Whose Line is It Anyway? Preventing Central Line Blood Stream Infection

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Whose Line is It Anyway? Preventing Central Line
Blood Stream Infection

• Gillian Revie RN, BScN, BA, CNCC(C)
• Nurse Educator ICU/CCU
• Credit Valley Hospital
• Safer Health Care Now! Teleconference
• February 2008

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Background

• The Credit Valley Hospital is a 383 bed community
  hospital in Mississauga, Ontario with a 16 bed
  ICU/CCU.
• ICU/CCU patients include a mix of general
  medicine, cardiology and surgical patients.

• The Central Line team includes the members of the
  ICU/CCU multidisciplinary team in addition to
  members from Quality and Risk Management, Health
  Records, Microbiology and Senior Management.

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How we are doing?
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The Numbers

• Tracking Lines calendar in CN binder, CN on
  nights enters of lines, of new lines
• Important to define
• Time frame midnight to midnight, 0700 0700,
• Take into account workload of CN, what time is
  best for them
• Engage them with defining the time parameters,
  how to promote communication
• Can this be entered on line?

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Insertion Bundle

• Caps
• Sterile drapes
• Chlorhexidine products
• Asking what is available, what to keep, who is
  affected if you remove a product, what to remove
  from ward stock
• Out of sight Out of mind
• Engage users into deciding what product they
  prefer

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• We knew
• Chlorhexidine 2 with 70 Alcohol for Insertion
• User Input is Key!
• Users were looking for
• Individual patient use
• Tinted (to know where you had cleaned)
• To have only this product available so they could
  get it quickly!
• This needs sterile gauze to be available to clean
  skin

• This is the preference of one of our users
• Eliminates the need for gauze
• Not tinted
• Can be used by RRTs to cleanse skin prior to
  arterial stabs
• Unique packaging makes teaching fun

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Cart

• Safer
• Portable
• One Stop Shopping

Buy in is important Changed a system in place
since the beginning of time Provide
opportunity for feedback/discussion Labeling
increase awareness of materials in cart and
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The Insertion Checklist

• Critical Care Central Line
  Insertion Checklist Draft Feb 6, 2006
• Purpose to work as a team to decrease patient
  harm from catheter-related bloodstream
  infections.
• When for all central venous line insertions and
  central line rewire. Use one form for each new
  site attempted per line.
• Who by bedside nurse.
• Todays date _____ / _____ / _____
• 
  year month day
• Bedspot number ___________________
• Procedure ? New Line ? Line Rewire
• Is the procedure ? Elective ? Emergent
• Site of insertion ? Subclavian ? Jugular ?
  Femoral
• (if
  NOT subclavian, write reason below)

Please answer these questions Yes Yes, after prompting by nurse
Did the physician complete a two minute hand wash before commencing the procedure?
2. Is the physician wearing mask, sterile gown and sterile gloves?
3. Is the insertion site prepared with 2 chlorhexidine solution?
4. Is the patient covered with sterile drape?
5. After procedure, was sterile dressing immediately applied to site?
6. After procedure, were sterile caps placed on all lumens?
7. Was a correction required to ensure compliance with above infection control practices? (explain below) Yes No
8. Did you wipe down the procedure cart before and after the procedure?

• Have no fear
• Corrections can be made
• Using forms will guide your direction
• Feedback is important

Comments Please place completed checklist in
envelope in bottom drawer of cart
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The Edits

• Critical Care Central Line Insertion Checklist
  Draft Feb 13, 2006
• Purpose to work as a team to decrease patient
  harm from catheter-related blood stream
  infections.
• When for all central venous line insertions and
  central line rewire (avoid if possible). Use one
  form for each new site attempted per line.
• Who by bedside nurse.
• Todays date _____ / _____ / _____
• 
  year month day
• Unit number ___________________
• Procedure
• ? New Line ? Line Rewire (not recommended,
  if needed include reason under comments)
• Is the procedure ? Elective ? Emergent
• Site of insertion
• ? Subclavian ? Jugular ? Femoral (not
  recommended, if needed include reason under
  comments)

