Clinical strategies to improve patient outcomes

Vascular Access Matters

...because one small act can save - or cost - a life.

Introduction

Proper care: saves lines, saves lives.

Standardization of Care: new technology, new challenges: how to stay current?

FMEA: Failure Mode Effects Analysis

Leaders FMEA #1:2007 Central Lines

Project Leader Joan Blondin, Institute for Quality

Inpatient Leaders: Mari Cordes, RN, Nurse Educator, IV Team

Outpatient Leaders: Karen McBride, RPh, Director of Pharmacy Debra Gibbs RPh, Outpatient Infusion

Coordinator Health Center Pharmacy Physician Leaders:

Kemper Alston, MD, Infectious Disease William Raszka. MD, Pediatric Infectious Disease

Kathy Castello RN, Outpatient Infusion Nurse, HCPDebra Wildermuth, Outpatient Infusion Nurse, HCPJohn Ahern RPh, Inpatient PharmacyHeidi Pentkowski, Clinical Case Manager Heidi Moore, RN, Children's Specialty Center Sally Hess, Infection Control PractitionerJoanne Barton, RN, Baird 5Keven Eriksen, RN VNANicole Courtois, RN, Nurse Educator Outpatient Cindy Gebo, RN, PICU EducatorDeb Kutzko, NP, Infectious Disease Donna Benway, RN, Value Analysis Coordinator, PurchasingSue Goetschius, RN, Nursing Education DirectorEllen Crook, RN, Hematology/Oncology ACC

TEAM MEMBERS

Process ReviewCentral Line Care

Process review for central line care revealed significant variation in:

medication administration dressing changes flushing process blood draw technique The variation occurred from unit to unit and clinic to clinic.

Education Material Review of the education material at FAHC revealed process

techniques that do not meet nationally acceptable best practice standards for central line care.

Supplies Review of supplies used at FAHC revealed 7 types of needleless

connectors that included positive, negative, and neutral displacement caps, all requiring different flushing techniques.

Statistics Catheter related bloodstream infections (CRBSI)

are the most costly & life threatening of all healthcare infections.

Between 500-4000 US patients die annually due to blood stream infections.

25% of all CVC usage ends in occlusion. ~ $100,000 of TPA used for PICC catheter

clearance @ FAHC 10/07-03/08. (Does not include expenses of nursing time,

supplies, delay of treatment, catheter replacement.)

1 References: Hadaway L. Flushing vascular access catheters: risks for infection transmission. Infection Control Resource. http://www.infectioncontrolresource.org/past_issues/IC14.pdf

2 Deitcher S, Fesen MR, Kiproff PM, et al. Safety and efficacy of alteplace for restoring function in occluded central venous catheters: results of the cardiovascular thrombolytic to open occluded lines trial. J Clin Oncol. 2003;20(1):317-324.

Statistics (cont’d)

271 people die from HAI every 24 hours2

40,000/dayibid

271 people die from HAI every 24 hours2

Case fatality rate for CR-BSI approaches 20%1

1www.ihi.org accessed 4/29/20082www.safecarecampaign.org, accessed 4/29/2008

Problem Solving Central Lines

•Occlusion•Emboli•Extravasation/Infiltration•Infection

Problem: Emboli

Different types of emboli Air Catheter Wire Thromboembolus

Occlusion Infection risk Appropriate line flushing – do not force Know your VAD – heparin, or saline

flush? Avoid plunging syringe to bottom Is line positional? Should have blood return each time

catheter is used. Nurse is liable for use of malfunctioning catheter.

tPA for catheter clearance

Problem: Emboli – Identification

Medical Emergency Deep respirations Coughing Cyanosis Gasping Weak pulse Low or absent BP

Problem: Embolus -Treatment CATHETER embolus (catheter fragment in

bloodstream): THIS IS CONSIDERED A MEDICAL EMERGENCY:

Immediate medical intervention is warranted. Implement strict bed rest. Immediately apply tourniquet PROXIMAL to the site to

retain the fragment in the arm. Obstruct venous, not arterial flow.

Assess pulses distal to tourniquet every 15 minutes. Initiate oxygen therapy. Notify physician, contact Interventional Radiology to

prepare for emergent procedure. Monitor vital signs. Ensure patient has adequate peripheral IV access. Only MD should remove tourniquet.

AIR embolus Clamp or kink catheter. Position patient on LEFT side in

Trendelenburg. Call MD immediately. Administer oxygen, monitor vital signs,

and setup for code 99.

