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1. Vanderbilt Infection Control & Prevention
Central Line Associated
Bloodstream Infections
Tennessee Center for Patient Safety
Vicki Brinsko RN, CIC

2. Goal: Preventing CLABSI
 Using the Central Line Bundle
 Hand Hygiene
 Remove Unnecessary Lines
 Use of Maximal Barrier Precautions
 Chlorhexidine for Skin Antisepsis
 Avoid femoral lines
 Report CLABSI rates to the units
 Celebrate success
Vanderbilt Infection Control & Prevention

3. Engage
 Partner with Infection
Control, ID experts
 Increase awareness
about morbidity and
mortality associated
with CLABSI
 Make harm visible
 Tell stories
 Post # infections
 Estimates of opportunity
to improve
Vanderbilt Infection Control & Prevention

4. Thank You Notes to NICU Staff
Thank You FromThank You From
Baby Boy JonesBaby Boy Jones
I have gone 136 days without a
bloodstream infection. Keep up the
good work! My Mom left some
“kisses” for you! XOXOX
Vanderbilt Infection Control & Prevention

5. Form the Dream Team
 Heterogeneous in make
up; homogeneous in mind
set
 All stakeholders must be
included
 All RN teams fail because
MDs insert lines
 Find a high profile
champion
 Get a process owner
Vanderbilt Infection Control & Prevention

6. TEAM FORMATION
ICU DirectorICU Nurse Manager
Infection Control
Practitioners
Chief Hospital
Epidemiologist
Attendings &
Residents
Nursing Staff
(ICU)
QA/Quality Staff
QI experts
Frontline
Staff
Infectious
Disease experts
Leaders
Vanderbilt Infection Control & Prevention
National Quality
Scholars

7. Educate
 Educate staff and senior leaders about CDC
guidelines
 Develop a resource notebook
 Develop policies and procedures
 CDC guidelines and Fact Sheet
 Power point slides for In-services
 Consider a quiz to evaluate provider
knowledge
 Can use on-line training
Vanderbilt Infection Control & Prevention

8. http://www.mc.vanderbilt.edu/root/vumc.php?site=micututoria

9. Evaluate
 Outcome measure: CLABSI rate
 Rate, # infections, weeks/months since last
infection
 Process measures
 % checklists completed
 % violations noted
 # lines removed
 Celebrate success
Vanderbilt Infection Control & Prevention

10. Share the Data
CLA-BSI in Trauma
0
1
2
3
4
5
6
7
8
9
2005 2006 2007
Infsper100devicedays
Trauma
CDC Benchmark
Vanderbilt Infection Control & Prevention
BSI Bundle

11. The Check List
 Adapt to your own
institution
 Must be filled out for each
line insertion
 Include 5 BSI bundle
elements
 Simpler is better
 Can always add
elements as you become
better at capturing data
LF
Time end
(catheter secured):
MR #:
Check if:
Femoral
Internal Jugular
//Date:
Type of catheter:
Triple lumen
Introducer
Swan-Ganz
Insertion Site:
Subclavian
Other (specify):
Pt/Family teaching done
Consent obtained
Pre-insertion skin prep (check any used):
Alcohol Betadine (povidone-iodine) Chlorhexidine Other (specify):
Describe the circumstances under which this line was placed:
Non-emergent Emergent (life-threatening or code situation)
Please file page 2 in patients chart and return top form to the designated location in the ICU.
List all sites where insertion was attempted.
Other (specify):
:Time start
(1st needle stick): :
How many different needle sticks did the patient receive (number of skin breaks)?
1 Unknown
The provider inserting this line:
* If “No”, was this procedure supervised by someone with least five (5) central lines experience?
Yes No Didn’t ask
Yes No
Please use military time
(i.e. 1:00 pm is 13:00)
a. Handed-off his/her pager before the procedure?
Yes Nob. Washed hands immediately prior to procedure?
Yes No *
Didn’t ask
Didn’t ask
Didn’t askc. Has previously placed at least five (5) central lines?
Describe the level of training of the person who actually inserted the line?
Medical Student Intern (PGY-1) Resident (PGY-2+) Fellow Attending
Barrier precautions (check any used):
Sterile gloves Sterile gown Mask Sterile towels Full body drape
Side:
Right
Left
2 3 4 5 6+
Follow-up CXR: Ordered Not ordered (specify reason):
CXR findings (check all that apply):
No pneumothorax Pneumothorax (describe action taken):
Catheter in good position Catheter position adjusted (describe):
Type of dressing: Bio-occlusive Gauze Other (specify):
Patient tolerated the procedure well? Yes No
Was the sterile field maintained throughout the entire procedure? Yes No
Complications? None Other (describe):
Dressing applied by: Nurse Proceduralist Other (specify):
Nursing Checklist:
Central Venous Catheter Insertion
Vanderbilt University Medical Center
RIJ LIJ RSC LSC RF
Guidewire exchange
Placement unsuccessful
MC 2705 (Rev. 06/04)
NOTE: Please use either black or blue ink to complete this form.
Comments:
Vascath
Signature: ______________________________________________ Date: _________________
Indications for use:
Pressors
Hemodynamic monit.
Fluids/blood products
Frequent lab draws
Pre-existing infection
Nurse Practitioner
Double lumen
atVanderbilt
Monroe Carell Jr.
OR
CCU MICU SICU
BICU PCCU NICU
NSICUTICU
Other
Vanderbilt Infection Control & Prevention

