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5. As of January 1, 2010, the critical access hospital educates health care workers who are involved in these procedures about health care­associated infections, central line­associated bloodstream infections, and the importance of prevention. Education occurs upon hire, annually thereafter, and when involvement in these procedures is added to an individual's job responsibilities.

Supplement Article: SHEA/IDSA Practice Recommendation

I. Basic practices for prevention and monitoring of CLABSI: recommended for all acute care hospitals A. Before insertion 1. Educate healthcare personnel involved in the insertion, care, and maintenance of CVCs about CLABSI prevention a. Include the indications for catheter use, appropriate insertion and maintenance, the risk of CLABSI, and general infection prevention strategies. b. Ensure that all healthcare personnel involved in catheter insertion and maintenance complete an educational program regarding basic practices to prevent CLABSI before performing these duties. c. Periodically assess healthcare personnel knowledge of and adherence to preventive measures. d. Ensure that any healthcare professional who inserts a CVC undergoes a credentialing process (as established by the individual healthcare institution) to ensure their competency before they independently insert a CVC. Page S23, S24

Moving toward Compliance

Document competencies for all staff. One strategy would include an education program with a "post test" to determine competence. (SHEA-Pg. S23)

*Insertion competencies on file for all inserters. Most facilities are also developing a policy for evaluation of continued competence. Methods utilized include documentation of a specific number of insertions and/or completion of another competency form.

Things to consider: Do your contracted PICC nurses have documentation that they are following your facilities standard of care? Has a competency been completed within your facility? . Do the physicians have documented competency? Any facility's Medical Affairs department should be able to answer the question regarding the credentialing for the MDs inserting any type of Central lines. PICC Educational Flyer Ensure that your booklet/education piece includes information about CL infections and methods of prevention. Discuss with patients prior to procedure. Consider carrying a PICC sample with you and demonstrate a 15 second "scrub the hub". Create a binder containing guidelines and documents. Include the following: . CDC MMWR SHEA/IDSA Practice Recommendation (Pg S23-"These guidelines should be easily

6.As of January 1, 2010, prior to insertion of a central venous catheter, the critical access hospital educates patients and, as needed, their families about central line­ associated bloodstream infection prevention. 7.As of January 1, 2010, the critical access hospital implements policies and practices aimed at reducing the risk of central line­associated bloodstream infections that meet regulatory requirements and are aligned with

Section 3: strategies to prevent clabsi 1. Existing guidelines and recommendations a. Several governmental, public health, and professional organizations have published evidence-based guidelines and/or implementation aids regarding the prevention of CLABSI, including the following: i. The Healthcare Infection Control Practices Advisory

evidence-based standards (for example, the Centers for Disease Control and Prevention (CDC) and/or professional organization guidelines). *Page 15 Note 1- This requirement covers short and long term central venous catheters and peripherally inserted central catheter (PICC) lines.

Committee ii. The Institute for Healthcare Improvement18 and iii. Making Health Care Safer, Agency for Healthcare Research and Quality b. The recommendations in this document focus on central venous catheters (CVCs) unless noted otherwise. i. These recommendations are not stratified on the basis of the type of catheter (eg, tunneled, implanted, cuffed, noncuffed catheter, or dialysis catheter). ii. These recommendations may not be applicable for prevention of bloodstream infections with other intravascular devices. Pg S23 Section 5: performance measures 1. Compliance with CVC insertion guidelines as documented on an insertion checklist a. Assess compliance with the checklist in all hospital settings where CVCs are inserted (eg, ICUs, emergency department, operating room, radiology, and general wards) and assign healthcare personnel familiar with catheter care to this task. i. For an example of a central catheter checklist, see the Institute for Healthcare Improvement Web site.

accessible". JC 2010 NPSGs INS Standards of Care IHI definition of Max Barrier

8.As of January 1, 2010, the critical access hospital conducts periodic risk assessments for surgical site infections, measures central line­associated bloodstream infection rates, monitors compliance with best practices or evidence-based guidelines, and evaluates the effectiveness of prevention efforts.

