Nurses Role in CLABSI Prevention – Do no harm

Donna Matocha, DNP, MSN, CNRN, VA-BC

DISCLOSURES

Employee of Medline Industries, Inc.

Opinions expressed are my own and not necessarily representative of Medline Industries, Inc.

Objectives

• Discuss nursing theory and ethics

• Examine steps for initiating change

• Describe a successful change process

The Philosophy & Science of Caring1

• Art-Humanities-Science

• Discipline versus Profession

• “Caring” is consistent with Nightingale’s sense of “calling”

• Evidence-Based Practice (EBP)

• Caring - Outcomes

Jean Watson, PhD, RN, AHC-BC, FAAN

Clinical Ethics2

• Beneficence, Non-maleficence, Justice and Respect for Autonomy

• Empathy, Compassion, Fidelity, and Integrity

• Clinical Judgement & Clinical Uncertainty

• Medical errors

• Moral distress

• Healthcare inequities

• Costs in clinical decisions

5

EBQI Versus Clinical Research

6

• Infusion Nurses Society Standards of Practice3

• CDC Guidelines for the Prevention of Intravascular Catheter Related Infections4

• Institute for Healthcare Improvement

Holistic Nursing & EBP

7

ORGANIZATION CHANGE

• Change theories

• Change in Healthcare

• Sustainability

• Change agent qualities

8

Healthcare Acquired InfectionsA Meta-Analysis

Over 5 million CVCs inserted annually6

Up to 25% mortality rate6

Estimated cost of the 5 most common HAIs = $9.8 billion5

CLABSI ranks 4th and accounts for 18.9% of total cost

Per case CLABSI was found to be the most costly = $45,814

• MRSA CLABSI = $58,614 + higher LOS

65-70% CLABSI are preventable with current EB interventions

What does this mean to hospitals?6,7

10

3% HRRP

2% VBP

1% HACs

6%

Financial Implications6

For every $100,000 that a hospital spent on safety programs, it realized an average $315,000 savings thanks to fewer infected patients6

More than 60,000 primary bloodstream infections related to central lntravenous catheters are estimated to occur each year in the U.S., with a fatality rate of 12% or more8

A study published in JAMA Internal Medicine Journal evaluated data from the last 10 years CRBSIs at 113 hospitals showed:

Safety interventions, on average, reduced infection rates by 57%

Produced a net savings of $1.85 million per site over three years.

Savings came from reduced costs in treating infected patients.

4/4/2018 |Presentation Title

IT IS TIME TO BUILD YOUR TEAM

YouPICC Team

Infection Prevention

Physician Champion

Nursing Education/Professional Practice

Chief Nursing Office

Purchasing

12

Facilitators & Barriers

• Interdisciplinary approach10

• Empowerment to STOP bad practice9

• Partnership with senior medical & nursing staff on individual units11

• Project leader is credible among peers and role models strict compliance with protocol/checklist and is sincere about the value of the program11

• Local leader driving change versus centrally lead programs11

• Goals, interest and priorities of the program are misaligned with staff11

• Unsupported hierarchical cultures – improvement opportunities often go unrecognized11

• Poor executive leadership11

• Hostile individuals – apathy, exasperation and bewilderment11

13

Facilitators Barriers

Vision, Innovation, TransformationQuestions to Ask

Does staff fully understand the IHI Bundle and are they compliant?

Who reviews your policies?

How often are policies reviewed?

What evidence supports your policies, procedures and practice?

Who does CVC/PICC insertion, education and competency?

How often is vascular access education done?

Upon hire?

Annually?

Change in job description?

How often is vascular access education done?

15

Find your story

• Compassion

• Empathy

• Fidelity

• Integrity

16

What Change Looks LikeMatocha, D. (2013). Achieving Near-Zero and Zero: Who Said Interventions and Controls Don't Matter?. The Journal of the Association for Vascular Access, 18(3), 157-163.

