Getting to Zero: A Standardized Best Practice Program Results in 

61% CLABSI Rate Reduction among Inpatient Spinal Cord Injury/Disorder Veterans 

SHIRELYN SMITH, MSN-ED, RN NURSE MANAGER, VA LONG BEACH HEALTHCARE SYSTEM

CHRISTINA DIBERNARDO, MSN, RN-BC, CNL CLINICAL NURSE LEADER, VA LONG BEACH HEALTHCARE SYSTEM

JUDY LIM, DNP, RN, PHN, NE-BC, CRRN, CNL, WCC, OMS, CHIEF OF PATIENT CARE SERVICES, VA LONG BEACH HEALTHCARE SYSTEM

LATOYA SMITH, MSN, ACNS-BC, RN

Disclosures

Shirelyn Smith, Christina Di Bernardo and Judy Lim are the Presenters and have no financial or non-financial interest to disclose.

This continuing education activity is managed and accredited by AffinityCE in cooperation with PVA. AffinityCE, PVA, as well as all accrediting organizations, do not support or endorse any product or service mentioned in this activity.Disclosure will be made when a product is discussed for an unapproved use.AffinityCE staff and PVA Staff, as well as Planners and Reviewers, have no relevant financial or non-financial interests to disclose.Commercial Support was not received for this activity

Learning Objectives At the conclusion of this activity, the participant will: Identify the importance preventing Central Line Associated Blood

Stream Infections (CLABSIs) in the spinal cord injury (SCI) patient population, describe pathogenesis, and examine complications related to Central Venous Access Devices (CVAD)

Identify tools used to capture accurate baseline and ongoing data related to CLABSI prevention practices.

Define deficiencies related to Central Venous Access Devices (CVAD) assessment of need, site care and maintenance.

Discuss effective interventions and management techniques in spinal cord injury units.

Background

What is a Central Venous Access Device (CVAD)?

**Commonly referred to as a “CENTRAL LINE”

A type of catheter that is placed in a large vein that allows for:Multiple IV fluids to be givenMonitoring of fluid volume statusAdministration of Chemo, vesicant, or long term antibiotic therapyMedications/Solutions to be given in patients with limited peripheral access

Access to Central Venous Circulation The tip of a CVAD is generally placed in the lower third of the superior vena cava (SVC)

near its junction with the right atrium.blood-flow rate here is approximately 2 liters per minute. infusates are rapidly hemodiluted and distributed in the central venous system.

What is a CLABSI?

Healthcare Associated Infection (HAI) Infections that patients acquire while receiving treatment for medical or

surgical conditions Many HAIs are preventable

Central line-associated bloodstream infection (CLABSI) Type of HAI Serious infection that occurs when germs (usually bacteria or viruses) enter

the bloodstream through the central line Determined by:

A confirmed laboratory report of bloodstream infection (LCBI) Central line in place for > 2 days (48 hours) All CLABSIs at our facility were attributed to MAINTENANCE & LINE CARE

Burden of Healthcare-Associated Infections

Healthcare-associated infections (HAIs) : Affect 1 out of every 20 patients Cause increased LOS, illness, death, and excess costs Most caused by bacteria, such as MRSA, that reside on the skin/nose and gain

access to the bloodstream via devices/ incisions Some of the most serious HAIs involve Central Lines Central lines are used in more than 25% of hospitalized non-intensive care unit patients Central Line Associated Blood Stream Infections (CLABSIs)

Affects 41,000 patients/year Up to 1 in 4 die Cost up to $100,000 per episode

Current evidence and expert opinion suggests that 65-70% of catheter-related infections may be preventable.

Burden of CLABSIs in the SCI/D Population

Spinal Cord Injury (SCI) patients: Often require prolonged central line placement for therapy At risk for line infection due to nutritional status Poor skin integrity Immunocompromise Frequent colonization with resistant pathogens

Increased risk for thrombosis include immobility, hospitalization, being paralyzed, presence of a central line

Presence of a central line with thrombosis increases risk of infection Central line occlusion occurs in 66% of adults with a long-term catheter placement, and

can cause long-term vascular complications. CLASBI prevention initiatives are imperative to protect the high-risk spinal cord injury

patients due to the tremendous negative outcomes of morbidity, mortality, length of stay, and overall costs

