Select team, educate and collect feedback▪ hospital ‘buy in’ sought and approved▪ CLAB team identified▪ instigate weekly/fortnightly meetings

Gather information▪ using resources from national groups to lower costs of implementation and save ‘re-inventing the wheel’▪ ghant chart developed▪ drapes/CVL pack

Evaluate current practice▪ identified CVL care of practice and blood culture collection▪ look at use of insertion and maintenance bundles▪ blood culture guidelines

Developed forms for WDHB▪ review national and regional pathways▪ review forms

Staff education▪ one to one▪ use of CVL pack▪ CLAB site on intranet▪ posters to identify key practice▪ flow charts for data collection▪ handover ‘hubs’▪ ward meetings▪ peer review

Commence use▪ bundles▪ pathways▪ insertion packs

Audit process reviewed▪ mini PDSA cycle▪ ongoing communication▪ daily rounding

Analyse▪ data collection▪ insertion and maintenance bundles perfect in CCU, OT and PACU first▪ wait to roll out to wards

Review▪ bundles and packs▪ blood cultures▪ data collection▪ education and communication▪ leads from other DHBs

Improve and implement▪ CLAB focus board for staff▪ CLAB free days sign▪ bundles formatted▪ surveillance and blood culture process▪ packs finalised

Support and commitment▪ keep momentum▪ indentify champions▪ involve ward CNC and educators▪ prepare for 2013 roll out▪ education▪ communication

PLAN

DO

STUDY

ACT

CLAB WDHB WhanganuiDistrict Health Board

What?Part of a national collaborative to provide baseline measuring of the extent of Central Line Associated Bacteraemia (CLAB) in NewZealand and provide a tool for measuring improvement

Central Line Associated Bacteraemia

Why? Zero incidence of CLAB will lower mortality, lessen associated costs and improve patient outcomes.

Hospital and Community

‘Barry’s’ storyConcern

How?

LessonsLearnt

POSITIVES▪ being a part of this new ‘national collaborative’▪ sharing ideas through the network▪ strengthening of relationships between ICU’s, particularly in our region▪ insertions were initially anaesthetist - quick acceptance. Now: physician, surgeon, Emergency Department SMO, PICC registered nurses▪ empowering our patients▪ utilising our own resources - packs and insertion kits▪ change of practice - the spin off is improved hand hygiene, blood culture collection and care of IV lines

FinalProduct

BUNDLES DATA COLLECTION DETECTION AND REPORTING

TheWDHBTeam

CCU CLAB Detection & reporting FLOWCHART

Central Line Inserted

Signs of Sepsis

Blood culture Taken

Microbiology contact CCU

MDT confirm CCU CLAB reportable event*

CCU review central line insertion

checklist & access simultaneous feedback data

CCU completes tally tool to

capture line days

Infection Control notify IHI of CLAB (Numerator*) &

tally data (denominator*)

CCU notify infection control

of tally data

IHI data feedback process

TheFuture

▪ Standardised bundles ▪ Involvement in other collaboratives ▪ Roll out to wards▪ Standardised practice ▪ Implement the hand hygiene ‘naked unit’ Clinical Lead

