Goal Zero: Helping Each Other Help our Patients

Transcription

1 Goal Zero: Helping Each Other Help our Patients Preventing CLABSI AND CAUTI For any questions regarding this presentation, please contact: Professional Department Ext 5241 PAD or 4196 OBD

2 Checklists Checklists help us do it right in a complex world. Checklists are less a documentation tool and much more a safety tool. Checklists teach us and remind us of best practice.

3 Checklists Checklists contribute to reducing infection when real time feedback is given. We are looking for opportunities for improvement in patient safety, not perfect forms.

4 Checklists for CLABSI Prevention

5 Which central venous catheters (CVC) are being addressed? All of them! Nontunneled CVCs : Multi-lumen catheters Peripherally Inserted Central Catheters (PICCs) Tunneled CVCs ( such as Broviac, Hickman, Groshong) Dialysis Catheters CRRT Catheters (MAHURKAR) Implanted ports

6 Risk Factors for CLABSI Prolonged duration of central line- reduce the risk by avoiding central lines Site of insertion Subclavian vein poses less risk than internal jugular or femoral vein, with the femoral being the least preferred. Multiple lumen catheters and use of stopcocks More manipulation and contamination of multiple ports/hubs Emergency insertion ---Increased tissue trauma predisposes to CLABSI

7 Risk Factors for CLABSIs (cont.) Infection elsewhere (remote, i.e., urinary tract infection or wound) secondary source Excessive manipulation of the catheter Prolonged hospital stay prior to central line insertion Total parenteral nutrition and/or lipids Prolonged neutropenia Soiled dressing not changed promptly

8 Sources of Contamination for Catheter-Related Infections

9 What is a Bundle of Care? A group of evidence-based practices when utilized together produces improvement in patient care outcomes They are used to promote standardization of care practices to prevent variation in use of best practices.

10 Evidence-Based Steps to Prevent CLABSI on Insertion Meridian Health CLABSI Insertion Bundle Safety Monitor / Stop the Line person identified Indication for the CVC is identified Strict attention to hand hygiene prior to insertion process Avoidance of femoral sites for adult CVC placement

11 Evidence-Based Steps to Prevent CLABSI on Insertion Maximum sterile barrier for patient (full body sterile drape) Cap, mask, sterile gown and gloves, eye protection for clinicians Instruct anyone assisting you to wear the same barriers. Chlorhexidine friction scrub at least 30 seconds with the swabstick (with products like Chloraprep) and allow to dry UNLESS it is a femoral site, where it is 2 minutes for both scrubbing and drying.

12 What does Safety Monitor/ Stop the Line mean? A healthcare professional (physician, PA, APN, RN) skilled in supporting or performing central line insertions will be designated as the individual called the Safety Monitor and empowered to Stop the line meaning they will STOP the physician or other credentialed practitioner if they observe a violation of the procedure, including but not limited to aseptic technique. Adapted from the Toyota Production line where any employee is encouraged to pull the chain to stop the production line when a defect is seen. It is a related HRO process.

13 Stop the Line Process: Non-emergent conditions Designating a clinician (Physician, APN, PA, RN) at the beginning of the procedure empowers that individual to speak up: My name is John and I am the Safety Monitor for this insertion. This is commonly a nursing role. The message is an objective one, such as Dr. Smith: Please stop; I have a safety concern: the sterile field has been contaminated. Another Stop the Line example is when not everyone involved in the insertion is wearing the complete protective garb. Finish the message with a recommendation to the team or a request for consideration.

14 Emergency Scenario with Stop the Line Begin the scenario as always by stating name and role as Safety Monitor. When a breech in technique is seen that is a concern, start message with Dr. Smith. I have a safety concern. The skin preparation was not long enough. Dr. Smith s message back includes acknowledgment of the concern: Your concern is acknowledged. The condition of the patient supercedes usual protocol. We will discuss plans to address this once the emergency subsides. The care team will then debrief afterwards on the potential harm to the patient and what steps will be taken to address them going forward.