Pathogenesis

Extraluminal Pathogen migration along external

surface < 7 days

Intraluminal Hub contamination >10 days

Less Common mechanisms Seeding from another source Contaminated Infusates

Getting to Zero…A NEVER EVENT

Our Facility & SCI/D Center

VA Tibor Rubin Medical Center Long Beach, California102 Bed Teaching Spinal Cord Injury

Center Acute CareLong Term Care

HAI Taskforce Established

Appointed by Nurse Executive Tasked with decreasing HAIs

Led by Nurse Chief Team Members include:

Clinical Nurse Leader Clinical Nurse Specialist Nurse Manager with background in education

Developed Prevent-Sustain-Review (PSR) Model to address multiple HAI initiatives A 3 step model to guide prevention of facility-wide changes

& standardize care

Our Strategy: Prevent-Sustain-Review (PSR Model)

P

R

S

Prevent Obtain Baseline Data & Identify Gaps in Practice Literature Review and Research of Best Practices Product Review for Streamlining Workflow & Efficacy Order Set & Documentation Updates to Support Practice Changes Develop & Implement Nurse Driven Protocols Facility-wide Training Regarding Changes

Sustain Establish Champions on Each Unit Conduct Monthly Meetings to Include Frontline Staff Compliance Rounds and Monthly Audits Provide Just-In-Time Teaching, Ongoing & Focused Trainings for Fallouts

Review Case Review Forms for Action Plans on Positive Cases Unit Tracker (Story) Boards to Display Performance Clinical Oversight and Leadership Rounding at Point of Care

Prevent Obtain & Evaluate Baseline Data Literature Review and Research of Best Practices Identify Gaps in Practice with standardized audit tool Product Review for Streamlining Workflow & Efficacy Develop Practice Changes & Nurse Driven Protocols Revisions to Order Sets, Documentation & Procedures

Support Practice Changes Conduct Facility-wide Training Regarding Changes Implement Practice Changes

PreventObtain & Evaluate Baseline Data

Long Beach# of CLABSI Infections

Long BeachRates per 

1000 line days of care

National SCI/D# of CLABSI Infections

National SCI/DRates per 

1000 line days of care

FY17 6 1.57 36 0.72

54% Higher than the SCI/D National Aggregate Rate

17% of the National SCI/D Infections from Long Beach

CALL TO ACTION!!!

PreventLit Review & Research of Best Practices

Insertion Bundle Performed by PICC line Nurse or Providers Align with Evidence- Based Insertion Standards

Hand hygiene & Aseptic technique, Maximal sterile barrier precautions, Insertion site selection, Chloraprep site prep, Biopatch & transparent dressing placement

Maintenance Prevention Bundle Daily assessment of need (C-line criteria)Q Shift Site Care-8 Maintenance Bundle elementsWeekly Dressing Changes

Insertion & Maintenance Prevention Bundles

PreventIdentify Gaps in Practice- Chart Audit

PreventIdentify Gaps in Practice- Bedside Audit

Gaps in PracticeWhy we need a new dressing kit?

100% Non-Aseptic

Aseptic Central Line Dressing Changes

n=16

Gaps in Practice Improvement Opportunities with Dressing Change

1931

4450 50

5662

8194

0102030405060708090

100

Mask placedon patient

UsedChloraprep

appropriately

HH b/wremoval and

sterileapplication

Appropriatesuppliesgathered

Biopatchproperlyapplied

Don glovesaseptically

Dressingappliedcorrectly

AllowedChloraprep to

dry

HH performedat beginning

of dressingchange

Insertion Adherence to insertion bundle elementsNo facility infections attributed to insertion practices

Maintenance Care Lack of standardized maintenance & care bundlesAll facility infections caused by improper maintenance

& care practices

Our Facility Practice Gaps

PreventProduct Review for Streamlining Workflow & Efficiency

ProductsUpgraded Disinfection cap New needless connectorsCHG wipes bathing protocol Integrated securement dressing…no more stat lockCustom Central Line Dressing Change kit

Promotes standardization Eliminates variation Ensures all supplies readily available Engineers compliance into the procedure

Daily assessment of needC-line criteriaNurse initiated removal

Q Shift Site Care8 Maintenance Bundle elementsNurse Driven Declotting Protocol

Weekly Dressing ChangesCustom designed Dressing Change Kit

PreventDevelop Practice Changes & Nurse Driven Protocols

Prevent Daily Assessment of Need (C-Line Criteria)

Assess ALL Central Lines Daily for continued use….. Clinical instability with life-sustaining infusions