Dr Marco MeijerAnaesthetist

Project LeadJoanne VigenserCNC - CCU/ED

Patient Safety & QualityDeclan RogersCNS - Infection Prevention & Control

Public HealthBronwynne AndersonIV Advisor, HITH Coordinator

TheatreDiane McClellandCNS

PACULyndel WilsonCNS

WDHB CCU CLAB data collection process

No

Insertion basket collected for CL

insertion

Insertion checklist included in the

insertion basket

Insertion checklist form completed at the

time of insertion. Form stays in patient

notes

Maintenance checklist form is used for every

line day thereafter until discharge

Completed forms copied and placed in

CLAB box

Daily checklists showing compliance

for insertion and maintenance

CNC checks non-compliant forms for

errors

Highlighted to staff; corrected if verified

Data input every Monday for the

previous week if able

Weekly/monthly chart printed and displayed

on CLAB board

No

Yes

▪ Barry Arthur is a 52 year old married male with Burketts Lymphoma.▪ Portacath insertion in 2008.▪ Monthly infusions of Intragram-P.▪ November 2010 developed a CLAB whilst in hospital and nearly died.▪ Portacath was removed.▪ After his miraculous recovery, Barry and Amelia went on a three day cruise to celebrate.▪ Venous access was discussed again as Barry required monthly infusions over the next 14 months.▪ Barry made his decision to have a new port inserted based on research and discussion with different staff.▪ New portacath inserted January 2012. ▪ Major education for Barry to not allow staff to use port access, unless hands had been washed and they had “scrubbed the hub” for 15 seconds. Barry realises that this is his “lifeline” and comments that many staff had not always done this with his previous portacath access.

▪ Barry is an advocate for patients being proactive in preventing CLAB, he is a great example to all.

Final Version following further Regional Consultation 23rd July 2012 48hr rule added 11.10.12.

Temp >38ºC

Signs of sepsis: ↑HR, ↓SBP, Rigors

Suspicion of sepsis

Or Or

Collect 2 blood culture sets (4 bottles): 10mls of blood per bottle

Take one set at a time (Paediatric volumes will be different)

Take blood from: Preferred: 2 separate peripheral sites or NEW CV line

Difficult access: 1 peripheral line and 1 existing line

No peripheral access 2 samples from any existing line, only to be used in extreme circumstances – least preferred

The two blood sets should be taken within 48hrs of each other.

o Perform hand hygiene o After removing blood culture bottle lids, swab with alcohol, allow 20 seconds to dry o Disinfect skin, allow 60 seconds to dry o Take cultures before taking other blood samples (no discard required) o Fill Aerobic bottle first, then Anaerobic,repeat for second set. o 10 ml blood per bottle (adults) o Clearly label each culture bottle and form with site of origin o Repeat at next site

How

Where

When

What

Blood Culture Guidelines

We have preventedCentral Line Associated Bacteraemia

in all of our patients

for

310days

WhanganuiDistrict Health Board

SOLUTIONS

▪ identifying champions ▪ communication ▪ slowly but surely▪ education packages and ongoing support ▪ look at data collection improvement

BARRIERS▪ time constraints - part of own workload▪ keeping the momentum▪ staff apathy to process changes and more paperwork▪ focus on packs and drapes▪ roll out to wards: fear of losing control, an increase in paper work and compliance (all on the ‘to-do’ list)▪ no electronic data collection in DHB▪ staff unable to visualise ‘the big picture’

STAT No: ?? Date form created: 12/02/2013 Catalogue No: ???? Review Date: 12/02/2015

MA

INTE

NA

NC

E B

UN

DLE

CLA

B

Patient Label Surname: NHI: First Names: Ward: Address: DOB: ACC No: GP: Consultant:

Please photocopy form and place in CLAB box when complete.

Ward/Unit: Line Day: Yes No Today’s Date: Yes No Time removed: Was Central Line reviewed

for necessity today? Was Central line removed today?

Is IVN/TPN being infused? If Yes, is dedicated port being used for IVN/TPN?

Did you check the site today for inflammation?

If any signs of infection present review the catheter promptly

High Risk Patient – Is there a prevention measure in place? e.g. Chlorhexidine Impregnated Dressing

Not a high risk patient

AM Shift 8hr Before accessing injection ports did you clean with 2% CHG in 70% alcohol each time?

Not accessed

PM Shift 8hr Before accessing injection ports did you clean with 2% CHG in 70% alcohol each time?

Not accessed

Night Shift

8hr Before accessing injection ports did you clean with 2% CHG in 70% alcohol each time?

Not accessed

Comments: Date/time transfer to another department:

Ward/Unit: Line Day: Yes No Today’s Date: Yes No Time removed: Was Central Line reviewed

for necessity today? Was Central line removed today?

Is IVN/TPN being infused? If Yes, is dedicated port being used for IVN/TPN?

Did you check the site today for inflammation?

If any signs of infection present review the catheter promptly

High Risk Patient – Is there a prevention measure in place? e.g. Chlorhexidine Impregnated Dressing

Not a high risk patient

AM Shift 8hr Before accessing injection ports did you clean with 2% CHG in 70% alcohol each time?