In the beginning

18

CMS ruling to stop paying for CLABSI

Assembled a team

Deep dive into practice, policy and products

Shared Governance

Education and Empowerment

Variability

• Education

• Train People

• Provide Instructions

• Provide the Same Materials

• Kits

• Develop Process Measure and Utilize to Control Variability

19

Strategies for the Prevention of Catheter-Related Infections in Adult & Pediatric Patients

20

Guidelines for the Prevention of Intravascular Catheter Related Infections

Education, Training & Staffing Recommendations

Educate healthcare personnel regarding the indications for intravascular catheter use, proper procedures for the insertion and maintenance of intravascular catheters, and appropriate infection control measures to prevent intravascular catheter-related infections [7–15]. Category IA

Bundles are intended to test a theory

Elements implemented together produce better outcomes

“Bundles” reduce variability and engineer standardized practice

The Benefit of the Bundle

CVC Maintenance Kits are clinically important in CLABSI reduction13

Best practice interventions that promote “bundles” of procedures and technology combined with multimodalstrategies of education, training, implementation and

dissemination 12

Single use kits are designed to follow the correct procedure sequence every time with every clinician 14

4/4/2018 |Presentation Title

Disseminate the Evidence15

• Podium/Oral Presentations

• Present a poster

• Publish a paper

• Write a healthcare policy

• Nursing grand rounds

• Local Professional Chapters

• Hospital/Organizational Professional Committee Meetings

• Apply for a grant

23

We can’t pretend any more that what we do doesn’t affect people

• Courage

• Compassion

• Connection

• Shame

• Vulnerability

24

In closing

• Uncertainty

• Gratitude

• Celebrate

25

References

1. Watson, J. (1979). Nursing: The philosophy and science of caring. Nursing administration quarterly, 3(4), 86-87.

2. Jonsen, A. R., Siegler, M., & Winslade, W. J. (2010). Clinical ethics a practical approach to ethical decisions in clinical medicine. McGraw-Hill Medical, New York, NY.

3. Infusion Nurses Society. (2011). Infusion Nursing Standards of Practice (2011) (Vol. 34).

4. O’Grady N, Alexander M, Burns L, et al., and Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee. Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 [Internet]. 2011 [cited 2013 Feb 28]. Available from: http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf

5. Zimlichman E, Henderson D, Tamir O, Franz C, Song P, Yamin CK, Keohane C, Denham CR, Bates DW. Health Care–Associated InfectionsA Meta-analysis of Costs and Financial Impact on the US Health Care System. JAMA Intern Med. 2013;173(22):2039–2046. doi:10.1001/jamainternmed.2013.9763

6. Miller, R.D., Eng, T., Kandilov, A., Cromwell, J., McCall, N. (2012). Readmissions due to hospital-acquired conditions: Multivariate model and under-coding analysis. Retrieved from: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Downloads/Final-Report-Readmissions.pdf

References

7. Bierman, S. (2017). A New Tool for the Vascular Access Toolbox. Infection Control Today, July 7, 2017

8. Lagasse, J Jan 10, 2017. Safeguards, safety programs slash catheter-related bloodstream infections, Cedars-Sinai research shows. Retrieved from: http://www.healthcarefinancenews.com/news/safeguards-safety-programs-slash-catheter-related-bloodstream-infections-cedars-sinai-research.

9. Ista, E., van der Hoven, B., Kornelisse, R. F., van der Starre, C., Vos, M. C., Boersma, E., & Helder, O. K. (2016). Effectiveness of insertion and maintenance bundles to prevent central-line-associated bloodstream infections in critically ill patients of all ages: a systematic review and meta-analysis. The Lancet Infectious Diseases, 16(6), 724-734.

10. Zingg, W., Cartier, V., Inan, C., Touveneau, S., Theriault, M., Gayet-Ageron, A., ... & Walder, B. (2014). Hospital-wide multidisciplinary, multimodal intervention programme to reduce central venous catheter-associated bloodstream infection. PloS one, 9(4), e93898.

27

References

11. Dixon-Woods, M., Leslie, M., Tarrant, C., & Bion, J. (2013). Explaining Matching Michigan: an ethnographic study of a patient safety program. Implementation science, 8(1), 70

12. Zingg, W. & Pittet, D. (2016). Central-line bundles need a multimodal implementation strategy. The Lancet Infectious Diseases , 16, (6), 631 – 632.

13. Ista, E., van der Hoven, B., Kornelisse, R. F., van der Starre, C., Vos, M. C., Boersma, E., & Helder, O. K. (2016). Effectiveness of insertion and maintenance bundles to prevent central-line-associated bloodstream infections in critically ill patients of all ages: a systematic review and meta-analysis. The Lancet Infectious Diseases, 16(6), 724-734.

14. Zingg, W., Cartier, V., Inan, C., Touveneau, S., Theriault, M., Gayet-Ageron, A., ... & Walder, B. (2014). Hospital-wide multidisciplinary, multimodal intervention programme to reduce central venous catheter-associated bloodstream infection. PloS one, 9(4), e93898

15. Melnyk, B. M., & Fineout-Overholt, E. (Eds.). (2011). Evidence-based practice in nursing & healthcare: A guide to best practice. Lippincott Williams & Wilkins.

28