The Road to Target Zero

The story of our journey to eliminate CLABSI’s

Suzanne Martin BSN, RN, VA-BC Tonya Suckley RN, VA-BC

Clinical team leader for the Vascular Member of the Vascular Access
Access Specialist Team at St. Joseph Specialist Team at St. Joseph Mercy
Mercy Oakland, and member since Oakland from inception to present.
inception.
St. Joseph Mercy Oakland (SJMO) is a 443-bed
comprehensive, community teaching hospital and a
member of the Saint Joseph Mercy Health System, a
subsidiary of Trinity Health. SJMO has been serving the
Pontiac, Michigan community for more than 80 years.
We now have a 24/7 full service Vascular Access
Specialist Team, integrated with our Rapid Response
Team. This unique and specialized team performs many
tasks including: Responding to and managing all Rapid
Responses, placing PICC lines, Midlines, Arterial lines,
difficult PIVs, obtaining difficult labs with ultrasound,
assisting and monitoring all central line insertions,
drawing all blood cultures for patients with central
lines, daily rounding, surveillance and maintenance of
all PICC lines, Midlines and Central lines newly admitted
and placed during hospitalization.
What is a CLABSI?
Why does it matter?
 The CDC definition: A lab confirmed bloodstream infection not related to an
infection at another site, that develops within 48 hours of a central line
placement
 Of all Healthcare Associated Infections (HAIs), CLABSIs are the most costly at
approx. $50,000 per case, and the most preventable, with proper aseptic
techniques, surveillance and management strategies
 CLABSI= prolonged hospital stay, increased healthcare costs, increased
mortality
 Factors affecting higher risk for CLABSI: patients with chronic illness, immune
compromised states, malnutrition, loss of skin integrity, prolonged hospital
stay prior to central access, certain central catheter types and location,
conditions of insertion, catheter site care, and skill of inserter

CDC.gov
 Many Inconsistencies:
2013 • Line monitoring & tubing changes
16 CLABSIs • Education
• Femoral line routine for emergency
• Outdated VA policy
Revision of VA
• PICC nurses provide placement only
policy began
• Blood cultures draws
• Flushing and maintenance of CVCs &
PIVs.
CHG baths Bedside insertion checklist for procedure 2016
given to all
pt.’s w/CVCs
bundle added to EMR. 2nd RN to present for
all sterile procedures, CVCs/PICCs.
1 CLABSI
VAT RN to assist at Continue VAT daily
Infection prevention every central line monitoring and
Began studying other institutions with zero
Begin PIV/CVC daily rounding begins. insertion. maintenance of all
CLABSI rates.
practices Midlines/CVCs,
Begin education on proper including all
meetings.
skin dressing changes.
2014 preparation/application of Michigan Hospital Medicine
Safety Consortium (HMS)
Consistent use of neutral
CHG2%/Alcohol 70% displacement, transparent,
16 CLABSIs collaborative initiated.
dead-end needless connectors
Consistent and alcohol impregnated
Vascular Access Team (VAT) All unit placing
• Weekly line monitoring and application of skin disinfection end caps for all
CVCs/foley catheter prep CHG VAT policy
maintenance and PRN on all CVCs lines.
counts on unit huddle 2%/alcohol 70%. revisions
• Line insertion date added to show in
board daily for completed
IVIEW/EMR monitoring. IO Used in codes
Inconsistent technique with 2015 consistently if PIV fails or
central access needed
blood cultures draws. EMTs in
ER drawing all blood cultures on 3 CLABSIs Vascular access/IV
education on hire for new
ER patients. Began SIM Lab Education for
Continued education nurses and individually
resident physicians and annual
Began changing all IV tubing on proper skin prep VAT continues to per unit.
education for nursing staff.
every 96 hours for cont. w/ CHG 2%/Alcohol provide 24/7
infusions. New tubing each 70% for physicians coverage for the
and nursing staff VAT to draw blood cultures for all
time with intermittent use hospital.
patients w/CVC present, throughout
Bordered, engineered, FDA VAT now daily the hospital.Brought contamination
approved, stabilization CHG bathes given to monitoring and rates from 3% down 0
dressing trial cont’d with all patients w/CVCs maintenance of all
noted success. daily and now prior midlines/CVCs, to Use of
8/14 Additional to insertions. include all dressing antimicrobial/antithrombo
FTEs approved changes.
Removed genic PICC lines
for Vascular
femoral lines implemented for high risk
Access Team to
from crash carts Switch to neutral displacement, patients.
provide 24/7
1/14, and spring transparent, dead end needless coverage.
loaded IO device connector, and alcohol impregnated 2017
add to all crash disinfection caps for all CVCs.
carts. 0 CLABSIs
The Road to Target Zero began in Oct. of 2013