15 The Safety Monitor From Your Patient s Perspective No one wants the patient to be frightened by the use of the Safety Monitor The best plan for managing this is to be PROACTIVE. Once you introduce yourself to the insertion team as the safety monitor, also share with the patient your role in the procedure.

16 The Patient Conversation Hello, Ms. Jones, my name is Sue and I am a nurse taking the role of Safety Monitor in this case. You may notice that I may ask the team to pause and readjust some aspect of the procedure. This is being done to keep you safe from harm and prevent any errors before they happen.

17 If the Stop the line process is enacted Update a leader as soon as possible: For guidance on next steps For support

18 What are the major indications for central lines? Elective or emergent? To replace a malfunctioning line? For a new indication which may include but is not limited to a lack of other vascular access, or vasopressor administration The purpose of noting this is to encourage reflection of the necessity of the central line.

19 Hand Hygiene with CVCs Wash hands with soap and water or use a waterless hand sanitizer This is done at the following times: Before and after palpating the insertion site prior antisepsis Before and after inserting, replacing, accessing, repairing or dressing a catheter Before and after removing gloves Between patients

20 Hand Washing Steps 1. Wet hands. 2. Obtain soap. 3. Lather for at least 15 seconds. 4. Rinse hands, scrubbing vigorously between fingers. 5. Turn off faucet handles with paper towel.

21 Waterless Hand Hygiene Steps Coat all surfaces of your hands thoroughly with waterless hand sanitizer, including palms, in between fingers, under fingernails, backs of hands, and around wrists. Rub your hands briskly until they feel comfortably dry. It takes about 15 seconds, and no water or towels are needed.

22 CVC Site Selection Use the subclavian site unless medically contraindicated (e.g., patient has an anatomic deformity, coagulopathy, or has renal disease that may require dialysis). Avoid femoral sites.

23 CVC Line Selection Use a single lumen CVC unless multiple lumens are absolutely necessary. Consider a tunneled or implanted CVC for patients requiring long-term access (>30 days) or a PICC or cuffed CVC for patients requiring therapy for >1 week.

24 Aseptic Technique: Goals Remove transient organisms and soil from the skin. Reduce the number of resident microbial flora and inhibit their rebound growth. Create a sterile working surface that acts as a barrier between the insertion site and any possible source of contamination.

25 Aseptic Technique Prepare skin with antiseptic/detergent chlorhexidine 2 percent in 70 percent isopropyl alcohol. Apply chlorhexidine solution using a back-and-forth friction scrub for at least 30 seconds with the swabstick if on the internal jugular or subclavian, 2 minutes for the femoral site. Do not wipe or blot. Allow the antiseptic solution time to dry completely before puncturing the site. This may take 2 minutes.

26 Caveats: Catheter Insertion IV antimicrobial prophylaxis does not reduce CLABSI. * Insertion of CVC through open techniques/cut down increases the risk of CLABSI. Adequate room is needed to perform the procedure without risk of contamination. *Ranson. J Hosp Infect. 1990;15(1):

27 TIPS

28 Meridian Health CVC Maintenance Bundle CLABSI Maintenance Bundle Replace CVC within 24 hours, if femorally inserted or inserted emergently and aseptic technique was in question RN-Physician review daily the necessity for CVC and remove promptly if not indicated RN-Physician identify the number of days the CVC is in place and consider removal for a CVC no longer essential. If longer term access is needed consider tunneled line.

29 Meridian Health CVC Maintenance, cont. Strict attention to hand hygiene prior to and after CVC related care Antiseptic cap in place over the end cap Disinfect/scrub the CVC access ports /hub/ connectors with antiseptic 15 seconds prior to accessing and let dry Sterile transparent dressing inspected (Soiled? Loose? Damp? If YES, change) Sterile dressing change: Transparent at 7 days along with antimicrobial patch change; 2 days if gauze

30 Meridian Health CVC Maintenance, cont. CVC site scrubbed with Chlorhexidine for 60 seconds each side of the swabstick; let dry 2 mins. Continuous maintenance IV tubing not used for blood/blood products/lipids replace at 96 hours; lipid infusion tubing and intermittent IVPB tubing replaced every 24 hours; blood/blood products as per policy. Chlorhexidine bath daily for all patients with central lines and all patients in Critical Care (be aware of contraindications/sensitivities with CHG).

