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VASCULAR ACCESS SPECIALIST TEAM

Ownership of the Bundle

April VanDerSlik BSN RN CICInfection Prevention Manager

November, 2013

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Bronson Healthcare System

• Regional, not-for-profit health system

• Recognized for workplace excellence

• National leader in healthcare quality• Keystone, including

CUSP

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Bronson Methodist Hospital

• 434 bed tertiary teaching hospital

• 11 VAST nurses (7 full-time, 2 part-time, 2 on-call)

• 642 Acute CVCs / year

• Approximately 1,000 PICCs / year• ~ 50% PICCs are placed in critical care units

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Commitment to Excellence

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The Bronson Story

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History• Team Beginnings: Hyperal Initiation• Formed 1978• Dr. James Heersink, General Surgeon• Hyperalimention Team (doctors, nurses,

pharmacist, and dieticians)• Duties

• Assisted with CVC inserts• Education of staff and patients• Improved patient outcomes• Decreased infection rate

• Team name change in 2009 (VAST)

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VAST: Team Responsibilities1. Education

a. Develop policies and procedures according to INS standards, CDC & Joint Commission guidelines

b. Teach IV & Infusion Management classc. Patient, family and staff educationd. Manage Champion programe. Clinical resource to community

2. Placementa. Assist providers with CVC insertionsb. Insertion of PICCs at bedside

3. Post Placementa. PICC daily surveillanceb. PICC dressing changes

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Central Line Associated Blood Stream Infections (CLABSIs)

Adult Population Only

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Low CLABSI National Recognition

• Healthgrades, 2013• Better than average

• Consumer Reports, Jun 2011• reported zero• received highest score

• Commonwealth Fund, Dec 2011• reported zero

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Bronson’s Implementation PlanReduce CLABSI

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MethodologyGuidance

• CDC & Joint Commission guidelines• Keystone: CVC bundle• PICC bundle (Bronson specific protocol)

Practice• Daily PICC and TPN surveillance• Dressing change protocols• Hand hygiene program with auditors• Ultrasound guided CVAD placement• Blood sampling protocols• Education• Scrub the hub• Chlorhexidine disc

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Actual Practice Example

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Keystone CVC Bundle

Before procedure• Hand hygiene, chlorhexidine prep

During Procedure• Full Barrier Pre-cautions: Hat, mask, sterile gown, sterile gloves• Assist physicians and residents with insertion – avoid femoral site• Monitor sterility• Empowered to stop procedure• Monitor traffic pattern• Use of checklist

After procedure• Sterile dressing applied• Removing unnecessary catheters

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Bronson PICC Bundleat the Bedside

• Hand hygiene• Max barrier precautions • pre-packaged insertion kit

• Chlorhexidine prep• Ultrasound guided PICC

insertion• Neutral connector system• Connector disinfection• Flushing protocol• Daily monitoring of all PICCs by VAST

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Scrub the Hub1

1. Wash hands or use hand sanitizer

2. Wear gloves3. Scrub the hub for 30

seconds each and every time with chlorhexidine

1Centers for Disease Control, Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011

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Patient Ownership

Goal: Patient Empowerment of their VAD• Inpatient

• Permission to say “no” to care being given (i.e. change your gloves, wash your hands, scrub for 30 seconds)

• Basic care & maintenance education

• Discharge• Care & maintenance instructions• Emergency contact information• All CVAD types

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Checklist and Nurse Empowerment

Goal: Assist providers with CVC insertion Checklist to delineate, guide and document

completion of each step

Source of data collection to verify adherence to protocol

Taught to speak up and “stop the line”

Patient safety strong backing by RN, MD and management

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Vascular Access Infusion Training(Who do we educate?)

• Physician and residents

• Clinical staff (more than 800 FTEs)

• Management

• Patients and families

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Post Insertion CareGoal: Dressing Change and Line Surveillance

• Daily: PICC & TPN lines –VAST Team

• Daily: Acute CVC – Staff Nurses

• Check bag & tubing–labeled with time/date/initials

• Lab values

• Fever

• Line Necessity

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Staff Engagement ActivitiesTraveling Story Board

Updated according to unit specific educational needs

»Transferred from unit to unit»

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Champion Program Selection

Clinician empowerment of insertion procedure, care & maintenance and training of staff

RN for two years at Bronson VAST and management approval needed Attends Champion class done by VAST Specially trained in high risk central line skills Ability to sign off other RN’s on certain procedures Yearly peer review

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Champion Program: Duties / Skills

• Champion Duties• Sign off floor staff• Removal PICC / CVC• Dressing Changes (CVC)• Catheter Clearance - Thrombolytic• Continuing Education

• Champion Sign off Staff (Procedures)• Hanging TPN• Blood draws• Dressing Change (CVC)• Port Access

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Champion Program: Competency

Goal: Proficiency Demonstration

VAST or unit champion to sign RN off on procedure• RN observation• RN practicum / performance

of procedure with assistance• RN demonstrated competency

without assistance

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New Hire Employee: Infusion Training

Computer Based Learning (CBL) class• IV insertion and infusion

management• Practicum for hands on

demonstration in classroom setting

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New Initiative: Community Education

Goal: Initiative to decrease readmits from community due to CLABSIs w/ outside staff training• Local Nursing homes• Home Health Agencies• Local Hospice – policies only

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Central Line Infection Rate History(Adult Population Only)

1988

1991

1993

1994

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All T

PN D

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Obstacles to Overcome

• Hospital Administration support of empowerment

• Finding a Physician(s) Champion

• A hospital wide culture change

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Lessons Learned

• Participate in infection prevention collaboratives to share your challenges and best practices with other hospitals.

• Involve physician champions and multidisciplinary teams. • Use checklists.• Employ small, specially trained teams and individuals

(including intensivists in the ICUs) to conduct and/or oversee line insertion and maintenance throughout the hospital.

• Sustain best practices with ongoing education, monitoring, and adjustments and provide performance data to staff to keep them focused on outcomes.

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References• Carroll SS (December 2011) Eliminating Central Line Infections and

Spreading Success at High-performing Hospitals Synthesis Report December 2011 Commonwealth Fund publication 1559 Volk 21

• Ending Health Care-Associated Infections Agency for Healthcare Research and Quality (2009) www.ahrq.gov/research/findings/factsheets/errors-safety/haicusp/index

• Lowes R (2011) High Central-Line Infection Rates at Many Teaching Hospitals New Consumer Reports Study Gives Poor Marks to 67 Institutions Medscape Medical News June 7,2011 www.medscape.com/viewarticle/744131

• O’Grady NP et al (2011). CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections

• Sardone F (2010) Celebrating Nursing Excellence Bronsonhealth.com• www.commonwealthfund.org• www.bronsonhealth.com/about • www.healthgrades.com/quality/top-hospitals-2013

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Thank You!

bronsonhealth.com