We have had 16 CLABSIs this year

reported from Jan. –Aug. alone!
Opportunities to achieve and maintain “Target Zero”
of Intravascular Catheter-Related Infections
 SJMO is at risk of losing approximately
$130,000-390,000 in reimbursement care
coverage
 CLABSI’s 13 total from January-August
2013, Per ID reporting to NHSN
 How do we compare? On the CUSP: Stop
BSI
 CLABSI is one of ten required conditions
to be reduced by 40% BY 2014
 SMJO Bundle Descriptors for calendar
years 2011-2013
 CDC and JCAHO recommendations to help
organizations reduce CLABSI’s and
associated morbidity and mortality
 Opportunities for education,
implementation and evaluation of best
evidence-based practice guidelines
 Empower nursing staff to have a voice
(successful CUSP=TEAM effort)
 Assess the need for change in practice
 Identify at risk nursing practices
 Use of NS ZR IV flush only 10 ml syringes
to dilute medications
 Non standardized “scrub the hub”/Swab
caps when assessing vascular assess lines
 No current annual bedside
education/competency for vascular
access care
 Lack of supplies for nursing to complete
best practice task (cvc drsg kit – no
statlocks)
Best Practices:
Engaging &  Absolutely requires 3 strong champions (nurse, physician,
administration)
Sustaining Nurse  Monthly meetings require email reminders, individual
Involvement in a invites, reminders throughout day, support to allow staff
to step away from patients
Comprehensive  Energy maintained if you focus on what matters to the
Unit-Based bedside nurse
Really resolve some problems!
Safety Program


or CUSP
2013

 This is the year we began to focus

on opportunities for improvement
with all central lines.
 We began looking at facilities
throughout the country that had
zero CLABSI Patient Harm
 Sutter Roseville Medical Center and
Bronson were two hospitals that
made the unachievable achievable.
 We identified many inconsistencies
at our facility, as well as in our
practices.
  Lack of education for bedside nursing
staff
2013  PICC line nurses who provide placement
only
What puts our  No accountability for line monitoring
patients at or IV tubing changes
 No regular flushing or maintenance of
risk for a PIVs or CVCs

CLABSI? 


Outdated Vascular Access policy
Femoral central access routine for
emergency. Nobody monitoring those
“emergent” lines and the need for
replacement within 24hrs.
  Started review and revision of Vascular Access policy
 Central line insertion kit added full max barrier
 Bedside insertion checklist for procedure bundle added to
EMR.

2013- 


2nd RN present for all sterile procedures, CVCs/PICCs
CHG baths given to all patients with CVCs

16 CLABSIs  Hospital wide Hand Hygiene compliance program pilot

5/2013 to reduce HAIs – “wash in- wash out”