Not accessed

PM Shift 8hr Before accessing injection ports did you clean with 2% CHG in 70% alcohol each time?

Not accessed

Night Shift

8hr Before accessing injection ports did you clean with 2% CHG in 70% alcohol each time?

Not accessed

Comments: Date/time transfer to another department:

Ward/Unit: Line Day: Yes No Today’s Date: Yes No Time removed: Was Central Line reviewed

for necessity today? Was Central line removed today?

Is IVN/TPN being infused? If Yes, is dedicated port being used for IVN/TPN?

Did you check the site today for inflammation?

If any signs of infection present review the catheter promptly

High Risk Patient – Is there a prevention measure in place? e.g. Chlorhexidine Impregnated Dressing

Not a high risk patient

AM Shift 8hr Before accessing injection ports did you clean with 2% CHG in 70% alcohol each time?

Not accessed

PM Shift 8hr Before accessing injection ports did you clean with 2% CHG in 70% alcohol each time?

Not accessed

Night Shift

8hr Before accessing injection ports did you clean with 2% CHG in 70% alcohol each time?

Not accessed

Comments: Date/time transfer to another department:

STAT No: ## Date form created: 12/02/2013 Catalogue No: ## Review Date: 12/02/2015

INSE

RTI

ON

BU

ND

LE

Patient Label Surname: NHI: First Names: Ward: Address: DOB: ACC No: GP: Consultant:

Please photocopy form and place in CLAB box when complete.

PLEASE COMPLETE FOR ALL CENTRAL LINE INSERTIONS ON ALL PATIENTS

Where was the line inserted?

CCU

Radiology

Theatre

SCBU

Other DHB

Other: _______________

Insertion site:

Right Left

Subclavian Jugular

Basilic Cephalic

Femoral Saphenous

UAC UVC

Other: ______________

Catheter Type:

Non-Tunnelled PICC Vas Cath

Tunnelled Implanted Vascular Device

Other: _______________________________

Line Coating: Antibacterial Antiseptic None

All Catheters Placement confirmed by X-ray and SMO Inserted Catheter Length: ________________

Date Line Inserted: __________________________ Time Line Inserted: ________________ INSERTION BUNDLE: To be completed by the observer and signed by both proceduralist and observer.

1. Hand Hygiene - Did the proceduralist?

Perform hand hygiene using chlorhexidine(CHG) solution Yes No

2. Chlorhexidine Skin Antisepsis - Did the proceduralist?

Prep the procedural site using chlorhexidine 2% in 70% alcohol (In NNU CHG % is titrated for weight/age) for 30 seconds and allow solution time to dry completely

Yes No

3. Maximum Barrier Precautions - Did the proceduralist?

Wear a hat Yes No

Wear a mask Yes No

Wear a sterile gown Yes No

Wear sterile gloves Yes No

Use a large sterile drape that covered the entire patient Yes No

Maintain sterile technique during procedure and when applying the dressing Yes No

Where high-risk patients have a CVC (e.g. burns, emergency insertion, TPN, ICU stay >7 days, immunocompromised, rewired line) consider using other preventative strategies, e.g. Chlorhexidine Impregnated Dressing , Antibacterial Line Applied on insertion? Yes No

Proceduralist Name: Proceduralist Signature:

Observer Name: Observer Signature:

Ward/Unit: Insertion Day 0 Insertion Time: Yes No Comments

Is IVN/TPN being infused?

If Yes, is there a dedicated port being used for the IVN/TPN?

Before accessing injection ports did you clean with 2% CHG in 70% alcohol?

Please check which shifts the line was in place for on the day of insertion.

AM Shift PM Shift Night Shift Date/time transfer to ward: ____________

CENTRAL LINE DEFINITION ANY CATHETER WHOSE TIP TERMINATES IN A GREAT VESSEL

INSERTION AND MAINTAINANCE AUDIT

Date Bed NHI Line day

Insert. bundle

Review line

Site Chlor hex

TPN Comment

MON

TUE

WED

THU

FRI

SAT

SUN