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News on Evidence-Based Care Second Quarter 2015 Volume 7 Issue 3

Goal Zero: Helping Each Other Help Our Patients

CLABSI and CAUTI Prevention

According to the Centers for Disease Control (CDC), on an average day in U.S. hospitals, one in every 25 patients have at least one health care-associated infection. The CDC’s latest statistics on health care-associated infections show that in 2011 there were 722,000 infections acquired by patients in U.S. hospitals under our care, and that 75,000 people died as a result. Of these total infections, catheter associated urinary tract infections (CAUTI) represent about 13 percent, central line associated blood stream infections (CLABSIs) represent 10 percent, and hospital-acquired pneumonia and surgical site infections are the majority. So, how are we doing at Meridian? Our performance is average at best compared to national benchmarks, and requires improvement. CLABSI and CAUTI rates are approaching zero in some facilities across the country for long periods of time. There are many reasons we should be focused on a goal of zero infections, including: reducing patient morbidity and mortality, achieving success in publically reported value based purchasing and ANCC Magnet indicators, reducing costs, and maintaining a reputation that we can all be proud of. It is not impossible. The Keystone Project in Michigan was an ICU project that reduced CLABSI to zero and saved 1,500 lives during the project period. Some shining stars in the New Jersey Hospital Association CAUTI reduction project were East Orange General and St. Clare’s Health Care System. In fact, St. Clare’s saw its two ICUs maintain zero CAUTI for 24 months. Meridian always strives to be the best, and average will not do. Our goal is to achieve a rate of zero infections at all times. Our Journey System-wide work teams on CLABSI and CAUTI were initiated in February 2015. These teams include direct care nurses, nurse educators, nurse leaders, and team members from Materials Management and Infection Control. Kathleen Casey, M.D., serves as the medical advisor. Many thanks to these teams who have explored evidence, studied statistics, reviewed current processes and supplies, identified best practices in checklist work, revised policies, developed educational modules, and much more. CAUTI Work Team: Rebecca Reiff, R.N., Jersey Shore Candace Horneck, R.N., Bayshore Sue Dolphin, R.N., Southern Ocean Sue Hanrahan, ICP, Jersey Shore Maureen Bracher, R.N., Materials Management Donna Ciufo, vice president and CNE, Jersey Shore Katie Belko, nurse educator, Bayshore Tamara Brown, nurse educator, Ocean Ellen Angelo, vice president and CNE, Ocean Kathleen Russell-Babin, R.N., senior manager, IEBC Erin Wood, nurse educator, Meridian Subacute Rehab at Wall

Special Edition:

CLABSI & CAUTI

CME Available!

CLABSI Work Team: Carla Guijarro, R.N., Ocean Laura Zurlo, R.N., Bayshore Nick Cardinale, R.N., Riverview Kim Simon, ICP, R.N., Riverview and Bayshore Maureen Bracher, R.N., Materials Management Sharon Jones, CNS, R.N., ICU, Ocean Kathy Colopoulos, CNS, R.N., Oncology, Jersey Shore Gen Bahrt, CNS, R.N., ICU, Jersey Shore Kathleen Russell-Babin, R.N., senior manager, IEBC Jackie Decker, R.N., director, Meridian Subacute Rehab at Wall

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Handwashing: The Proof is in the Numbers

Evidence-based bundles of care: What are bundles? They are a set of key care elements to follow at all times in the quest to improve care. The Institute for Healthcare Improvement (IHI) defines a bundle as “a structured way of improving the processes of care and patient outcomes: a small, straightforward set of evidence-based practices that, when performed collectively and reliably, have been proven to improve patient outcomes.”

The teams reviewed evidence minimally from the Infectious Disease Society of America (IDSA), the Centers for Disease Control (CDC), and the Society for Healthcare Epidemiology of America (SHEA) in the course of their analysis. The findings were incorporated into bundles for Meridian clinicians to use. An example of a bundle is the central line insertion bundle. It consists of the following: 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 Maximum sterile barrier for patient (full body sterile drape) Cap, mask, sterile gown and gloves, eye protection for clinicians For INSERTION: Chorhexidine friction scrub at least 30 seconds with the swabstick (with products like chloraprep)

and allow to dry 30-60 seconds, UNLESS femoral line is inserted whereby the scrub is two minutes and the drying time is one to two minutes

Checklists: In 2001 at Johns Hopkins Hospital, Dr. Peter Pronovost implemented a CLABSI insertion checklist with empowerment of the nurses to stop the procedure for any violations. In implementing the insertion checklist, the ten-day line infection rate went from 11 percent to zero and they only had two central line infections in the next 15 months. Forty-three infections were avoided and eight patients were saved. (Gawande, 2009). Checklists help us to do it right in a complex world, whether we are flying airplanes or inserting central lines and urinary catheters. Checklists evolved from the evidence-based bundles. The Meridian teams created them for both insertion and maintenance safety. Most clinicians find the maintenance checklist to be a new concept and might think it is excess documentation. Although it is a piece of paper, it is more about the safety process than the paper. Checklists are not permanent parts of the patient record. Recently, one of our nurse leaders, who is an ANCC Magnet appraiser, shared that she learned of an organization that was able to get CAUTI rates down to zero, and therefore let some of the units performing the best relinquish use of the maintenance checklists. CAUTI infections began appearing again and they resumed the maintenance checklists. Their CAUTI rates went back to zero.

