2. Disclosure
 No Disclosures

3. SUTTER ROSEVILLE MEDICAL CENTER
Roseville California
315 Bed Acute Care, Community Based, Not For Profit Hospital, Includes:
32 Critical Care Beds, 16 Bed NICU, 55 Bed Rehabilitation Unit, 30 Bed Extended Vent Unit,
13-07-2012 Free template from www.brainybetty.com
31 Bed Emergency Department (77,000 Visits) Level II Trauma Center 3

4. Make
Safe
Speak
Up
for
Choices
Pa,ent
Safety
Spread
Safe
Design
Safe
Prac,ces
Care
Processes

5. Patient Safety Culture of Patient Safety
 Preventing harm to  The way we think, talk
patients about, act/react,
prevent, and learn
about harm to patients

7.  Reduced catheter dwell
time (7-14 days)
 Requires physician
placement
 Increased patient
discomfort
 Dressing/securement
challenges

8.  11 CLABSIs in 2005
 Decline in patient satisfaction
 Decline in IV team productivity
 Decline in FTEs/IV team
 Inpatient IV Team combined with Outpatient
Infusion Clinic

9. Bundle Descriptors 2005
Average Monthly PICC Volume 60
PICC Volume 767
Insertion Success Rate 92%
Interventional Radiology Rate 8%
Maximum Barrier PICC team only
Insertion Site Antecubital
Technique Traditional/Modified Seldinger
Dressing 24 hour pressure gauze dressing then weekly
Skin Preparation Alchocol/Betadine
Protective disk with CHG Inconsistent
Line Securement device Inconsistent
Connector Positive Pressure Connector
Flushing Protocol Normal Saline followed by Heparin (positive pressure flush)
RN Training Annual In-Service Day
Line Monitoring Completed q week with dressing change

10. Prior: Current:
2005: Primarily a peripheral Current: Advanced vascular
IV team. access team.
2005: 7A-7P coverage Current: 7A-11:30P
with one IV nurse coverage with 4-5 PICC
nurses
2005: line of choice,
peripheral IV and Centrally Current: line of choice PICC,
Inserted Central Catheters and peripheral IV. 40%
(CICC). decrease in CICCs.
CLABSI = 11 CLABSI rate of Zero.

11. Set a standard of practice for choosing the…..
Right Right
Line Patient
Right Right
Diagnosis Therapy
11

12.  Enhanced Flow Rates (1000ml.hr.)
 Hemodynamic Monitoring
 Power Injection (up to 5ml/sec.)
 Dual and Triple Lumen
 Larger lumen sizes- up to 17 gauge
 Santolucito, J.B. (2007). Role of Peripherally Inserted Catheters in the Treatment of the Critically-ill.
Journal of Vascular Access Devices, 12(4), 208-217.

13. 1 Santolucito, J.B. (2007). Role of Peripherally Inserted Catheters in the Treatment of the Critically-ill. Journal of Vascular Access Devices, 12(4), 208-217.

14. Patient Practice
Interrelationship
CR-BSI
Product
Source: D.Macklin Technology
and Practice: Collaboration for
successful positive patient
outcomes Infection Control Today
Sept 2007.
http://www.iceinstitute.com/
education.html

15.  CDC, SHEA, & IHI Recommendations
 Research
 Impact both extraluminal catheter
tract, and intraluminal fluid pathway
 New product technology
 Minimal bedside change
 Product ease of use

16.
Inser1on
Maintenance
Specialized
nurse
team
relied
on
expanded
bundle
IHI Central Line Bundle to
perfect
prac1ce
Maximal
Op,mal
Hand
Chlorhexidine
Daily
Barrier
Catheter
Site
Hygiene
An,sepsis
Monitoring
Precau,ons
Selec,on
SRMC Central Line Bundle
Change
from
Maximal
IV
Connector
Ultrasound
CL
Kit
Posi,ve
Flushing
Daily
Barrier
Septum
Guided
Revision
Pressure
Protocols
Monitoring
Precau,ons
Disinfec,on
Connector
Aids
Limits
provider-­‐ Expanded
to
Neutral
Vigilant
Rou1ne
8
Ongoing
appropriate
to-­‐pa1ent
include
connector
system
cleaning
of
hourly,
10ml
evalua1on
venous
transmission
Chloraprep®,
prevents
line
septum
and
saline
flush
of
line
loca1on
through
use
of
Statlock®,
blood-­‐reflux,
change
aEer
necessity
glove,
gown,
Biopatch®
reducing
colony
each
blood
mask,
drape,
etc
opportunity
draw

17. Interventions and Rationale

18. Intervention
 Maximum barrier
precautions, including
addition of full body drape
for all central line
insertions
Rationale
 CDC recommends full
barrier precautions with
CVC insertion: cap, mask,
sterile gown, drape to
fully cover patient.

19. Kit Contents
Bouffant Cap, Mask,
Gown, Alcohol swab
sticks, CHG skin prep,
CHG containing sponge,
O.R. Towel, and Drapes.

