tth qi presentation

+

Quality Improvement: IV TubingToledo Hospital – Urology, Nephrology, & Vascular

Erin Bedell, Katelynn Butler, Sarah Dinger, Jacquelyn Gawle, Thomas Meridieth, Cait Zimmel

+Research Outline

Population: 39 beds out of 40 Compliance: Low Problem: Noncompliance & Lack of Supplies Consequences: Financial Burden & Infection Risk

+Pre-Data Collection Questionnaire

IV Tubing Change Primary66% - 96 hours22% - 96 hours and 24 hours intermittent11% - 24-72 hours

Secondary 55% - 24 hours33% - 96 continuous/24 intermittent11% - after infusion complete

Swab Caps to Each Port 100% - Yes

Changing Swab Caps 44% - every time used22% - as needed34% - every 24 hours

Primary Solution 100% - change every 24 hours

Primary Solution Label 100% - said blue label22% - admitted to forgetting to label every time67% - answered yes that they use them every time and a blue label 11% - blue label if it is stocked

+Pre-Data Collection QuestionnairePrimary Tubing Label 34% - admitted to forgetting; knew white for

96 hrs. and pink for 24 hrs. 22% - white for 96 hrs. & pink for 24 hrs.44% - white

Secondary Tubing Label 22% - admitted to forgetting; answered pink 22% - admitted to forgetting; use pink for 24 hour intermittent and white for 96 hour continuous56% - pink and change every 24 hours

Labeling Improvement 44% - “none”11% - “none, but needs stocked”11% - “check daily”33% - “needs to be stocked”

Suggestions 44% - “N/A” or “none”56% - “stock labels”

+IV Tubing Data: 6 North TTH

11%

89%

IV Catheter Dressing Labeling on 6N

Labeled CorrectlyLabeled Incorrectly

+IV Tubing Data: 6 North TTH

38%

63%

Primary Tubing Labeling on 6N

Labeled CorrectlyLabeled Incorrectly

+IV Tubing Data: 6 North TTH

17%

83%

Secondary Tubing Labeling on 6N

Labeled CorrectlyLabeled Incorrectly

+IV Tubing Data: 6 North TTH

56%44%

Fluid Bag Labeling on 6N

Labeled CorrectlyLabeled Incorrectly

+IV Tubing Data: 6 Northeast TTH

13%

88%

IV Catheter Dressing Labeling on 6NE

Labeled CorrectlyLabeled Incorrectly

+IV Tubing Data: 6 Northeast TTH

88%

13%

Primary Tubing Labeling on 6NE

Labeled CorrectlyLabeled Incorrectly

+IV Tubing Data: 6 Northeast TTH

100%

Secondary Tubing Labeling on 6NE

Labeled CorrectlyLabeled Incorrectly

+IV Tubing Data: 6 Northeast TTH

75%

25%

Fluid Bag Labeling on 6NE

Labeled CorrectlyLabeled Incorrectly

+IV Tubing Data: 6 South TTH

44%56%

IV Catheter Dressing Labeling on 6S

Labeled CorrectlyLabeled Incorrectly

+IV Tubing Data: 6 South TTH

36%

64%

Primary Tubing Labeling on 6S

Labeled CorrectlyLabeled Incorrectly

+IV Tubing Data: 6 South TTH

71%

29%

Secondary Tubing Labeling on 6S

Labeled Correctly Labeled Incorrectly

+IV Tubing Data: 6 South TTH

19%

81%

Fluid Bag Labeling on 6S

Labeled Correctly Labeled Incorrectly

+Dressing Label Compliance

North Wing Northeast Wing

South Wing Entire 6th Floor

0%5%

10%15%20%25%30%35%40%45%

11% 12%

44%

27%

Dressing Label Compliance

+Primary Tubing Label Compliance

North Wing Northeast Wing

South Wing Entire 6th Floor

0%10%20%30%40%50%60%70%80%90%

37%

87%

44%50%

Primary Tubing Label Compliance

+Secondary Tubing Label Compliance

North Wing Northeast Wing

South Wing Entire 6th Floor

0%10%20%30%40%50%60%70%80%90%

100%

17%

100%

71%

53%

Secondary Tubing Label Compliance

+IV Fluid Bag Compliance

North Wing Northeast Wing

South Wing Entire 6th Floor

0%10%20%30%40%50%60%70%80%

56%

75%

19%

42%

IV Bag Label Compliance

+Follow-Up Questionnaire

Reminder Sign11%

Central Supply Labeling

34%Labels Next to

Bag33%

Labels at Sta-tion11%

Other11%

Question 1: “What would help you to remember to label your IV solution bag?”