Please answer these questions Yes Yes, after prompting by nurse
Did you wipe down the bedside table before and after the procedure?
2. Did the physician complete a two minute hand wash before commencing the procedure?
3. Is the physician wearing mask, sterile gown and sterile gloves?
4. Is the insertion site prepared with 2 chlorhexidine in 70 isopropyl alcohol?
5. Is the patient covered with sterile drape?
6. After procedure, was sterile dressing immediately applied to site?
7. After procedure, were sterile caps/lines placed on all lumens? Yes No
8. Was there any identifiable contamination during the procedure? If yes, explain under Comments.
Comments Please place completed checklist in
envelope in bottom drawer of cart
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The Edits

• Critical Care Central Line Insertion Checklist
  Draft Feb 20, 2006
• Purpose to work as a team to decrease patient
  harm from catheter-related blood stream
  infections.
• When for all central venous line insertions and
  central line rewire (avoid if possible). Use one
  form for each new site attempted per line.
• Who by bedside nurse.
• Todays date _____ / _____ / _____
• 
  year month day
• Unit number ___________________
• Procedure ? New Line ? Line Rewire
  (not recommended, please comment below)
• Is the procedure ? Elective ? Emergent
• Site of insertion
• ? Subclavian ? Jugular ? Femoral (not
  recommended, please comment below)

Please complete the check list Check
RN bedside table disinfected before procedure, hands washed and mask worn
2. MD(s) hands washed
3. MD(s) mask, sterile gown, sterile gloves, cap worn
4. Insertion site - prepared with 2 chlorhexidine in 70 isopropyl alcohol
5. Sterile drape covered patient
6. Caps/lines attached using sterile technique
7. RN bedside table disinfected after procedure
8. Identifiable contamination occurred if yes, explain under comments
9. MD documented insertion with date on Admission record
Comments Please return the completed
checklist to the bag on the Special Procedures
Cart
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Grouping and Colour

• Viewing other hospitals checklists (Virginia
  Mason Medical Center)
• ICU Collaborative Conference Calls
• Look outside your initiative to see what may
  apply to you
• Jonas Shultz, M.Sc. Human Factors Consultant.
  Calgary Health Region
• Spoke on Human Factors in Healthcare used
  examples related to medication safety

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The Final Edition
Critical Care Central Line Insertion Checklist
Purpose To work as a team to decrease patient harm from catheter-related blood stream infections.
When For all central venous line insertions and central line rewire (avoid if possible). Use one form for each new site attempted per line.
Who By bedside nurse (include name to win Tim Hortons gift certificate)______________
Todays date (Month/day/year)
Patient Unit Number
Procedure ? New Line ? Line Rewire (not recommended, please comment below)
Is the procedure? ? Elective ? Emergent
Site of insertion ? Subclavian ? Jugular ? Femoral (not recommended, please comment below)
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Please complete the check list ?
RN bedside table disinfected before procedure, hands washed and mask worn
2, MD(s) hands washed
3, MD(s) mask, sterile gown, sterile gloves, cap worn
4. Insertion site - prepared with 2 chlorhexidine in 70 isopropyl alcohol
5. Sterile drape covered patient
6. Caps/lines attached using sterile technique
7. RN bedside table disinfected after procedure
8. Identifiable contamination occurred if yes, explain under comments
9. MD documented insertion with date on Admission record
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Location, Location, Location!

• Checklists placed on all central lines
• Extras placed where lines are stored
• Return location is in the same place
• Contest
• To promote use of checklists!!
• Whose Line is it Anyway?

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So how are we doing?
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Things to Celebrate

• Use of the bundle has become the standard
• Consider when to stop using checklists (or change
  frequency of use)
• Intensivists, Nephrologists, Cardiologists are
  all willing to comply with the bundle
• Taking to the ER (use of insertion checklist),
  RACE team

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One Stop Shopping for One Line Link with key
stakeholders in each area
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Education

• RN champion allows for education to occur on all
  shifts
• ICU rounds present to multidisciplinary team,
  introduction of audit tools
• Skills Day Halloween theme RN champion dressed
  as MD ready to insert a line, all supplies
  available for RNs to see
• One to One slow process, promotes discussion,
  discover/dispel myths

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Maintenance List

• Policies and Procedures currently in place
  reflecting SHN! Maintenance bundle
• Focus placed on Insertion bundle initially
• Create audit tool and go!!