Let the journey  Begin education on proper skin preparation with

CHG2%/Alcohol 70%, application, dry times and
application of chlorhexidine gluconate impregnated foam

begin! 
disc, for all physicians and nursing staff
Began studying other institutions with zero CLABSI rates
 Began PIV/CVC practice meetings
 Bordered, engineered, FDA approved Stabilization
dressing trial on all PICC lines- stopped using statlocks
 Alcohol impregnated end caps on all central lines
 Beginning of Vascular Access Team formation and
responsibilities to include weekly maintenance and
surveillance all central lines
 Hospital Acquired Infections (HAI) Reduced
with Hand Hygiene Compliance
Hand Hygiene Adherence:
"Wash-in / Wash-out"
90%
Over 14.5 Million hand washes have
80% taken place since a pilot in May 2013.
70%
All medical-surgical and critical care
patient care areas have the hand
hygiene surveillance system.
60%
% Hand Hygiene Adherence

50%

40% Housewide adherence: 75%

30%

20%
C. Difficile & MRSA Bacteremia
10%
Standardized Infection Rate (SIR)
1.8
0%
13 l- 1
3
-1
3
-1
3 1 4 14 14 l- 1
4
-1
4
-1
4 1 5 15 15 l- 1
5
-1
5
-1
5 1 6
y- u p v n- r- y- p v n- r- y- p v n- 1.6
Ma J Se No Ja Ma
Ma Ju Se No Ja Ma
Ma Ju Se No Ja

Hand Hygiene Compliance Pilot

1.4

Hand Hygiene Compliance Pilot 1.2

Housewide Hand Hygiene 1

CY 2014
Compliance Program 0.8
CY 2015
0.6

0.4

0.2

0
C. Difficile (SIR) MRSA Bacteremia (SIR)
  Vascular Access Team to provide weekly & prn line monitoring
and maintenance on all CVCs
 Bordered, engineered, FDA approved Stabilization dressing
trial on all central lines (1/14-5/14 when we ran out of trial
stock)
2014-  Discovered pre-filled NS flush syringe NOT for medication

16 CLABSIs 
mixing, and education for staff- NOT for sterile field use
Added central line “date of insertion” component to IVIEW in
The journey to our EMR, and would show “central line days” for admission on
safety page

zero…  Updated central line insertion sheet to include alcohol

impregnated end caps
 Exclusive use of CHG bath in ICU & CHG bath prior to insertion
 Intermittent IV tubing changes required with every use or
disconnect
  Noted inconsistent technique with blood culture draws throughout
the hospital. EMTs drawing all blood cultures on ER patients-
Education necessary for consistency and proper procedure
 Began changing all IV tubing every 96 hours for cont. infusions and

2014 
new tubing each time for intermittent use
Femoral lines removed from the crash carts, and spring loaded

The journey to 
Intraosseous device added to all crash carts
Bordered, engineered, FDA approved Stabilization dressing trial
zero 
continued with noted success
Switch to neutral displacement, transparent, dead end needleless
continues…. 
connector, and alcohol impregnated disinfection caps for all CVCs
8/2014 Additional FTEs approved for Vascular Access Team to
provide 24/7 coverage in the hospital
 CHG baths given to all patients with CVCs DAILY and now prior to
insertions
  VAT now doing DAILY monitoring and maintenance of all midlines/CVCs,
to include all dressing changes
 All units placing CVCs/foley catheter counts on a unit specific huddle
board daily for monitoring by IP and VAT
 Began SIM Lab education for resident physicians and annual education for
2015- 
nursing staff
Michigan Hospital Medicine Safety Consortium (HMS) collaborative

3 CLABSIs 
initiated
IO now used in codes consistently if PIV fails or central access needed

We’re making  Now seeing consistent, proper application of skin prep CHG 2%/alcohol
70%

progress!  7/2015 Infection Prevention daily rounding begins on all Central lines and
foleys in collaboration with VAT to reduce HAIs
 Consistent use of neutral displacement, transparent, dead-end,
needleless connectors and alcohol impregnated disinfection end caps for
all lines
 VAT RN to assist at every central line insertion
  Continue VAT daily monitoring and
maintenance of all Midlines/CVCs,
including insertion, admission
assessments, maintenance orders and
all dressing changes
VAT policy revisions completed
2016-