Lengthy infusion therapy greater than 6 days for Inpatient, Outpatient and CLC

Invasive hemodynamic monitoring

Need central line due to poor vascular access (history of failed peripheral venous access, including ultrasound guided)

Essential for TPN therapy, chemotherapy, or irritating drug therapy (vesicants, osmolarity >900 mOsm/L)

PreventQ-Shift Site Care

Q-Shift Site Care - “Use 8 Maintenance Bundle Elements” 1. Hand Hygiene prior to line manipulation2. Disinfect access port prior to each use 3. Only use sterile devices to access catheters 4. Perform patency check 5. Use Push-Pause-Push Flushing 6. Keep LINE closed as much as possible7. Bathe with CHG Daily8. Replace compromised dressing PRN if wet, soiled, or loose

PreventNurse Driven Protocol

Occlusions can cause Infection 66% of adults with a long term central line will develop line occlusion May occur soon after insertion or develop at any time during the course

of IV therapy Thrombotic occlusions result from the formation of a thrombus Nurse Driven Declotting Protocol Prevents:

Delays in Care Risk of Infection Incidence of Line Replacement

Nurse Driven Protocol

Nurse Driven Protocol

It’s ok, I’m a DOGTORIt’s ok, I’m a DOGTOR

Prevent Weekly Dressing Changes

Custom Designed Dressing Change Kit Perform routine dressing changes Q7days = Q Sunday

Change IV tubing Change needless connectors

Customized central line dressing kit based on lean methodology Promotes standardization Eliminates variation Ensures all supplies readily available Engineers compliance into the procedure – step by step guidance

Integrated securement dressing = no more stat lock!

Prevent Central Line Kits – 3 types & 3 dressings

PICC, MIDLINE, SUBCLAVIANMedium Sorbaview Shield

FEMORAL- IMPLANTED PORT Oval Sorbaview Shield

INTERNAL JUGULARContour Sorbaview Shield

PreventCustom Central Line Dressing Kit

INCLUDES TWO KITS #1 for removal #2 for application

Custom Central Line Dressing KitRemoval

PLACE INSERT CARDS ABOVE POCKET ITEMS

Custom Central Line Dressing Kit

KIT #1 REMOVAL – includes 9 Steps

Custom Central Line Dressing Kit

KIT #2 APPLICATION – includes 8 Steps KIT #2 APPLICATION

MUST TRANSITION TO STERILE FOR DRESSING APPLICATION

Custom Central Line Dressing KitApplication

PLACE INSERT CARDS ABOVE POCKET ITEMS

PreventOrder Set Revisions

NURSING CARE ORDERS

PRN ALTEPLASE ORDERS

Prevent Documentation Revisions

Is Central Line still needed?

IV ACCESS NOTEIs Central Line still needed?

If No contact provider for possible removal

Prevent Documentation Revisions

MAINTENCE BUNDLE QSHIFT

Prevent Document Dressing Changes Q 7days & PRN

Must Choose One

Prevent Document Declotting Protocol

PreventFacility-wide Training Regarding Changes

Nursing Education4 phases of Off-Unit training to include:

Didactic & Hands-on Topic Specific Sessions:

1. Disinfecting caps2. CHG wipes & bathing protocol 3. Needleless Connector4. Central Line Dressing change kit, alteplase declotting protocol,

documentation changes (with recap of all previous topics)

PreventImplement Practice Changes

Steps taken to ensure smooth implementation process: Published revised nursing procedures and competencies to

reflect changes: C-line criteria, maintenance bundle elements, and dressing change

practices

Products stocked and available on all inpatient units Established “Go-Live Date” for all order sets and documentation

changes Emailed “Nurse Practice Alerts” regarding changes

SUSTAIN Establish Champions on Each Unit Conduct Monthly Meetings to Include Frontline Staff Compliance Rounds and Monthly Audits Provide Just-In-Time Teaching, Ongoing & Focused

Trainings for Fallouts Provider Training (Hospitalist & New Resident

Orientation)

SustainEstablish Champions on each unit

Recruit at least two RN champions for each unit Champion Kickoff Training

2.5 hour Off-Unit Training, Didactic, Hands-onDemonstration with return demonstration of topics covered

during facility-wide training Champion Toolkit Audit tool

Champion responsibilities

SustainChampions Toolkit

SustainConduct Monthly Meetings

Lead by Infection Prevention & Vascular Access Nurses Attended by Unit Champions, Clinical and Administrative