31 Hand off of Communication When? Shift Report Report from sending units ED ICU What? How long has catheter been in? Why? Indication appropriateness? Removal before or upon transfer? A Best Practice is to discuss line necessity in every shift huddle.

32 Post Insertion: CVC Care Antimicrobial ointments do not reduce the incidence of CLABSI. A sterile dressing should be applied to the insertion site before the sterile barriers are removed. Transparent dressings are preferred to allow visualization of the site. However, if the insertion site is oozing, apply a gauze dressing with anti-microbial patch and transparent dressing over. When the CVC dressing becomes damp, loosened, or soiled, replace the dressing.

33 PICC lines should be secured with a securement device Securement devices not only stabilize lines, but prevent them from complications. Upon initial insertion the PICC is secured with StatLock. With subsequent dressing changes the WingGuard securement device is used If an RN who is not an IV Nurse changes a dressing, secure the PICC with steristrips and leave a message informing IV Therapy that the dressing was changed.

34 CUROS Caps CUROS caps are RBMCs choice for use as antiseptic caps for peripheral and central lines. Each Curos disinfecting product contains 70% isopropyl alcohol (IPA). The IPA bathes the surface of the luer-activated device and disinfects it in just 1 minute. Curos disinfecting caps can be left in place to keep needleless connectors clean and protected for up to 7 days. However, they are changed with every line access. Check that the Curos cap is in place with every bedside shift report and on rounds. The cap must be in place at all times.

35 Antiseptic caps in practice If the Curos cap has been on for at least 60 seconds the port has been disinfected. Example of sequence in hanging a PB: Remove Curos cap; insert syringe to check for patency of line Remove syringe and wipe port with alcohol prep for 15 seconds and allow to dry Insert PB infusion. Post infusion remove and wipe port with alcohol X 15 seconds and allow to dry Insert syringe for flush Apply new Curos cap

36 Curos Caps and Intermittent IV Intermittent IV Tubing is good for 24 hours Label tubing X 24 hours Cap tubing with Curos cap Curos caps do not replace the need to change tubing every 24 hours REMEMBER: Any disconnected line not in use requires a sterile cap.

37 Do not disconnect continuous IV tubing Do not disconnect IV tubing of any kind For example, do not disconnect the line to ambulate a patient. Use gowns with shoulder snaps that make gown changing easier.

38 Chlorhexidine Bathing Another source of protection for our patients.

39 Chlorhexidine (CHG) Baths CHG bathing is done for all patients with central lines of any kind over the age of 2 months. Note: Critical Care units are to bathe entire unit population CHG is applied from the neck down avoiding face, eyes, ears, mouth, genital areas Do not apply to wounds or drain areas. Avoid with patients with epidural or lumbar drains. Do not use regular soap, non-compatible lotion, powder or deodorants after washing with CHG. Instruct patient regarding the same.

40 Chlorhexidine Do not dilute the CHG Foam in the bath water Wash the patient daily but also after soiling. Use the basin liners for all basin use.

41 Re-Bathing with CHG When you have a patient with frequent diarrhea or secretions/excretions: Re-bathe with CHG up to 4 times in 24 hours (up to once every six hours) Communicate this re-bathing in shift hand-offs

42 Replacing CVCs Lines should be removed as soon as possible. Routine CVC guidewire exchange or site rotation is not recommended.* Guidewire exchange is acceptable for replacing a malfunctioning catheter or downsizing a pulmonary artery catheter to a central venous catheter. Patients who clearly have a CLABSI should not undergo a guidewire exchange. *Eyer, et al. Crit Care Med. 1990;18(10):

43 Insertion Checklists Is completed by the Safety Monitor who is empowered to Stop the line A copy is forwarded to the local campus infection control department. A copy is retained on the unit in the CLABSI/CAUTI binder to help assist in tracking the line. NOTE: On checklist RBMC Perth Amboy is abbreviated as RBP and Old Bridge is abbreviated RBO

