Now that you’ve carefully planned your patient safety and quality improvement project, the real work can begin. This course will introduce students to the unique challenges encountered when implementing, maintaining, and expanding a patient safety and quality initiative. Students will learn to apply lessons learned from the 4 E model and TRiP into developing specific aims for their QI project. Additionally, students will develop a plan to address the adaptive and technical challenges in their projects including whether their initiative needs to be submitted to an Institutional Review Board (IRB). Finally, students will develop plans to grow their local QI project into a system-wide project.
Maintenance Focused
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From the course by Johns Hopkins University
Implementing a Patient Safety or Quality Improvement Project (Patient Safety V)
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From the lesson
case story: building momentum
In this module we will introduce you to a quality improvement project that was built following successful implementation of the Central Line Associated Blood Stream Infection program developed and implemented at Johns Hopkins. The learner will see that building momentum from a previous success is possible using proven quality Improvement bundles and the results of the adaptive work using the Comprehensive Unit-Based Safety Program to improve unit based culture. The learner will understand the rigorous preparation and tool development needed to support clinicians when you move a program to another venue. They will develop an understanding of the Collaborative approach that includes on-boarding or immersion into the content, allowing preparation time and providing both content and coaching call that support the teams implementing the initiative. Learners will see how to utilize the CUSP program to meet adaptive challenges. Learners will also see the tool-kit that was developed including the documents necessary to provide support for front line clinicians that we believed necessary for a successful quality improvement and patient safety program.
Meet the Instructors
David Thompson DNSc, MS, RNAssociate Professor
Armstrong Institute for Patient Safety and Quality/Anesthesiology and Critical Care Medicine
So next, we're going to talk about maintenance focus.
I think when we got started with the whole thing,
we were looking at line insertion.
But what we also learned was that patients that were
developing clubb cysts despite our work at day three,
or day four, and greater.
It was definitely due to how we maintain the line.
And I think it's really important that we address that in the collaborative as well.
So, again, we've identified that anything
that happens within the first 48 hours is related to insertion,
but anything that happens after 48 hours really has to
do with the maintenance problems that we have with central lines that I've talked about.
So one of the first things is
the maintenance bundle components
were general care and maintenance that we wanted to look at.
We wanted to remove the lines as soon as possible,
which was a new way of thinking for most of the ICU providers.
We always wanted to have access just in
case something was going to happen with our patients.
The other thing was that we wanted to minimize central line entries,
which means we did not want to access
the central line to draw blood cultures and to draw labs.
And it was best if those were needed that we
went ahead and did a stick because we had to talk to the patients,
educate them to let them know that the more time we accessed the central line,
the greater the opportunity for a contamination.
Fourth was, of course,
the procedure for all entries.
So when they did occur, and again,
this was a lot more in pediatrics than in the adult,
that they were done with cap and tubing, and extensions,
and that they were replaced afterwards,
and that there was a policy and procedure for that just as well.
And then, site care.
So how do you do the dressing change so that it's effective,
and the dressing actually adheres to the patient?
And then, we have the cap change or
the clave change to make sure that that's done on a regular basis.
And as I said earlier,
everything has a shelf life,
and it's the same with the clave,
or the cap, the IV tubing,
the bags, everything, there's no limit.
And how and when we do our tubing changes?
And are they identified as to what day they would expire based on
the 72 to 96 hour of recommendation change by the Center for Disease Control?
So, the general care and maintenance
really should be visually assessed through the transparent dressing,
which is why we like transparent dressings like NCBI C-View, and things like that,
really looking for signs of inflammation and/or complications such as, oozing.
And do not expose or submerge the dressing,
the catheter, or any of the components in water.
So, I always think of the patients who becomes detached from their ventilator,
and the spray goes all over their tubing and their central line,
that really needs to be changed because we have to be really careful of that.
And if we have a patient that's well enough to get up
and walk to the shower or have a bath,
that we have made sure that not only have we covered them in plastic, or saran wrap,
or whatever, but we've also put on some waterproof seal
to make sure that that is not contaminated with the water.
And I think that that's really what's important.
The other thing is just as with insertion,
removing of unnecessary lines.
So that's one of our pieces of evidence that goes for both.
And we assess the need on a continual basis.
And again, one of the things that we had to do
was give a trigger to the frontline providers.
And we developed the daily goals for them that asks everyday,
"Do you still need your line?"
Which is supposed to spark a conversation between the physicians and nurses.
Do I need the line for volume?
Do I need the line for antibiotics?
Is there something else that I can do?
Because we want that line out as quickly as possible.
If they need something,
we can perhaps put in a preferral line.
Decrease central line entries.
And again, this really taught us a lot about consolidating our blood draw.
So we wanted to draw blood as infrequently as possible.