An example of a portion of a checklist for urinary catheter insertion is shown below:

Meridian Health Urinary Catheter Insertion Checklist ___BCH ___JSUMC ___OMC ___RMC ___SOMC

Date of Insertion: ________________________ Time__________________

Nursing unit:____________________________ Catheter size:__________________

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

How Will We Get There?

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Handwashing: The Proof is in the Numbers

According to Sue Hanrahan, MS, CIC, manager of Infection Control at Jersey Shore, “The intent of the checklist is to standardize our practice to eliminate device-related infections that harm patients. The intent is not to hand in a completed checklist as proof of participation.” Blue binders will be distributed to all units with a supply of checklists. Safety Monitor: A special intervention designed to prevent lapses on insertion of central line and indwelling urinary catheters is the introduction of the Safety Monitor. This is a state-of-the-art patient safety practice and requires exceptional team communication. The Safety Monitor role is the ultimate in patient advocacy. Nurses will carry out this role most often and essentially “stop the line.” Stop the line is a process borrowed by the Toyota Production line where automobile workers are encouraged to stop the line if they suspect or see a defect. This empowered move is a significant one. We should treat our patients at least as well as the automobile workers treat the cars. What does a safety monitoring process look like? Let’s pretend you are the safety monitor (Any physician, PA, APN, or R.N. may function in the role). After you declare, “My name is John and I will be the Safety Monitor for this case,” your next step would be communicating with the alert patient: “Hello, Ms. Jones, my name is John 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.” As Safety Monitor, if any kind of potential or actual error occurs, your job is to speak up: “Dr. Smith, please stop. I have a safety concern. We need to adjust the patient’s barrier to completely cover him.” You can make the recommendation for adjustment in your own words, but it is important for you to say, “I have a safety concern.” You will state the actual concern in objective, non-judgmental terms and offer a recommendation or make a suggestion. If there are lapses that are not remedied, or reminders were required, a debriefing should occur. What can we still do to reduce infection? What can we do to do better next time? Is redirection on communication needed? Please document lapses on the insertion checklist and share it with your leader for follow up. The CNEs and medical VPCEs at each campus are committed to supporting this process. Finally, please complete the insertion checklist as fully as possible, and make sure it is FAXED to your local infection control office.

A special case version of the Safety Monitor will occur in urinary catheter insertions. Here, not every case will have a Safety Monitor, (unlike a central line insertion). The cases that will have a Safety Monitor (R.N. / LPN, usually) will include: Obese patients Agitation / flailing Lower body paralysis Low experienced inserter Nursing/physician / APN / PA judgment

These processes, designed in the bundles and formalized in checklists, are to be completed everywhere insertion, care of

central lines of all kinds, and urinary catheters exist.

How Will We Get There?

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Handwashing: The Proof is in the Numbers

Standardization of equipment and supplies: In the course of this work, it was learned that we don’t all do things the same way at Meridian. As a result, we are now standardizing our policies across the system and incorporating the following: Chlorhexidine baths for all patients with central lines, regardless of their location as long as they meet criteria (i.e, no

child under two months is bathed in chlorhexidine). ICUs are to bathe all patients in the unit with chlorhexidine to reduce the bioburden in the unit. Evidence supports the use of chlorhexidine baths for prevention of central line infections.

Antiseptic caps will be used on all central lines except dialysis catheters that already have Tego devices on them. Antiseptic caps have been shown to reduce CLABSI by as much as 68 percent over two years (Loyola University Medical Center).

Basin liners will be used for all bathing with wash basins. These liners are disposable and look like shower caps. They are to be used for each different type of bathing done, for example, the perineum is washed with one basin liner and other parts of the body with another. Research has shown that bath basins are an incredible source of infection for our patients.

Castile soap towelettes will be used for all urinary catheter perineal care. Bladder scanner and vein finder devices are strongly encouraged. If you do not have these devices, please

discuss this promptly with your leader. Central lines, including PICCs and indwelling urinary catheters, should not be first-line care.