Leadership Analyze CLABSI data (facility-wide vs. unit rates) Review Fallouts:

Leadership Rounding Audits Positive CLABSI Cases

Discuss Best Practices & Evaluate Current Practice

SustainCompliance Rounds & Monthly Audits

Conducted by Unit Champions Vascular Access Nurses (weekly)

Utilize paper version of audit tool for bedside rounding Minimum of 10 audits per month Concentrate on noted fallouts Just in time teaching & correction of fallouts by

champions/vascular team

Maintenance Audit ToolPaper Version (For bedside use ONLY)

Sustain Nurse & Provider Trainings

Just-in-time Teachings, Ongoing & Focused Trainings Driven by findings during compliance rounds Point of Care Bedside Teaching Monthly Competency Training by Vascular Access Nurses

Provider Training (Hospitalist & New Resident Orientation) PICC line consult and Maintenance Order Set Introduction Midline vs. PICC Utilization Nurse Driven Declotting Protocol

REVIEW Case Review Forms for Action Plans on Positive Cases Unit Tracker (Story) Boards to Display Performance Clinical Oversight & Leadership Rounding at Point of

Care Ongoing Evaluation of Data

ReviewCase Review Forms & Action Plans

Case Review Completed for every CLABSI Performed by champions, frontline staff and unit

leadership Focus is on identifying root cause & gaps in practice Lessons Learned & Process ImprovementGOAL is to prevent a similar CLABSI from occurring Discussed & reviewed at monthly CLABSI meeting

ReviewElectronic Case Review Form

ReviewUnit Tracker (Story) Boards

Displays Unit Data Updated monthly Tracks “Months

Without” Graphs & Tables Visual

Reminder/Awareness Staff By-In of Initiatives

ReviewClinical Oversight & Leadership Rounding

Oversight of Program and Practice Changes: By HAI Taskforce Handed off to Vascular Access Team and Infection Preventionist

Expanded availability of Vascular Access Team with additional nurses/added hours (7 days/wk)

Accessibility of Leadership to Unit Staff Continued Leadership Rounding

Support changes Ensure compliance

Review: Data Evaluation Long Beach Tibor Rubin CLABSI Rates

Long Beach# of CLABSI Infections

Long Beach# of lines days

Long BeachRates per 

1000 line days of care

National SCI/D# of CLABSI Infections

National SCI/DRates per 

1000 line days of care

FY17 6 3824 1.57 36 0.72

FY18 2 3291 0.61 29 0.63

61% CLABSI Rate Reduction among Inpatient Spinal Cord Injury/Disorder Veterans

0

2.872.35

0

3.123.22

0 0

4.03

0

3.58

0 0 0 0 0 0

3.7

0

3.17

0 0 0 0 0 0 0 0

7.41

0 0 0

FY17 – April 2019(# of CLABSI/# of line days) x 1000

Review: Data Evaluation SCI/D CLABSI Rates

CLOSING THOUGHTS

It takes a team! Have fun!!! Standardize! Standardize! Standardize! Reevaluate and tailor actions PRN Nurse driven protocols are powerful! Clinical oversight and leadership at the point of care is

imperative We all have the ability to drive transformation in

healthcare!

References

*Timsit, Jean-Francis MD, Dressing disruption is a major risk factor for catheter-related infections, Critical Care Medicine (June 2012); Vol. 40 No. 6.

Silow-Carroll, S. and Edwards, J. N., (2011). Eliminating Central Line Infections and Spreading Success at High-Performing Hospitals. The Commonwealth Fund, December.

Centers for Disease Control and Prevention (2011). Checklist for Prevention of Central Line Associated Blood Stream Infections, 2011.

Centers for Disease Control and Prevention (2011). 2011 Guidelines for the Prevention of Intravascular Catheter-Related Infections. Retrieved from http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf.

Marshall .et al. (2014). Strategies to Prevent Central-Line Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update. Infection Control and Hospital Epidemiology Vol. 35 (7), 753-771.

Gorski et al. (2016). Infusion Therapy Standards of Practice. Journal of Infusion Nursing Vol. 39 (1S).

Ling et al (2016). APSIC Guide for Prevention of Central Line Associated Bloodstream Infections (CLABSI). Antimicrobial Resistance and Infection Control Vol. 5 (16), DOI: 10.1186/s13756-016-0116-5

QUESTIONS

How to Claim CE Credit“If you would like to receive continuing education credit for this activity, please visit https://pva.cds.pesgce.com”