20. Rationale
 Normal skin bacteria counts
 Subclavian/jugular 10,000
cfu/cm2
 Anticubital fossa 10 cfu/
cm2
 Evidence has demonstrated
increased safety
Intervention
 All PICCs placed by  Recommended by
ultrasound guidance/  Agency for Healthcare
basilic vein, upper arm Research Quality
vein of choice
 American College of
Emergency Physicians

21.  Application of ECG placement/confirmation performed
during insertion:
 Eliminates time previously spent waiting for X-ray
confirmation readings
 Allows immediate release of the line/time savings
 Eliminates patient exposure to radiation/costs
 Saves time required for tip repositioning of
malpositioned tips found after the end of the procedure

23. Rationale
 Alcoholic Chlorhexidine
Swab Sticks and
Chlorhexidine-containing
sponge dressing around
catheter at the insertion
site reduces colonization
 Supports current weekly
dressing change practice
Intervention  Minimized the impact on
 Central line dressing kit revised to the bedside nurse
include Chlorhexidine-containing
sponge and chlorhexidine swabs in
each kit
 Securement device added by PICC
Nurse

24. Kit Contents
Mask, Cap, Gloves, Alcohol swabs, Alcoholic Chlorhexidine Swab
Sticks, Chlorhexidine-Containing Sponge, Tape Measure, 4X4’s,
Dressing, Tape, Skin Protectant, and Drape.

25. Rationale
 Supports Successful
Septum Disinfection
 Minimal priming volume
and no dead space
 Eliminates blood reflux in
lines
 No clamping required
Intervention  Saline Flush only
 Zero Fluid Displacement
Connector for all central
lines

26. Rationale
 SHEA,IDSA,CDC,
recommends cleaning
with an alcoholic
chlorhexidine preparation
or 70% alcohol prior to
each access.
 Rapid action time, kills on
contact. Kills bacteria by
Intervention denaturing proteins.
 Cleanse IV connector  Vigorously scrub threads
threads/septum with 70% and septum of
isopropyl alcohol or alcoholic needleless connector
CHG for 10-15 seconds prior to EVERY access.
(squeeze an orange). Apply
friction and scrub!!!

27.  Scrub the needleless connector with an alcohol prep
for 15 seconds using friction, as if you were juicing an
orange, before each access.
 Purpose: Time + Friction= Disinfection

28. Rationale
 Effective cleaning of
intraluminal surface
removes fibrin
 Minimizes bacterial
opportunity for
adherence
Intervention  Prevents mixing of
 Flush all CVC lumens incompatible
(except implanted port medications
and dialysis) with 10 ml
normal saline every 8
hours as needed,
utilizing a push-pause
technique

30. Intervention
 Daily monitoring of ALL
Central lines by PICC
team
Rationale
 Continuous monitoring
of practice decreases
complications and
increases compliance
with bundle

31. Data Collection
Tool
White Board
 White board tracks
patients with CVCs:
type of line and
insertion site.
 Data Collection
Tool: tracks all
patients with CVCs,
type of line, site of
insertion, dressing
change, and possible
complications.

32. Bundle
2005 2006 2007 2008 2009 2010 2011
Descriptors
Average Monthly
60 131 189 187 159 160 158
PICC Volume
Yearly PICC
767 1570 2266 2243 1904 1929 1898
Volume
Insertion Success
92% 98% 98%
Rate
Interventional
8% 2% 1.5% 1%
Radiology Rate
Maximum Barrier PICC team only All central lines All central lines
Insertion Site Antecubital Upper Arm, Basilic Vein Upper Arm, Basilic Vein (preferred)
Traditional/Modified
Technique 100% Ultrasound Guided 100% Ultrasound Guided
Seldinger
24 hour pressure No pressure dressing
No pressure dressing (exception excessive
Dressing gauze dressing then (exception excessive bleeding)
bleeding) Weekly dressing change
weekly Weekly dressing change
Skin Preparation Alchocol/Betadine Chlorhexidine Chlorhexidine
Protective disk
Inconsistent Consistent Consistent
with CHG
Line Securement
Inconsistent Consistent Consistent
device
Positive Pressure
Connector Neutral Connector Neutral Connector
Connector
Normal Saline
Flush 10ml NS every 8 hours
followed by Heparin Flush 10ml NS every 8 hours and PRN use
Flushing Protocol and PRN use (push/pause
(positive pressure (push/pause technique)
technique)
flush)
One-on-One Training at the One-on-One Training ,Vasc. Access Class,,
RN Training Annual In-Service Day
bedside housewide ongoing education
Completed q week Completed daily during site
Line Monitoring Completed daily during site checks.
with dressing change checks.

33.  Specialized PICC Teams can reduce the risk of
CLABSIs
 PICC Teams used as an improvement strategy to
reduce CLABSIs
 PICC Teams can lead to decreased infusion–related
complications
 PICC Teams can improve patient care outcomes
 PICC Teams can increase patient satisfaction
 Clin Infect Dis. 2011 May;52(9):e162-193. Epub 2011 Apr.1
 Infect Control Hosp Epidemiol. 2008 Oct;29 Suppl.1:S22-30.
 Joint Commission Resources, May 2012. http://www.PreventingCLABSIs.pdf.

36. Dialysis
CLABSI indicated in graph below was inserted and maintained by contracted
agency that did not follow Sutter Roseville Medical Center policies or bundle.

37. Nurse Physician
CLABSI
PICC Team

38. Determined…Relentless…Tenacious