Insertion Checklist- See attached . Random Audits of Checklist and Observe Procedures ( Not Just PICC Teams but anyone who Puts in a Central Line.) Could a member of the PICC team be responsible for this? Focus on Hand Hygiene and Max Barrier. Does the Max Barrier cover Head to Toe (See Attached IHI Recommendations for Max Barrier) . Possibly add these Three interventions on the Checklist to the Data Tracking that the Hospital records Does the Hospital have a good tracking system in place. Most PICC Teams have something. Could this be rolled out Hospital Wide ­ Could the PICC Team be responsible for this?

b. Measure the percentage of CVC insertion procedures in which compliance with appropriate hand hygiene, use of maximal sterile barrier precautions, and use of chlorhexidinebased cutaneous antisepsis of the insertion site is documented. i. Numerator: number of CVC insertions that have documented the use of all 3 interventions (hand hygiene, maximal barrier precautions, and chlorhexidine-based cutaneous antiseptic use) performed at the time of CVC insertion. ii. Denominator: number of all CVC insertions. iii. Multiply by 100 so that the measure is expressed

as a percentage. Pg S27 5. Perform surveillance for CLABSI a. Measure unit-specific incidence of CLABSI (CLABSIs per 1,000 catheter-days) and report the data on a regular basis to the units, physician and nursing leadership, and hospital administrators overseeing the units. b. Compare CLABSI incidence with historical data for individual units and with national rates (ie, data from the National Healthcare Safety Network56). c. CLABSI has been documented in large numbers of non-ICU patients with CVCs. Surveillance for CLABSI in these settings requires additional resources. Pg S25 Section 3: strategies to prevent clabsiB. At insertion 1. Use a catheter checklist to ensure adherence to infection prevention practices at the time of CVC insertion (B-II).23,29 a. Use a checklist to ensure and document compliance with aseptic technique. i. CVC insertion should be observed by a nurse, physician, or other healthcare personnel who has received appropriate education (see above), to ensure that aseptic technique is maintained. b. These healthcare personnel should be empowered to stop the procedure if breaches in aseptic technique are observed. Pg S24 I. Basic practices for prevention and monitoring of CLABSI: recommended for all acute care hospitals 2. Perform hand hygiene before catheter insertion or manipulation a. Use an alcohol-based waterless product or antiseptic soap and water. i. Use of gloves does not obviate hand hygiene. Pg S24 I. Basic practices for prevention and monitoring of CLABSI: recommended for all acute care hospitals 3. Avoid using the femoral vein for central venous access in adult patients

9.As of January 1, 2010, the critical access hospital provides central line­ associated bloodstream infections rate data and prevention outcome measures to key stakeholders including leaders, licensed independent practitioners, nursing staff, and other clinicians.

Track all CLABSI (on all units...not just ICUrefer to SHEA Pg S22 1.1.B) Are PICC Teams responsible for Care & Maintenance of the Lines? Who DC's? Who tracks Infections?

Track PICC lines separately from other Central lines. Track individual units. Separate tracking allows for targeted education and identification of opportunities for improvement. SEE IHI Checklist Requires a Second Person to complete the Checklist and requires 2 signatures. This person will be required to stay in the room for the entire sterile process, from handwashing to placement of the sterile dressing. Perhaps a Tech who is Trained in aseptic Technique? The tech can be used to set up the room while the RN checks the chart and then they might clean the room while the RN does the charting.

10. As of January 1, 2010, use a catheter checklist and a standardized protocol for central venous catheter insertion.

11. As of January 1, 2010, perform hand hygiene prior to catheter insertion or manipulation.

Ensure that handwashing is included on your checklist and your protocol for hub and injection port disinfection (described later in this document).

12. As of January 1, 2010, for adult patients, do not insert catheters into the femoral vein unless other sites are unavailable.

Reduce the Use of FemoralsDocument that other sites were not available ­ Is there documentation that a PICC could not

a. Use of the femoral access site is associated with greater risk of infection and deep venous thrombosis in adults. i. Increased risk of infection with femoral catheters may be limited to overweight adult patients with a body mass index higher than ii. Femoral vein catheterization can be done without general anesthesia in children and has not been associated with an increased risk of infection in children. b. Several nonrandomized studies show that the subclavian vein site is associated with a lower risk of CLABSI than is the internal jugular vein, but the risks and benefits in light of potential infectious and noninfectious complications must be considered on an individual basis when determining which insertion site to use. c. The use of peripherally inserted CVCs is not an evidencebased strategy to reduce the risk of CLABSI. i. The risk of infection with peripherally inserted CVCs in ICU patients approaches that with CVCs placed in the subclavian or internal jugular veins. Pg S24 PERFORMANCE MEASURES 4. Compliance with avoiding the femoral vein site for CVC insertion in adult patients a. Perform point prevalence surveys or use information collected as part of the central line insertion checklist to determine the percentage of patients whose CVCs are in the femoral vein versus the subclavian or internal jugular veins. b. Calculate the percentage of patients with a femoral vein catheter. i. Numerator: number of patients with a CVC in the femoral vein. ii. Denominator: total number of patients with a CVC in unit population being assessed. iii. Multiply by 100 so that the measure is expressed as a percentage. Pg S27 Section 3: strategies to prevent clabsi D 4. Use an all-inclusive catheter cart or kit. a. A catheter cart or kit that contains all necessary components

