Background to Care Bundles

16. Bundle: Hand hygiene MSB Skin antisepsis with chlorhexidine Avoiding femoral access Remove of needless CVC

17. Keystone ICU Project: The Results 66% reduction in Central Line Bloodstream Infections (CLBSI) Interventions: Hand hygiene Max. barrier prec. during insertion CHG antiseptic on insertion site Avoid femoral CLs Remove CL when not needed Pronovost P, et al. NEJM 2006;355:2725-32.

18. Keystone Project Michigan Hospital Association 127 intensive care units (ICUs) in Michigan and five other states. 68 ICUs totally eliminated CVC-BSIs. For 6 months, they eliminated VAP. Estimates that they saved >1,578 lives, reduced 81,000 hospital days, and saved $165 million. Hospitals in Rhode Island, New Jersey and Maryland are replicating the Keystone Project locally and others will follow. Pronovost P. et al NEJM 2006;355:2725-32

19. A care bundle is a collection of interventions (usually 3-5) that are evidence based All clinical staff know that these interventions are best practice but frequently their application in routine care is inconsistent A care bundle is a means to ensure that the application of all interventions is consistent for all patients at all times thereby improving outcomes Care bundles

20. Care bundles explained A global standard of care management A defined as a group of interventions related to a disease process that when implemented together result in better outcomes than when implemented individually Bundle components can easily be measured as completed or not completed: �all-or-none� compliance A concept created by the IHI The term Bundle is growing in popularity throughout the Health Care Quality Improvement world. A grouping of several scientifically grounded elements essential to improving clinical outcomesA concept created by the IHI The term Bundle is growing in popularity throughout the Health Care Quality Improvement world. A grouping of several scientifically grounded elements essential to improving clinical outcomes

21. What makes a bundle so special? The power of a bundle comes from the body of science behind it and the method of execution: with complete consistency.� It�s not that the changes in a bundle are new; they�re well established best practices, but they�re often not performed uniformly, making treatment unreliable. A bundle ties the changes together into a package of interventions that people know must be followed for every patient, every single time.

22. What else is a bundle? Methodology to spread the use of generally accepted science Provide a �pressure� for teamwork Simple, memorable checklist Audit tool All aspects should be done to get the maximum benefit

23. WHO Surgery Safety Checklist Urinary Catheter Care Bundle Insertion and Management Clostridium difficile care bundle Ventilator assisted Pneumonia care bundle Palliative care bundle Pressure area care bundle Sepsis care bundle PVC care Bundle Types of Care Bundles

26. Guidelines don�t work on their own? What �normally� happens to guidelines ??? The get filed away in a dark scary place � like the Lost Arc kept in a vast repository or in our case the place known as �The Intranet�What �normally� happens to guidelines ??? The get filed away in a dark scary place � like the Lost Arc kept in a vast repository or in our case the place known as �The Intranet�

