NewYork-Presbyterian

Morgan Stanley Children’s Hospital

Columbia University Medical Center
“Clean It Like You Mean It!”
A 3-ICU Collaboration on Central Line-Associated
Bloodstream Infection Prevention

Svetlana Streltsova
Clinical Nurse III/RN, MSN, CCRN
Kathy Lee
Clinical Nurse II/RN, BSN, CCRN
Regan Morimoto
Clinical Nurse II/RN, CCRN
Anisha Soman
Clinical Nurse I/RN, MSN
Brian Harding (Sep 2013-Jul 2014)
Clinical Nurse I/RN, BSN, CCRN
NewYork-Presbyterian
Morgan Stanley Children’s Hospital
Columbia University Medical Center
Problem Statement
Do continuous education sessions, central line maintenance
protocol, and weekly surveillance by nurse champions reduce
the incidence of central line-associated bloodstream
infections (CLABSIs) in neonatal, pediatric, and pediatric
cardiac intensive care settings?
Purpose
 The “Clean It Like You Mean It” campaign is a collaborative
initiative between 3 ICUs
 The team uses evidence-based best practices to reduce
CLABSIs
 The purpose of the project is to prepare hospital nurses
with the knowledge, skills, and practice guidelines to
reduce CLABSIs and maintain a low incidence
Goals
 Decrease morbidity associated with CLABSIs in our patient
population
 Improve patient outcomes
 Reinforce and improve best practices
 Decrease overall hospital cost
 Decrease hospital length of stay associated with CLABSI
 Reduce CLABSI incidence by 50% in the 3 units
Goals
 Each unit will remain below NYP’s 2014 standardized
infection ratio (SIR) goal
 The NICU, PICU, and PCICU will each work to remain at or
below the 2013 SIR for their unit
Plan-Do-Study-Act
Methodology

Act Plan

Study Do

Testing Practice Change to Prevent CLABSIs

Plan-Do-Study-Act
Plan
 Logic Model
 Current practice
 Short-term goals
 Long-term goals
 Timeline for intervention implementation
 Surveillance
 Data collection (past, current, and goal)
 Data dissemination
Plan-Do-Study-Act
Do
 “Scrub the Hub” hangtags on all IV poles
 CLABSI prevention posters in all 3 units
 Continued educational strategies:
 Education and practice validation through return demonstration
 Central line maintenance and care
 Dressing changes
 Central Line changes
 Scrubbing the hub
 Chlorhexidine (CHG) baths
 Hand hygiene
Plan-Do-Study-Act
Do
 Use of alcohol-impregnated caps on needleless ports
 Timely removal of central lines when no longer necessary
 CLABSI prevention education in groups and 1-on-1
 Team conducted weekly central line surveillance:
 Assessing sites
 Assessing central lines
 Dressings
 Length of time the central line has been in place
 Real-time maintenance care
CLABSI Carnival Kickoff
January/February 2014
Nurses Week
100+ Nurses Attended (May 2014)
 CLABSI Awareness Prevention Table
 Hands-on demonstration of “Scrub the Hub”
 Trivia questions on central line care
 Review of central line dressings and changes
 Education and use of alcohol-impregnated caps on
needleless ports
 Review of central line change policy and central line care
Plan-Do-Study-Act
Study
 Nurse champion team analyzed how well nurses are
sustaining evidence-based practice in central line care
 Best practice in accessing central lines, dressing changes, use
of alcohol-impregnated caps on needleless ports, and CHG
baths
Plan-Do-Study-Act
Study
 Weekly central line surveillance
 32 weeks of surveillance
 300+ central line assessments
 Central line appearance, needleless caps, central line sites, and
dressings
 CLABSI data/statistics compared to 2013
 # of Assessments

5
0
10
15
20
25
30
Line Saturated

10
with Blood

Caps saturated

5
with Blood

Inappropriate
3

Needleless Caps
Central Line Surveillance
Based on 309 Central Line Assessments

Reddened
2

Central Line Sites

Central Line Sites

17

Leaking/Bleeding

Dressings Loose,
25

Soiled, Overdue
MSCHONY ICU CLABSI Data
2012 Data by ICU Unit (19 CLABSIs)
 The hospital’s overall SIR for 2012 was 0.60
 Infection Protection & Control SIR goal of 0.75

Unit CLABSIs SIR

NICU 6 0.43
PICU 6 0.81
PCICU 7 0.85
MSCHONY ICU CLABSI Data
2013 Data by ICU Unit (17 CLABSIs)
 The hospital’s overall SIR for 2013 was 0.58
 IP&C SIR goal of 0.65

Unit CLABSIs SIR CL-Days

NICU 7 0.43 7,430
PICU 4 0.43 3,072
PCICU 6 0.51 3,572
CLABSI Data With CSI Intervention
CLABSI Data: January 2014 – September 2014
 6 NICU CLABSIs
 5,221 central line days (CL-days)
 September 2013: 4 CLABSIs with 5,396 CL-days
 CLABSI rate 2013: 0.74 per 1,000 CL-days
 CLABSI rate 2014: 1.15 per 1,000 CL-days
Patients by
 55% increase in CLABSI rate CLABSIs
Grams
<= 750 1
751-1,000 1
1,001-1,500 1
1,501-2,500 1
> 2,500 2
MSCHONY 2013 NICU CLABSI Rates
3.0
Rate per 1,000 CL-Days