More often, we would prefer to do a stick rather than a blood draw.
But for many of the pediatric units,
the pediatrician said," We would be hard-pressed to
get people to stick their children for a blood draw."
So, this was a lot of work for the providers
because they had to identify what was absolutely necessary.
And, of course, the more acute the child,
the greater the risk of needing more blood draws than before.
We also really wanted to focus
on getting people to not use the central line as a way to get a blood culture.
It's often contaminated or colonized,
and that really is not what the CDC says.
It says, "Two peripheral sticks within 24 hours."
So, another piece that took a little while to get implemented,
but definitely was well worth the work.
The next thing was develop and educate our staff for entries into the catheter.
And these included hand hygiene, non-sterile gloves.
If you're doing something, disinfect.
And we could do that two different ways.
We had an alcohol with a 15 second rub and 15 second dry, or chlorhexidine,
and we scrubbed with 30 seconds,
and we allowed that to dry up to 60 seconds if we were
going to access one of those claves to draw blood from.
In some of the units,
they found that the lab results were different.
So, before they actually drew the lab,
they changed the clave in order to make sure that they had an accurate blood draw.
However, that was not supported by
the Center for Disease Control Guidelines or the CH guidelines,
and that was something that we had to work within with.
Really, the issue turned out to be leftover blood that was in the clave
that should have been removed a little bit more
frequently any time you have contaminated that clave.
And then, I think when we were doing this first, we had said,
scrub like you were squeezing an orange to take
the clave or the cap and do 10 times with the alcohol prep.
What we did here using the ultraviolet light,
we looked at the different scrubs that we did.
So, as you can see,
and we always say this,
what would you want when you're looking at patient safety?
What would you what happen to your loved one?
So, is it your grandmother, is it your wife,
whoever, which one would you want them to have?
So it was really a 15 second prep that we move to,
and that's what we recommended here on out.
And depending on what unit you were,
so some units used the alcohol,
which worked very well,
other units used the chlorhexidine.
Some of them complained that the chlorhexidine made the cap sticky,
it sticked to the bedlinen,
and they ultimately went back to the alcohol prep.
But you definitely had your choice.
Procedures for catheter site care,
I think what was really interesting is,
when we set out to make a video for one of the sites,
they wanted their own video.
We had several different nurses with a lot of experience,
each one of them came in and did it a different way.
So what we did was,
we had an expert demonstrate to the frontline providers how they were going
to do the dressing change based on what the evidence said was level 1A,
which meant it was from a sample that was powered high
enough and strong enough to say that this was
generalizable and this is how it should be done.
So, any dressing, again,
that was damp, loose,
or soiled, needed to come off,
and not sometime that day,
but as soon as possible.
It really needed to be changed quickly.
Transparent dressings every seven days.
And if you're using a gauze dressing because your patient was oozing,
those get changed every 48 hours.
So the dressing change.
We first start with hand hygiene, of course,
washing the hands, most important thing we do before we enter the room.
The next thing that we do,
get our designated kit or we keep all of
our designated supplies in the same area so that we have access to them,
and we aren't running around,
and we have the opportunity to miss one of the steps that we have.
Assess the exit site or the insertion site,
we're looking for either edema,
inflammation, puss, we're looking for bleeding,
anything that we really don't want to see,
and we document that very thoroughly.
We don our sterile gloves.
We put on a mask for all providers and anybody that's there for assistance.
So if you're in a teaching hospital,
this is a great time to teach your nurses and your techs using proper technique.
And we recommend this.
Hands-on has always been better than just talking somebody through
it or giving them a stepwise progression of how to do the dressing change.
And for the patients face,
you shield them the ETT, endotracheal tube,
et cetera with a mask or drape to make sure that there's no risk of
contamination of the site if the endotracheal tube does become disconnected.
And then, the 30 second chlorhexidine wash. Again,
this is very different for a lot of the staff.
This was not from inner to outer.
This was a scrubbing motion.
And we found that even though the evidence had often said a minute,
the representative said that it often took two minutes to dry.
And then even then,
it might be a little bit sticky.
So we were looking at two minutes for it to dry.
And these were based on
individual guidelines for each one of the different sites for their preferences.
The next step was no ointments.
Depending on how many years you've been in practice,
there was a time when we would have put betadine ointment at the site.
There was no ointment use for any of the central lines
with the exception of some dialysis catheters.
The other thing was is that,
we wanted that sterile transparent dressing,
and we wanted that to stay on as long as possible.
So again, this had to do with site selection so
for our male patients maybe an IJ wasn't as good.
We also tried lots of different products to see
which ones work the best and what we found was a two piece transparent dressing.
One that covered the dressing,
and then another one that held the tubing in place.