Care Giver Audit Is needleless connector disinfected for 15 sec. prior to

flushing and prior to connecting infusions? Are needleless connectors changed every 72 hours

(central lines) and after blood draws? Are needleless connector changes documented

anywhere? Are peripheral and central line dressings dated? Is dressing change documented in HISS caredex? Is dressing dated? If dressing dated, is it current? Is administration set labeled with date? If administration set labeled with date, is it current? Is flushing appropriate for line type? Is flushing appropriate after blood draw?

Infection Control

97%

55%

100%

0%

20%

40%

60%

80%

100%

120%

Hand Hygene Performed Connector Disinfected 15 sec. Contaminated after disinfected

Infection Control

Central Line Knowledge

76%79%

33%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Non-valved lines clamped when not in use RN knows what line Pt has RN knows if line is valved or non-valved

Central Line Knowledge

PrinciplesOf Asepsis

Problem: Infection pretest

If the nurse touches any pt. object after she performed hand hygiene, she must repeat hand hygiene immediately prior to handling vascular access devices.

T F

Problem: Infection

pretest Evidence based: A ____ second

scrub of hub will provide adequate disinfection.

Catheter related infections related to inadequate disinfection can most likely be classified as

a. intraluminal b. extraluminal

“All models of needleless access ports were successfully disinfected..” with 15 second scrub with isopropyl alcohol (IPA).

Wendy, MT, MPH, CIC and Chinn, Raymond, MD, FACP “Successful Disinfection of Needleless Access Ports: A Matter of Time and Friction”, JAVA (12; 3) 2006 pps 140-142

Principals of Asepsis

Medical Asepsis • clean: reduce and prevent spread of microorganisms

Surgical Asepsis • sterile: aim to eliminate microorganisms

Contamination – caused by:•prolonged exposure to air•wicking (capillary action) from wet areas•out of field of vision•objects below waist•touched by non-sterile objects

•bedsheets, skin, contaminated syringes/tubing

Biofilm

• Fibrin is not necessary to make biofilm• All indwelling devices have biofilm• Biofilm formation begins immediately

“…Biofilm forms when bacteria adhere to surfaces in aqueous environments and begin to excrete a slimy,glue-like substance that can anchor them to all kinds of material…”

Center for Biofilm Engineering, Montana State University

permission P. Stoodly

Biofilm and Infection

Biofilm clusters with streamers Showing flow in channel (e.g. blood vessel)

Biofilm: slimy glue like matrix created by bacteria that cannot be eliminated and is resistant to antibiotics.1 Planktonic intra or extraluminal ‘clumps’ can be released into the bloodstream.

1Catheter-Related Infections: It's All About Biofilm, Marcia A. Ryder, PhD, MS, RN Topics in Advanced Practice Nursing eJournal.  2005;5(3) ©2005 Medscape, Posted 08/18/2005

Integration

how you practice.

Transform intowhat you know

Catheter Site Assessment

Assess all VAD sites for: erythema, induration edema (swelling) pain discharge catheter migration (measure external

length of central lines)

With permissionJ. Bowen-Santolucito

Perform hand hygiene EVERY time immediately prior to handling vascular access devices.

Chlorhexidine and isopropyl alcohol (e.g. Chloraprep) is FAHC preferred antiseptic for central line insertion and maintenance

MUST use sterile procedure and wear mask (for IVAD accessing as well).

Home patients must wear mask; highly recommended for inpatients as well.

Infection: Managing catheters

•FAHC IV Therapy 847-3647•Intradoc

NGP0009 Central Venous Access DevicesINFC00003 Prevention of IV Device Related Infections

NGP 119 De-Clotting Central Venous Catheters Using Thrombolytic Agent tPARenal policies•NKF, Safe Care Campaign, and IHI websites•Professional forums

Resources

Infection: The Impact

A Mother’s Letter to a Hospital CEO safecarecampaign.org

Our son died in your hospital 7 days ago. He died from a bacterial infection he caught there as a result of his medical care while being treated for something else. It created so much pressure around his brain that it caused part of it to be pushed into his spinal column, leaving him a helpless ventilator-dependent quadriplegic and ending his short but unforgettable life among us all…….

………..Dear CEO, I hope you read this letter to your team aloud. Tell your board that we do not want anything for the loss of our dear son but a dramatic and effective plan for change that will make a difference for others who trust healthcare in general and your hospital specifically. We look to you to partner with us as patients and caregivers so that we may all be safe and well, both now, and in the future.

Sincerely, Victoria Nahum

Questions?