+Follow-Up Questionnaire

Question 2: “What would help you to remember to label your IV tubing?”

Reminder sign22%

Sticker on pump22%

Sticker on tubing44%

Other11%

+Follow-Up Questionnaire

Caps Container

67%Flushes w/Cap Only11%

IV Bundle Kit22%

Question 3: “What would help you to remember to place swab caps on each port?”

+Follow-Up Questionnaire

Yes67%

No33%

Question 4: “Would an IV tubing/infusion bundle kit be more beneficial to facilitating care in a more timely fashion?”

+Follow-Up Questionnaire

Yes33%

No67%

Question 5: “Are there any other physical barriers besides not having the labels stocked on the floor that prevent you from labeling your solution/ tubing?”

+Follow-Up Questionnaire

Safety

Pain A

ssess

ment

Blood Sugar

60 seconds

Inta

ke and Outp

ut

Daily w

eights

Hourly R

ounding

IV tu

bing

0

1

2

3

4

5

6

7

8

97.66

5.88 5.554.88

4.333.55

2.77

1.33

Question 6: “Rate these tasks by importance.”Options

Mean rank

+Root Cause Analysis

Nursing Noncompliance Lack of Supplies on the Units Low Nursing Priority Lack of Auditing

+Financial Impact from Primary IV Sets

Cost of Primary Tubing is $8.37 per Tubing Set (based on MedShop.com)

15 total primary tubing sets in noncompliance on 6th floor 30 total sets of primary tubing at $8.37/set, on the floor

costing $251.10 15 additional sets of primary tubing at $8.37/set, to

replace noncompliant tubing costing $125.55 Total cost of primary tubing per day on the 6th floor is

$376.65 With 100% compliance, tubing would cost $91,651.50 in

one year With the Primary Tubing Compliance at 50%, over one

year, the additional cost to replace noncompliant tubing is $45,825.75

+Financial Impact from Secondary IV Sets

Cost of Secondary Tubing is $2.13 per Tubing Set (based on LetMedco.com)

7 total secondary tubing sets in noncompliance on 6th floor 15 total sets of secondary tubing at $2.13/set, on the

floor costing $31.95 7 additional sets of secondary tubing at $2.13/set, to

replace noncompliant tubing costing $14.91 Total cost of secondary tubing per day on the 6th floor is

$46.86 With 100% compliance, tubing would cost $11,661.75 in

one year With the Secondary Tubing Compliance at 53%, over one

year, the additional cost to replace noncompliant tubing is $5,442.15

+Financial Impact for Potential CLABSI’s

$16,350/CLABSI based on research (Ramirez, 2012) For example, the floor has one CLABSI event in a given

calendar year Cost: $16,350.00 for CLABSI event Additional cost: $45,825.75 for noncompliant primary

tubing Additional cost: $5,442.15 for noncompliant secondary

tubing Potential additional cost from noncompliant IV tubing

sets: $67,617.90 for one CLABSI event and noncompliant IV tubing in one calendar year

+National QI Initiatives Five Evidence Based Steps to Prevent CLABSI

Use appropriate hand hygiene Use chlorhexidine for skin preparation Use full-barrier precaution during central venous catheter insertion Avoid using the femoral vein for catheters in adult patients Remove unnecessary catheters

IV Tubing Recommendation for use Replace tubing used to infuse blood or blood products or lipid-

containing solutions at least every 24 hours Replace tubing used to infuse Propofol every 6-12 hours Replace tubing used to infuse solutions containing dextrose and

amino acids without lipids every 72 hours Replace other tubing every 96 hours

Agency for Healthcare Research & Quality, 2013

+Central Line-Associated Bloodstream Infections Among Critically Ill Patients in the Era of Bundle Care Level 4 - Systematic Review and Cohort Study Limitations (Lin K-Y, et. al., 2015)

These findings were different from the NHSN report and other studies

Considerable overlap between the definition of CLABSI and CRBSI They assume that diagnosis of CLABSI often overestimates the

true number of infections that are attributable to central lines Sample size was limited to a single medical center The definition of CLABSI had changed since 2011 Compliance rate of intervention bundle and checklist was nearly

95%, so the findings may not be comparable to those in intuitions whose compliance rates are substantially different from theirs

+Disinfection of Needleless Hubs: Clinical Evidence Systematic Review Level 1 - Systematic Review of Current Literature Limitations (Flynn and Moureau, 2015)

Studies spanned from 1977-2014 Lack of high quality research Absence of high quality RCT Low level evidence base Lack of randomization – unintentional bias

+Swab Cap Articles “Reducing Bloodstream

Infection Risk in Central and Peripheral Intravenous Lines: Initial Data on Passive Intravenous Connector Disinfection” (DeVries et. al., 2014)

Provides information on Bloodstream Infection prevention with the use of swabcaps on all ports as an intervention. As a result the BSI’s decreased in both central and peripheral lines overall by 45%. This was an observational study.