be inserted or that the IR dept tried to get different access and failed?

13. As of January 1, 2010, use a standardized supply cart or kit that is all inclusive for the insertion of

Full Kits with Integrated Max Barrier?

central venous catheters.

for aseptic catheter insertion is to be available and easily accessible in all units where CVCs are inserted. Pg S24 I.

14. As of January 1, 2010, use a standardized protocol for maximum sterile barrier precautions during central venous catheter insertion.

Basic practices for prevention and monitoring of CLABSI: recommended for all acute care hospitals

IHI definition of Max Barrier: "For the operator placing the central line and for those assisting in the procedure, maximal barrier precautions means strict compliance with handwashing, wearing a cap, mask, sterile gown and gloves. The cap should cover all hair and the mask should cover the nose and mouth tightly. These precautions are the same as for any other surgical procedure that carries a risk of infection. For the patient, maximal barrier precautions means covering the patient from head to toe with a sterile drape with a small opening for the site of insertion." . Chlorhexidine included in full kits with and without integrated Max Barrier.

At insertion 5. Use maximal sterile barrier precautions during CVC insertion a. Use maximal sterile barrier precautions. i. A mask, cap, sterile gown, and sterile gloves are to be worn by all healthcare personnel involved in the catheter insertion procedure. ii. The patient is to be covered with a large sterile drape during catheter insertion. b. These measures must also be followed when exchanging a catheter over a guidewire. Pg S24

15.As of January 1, 2010, use a chlorhexidine-based antiseptic for skin preparation during central venous catheter insertion in patients over two months of age, unless contraindicated.

I. Basic practices for prevention and monitoring of CLABSI: recommended for all acute care hospitals A. Before insertion 6. Use a chlorhexidine-based antiseptic for skin preparation in patients older than 2 months of age a. Before catheter insertion, apply an alcoholic chlorhexidine solution containing a concentration of chlorhexidine gluconate greater than 0.5% to the insertion site. i. The antiseptic solution must be allowed to dry before making the skin puncture. ii. Chlorhexidine products are not approved by the US Food and Drug Administration for children younger than 2 months of age; povidone-iodine can be used for children in this age group. Pg S24 I. Basic practices for prevention and monitoring of CLABSI: recommended for all acute care hospitals C. After insertion 1. Disinfect catheter hubs, needleless connectors, and injection ports before accessing the catheter a. Before accessing catheter hubs or injection ports, clean them with an alcoholic chlorhexidine preparation or

16. As of January 1, 2010, use a standardized protocol to disinfect catheter hubs and injection ports before accessing the ports.

Create a Procedure. It needs to include handwashing as first step.

70% alcohol to reduce contamination. Pg S25 17. As of January 1, 2010, evaluate all central venous catheters routinely and remove nonessential catheters. I. Basic practices for prevention and monitoring of CLABSI: recommended for all acute care hospitals C. After insertion 2. Remove nonessential catheters a. Assess the need for continued intravascular access on a daily basis during multidisciplinary rounds. Remove catheters not required for patient care. Pg S25 Sources: The Joint Commission Guidelines 2010 Accreditation Program: Critical Access Hospital National Patient Safety Goals Pre-Publication Version © 2008 The Joint Commission on Accreditation of Healthcare Organizations Strategies to Prevent Central Line­Associated Bloodstream Infections in Acute Care Hospitals : S22 infection control and hospital epidemiology october 2008, vol. 29, supplement 1 IHI Website: www.IHI.org CDC Guidelines: Guidelines for the Prevention of Intravascular Catheter-Related Infections; The material in this report was prepared for publication by the National Center for Infectious Diseases, James M. Hughes, M.D., Director; Division of Healthcare Quality Promotion, Steven L. Solomon, M.D., Acting Director Document this "Daily review of Lines" to show compliance.

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