27. Plan All staff needed to develop an awareness of the surviving sepsis campaign and the care bundle elements. We are very fortunate to have a team of dedicated educators within Critical Care. This team forms ready made champions of quality improvement care packages. These champions will prove to have a direct impact on the success of the implementation of the bundles. Myself and the team developed a multi-phased approach: Teaching boards displayed within Critical Care with brief info on the care bundle concept and all the elements Presentations at G grade away day Discussion at Consultants meeting The offer of one-one teaching sessions by any member of the education team The G grade shift co-ordinators were the target group for assessing which patients had developed or admitted with sepsis. However initially I undertook this role and then worked on a one-one basis with each shift co-ordinator to ensure that they understood everything Do Initially the information system was not ready for data collection, so I used pen and paper to collect the data however I�ve recently had the opportunity to play with the new data base and it is extremely easy to use and it analyses the results as soon as the data is put in Study This is an important element in order to see the weaknesses of implementation and act on them Evaluate the available information Understand what the info is telling you If there is a particular problem area what are its symptoms and causes Make the plan permanent / study the adjustments Decide what action is needed Adopt the change permanently Abandon the change Make some adjustment and go round the cycle again Plan All staff needed to develop an awareness of the surviving sepsis campaign and the care bundle elements. We are very fortunate to have a team of dedicated educators within Critical Care. This team forms ready made champions of quality improvement care packages. These champions will prove to have a direct impact on the success of the implementation of the bundles. Myself and the team developed a multi-phased approach: Teaching boards displayed within Critical Care with brief info on the care bundle concept and all the elements Presentations at G grade away day Discussion at Consultants meeting The offer of one-one teaching sessions by any member of the education team The G grade shift co-ordinators were the target group for assessing which patients had developed or admitted with sepsis. However initially I undertook this role and then worked on a one-one basis with each shift co-ordinator to ensure that they understood everything Do Initially the information system was not ready for data collection, so I used pen and paper to collect the data however I�ve recently had the opportunity to play with the new data base and it is extremely easy to use and it analyses the results as soon as the data is put in Study This is an important element in order to see the weaknesses of implementation and act on them Evaluate the available information Understand what the info is telling you If there is a particular problem area what are its symptoms and causes Make the plan permanent / study the adjustments Decide what action is needed Adopt the change permanently Abandon the change Make some adjustment and go round the cycle again

28. Prevention of CVC-BSI

29. Reducing HCAI CLC Bundle.....insertion Hand hygiene Decontaminate hands before and after each patient contact Use correct hand hygiene procedure Maximal barrier precautions PPE Single use gloves Eye/face protection Aseptic technique Sterile gown, gloves,mask and full body drape Chlorhexidine skin antisepsis (2% Chlorhexidine Gluconate in 70% Isopropyl Alchohol) Catheter Optimal catheter site selection, with subclavian vein as the preferred site for non-tunnelled catheters Single lumen unless indicated otherwise

32. Care bundle checklist for insertion of CVC

33. Insertion checklist in the notes

34. Reducing HCAI CLC Bundle....maintenance Hand hygiene Decontaminate hands before and after each patient contact Use correct hand hygiene procedure Catheter site inspection Regular observation for signs of infection ie. leakage, inflammation etc � AT LEAST DAILY Dressing A sterile, transparent, semi-permeable dressing should be in place Ensure dressing is intact and dry Catheter access Aseptic technique swabbing ports/hubs with 2% Chlorhexedine prior to access Clinical indicator for line has been reviewed to-day Daily review of line necessity with prompt removal of unnecessary lines

37. Comment (if required) Total number of CVCs in situ at start of CVC Maintenance Bundle � � Total number of CVCs with documented need to remain in situ. � � Total number of CVCs with evidence of optimal dressing (intact and changed within past 7 days) � � Total number of CVCs with evidence of alcohol hub decontamination prior to all line maintenance/access procedures. � � Total number of CVCs with evidence of hand hygiene performed before and after all CVC procedures � � Total number of CVCs with evidence of Chlorhexidine gluconate 2% used for insertion site antisepsis at last dressing change. � � � Summary Table of CVC Bundle Findings

38. 5. Hand Hygiene

39. 39

40. Catheter Associated Urinary Tract Infection (CAUTI) is the second leading cause of device-related bacteraemia. They increase the risk of UTI by: enabling organisms to gain entry to the bladder - via external surface or opened connection reducing the bodys defence of flushing out organisms during mictuition facilitating biofilm formation The organisms causing CAUTI, can be endogenous - from the patient's own gut flora, or cross-transmitted through poor infection control practices. Catheter Associated Urinary Tract Infection

41. The organisms causing CAUTI, can be endogenous - from the patient's own gut flora, or cross-transmitted through poor infection control practices. Healthcare workers should always look for opportunities to reduce the use of invasive devices. Catheter Associated Urinary Tract Infection

