c podium 3b arina jenkins.pdf
TRANSCRIPT
The Best Care...Always! CLABSI bundle: Reducing CLABSI
in a public sector Neonatal Intensive Care Unit
Pn Arina Jenkins A9 NICU Tygerberg
Children’s Hospital
Context
• 12 bed unit à Tygerberg Children’s Hospital • first to implement BCA CLABSI bundle in public sector -‐ 2012
• AdmiKng newborns – intensive, highly specialised care • TBH ↔ US with medical and nursing staff
• no baseline CLABSI data or prior surveillance • using results from first year to set targets:
■ ↓ CLABSI-‐rate ■ á compliance with bundle
Context
• 12 bed unit -‐ Tygerberg Children’s Hospital • admiKng newborns • medical and nursing staff • first to implement BCA CLABSI-‐Bundle 2012 • no CLABSI surveillance before • using results from first year as baseline
Aims
• ↓ CLABSI-‐rate • á Compliance with bundle
Problem
v HAI à CLABSI : á morbidity, mortality, healthcare costs Use of central lines -‐ unavoidable1 Neonates at increased risk v Public sector ¬ overcrowded ¬ infecTon control challenges ¬ difficult to isolate ¬ ↓ stock, staff ¬ rotaTng staff
v …….STILL CLABSI……! ↑ length of stay ↓ ability to admit
IntervenTon
Ø Formulated goals for 2nd year: § CLABSI rate < 4/1 000 line days § >95% compliance with CLABSI-‐bundle
Ø Implemented: § separate bundles established 1st year § changes in programme → report UAC → use hand hygiene tool -‐ with IHI model for improvement Ø Informed, trained, gained input
Ø on-‐the-‐spot teaching – surgeons, Ø anaestheTsts
Before touching paTent
Before clean/asepTc procedure
A_er body fluid exposure risk
A_er touching paTent
A_er touching paTent surroundings
B. ACCESS OF CENTRAL LINE (AT HUB) (Changing TPN, starTng inotropes, flushing line, administering medicine through line, drawing blood from UAC, etc.)
Oppor= tunity
HCW code
Time Mark with ( √ ) or ( X )
AsepTc (sterile pack, sterile syringes, sterile gloves, mask,
etc.)
Hub/Clave rubbed with Biotaine for at least 15s before accessing
1 2 3 4 5
Before touching paTent
Before clean/asepTc procedure
A_er body fluid exposure risk
A_er touching paTent
A_er touching paTent surroundings
B. ACCESS OF CENTRAL LINE (AT HUB) (Changing TPN, starTng inotropes, flushing line, administering
medicine through line, drawing blood from UAC, etc).
Opp
ortunity
HCW
Code
Time
Mark with (R) or (T )
AsepTc (sterile pack, sterile syringes, sterile gloves, mask, etc.)
Hub/Clave rubbed with Biotaine for at least 15 s before accessing
1
2
Context
• 12 bed unit -‐ Tygerberg Children’s Hospital • admiKng newborns • medical and nursing staff • first to implement BCA CLABSI-‐Bundle 2012 • no CLABSI surveillance before • using results from first year as baseline
Aims
• ↓ CLABSI-‐rate • á Compliance with bundle
Ø On-‐going moTvaTon: R support, compliance L root cause analysis → discuss problems « suggesTons -‐ new hydrophobic dressing -‐ reduce skin colonizaTon at inserTon sites 2
Ø Updated checklists, noTce boards J informaTve ® new changes ® safe pracTces J reinforce I stop unsterile procedures ? quesTon need for CL Ø weekly and monthly feedback ▪ management, staff, stakeholders ▪ CLABSI-‐surveillance, problems, plans Ø ProacTve Strategies → mulT-‐disciplinary
ü early breast milk-‐feedings ü ↑ feeding volumes ü removal of lines ü diagnosis and P treatment ü anTbioTc stewardship
No needleless connector -‐ no CuTmed!