44 Insertion Checklist Meridian Health Central Line Insertion Checklist BCH JSUMC OMC RMC SOMC RBO RBP Date of Insertion: Time Initial Stick: Time Catheter Fully Inserted: Nursing Unit: Catheter Lot Number: Allergies: Site of Line: Type of Line: Location: # lumens: Site of Line: Subclavian, Internal Jugular, Femoral, Peripheral;Type of Line: Vascath/Permacath, TLC, Cordis,Mahurkar, Other Dialysis (Tunneled or NonTunneled), PICC ; Location: Left or Right Critical steps Yes Yes w. reminder No Comments/Deviations The Safety Monitor identified to Stop the Line Before the procedure, did the clinician: Obtain consent for procedure (signed & witnessed) Perform time out & document Confirm hand washing immediately prior Wear cap, mask, sterile gown & gloves; eye protection for all clinicians involved Properly position patient to prevent air embolism Prep site with chlorhexidine for 30 seconds, unless femoral then it is 2 minutes

45 Insertion Checklist Allow site to dry Use sterile technique to drape head to toe During the procedure Maintain a sterile field Use ultrasound guidance N/A Clamp any ports not used in insertion Aspirate blood from ea. lumen; flush; new cap placed

46 Insertion Checklist After the procedure Clean blood from site using chlorhexidine Apply Biopatch dressing with transparent drsg. over Verify placement of line by x-ray (N/A if placed under fluoroscopy or femoral line) N/A fluoro General: Was this a change over a guide wire? General: Was more than 1 site attempted? General: Was more than 1 stick attempted? General: If more than 1 stick, was new needle used? General: Was the standard central line supply cart used?

47 Checklists INSERTION CHECKLISTS WILL REMAIN A PAPER PROCESS

48 Maintenance Checklists Completed at 7am and 7pm daily as a quality and safety checklist. Samples of the central line and urinary catheter maintenance checklists are in the last section of this presentation entitled Checklist 2.0

49 Urinary Catheter Bundle -- Insertion: Insertion only with approved indication If urinary retention is present, use the bladder scanner first Alternatives to urethral catheterization have been attempted if appropriate Strict hand hygiene Prior to aseptic insertion, cleanse with soap and water towelette (no antiseptic like chlorhexidine) Use smallest size catheter appropriate to patient (usually 14 or 16), using size 18 for use with hemorrhagic clots

50 Alternatives to Catheterization Programmed toileting (every 2-3 hours) Male condom catheters Encouraging fluid intake unless fluid restrictions are in place Having a commode available for those with mobility limitations Bladder scanning Straight catheterization

51 Urinary Catheter Bundle -- Insertion: Strict aseptic technique performed at every insertion. The following conditions require a second RN as the Safety Monitor who stops the line and documents the checklist. obesity agitation/flailing lower body paralysis low experience inserter nursing judgment Secured catheter using securing device Document insertion date and catheter size and indication/necessity in Net Access

52 INDICATIONS For Indwelling Urinary Catheters Urologic, Gynecologic, Perineal Surgery Urinary retention and or obstruction Accurate output measurement-hemodynamic instability Chronic indwelling catheter Comfort End of Life Care/Hospice Assist healing of Stage III/IV sacral pressure injury and or perineal wounds for patients incontinent of urine SCIP

53 Just say no to Indwelling Urinary Catheters! Do all we can to avoid Urinary catheterizations!

54 Catheters should not be used for the management of incontinence or convenience of personnel. Routine placement of indwelling catheters should be discouraged.

55 Bladder Scan Research has demonstrated bladder scanners to be accurate in the measurement of urine volume without the risk of developing UTIs from use of the gold standard of intermittent catheterization (Sparks et al. 2004)

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57 Bladder Scanning

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59 What does Stop the Line mean? A healthcare professional (another RN) skilled in supporting or performing urinary catheter insertions will be designated as the individual empowered to be a Safety Monitor who Stops the line meaning they will STOP the nurse, physician or other credentialed practitioner if they observe a violation of the procedure, including but not limited to aseptic technique. Adapted from the Toyota Production line where any employee is encouraged to pull the chain to stop the production line when a defect is seen.