“Impact of universal disinfectant cap implementation on central line- associated bloodstream infections” (Merrill, K. C. et. al., 2014)

Provides information on central line associated blood stream infections resulting in length of stay, cost, patient morbidity and mortality. This quasi- experimental study determined the placement of disinfectant caps decreased infection rates by >40% and saved approximately $300,000 per year. Limitations of this study include ongoing education to nurses on the prevention of CLABSI while the study was in progress.

+Change IV Tubing Less Often Not backed by evidence

Cost Australia $1 billion each year Free up nurses time for patient care

Save 2 million nursing hours 3 year study of 6,500 patients

Comparing 4 and 7 day tubing changes Largest National Health and Medical Research Council

funded nursing project and research grants awarded

Australian Nursing Journal, 2016

+Change Theory

Kurt Lewin’s Force-Field Model (Finkelman, 2016) Improves the Change Process Clarifies Balance of Power Identifies the Key Players Identifies Opponents and Allies Identifies How to Influence Each Other

+Recommendations

Reinforce 60 second assessment

Ensure adequate stock is ordered

Notify immediately if labels are not stocked

Prompt when scanning IV fluids

Care alert notification

Verbalize IV bag and label changes in bedside report (IHI, 2016)

Morning huddle discussion (IHI, 2016)

Nurse leaders audit unit (O’Grady, 2011)

Mandatory in-service on policy and procedure (O’Grady, 2011)

Additional research to support need to change tubing every 24-96 hours (O’ Grady, 2011)

Internal Evidence & Clinical Expertise Evidence Based

+Hypothesis

Using Lewin’s Change Theory and our recommendations, the unit will maintain their low CLABSI rate and ensure patient safety, as well as save their unit money by wasting less equipment through compliant labeling of solutions and tubing and keeping accurate records through charting.

+Resources(2011). Change IV tubing less often. Australian Nursing Journal, 19(4), 22-221p

(2013). Agency for Healthcare Research & Quality. Retrieved April 16, 2016, from http://www.ahrq.gov/professionals/education/curriculum-tools/clabsitools/clabsitoolsap3.html

DeVries, M., Mancos, P. S., & Valentine, M. J. (2014). Reducing Bloodstream Infection Risk in Central and Peripheral Intravenous Lines: Initial Data on Passive Intravenous Connector Disinfection. Journal Of The Association For Vascular Access, 19(2), 87-93 7p. doi:10.1016/j.java.2014.02.002

Finkelman, A. (2016). Leadership and management for nurses: core competencies for quality care. 3rd Ed. Pearson Education, Inc: New York.

Flynn, J. & Moureau, N. L. (2015). Disinfection of needless hubs: clinical evidence systematic review. Nursing Research and Practice 2015,796762.doi:10.1155/2015/796762

Lin K-Y, et. Al. (2015). Central line-associated bloodstream infections among critically-ill patients in the era of bundle care, Journal of Microbiology, Immunology and Infection. http://dx.doi.ord/10.1016/j.jmii.2015.07.001

Merrill, K. C., Sumner, S., Linford, L., Taylor, C., & Macintosh, C. (2014). Impact of universal disinfectant cap implementation on central line- associated bloodstream infections. American Journal of Infection Control, 42, 1274-1277.

O'Grady, N. P., Alexander, M., Burns, L. A., Dellinger, E. P., Garland, J., Heard, S. O., . . . Saint, S. (2011). Guidelines for the prevention of intravascular catheter related infections. American Journal of Infection Control, 39(4), S1-S26.

Ramirez, C., Lee, A. M., & Welch, K. (2012). Central Venous Catheter Protective Connector Caps Reduce Intraluminal Catheter-Related Infection. Journal Of The Association For Vascular Access, 17(4), 210-213 4p. doi:10.1016/j.java.2012.10.00

Relay Safety Reports at Shift Changes. (n.d.). Retrieved April 20, 2016, from Institute for Health Care Improvement website: http://www.ihi.org/resources/pages/changes/developacultureofsafety.aspx

+Questions?

+ Thank You For Your Time & Attendance