Please use………
THIS PROCEDURE MUST BE STOPPED ON ANY VIOLATION OF THIS PROTOCOL!
Applied CuTmed Sorbact over inserTon site (not UVC and UAC)
STll a need for CL? (If not, please moTvate removal!)
Dressing intact? Please change when loose/soiled/wet! No gauze!
Remember CuTmed Sorbact
Context
• 12 bed unit -‐ Tygerberg Children’s Hospital • admiKng newborns • medical and nursing staff • first to implement BCA CLABSI-‐Bundle 2012 • no CLABSI surveillance before • using results from first year as baseline
Aims
• ↓ CLABSI-‐rate • á Compliance with bundle
Measurement of Improvement and Results
v diagnosis of laboratory confirmed CLABSI events → CDC/NHSN3
0
2
4
6
8 8
4,9 6
3,86
1st year 2nd year
#CLABSI CLABSI rate
Comparison: total of CLABSI events and CLABSI rate during first two years of programme
Achieved goal! Reduced CLABSI rate to 3.86 / 1 000 line days, 2 less CLABSI events!
Measurement of Improvement and Results (cont.)
6 CLABSIs cultured in * 3 CVPs * 3 UVCs 5/6 • premature (low birth weights: 780g – 1 200g) • very ill babies – high risk: mulTple central lines, immaturity, major IV access problems, prolonged use of central lines for TPN, > 10% Neonatalyte, inotropes No hydrophobic dressing used for these babies!!
0
0,5
1
1,5
2
2,5 6 CLABSI events during 2nd year
Staphylococcus spp
Candida spp
Klebsiella spp
Acinetobacter spp
Staphylococcus epidermidis
0
2
4
6
8
10
12 CLABSI rate / 1 000 line days
CLABSI rate per month Average CLABSI rate during 2nd year
Poor Compliance
Average CLABSI rate during 1st year CLABSI events
Cu#m
ed
Context
• 12 bed unit -‐ Tygerberg Children’s Hospital • admiKng newborns • medical and nursing staff • first to implement BCA CLABSI-‐Bundle 2012 • no CLABSI surveillance before • using results from first year as baseline
Aims
• ↓ CLABSI-‐rate • á Compliance with bundle
Central Line days
Nr of new paTents
Nr of central lines
1st year 1 633 256 303 2nd year 1 554 274 403
0 200 400 600 800
1 000 1 200 1 400 1 600 1 800
Comparison of the first and second year of program
More lines inserted:
↑ risk for CLABSI but…
less central line days:
↓ risk for CLABSI
0
20
40
60
80
100
120 Days between CLABSI events
81
96 84
40 40
12
01/A
ug/’13
20/O
ct/’13
24/Jan
/’14
18/A
pr/’14
28/M
ay/’14
07/Jul/’14
19/Jul/’14
Calend
ar days
% Compliance with bundles:
08 – ‘13
09 – ’13
10 – ‘13
11 – ‘13
12 – ‘13
01 – ‘14
02 – ‘14
03 – ‘14
04 – ‘14
05 – ‘14
06 – ‘14
07 – ‘14
InserTon bundle
100 75 100 100 100 100 100 100 100 100 100 ?
Maintenance bundle
60 50 40 50 25 60 25 0 75 100 100 ?
Checklists used – measurement of compliance with bundle elements and bundle as a whole. InserTon bundle compliance almost 100% Compliance with elements of maintenance bundle not as good, but average > 80%
Measurement of Improvement and Results (cont.)