60 The Smallest Catheters should be used in all cases A 14 or (16 Fr. catheter if necessary) should be used. Patient specific conditions, such as anticipated clots, might require an 18 Fr. Catheter.

61 Infection Prevention: Additional Insertion Notes Secure Foley catheter at the foot of the bed and confirm tube not kinked or looped Indicate time and date of catheter insertion on provided labels and place designated labels on the drainage system.

62 Insertion Checklists: monitors the insertion process and technique To be completed by the person empowered to Stop the line when present. Inserter completes the form when no Safety Monitor is present. A copy is forwarded to the local campus infection control department. A copy is retained on the unit in the CLABSI/CAUTI binder to help assist in tracking the line.

63 First Section of the Urinary Catheter Insertion Checklist Critical Steps YES YES with reminder ( ) No Deviation with comment Allergies reassessed (e.g. latex) Assure approved indication (necessity) Bladder scan as appropriate, first Alternatives attempted Soap and water perineal cleansing Standard kit used Choose smaller size catheter ie. 16 French Strict hand hygiene Aseptic technique

64 Second Section of the Urinary Catheter Insertion Checklist Critical Steps YES YES with reminder ( ) No Deviation with comment Did insertion require two staff present? Which of these is the specific reason. o obesity o agitation/flailing o low experienced inserter o lower body paralysis o nursing judgment Catheter secured (top of leg) Documented date and size, necessity Label drainage bag with date on sticker Drainage bag below bladder, not on floor Catheterization accomplished with 1 attempt

65 Maintenance Checklists are completed Daily at 7am and 7pm as a quality and safety reminder system. For the roster of patients with indwelling urinary catheters To monitor continued need for the catheter and assure proper maintenance procedures are followed

66 Urinary Catheterization Bundle: Maintenance Assessed daily for ongoing approved indication; no approved indication no catheter Alternatives are reconsidered For surgical patients with catheter at or beyond 48 hours obtain order for catheter to be removed or provider documents indication daily For medical patients without indications, remove the catheter within 48 hours of insertion in the absence of an order to maintain

67 The seal is intact How Should It Look?

68 The catheter securement device is secured on top of the thigh. How Should It Look?

69 Urinary Catheterization Bundle: Maintenance, cont. Drainage bag and tubing below bladder and off floor at all times Confirm attachment of catheter securing device each shift, positioned on top of the leg Tubing is free of kinks with no dependent loops and not clamped for over 2 hours for specimens

70 How Should It Look? Drainage bag is below the level of the bladder Drainage bag does not touch the floor. Loops should be avoided as much as possible Tubing is free of Kinks.

71 Catheter Care: Females Clean with Castile soap towelettes from front to back; may also use Castile liquid soap with basin and liners One towelette down each side of the labia minora and then down the center (3 separate towelettes). One towelette from meatus & 6 inches down catheter, away from the patient. *Use at least 4 towelettes for cleansing females. Use as many towelettes or cloths as needed to clean the patient properly

72 Catheter Care: Males Males: One towelette : cleanse from the meatus at the head of the penis in a circular motion then down the shaft. Retract foreskin if present and return after cleansing. Clean with second Castile soap towelette from meatus and 6 inches down catheter, away from the patient.

73 Bathing Guidelines for Patients Experiencing Diarrhea Fully bathe patient with warm water and disposable washcloths to remove all stool. Wipe front to back and dispose of washcloth after each wipe. Remember to use a basin liner and change it and the warm water as needed. *For patients with a central line, remember to perform CHG bath daily and once every 6 hours for extensive soiling* Once stool is completely removed, use castile towelettes/soap to provide proper catheter care Teach bowel continent patients how to properly perform self care with a catheter. Remind to wipe front to back, completely removing all stool!

74 Maintenance Checklist Item: Pericare Pericare twice/day (with AM and PM care)with castile soap and water (unless the patient has an allergy, then use soap and water) (no CHG) and after bowel movement; cleanse six inches down the tubing as well, moving from the patient outward.