Approvals: The bundles, checklist, and Safety Monitor process were all approved via Nursing Professional Practice Committees at each campus, the system Infection Control committee, and the Clinical Excellence Committee. Education: Education for all nurses will be begin June 15 via HealthStream modules for both CAUTI and CLABSI. These modules must be completed by July 3. Physicians received an introduction to the work in the June issue of Doctors’ eNotes. A poster will be placed near the doctors’ lounge areas at each facility emphasizing the Safety Monitor process. VPCEs will be sharing the information at medical department meetings. Individual meetings reviewing the content with such areas as IR are in progress. This newsletter serves as additional education for both nurses and physicians. It’s a Team Sport: Team communications about infection prevention on a daily basis is a best practice. Boev and Xia (2015) published in the April issue of Critical Care Nurse that for every 0.5 unit increase in nurse-physician collaboration in critical care, the rate of bloodstream infections decreased by 2.98 (p=0.005). Collaboration on daily necessity and of infection reducing interventions is critical in all areas of patient care. Involving the patient through education is a necessity. We all have the responsibility and authority to protect our patients. Theme: Meridian’s theme for this work is Goal Zero: Helping Each Other Help Our Patients. First and always in our work is preventing patients from harm through health care-associated infections. We will use this theme in many communications, including fliers to be posted in off-stage areas.

Progress: We will share progress regularly. Our goal in information sharing is not to portray progress in rates that feel

less tangible, but visually through diagrams showing raw counts of people affected. Please see the following page.

How Will We Get There?

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Handwashing: The Proof is in the Numbers

Our educational period is June 15 through July 3. We expect all processes to go into effect July 8, 2015. Ongoing communication will be accomplished on the Team Member Intranet, where a site will be established with links to policies, educational materials, and appropriate forms. The site can be found at Resources Tab > Quality, Safety and Experience.

The CLABSI and CAUTI teams thank you in advance for “helping each other help our patients.”

How Will We Get There?

What’s Next?

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This issue of Eye on Evidence is now approved for use as an independent study. In order to receive these credits you must complete the attached quiz and evaluation form. When completed, please fax to: Jean Primavera, Meridian Health CME Coordinator Phone: 732-776-4072; Fax: 732-776-2432 Email: Pprimavera@meridianhealth.com Be sure to include your contact information so you can receive your certificate.

Target Audience: Physicians, physician assistants, APNs, nurses, respiratory therapists, and pharmacists. CME Accreditation Statement: Meridian Health is accredited by the Medical Society of New Jersey to provide continuing medical education for physicians. AMA Credit Designation Statement: Meridian Health designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credit(s).™ Physicians should claim only the credit commensurate with the extent of their participation in the activity. Disclosure Statement: Meridian Health, in approving activities for AMA PRA Category 1 Credit™, adheres to the ACCME Standards for Commercial Support.SM Meridian Health is responsible for every aspect of the activity it certifies. Faculty and/or planners in a position to control content are expected to disclose relevant financial commercial relationships related to the activity. If a conflict is identified, it is Meridian Health’s responsibility to initiate a mechanism to resolve the conflict. The CME enduring activity is in effect for 1 year after release of the newsletter.

Attention Physicians: Need CMEs?

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Meridian Health

CME Post-Activity Evaluation Name: Dept.: (Please print)

Professional Title: M.D./D.O. Other (Please Specify)

CME Activity: Eye on Evidence Newsletter Special Edition CLABSI and CAUTI Prevention Location: Online or document Activity Date: NA Speaker(s): NA 1. Do you intend to make changes or apply learnings to your practice as a result of this educational activity?

If Yes, describe two things you intend to try or do differently as a result of this educational activity: 2. Identify the major strengths of this educational activity: (check all that apply)

Speaker (s) Networking Other:

Discussions Support materials Clinical Case Presentations Demos/Hands-on

Knowledge gained Case Vignettes

3. Was this educational activity appropriate for your level of training? Yes No (Describe)

4. Were the educational activity’s objectives met? Yes No (Describe) The reader should be able to demonstrate knowledge of current evidence care related to quality issues addressed in the newsletter. 5. What additional education and training would be helpful to your practice? 6. Other comments:

7. Was this educational activity free of commercial bias? Yes No (Describe)

The editor, K. Russell-Babin, and all planners involved with this educational activity have nothing to disclose.

Yes, I plan to make changes

Yes, I’m considering changes

No, I already practice these recommendations

No, I don’t think this applies to my practice

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CME Quiz Questions

Name: Dept.:

(Please print)

Please answer these questions “T” for True and “F” for false. _____1. One in every 100 patients experiences a health care-associated infection. _____2. The intent of checklists is to provide a legal record of documentation of processes of care. _____3. A safety monitor is present for all urinary catheter insertions. _____4. Chlorhexidine baths will only be used for traditional central lines, not PICCs. _____5. Daily collaboration on the necessity of a central line or urinary catheter by nurses and doctors can reduce infections significantly.