We also used different supplements to make the skin more adherent to the dressing.
So tincture ben and those kind of things and skin preps which we'll
use a lot and recommend those for our frontline providers.
The other thing was gauze dressings.
Remember if your patient is oozing,
changed every two days,
or until they can have a clear dressing.
And PRN, if it's saturated or loose.
So if your patients got coagulate apathy and they're bleeding a lot,
it's going to be changed a lot more than every two days,
because you want to make sure that it's
dry and intact and not a place for organisms to grow.
And then labeling and documentation.
I think that this is what's really important.
And there's nothing worse than coming in to find
that something is not labeled so that you don't know how old it is.
And if it's intact,
are you taking down addressing it's still viable?
Then we moved on to cap change frequency.
As we finished up our central line,
we were checking to make sure that both our caps were in place,
that they had no blood in them,
and the rule of thumb were that caps were changed
every 24 hours if they received a blood product,
and or propofol, and caps were also used
for propofol infusion and they were changed every 6 to 12 hours with the tubing.
Infact tubing that had propofol in it was
supposed to stay for 6 to 12 hours and most sites show six hours.
Based on those guidelines,
caps not exposed to blood products,
or anything other than IV fluids,
or antibiotics could stay as many as 72 and sometimes up to 96 hours.
But for most of our patients we had said 72 hours for this program.
And then lastly we wanted to get rid of anything that had been contaminated.
So if we had soiled anything,
if we saw blood that was left over in the tubing,
that was another opportunity to change the tubing.
We didn't want there to be anything that would
be a great opportunity for bacterial growth to occur.
The procedure was simple for the cap change,
a mask for the nurse,
optional for the patient, sterile gloves,
and then we have the kit that we used.
I think what's really important here was that we decided that we would
do this with our central line tubing changes,
which made it very easy to do.
The other thing that we wanted to do and as you can see here,
was to make sure just like the dressing change that we had documented when it was done.
So, if you had an electronic medical record,
or if you had a paper record that was great.
Something visual for the nurse or the tech to see,
so you see the different colors.
So if that was on the IV tubing and it said Monday,
you knew that that was the last time it was done and that would let you
know within 72 hours when the next time will change.
Some units just went to twice.
They used the beige and blue.
One meant changed every Monday,
one meant to be changed every Thursday,
so that we always made sure that
the cap change and the tubing changes occured at the same time,
the same date, all of the time as long as the patient had the central line.
And then finally, on cap change procedure,
we have to make sure before we remove the old cap that we disinfect the connected cap.
And how we did that was with an alcohol prep,
they found that cohexing wasn't any more helpful,
but using the alcohol prep and
scrubbing it for a good 15 seconds just like we did the cap,
so that we make sure that there's no contaminant before we separate.
And the reason we do that is to make sure that
potentially any bacteria or colonization that are on the tube,
doesn't go within the tube when we go ahead and make that change.
Tubing care. As I said,
we had looked at blood products as every 24 hours.
That evidence again by several studies the 1B level, and for Lipids.
So for patients that are on total parenteral nutrition,
with lipids that was also a 1B recommendation every 24 hours.
And that was usually in the night shift,
and that was propofol every 6 to 12 hours and most of the units chose every six hours,
except in some of the recovery areas that we looked at.
And that was on 1A recommendation.
Further, for any continuous IV administration we were looking at as many as 96 hours,
and as short as 72 hours,
and not longer than seven days for our patients.
What we decided ultimately was that 96 hours was going to be our cut off.
So 96 hours is what we chose for adults, pediatrics chose 72,
because of the increased access for the central line to draw blood samples from.
And there were no additional information
or formal recommendations for other administration sets like secondary tubing.
So we chose to change secondary tubings the same time we changed our primary tubings,
whether they be for continuous IV at 96 for adults or 72 for pediatrics.
The procedure, very simple again we start with hand hygiene.
Always wash the hands.
Non sterile gloves to begin to pull that apart if connecting the tubing,
to the hub of the catheter sterile gloves because you're taking someplace
that really you've already decontaminated with your alcohol scrub,
and you want to make sure that you're introducing no bacteria.
So sterile gloves when that's the case.
The next is scrubbing the tubing site connection prior to removing the old tubing.
Again, we want to reduce the potential for causing bacteria to go into the source.
And then clearly document that this is actually occurred.
And again we found it simpler to do the tubing and the cap change at the same time,
so that they were both put up at the same time,
and we had those visual reminders of the colors.
And this is really what we did for the nurses and the technicians,
was we developed this form which was a step by
step process of what should be done for the patients when they were changed.
And these could be kept as part of the charts for us to later audit,
to make sure that the front line personnel were compliant with
the maintenance that was required to
reduce central line associated bloodstream infections.
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