 Vascular Access/IV education on hire for

1 CLABSI new nurses and individually per unit
VAT to draw blood cultures for all
Almost There!

patients with CVC present, throughout
the hospital – this brings contamination
rates from 3% down to 0
 Implement use of
antimicrobial/antithrombogenic PICC
lines for high risk patients
2017 Zero CLABSIs

After over 3 years of

multidisciplinary
efforts and
interventions, we met
our goal and crossed
the finish line!
Blood Cultures
Why do they matter?
 Studies show a dedicated team drawing blood
cultures exhibit a decrease in contamination rates
and false positives. Continuity = less chance of error
 Having a dedicated team drawing blood cultures
on all patients with central lines, brings us to the
forefront for decision making processes regarding
central lines
 A collaborative approach between us and physicians
equals better outcomes for the patient
 As a vascular access team, we’re invested in the
results and outcomes, not task focused
 Lab notifications by email for all preliminary
positive blood cultures in the hospital and high
risk patients
  We now have a 24/7 full service Vascular Access
Specialist Team, integrated with our Rapid Response
Team. This unique and specialized team performs many
tasks including: Responding to and managing all Rapid
Responses, placing PICC lines, Midlines, Arterial lines,
2017-2018 difficult PIVs, obtaining difficult labs with ultrasound,
assisting and monitoring all central line insertions,
Maintenance drawing all blood cultures for patients with central lines,
daily rounding, surveillance and maintenance of all PICC
of Zero lines, Midlines and Central lines newly admitted and
placed during hospitalization.
 Interdisciplinary collaboration continues with:
Administration, Infection Prevention, Physicians,
Quality, Managers, and all staff to ensure there are zero
CLABSIs for SJMO.
 SJMO CLABSIs 2013-2018
20

16 1
PICCs Maintenance 5
PICCs Insertion 12
CLABSIs Maintenance 2 8
CLABSIs Insertion 8
4
4 7
5 1
1
0 1 1
2013 2014 2015 2016 2017 2018
2019- 2 CLABSIs
All good journeys must come to an end…so a NEW one can begin!
  5/2019 SJMO IP department identifies
CLABSI on a patient in CCU. Pt. has
positive blood cultures with pathogen
from no other potential source, has
trialysis catheter being accessed for use
by multiple bedside nurses other than
2019 VAST, pt. getting CRRT, blood cultures
were not drawn by VAST
2 CLABSIs  10/2019 SJMO IP department identifies
Where did we CLABSI on a patient in ICU. Pt. has
positive blood cultures with pathogen
go wrong? from no other potential source, has a
hemodialysis catheter being accessed
for CRRT by ICU nurses, VAST not aware
of this patient’s HD catheter to assess
on admission and for 4 days post-admit,
blood cultures not drawn by VAST, no
email notification of pos. blood culture
CLABSI Identification Process

Midas email notification of

pos. blood cultures on all
patients to IP and VAST
clinical team leader, and
patient with central line and
pos. blood cultures identified
Other infections to consider:
Always look at the full picture
Pneumonia, Urine, Wound, Always culture appropriately
of the patient
SSI?

Learning From Defects

meeting scheduled after each
Unit specific nurse manager
event with: Administration,
for identified CLABSI is
Unit specific Management, IP,
notified, as well as all staff
VAST, & bedside nurses caring
caring for patient
for the patient, including
Hemodialysis
LFD= case reviewed, potential
process breakdown identified,
What did we do wrong? How
opportunities for education
can we prevent it from
and plan for process
happening again?
improvement, follow-up
meeting
TEAM: Together
Everyone Achieves
More
 Take it to the bedside
 Share findings and reports with the
hospital- we all own what goes on here
 Work together as a team to create and
maintain a culture of patient safety
and excellent care
2013-2019

We have developed a strong multidisciplinary team that

includes the Vascular Access Specialist Team, Infection
Prevention, Administration, Quality, Managers, Physicians and
staff.

Working together, holding one another accountable,

encouraging one another, teaching one another… we are
accomplishing great things at St. Joseph Mercy Oakland as a
team, per our mission.