12. Execute
 Hand Hygiene
 Remove Unnecessary Lines
 Use of Maximal Barrier Precautions
 Chlorhexidine for Skin Antisepsis
 Avoid femoral lines
Vanderbilt Infection Control & Prevention

13. Hand Hygiene
 Empower nursing to enforce use of a central line checklist to be
sure all processes related to central line placement, including
hand hygiene, are executed for each line placement.
 Include hand hygiene as part of your checklist for central line
placement.
 Keep soap/alcohol-based hand hygiene dispensers prominently
placed and make universal precautions equipment, such as
gloves, only available near hand sanitation equipment.
 Post signs at the entry and exits to the patient room as
reminders.
 Initiate a campaign using posters including photos of celebrated
hospital doctors/employees recommending hand hygiene.
 Create an environment where reminding each other about hand
hygiene is encouraged.
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14. Posters of Prominent MDs

15. Maximum Barriers
 Empower nursing to enforce
use of a central line
checklist to be sure all
processes related to central
line placement are executed
for each line placement.
 Include maximal barrier
precautions as part of your
checklist for central line
placement.
Vanderbilt Infection Control & Prevention

16. Insertion Kits or CL Carts
 Keep equipment stocked in
a cart for central line
placement to avoid the
difficulty of finding
necessary equipment to
institute maximal barrier
precautions.
 Some companies offer CL
insertion kits with maximum
barriers included
 Value in keeping as many
parts together as possibleMay Need to Order CHG and/or Kits

17. CHG Skin Asepsis
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 Empower nursing to enforce use of a central line
checklist to be sure all processes related to central
line placement are executed for each line placement.
 Include chlorhexidine antisepsis as part of your
checklist for central line placement.
 Include chorhexidine antisepsis kits in carts or grab
bags storing central line equipment. Many prepared
central line kits include povodine-iodine kits and
these must be avoided.
 Ensure that solution dries completely before
attempting to insert the central line.

18. Central Line Site Selection
 Whenever possible, and
not contraindicated, the
subclavian line site
should be preferred
over the jugular and
femoral sites for non-
tunneled catheters in
adult patients.
Vanderbilt Infection Control & Prevention

19. Daily Review of CL Necessity
 Include daily review of line necessity as part of your
multidisciplinary rounds.
 Include assessment for removal of central lines as part of your
daily goal sheets.
 Record time and date of line placement for record keeping
purposes and evaluation by staff to aid in decision making.
Vanderbilt Infection Control & Prevention

20. Create Redundancy
 Develop strategy to ask daily if lines can be
removed
 Daily Goals
 Nursing/physician sign outs on Rounds
 Implement checklist to be completed at time
of insertion
 Nurses present during line insertion
 Support for speaking up
 Modify checklist for local use
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21. Getting Started
 Do Your Homework
First!!
 Interdisciplinary team
 Gain consensus on
plans
 Create timeline for
deliverables
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22. Start Small
 Select the team and the venue. It is often best to start in one
ICU. Many hospitals will have only one ICU, making the choice
easier.
 Assess where you stand presently. What precautions are taken
presently when placing lines? Is there a process in place? If so,
work with staff to begin preparing for changes.
 Contact your Infection Control Department. Learn about your
catheter-related bloodstream infection rate and how frequently
the hospital reports it to regulatory agencies.
 Organize an educational program. Teaching the core principles
to the ICU staff will open many people’s minds to the process of
change.
 Introduce the central line bundle to the staff.
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23. First Test of Change
 Begin using the bundle with one
patient from the time of catheter
placement.
 Work with each nurse who cares
for the patient to be sure they are
able to follow the bundle and
implement the checklist and daily
goals sheet.
 Make sure that the approach can
be carried over from shift to shift
to eliminate gaps in teaching and
utilization.
 Process feedback and incorporate
suggestions for improvement.
Vanderbilt Infection Control & Prevention

24. One ICU…then the Rest
 Once the bundle has been applied
to one patient and subsequent
shifts, increase utilization to the
remainder of the ICU.
 Engage in additional PDSA cycles
to refine the process and make it
more reliable.
 After achieving reduction in CR-BSI
in the pilot ICU, spread the changes
to other ICUs, and eventually to
other places in the hospital where
central lines are inserted
…So Use Data
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25. CLABSI per 1000 Line Days
 CLABSI X 1000
CL Days
 How do I get the central line
days?
 Get ICU staff involved
 Unit secretary counts #
lines each day at 12MN
 Charge nurse counts each
day at change of shift
 See if IT can give you the
numbers electronically
Vanderbilt Infection Control & Prevention

26. Potential Barriers
 Fear of change
 Use knowledge
 Use optimism
 Communication breakdown
 Involve all stakeholders
on the front end
 MD and staff partial “buy-in”
 Supply continuous data to
all groups
 Changes in rates convert
the non-believers
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27. Questions?
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