Context
• 12 bed unit -‐ Tygerberg Children’s Hospital • admiKng newborns • medical and nursing staff • first to implement BCA CLABSI-‐Bundle 2012 • no CLABSI surveillance before • using results from first year as baseline
Aims
• ↓ CLABSI-‐rate • á Compliance with bundle
Challenges & Lessons learned To sustain program: ü compose team to ensure on-‐going:
§ moTvaTon, educaTon, CLABSI surveillance, feedback ü on-‐going compliance -‐ bundle ü compleTon of checklists, safety cross, stats book -‐ ensure reliable data (already used for research) ü Spread the news, encourage collaboraTon
• The commitment and passion of staff to ↑ quality of care of our babies -‐ ↓ CLABSI • PosiTve feedback, success in ↓ CLABSI, made road easier v Challenge to reach goals set for 3rd year
TOTALS: 1 –30 September
2014 according to
5 birth weight categories
BIRTH WEIGHT
≤ 750g
751-‐1 000g
1 001–1 500g
1 501–2 500g
› 2 500
g
Total number of new paTents:
0 3 4 3 7
Total number of new lines:
3 5 6 4 8
Total of CLABSIs diagnosed:
0 0 ?1 0 0
Message to others
v Neonates: ± 40% of deaths under 5 years of age globally v Reducing neonatal deaths necessary → achieve MDG4 v NMR in SA -‐ no improvement 1990 – 2009 4 v Main causes of neonatal deaths: • preterm birth (28%) • severe infecTons (26%)5 • asphyxia (23%)
v We have to be advocates for our babies!
Context
• 12 bed unit -‐ Tygerberg Children’s Hospital • admiKng newborns • medical and nursing staff • first to implement BCA CLABSI-‐Bundle 2012 • no CLABSI surveillance before • using results from first year as baseline
Aims
• ↓ CLABSI-‐rate • á Compliance with bundle
“There are two primary choices in life:
to accept conditions as they exist, or accept responsibility for changing them”
- Denis Waitley
Acknowledgements
Mrs Rachel Basson -‐ for driving and supporTng the Best Care iniTaTve in our hospital -‐ we will miss you! Ms L. Cloete – supported Zero CLABSI unTl reTrement Drs C. Geldenhuys, A. Bekker and A. Dramowski – helping with abstract and poster, diagnosing CLABSIs, supporTng The IPC team, neonatologists, registrars, medical officers and nursing staff caring for our babies The neonatal fund and University of Stellenbosch
Context
• 12 bed unit -‐ Tygerberg Children’s Hospital • admiKng newborns • medical and nursing staff • first to implement BCA CLABSI-‐Bundle 2012 • no CLABSI surveillance before • using results from first year as baseline
Aims
• ↓ CLABSI-‐rate • á Compliance with bundle
References
1. Wirtscha2er, D. et al. A statewide quality improvement collaboraTve to reduce neonatal central line-‐associated bloodstream infecTons. Journal or Perinatology 2010, 30: 170-‐181.
2. Powers, R. Decreasing Central line associated bloodstream infecTon in Neonatal Intensive Care. Clin Perinatol 2010, 37: 247-‐272.
3. Device-‐associated module, 4PSC-‐CLABScurrent, CDC guidelines, January 2014. 4. Reducing neonatal deaths in South Africa – are we there yet, and what can be
done? S AFR J Child Health 2012, 6 (3) 67-‐71. 5. 4 million neonatal deaths: When, Where, Why? Lancet 2005, 365 (462) 891-‐900.
17
C. SAFETY CROSS
A = Coloured in every calendar day B = RetrospecTvely coloured in on date CLABSI cultured C = Colours to use
18
CDC -‐ guidelines
PRIMARY CLABSI OR NOT?
PLEASE CHECK LAB. RESULTS EVERY DAY !
The CDC guidelines: -‐ A Recognized pathogen from at least one blood
culture, or -‐ A skin pathogen from 2 blood cultures -‐ A laboratory-‐confirmed bloodstream infecTon (LCBI)
where central line (CL) or umbilical catheter (UC) was in place for >2 calendar days on the date of event, with day of device placement being Day 1,
and a CL or UC was in place on the date of event or the day before. -‐ If a CL or UC was in place for >2 calendar days and
then removed, the LCBI criteria must be fully met on the day of disconTnuaTon or the next day.
-‐ No other documented primary site of infecTon -‐ One or more clinical signs of infecTon