2.5 2.5

2.0 2

1.5 1.3
1.37 0.93
1.0 1.2
0.9
0.5 0.6 0.6
0.4
0.0
750g 751-1000g 1001-1500 g 1501-2500g >2500 g
MSCHONY NICU National Healthcare Safety Network (NHSN) BENCHMARK
CLABSI Data With CSI Intervention
CLABSI Data: January 2014 – September 2014
 3 PICU CLABSIs
 2,209 CL-days
 September 2013: 4 CLABSIs with 2,306 CL-days
 CLABSI rate 2013: 1.73 per 1,000 CL-days
 CLABSI rate 2014: 1.36 per 1,000 CL-days
 21% decrease in CLABSI rate
CLABSI Data With CSI Intervention
CLABSI Data: January 2014 – September 2014
 0 PCICU CLABSIs
 2,427 CL-days
 September 2013: 4 CLABSIs with 2,722 CL-days
 CLABSI rate 2013: 1.47 per 1,000 CL-days
 CLABSI rate 2014: 0.00 per 1,000 CL-days
 100% decrease in CLABSI rate
 MSCHONY 2013 ICU CLABSI Rates
1.8 1.7
1.6
Rate per 1,000 CL-Days

1.4 1.4
1.4 1.3
1.2
1.0
0.8
0.6
0.4
0.2
0.0
PICU PCICU
2013 NHSN Benchmark
MSCHONY ICU CLABSIs by Unit
8
7 7
7
6 6 6 6
6
5
# CLABSIs

4
4
3
3
2
1
0
0
NICU PICU PCICU
2012 2013 2014
Length of Stay

Unit 2013 2014*

NICU 26.27 25.16
PICU 13.78 8.91
PCICU 18.91 19.23
*January to August data
Fiscal Impact
Projected Project Savings
 Estimated cost per CLABSI infection ranges from $6,000
– $29,000
 CMS average: $12,378
 MSCHONY spent anywhere from $102,000 – $493,000
for ICU CLABSIs in 2013 alone
 At least a 50% reduction will save the hospital as much
as $250,000
Fiscal Impact
Actual Savings
 2013 ICU CLABSIs = 17
 ICU CLABSIs January 2013 – September 2013 = 12
 ICU CLABSIs January 2014 – September 2014 = 9
 As much as $87,000 saved in CLABSI prevention to date
 Using the CMS average of $12,378/CLABSI translates to a
savings of $37,134 (over 9 months)
 Projected annual savings: $99,024 (assuming 9 CLABSIs in 2014)
Cost of a Child Without a CLABSI:

IMMEASURABLE
CSI Budget
 Total dollars spent: $2751.76

9%
25%
12% Posters
Educational Material
Team Shirts
Staff Gift Giveaway
Food
25% Printed Water Bottles
22%

7%
Barriers/Lessons Learned
NICU
 Inadequate number of CLABSI champions identified early
in the initiative to support the volume of patients and
the unit staff
 Need increased education efforts on central line care
and maintenance
 Need increased central venous line (CVL) surveillance in
the unit
Barriers/Lessons Learned
PICU
 Nurse and physician buy-in
 Protected time for education and validation
 Significant percentage of rotating staff (RN/MD)
 Practice deviation from policy
 Barriers encountered with interdisciplinary team
collaboration – situation has improved
Barriers/Lessons Learned
PCICU
 Protected time for education and practice validation,
data collection, and data dissemination
 Barriers encountered with interdisciplinary team
collaboration – situation has improved
 Early staff buy-in, ownership, and practice collaboration
improve outcomes
 Surveillance is KEY to sustaining best practice
Sustainability
 Continue weekly surveillance
 Frequent huddles on infection prevention, best practice,
and barriers to following evidence-based practice
 Protocol changes per evidence-based literature
 Nurse champions identifying unit MVPs in CLABSI
prevention
 Daily CLABSI champions available in units to assist and
troubleshoot with central line maintenance and care
Sustainability
 Continue education and practice validation for nursing and
medical staff alike
 Identify new medical products to support our initiative in
CLABSI prevention
 Implement universal gloving
 Initiate parent education on CLABSI prevention
 Roll out initiative of CLABSI prevention and CHG baths to
other units
 Disseminate data to staff to maintain awareness and
compliance
Conclusions
 CLABSIs are preventable
 Nurses empowered in CLABSI prevention on a daily basis
 Continued education, surveillance, and practice validation
improve adherence to proper central line insertion
technique, maintenance, and care
 Recruit CLABSI champions on your unit to assist and
adhere to best practices
Thank You
 Kari Mastro, MSN, RN, NEA-BC, VP Nursing, Patient Care Services
 Margaret Quinn, MPH, RN, Senior Director Nursing, Director of Quality and
Compliance
 Donna D. Johnson, MS, MBA, NE-BC, CPHQ, Director of Nursing, Critical
Care
 Fern Butler, RN, Director of Women’s Health and Neonatal Services
 Maria Esperanza L. Estilo, MSN, Patient Care Director, Pediatric Cardiac
Intensive Care
 Andrea Hughie, MSN, Patient Care Director, Pediatric ICU
 Ramon Abuedo, MSN, Patient Care Director, Neonatal ICU
 Eunice Clark, BSN, RN, CCRN, Project Logo Contributor
 Nathan Chang, BSN, RN, CCRN, Creative Artist
Our sincere gratitude to the following
individuals for all their support:
Myrlene Madelon, RN, MSN, CCRN
 Internal Coach
Marian Altman, RN, MS, CNS-BC, ANP
 CSI Instructor
Debbie Brinker, RN, MSN, CNS
 CSI Instructor
 STOP
CLABSIs
References
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References
 The Joint Commission. Preventing central line-associated bloodstream infections: a global
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