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Daily Evaluation Form
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What went wrong?

• Kept on patients chart
• To be returned to central spot on discharge -did
  not happen
• Allow for daily auditing of individual patient
• Addition to workload another piece of paper
• Needed new plan

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Date Patient U New Line Chlorhexidine used when lumens opened (tubing changes or capping off) Chlorhexidine used when lumens opened (tubing changes or capping off) Dedicated Lumen for TPN Dedicated Lumen for TPN Entry Site Examined (Dressing change q. 6-7 days or prn) Entry Site Examined (Dressing change q. 6-7 days or prn) CL(s) Reviewed in rounds (to be completed by day shift only) CL(s) Reviewed in rounds (to be completed by day shift only)
Days/Nights Please circle   Yes/No/ Rewire Yes/No If not, why? Yes/No or N/A If not, why? Yes/No If not, why? Yes/No If not, why?
                     
                     
                     
                     
                     
                     
                     
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How well are we doing?
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So how are we doing?
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Patient U New Line Yes/No/ Rewire Chlorhexidine used when lumens opened (tubing changes or capping off) Chlorhexidine used when lumens opened (tubing changes or capping off) Dedicated Lumen for TPN Dedicated Lumen for TPN Entry Site Examined Entry Site Examined CL(s)/site reviewed in rounds/with MD (to be completed by day shift only) CL(s)/site reviewed in rounds/with MD (to be completed by day shift only) Perfect Care Yes/No
    Yes No Yes No Yes No Yes No  
    tubings not changed tubings not changed No TPN        
    lines not capped lines not capped        
    Yes No Yes No Yes No Yes No  
    tubings not changed tubings not changed No TPN        
    lines not capped                
    Yes No Yes No Yes No Yes No  
    tubings not changed tubings not changed No TPN        
    lines not capped                
    Yes No Yes No Yes No Yes No  
    tubings not changed tubings not changed No TPN        
    lines not capped                
    Yes No Yes No Yes No Yes No  
    tubings not changed tubings not changed No TPN        
    lines not capped                
    Yes No Yes No Yes No Yes No  
    tubings not changed tubings not changed No TPN        
    lines not capped                
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Patient Information Sheet
CVH is committed to improving patient care by
participating in a nationwide initiative called
Safer Healthcare Now. One project being led by
the Critical Care staff is aimed at reducing
Central Line Bloodstream Infections.

• What is a Central Line Bloodstream Infection?
• It is an infection of the bloodstream that occurs
  in patients who have
• a central line or central venous catheter.
  Central lines are necessary
• for patients who need frequent intravenous (IV)
  medications, blood,
• fluid replacement, dialysis and/or nutrition.
• What causes Central Line Bloodstream Infections?
• Sometimes bacteria on the skin start growing in
  the central line and
• can then spread to the patients bloodstream.
  This is a very serious
• infection which requires treatment with
  antibiotics and removal of the line.
• What are we doing to prevent Central Line
  Bloodstream Infections?
• We will take the following steps whenever
  possible for all patients who have central lines
  
• Use proper hand hygiene. Everyone who touches the
  central line must wash their hands with soap and
  water or an alcohol cleanser.
• Use maximal barrier precautions. The person who
  inserts the line should be in sterile clothing
  wearing a mask, gloves, and cap. The patient
  should be fully covered with a sterile drape,
  except for a very small hole where the line goes
  in.
• Clean the patients skin with chlorhexidine (a
  type of soap) when the line is put in.

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Keys to success

• Keeping it fun
• Sometimes, it doesnt work, use feedback to
  improve
• Actively involved RN champion (teaching,
  generating ideas, seeking feedback)
• Frequent meetings (weekly to biweekly to monthly,
  special meetings to help with implementation)
• Communication
• Involve all members of team
• Support of all levels of administration

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Future Steps

• Expanding maintenance to all inpatient units
  (work with who will work with you)
• Continue to promote use of cart/kits for
  insertions in those units
• Explore possibility of evaluating the patient
  information sheet
• Celebrate the success thus far!!

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Customize to each area!