42. The CAUTI maintenance bundle is to optimise the care of patients who require urinary catheterisation during acute care - and to ensure that urinary catheters are removed as soon as clinically indicated. AIM OF CAUTI MAINTEANCE BUNDLE

43. Perform a daily review of the need for the urinary catheter. Check the catheter has been continuously connected to the drainage system. Ensure patients are aware of their role in preventing urinary tract infection. (Alternative bundle criterion if the patient is unable to be made aware: Perform routine daily meatal hygiene). Regularly empty urinary drainage bags as separate procedures, each into a clean container. Perform hand hygiene and don gloves and apron prior to each catheter care procedure; on procedure completion, remove gloves and apron and perform hand hygiene again. THE BUNDLE -CAUTI

44. Insertion Insert only for specific reasons Urinary output in critical ill Bladder outlet obstruction or neurogenic bladder dysfunction Prevent contamination of sacral wounds Terminal care Competent HCW to insert Aseptic technique Closed system with bag below bladder Urinary Catheter Care Bundle 

45. Management Review need for catheter daily Empty when � full and use clean container for each patient Secure catheter to leg/abdomen Urine samples from sampling port only Hand hygiene & PPE before and after any catheter care Urinary Catheter Care Bundle

46. SARI Guidelines on Prevention of Catheter Related Urinary Tract Infections will be published later this year Care Bundle will be published with the guidelines Urinary Catheter Care Bundle

48. Insertion

50. The Catheter in the Community is to optimise the care of patients who require urinary catheterisation - and to ensure that urinary catheters are changed and maintained appropriately. This bundle is different from the bundle used in acute settings where the emphasis is on removal of the urinary catheter when clinically indicated as opposed to ensuring urinary catheters are changed and maintained appropriately in the community setting. The Catheter Associated Urinary Tract Infection (CAUTI) maintenance bundle for use in the Community

51. The review date for urinary catheter change has not passed. The catheter has been continuously connected to the drainage system and the tap remains closed following emptying, connecting and reconnecting. Patients/carers are aware of their role in daily personal hygiene to minimise the risk of developing UTI or daily meatal hygiene has been performed by nurses/carer. Urinary drainage bags are regularly emptied into a clean container or WC. Hand hygiene is performed before and after catheter care procedure; MAINTENANCE BUNDLE IN THE COMMUNITY

52. Very little information available on this issue Dependent on the culture of the organisation The following ideas may help 1.Find a colleague who is interested also! 2.Find out all the info on the subject you can 3.Liase with other colleagues in other organisations for good ideas 4.Leader-nominate/high visibility 5.Buy in-staff/other disciplines 6.Education 7.Communication channels 8.Time-implement/wont get it perfect 9. Review current policy/guidelines 10.MOTIVATION AND ENERGY How to implement

55. Centres for Disease Control and Prevention (2002). Guidelines for the prevention of intravascular catheter-related infections. MMWR Mortality and Morbidity Weekly Report 2002, vol 51, (No RR10), pp 1-26. Health Information Quality Authority (2009). National Standards for the Prevention and Control of Healthcare Associated Infections. Health Protection Surveillance Centre. (2009). SARI Prevention of Intra- Vascular related Catheter Infections in Ireland. REFERENCES

56. Pittet, D. (2005). Infection control and quality health care in the new millennium. American Journal of Infection Control, vol 33, pp 258-67. An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU Peter Pronovost et al N Engl J Med 2006; 355:2725-2732December 28, 2006 REFERENCES

57. References Institute for Healthcare Improvement website for infection prevention bundles: www.IHI.orghttp://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/ImplementtheVentilatorBundle.htm and http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/ImplementtheCentralLineBundle.htm and http://www.ihi.org/IHI/Programs/AudioAndWebPrograms/ExpeditionReducingCatheterAssociatedUrinaryTractInfections.htm Health Protection Scotland Bundle site 2009 http://www.hps.scot.nhs.uk/haiic/ic/guidelines.aspx#bundles