75 Pericare using our regular basins May contribute to infection as they are re-used many times and may harbor germs.

76 Urinary Catheterization Bundle: Maintenance, cont. When sampling, SCRUB PORT VIGOROUSLY with alcohol 15 seconds Empty urinary catheter drainage bag prior to transport Presence of catheter documented and indication/necessity in the medical record at least daily

77 Checklists : Practical Issues ALL INSERTION Checklists (Central Line and Urinary Catheter) should be FAXED immediately to infection control. This includes the insertion checklists from ALL areas, including ED, IR, OR, Critical Care, Telemetry, Med-Surg, MCH. When the RN is in doubt to the date of an insertion and cannot find it in the record, consult infection control for their assistance or check the CLABSI/CAUTI binder. Central Line/Urinary Catheter INSERTION checklists MUST be transferred with the patient as they move from unit to unit throughout the hospital This ensures continuity of information regarding insertion date and days of use.

78 Checklists 2.0

79 Remember Scantron Forms? No, we aren t going to test you like in school, but we are changing our checklists to Scantron formats in February 20, 2017

80 Checklists and the Highly Reliable Organization By this point, many of us have completed training on high reliability and understand the need for mindful practice. Checklists are part of mindful practice. They help us complete a STAR moment (Stop-Think-Act-Review) for patient safety.

81 Checklists are /are not Checklists are not a classic audit form done by someone retrospectively. They are not done by a charge nurse or leader or someone needing some points for the clinical ladder. They are a part of the day. Working checklists into your routine is part of the trick to making them effective.

82 Checklists Checklists help us do it right in a complex world. Checklists are less a documentation tool and much more a safety tool. Checklists teach us and remind us of best practice.

83 How will this work? Scantron forms will be custom printed and available for every unit to stock monthly. Every hospital will have a Scantron scanner (Exception: RBMC one for two campuses). All forms must be delivered no later than once every 2 days to the designated clerical person for the campus. Please do not hold back forms on the unit. All Scantron forms will be fed into the scanner by one central clerical person. We will use the SCANTRON process with maintenance forms only. (Insertion forms will need to continue to be faxed for now to your local infection control dept).

84 To whom do we send the maintenance checklist Scantron forms? BCH: Dawn Gianfrancesco JSUMC: Andrea Bauter OMC: Allison Banach RMC: Meghan Matonti RBMC: Nancy Viernes for both sites SOMC: Kari Hamlin

85 Scantron Central Line Maintenance Form

86 Scantron Central Line Maintenance Form PLEASE NOTE: The checklist references dual caps and the BioPatch. Although RBMC does not use these specific items, we do use items that are the equivalent. For purposes of the checklist, please consider the below equivalents : BioPatch =Algidex Patch Dual Cap = Curos Cap

87 Scantron Urinary Catheter Maintenance Form

88 Unit Codes are on the Back of the Form

89 Key Points Use one form for TWO patients Use the unit codes that are on the back of the form only. Use ACCOUNT NUMBER AND NOT MEDICAL RECORD NUMBER. This point is critical for us to get the correct patient across the seven hospitals! (Some campuses have 10 digits and some have 11 digits for the account number. Always start digit entry on the left to enter the number). The form is set up with the four common elements being campus, shift, unit code and today's date; it will not work to use the form for two different shifts.

90 What advantages are there to the Scantron method? Results reporting is now based on sampling. Using Scantron will capture 100% of the checklist entries so we can learn more about all practice. Clerical and analytic personnel will not have to enter about 18,000 medical record numbers and the contents of over 5,000 checklists monthly. Scantron automatically produces an Excel worksheet of all the data that can be used by Nursing Quality to generate timely reports.

91 Do I have to use a #2 Pencil?!? No You may use a #2 Pencil OR a black ink pen. JUST LIKE THE OLD TESTING EXPERIENCE, YOU MUST FILL IN THE BUBBLE ANSWER COMPLETELY AND NOT GO OUTSIDE THE LINES

92 Thank you for keeping our patients safe! Goal Zero: Helping Each Other Help our Patients CLABSI/CAUTI Prevention