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September 14, 2010

Operator: Good day, ladies and gentlemen and welcome to the CUSP content call. At this time, all participants are in a listen-only mode. Later, we will have a question-and-answer session, and instructions will be given at that time. As a reminder, this conference is being recorded. If anyone should require audio assistance during the conference, please press star then zero on your touchtone telephone. I would now like to introduce your host for today’s conference, Ms. Melinda Sawyer. Ms. Sawyer, you may begin.

Melinda Sawyer: Thanks. I just want to say welcome, everyone. We have a large number of people on the call, over 275 people on the call today, so obviously a lot of interest in this topic. I have with me today David Thompson, who has a doctorate of nursing and he is what I consider an expert in this topic. Together, we are going to hopefully give you some suggestions and or recommendations that you can take back to continue to drive your blood stream infection rate down to zero, if you are not already there.

Just briefly on the second slide, I’ll just go over the learning objectives. Today, we want to basically describe the steps to take if your unit infection rate is higher than zero. Now you could be having just one pretty consistently, one infection pretty consistently, or you could be at a point where you are going long periods of time without infections, but then all of a sudden on some routine basis you are having one pop up and you are just trying to get down to zero and maintain zero for a year or 2 years, from what we’ve heard some units are doing out there. And then, we want to talk to you about some of the lessons we’ve learned from others just like you who’ve gone through and walked their process to try to figure out what’s keeping them from being able to maintain a rate of zero. Those are our two objectives, and we can get started so next slide.

When we talk about this, I just basically described this: Is your infection rate above zero or are at zero for long periods of time and then you have a spike in your infections, what should you do? I actually kind of think of those separately and have some different interventions that we can talk about based on which problem you might be finding. I know in one of my units right now, we went 52 weeks without an infection and then we had a spurt of 3 of them. We are handling that a little differently than if we’d had one all along or one every month or two.

Next slide, when you have a spike in your infections, we recommend walking the process. What do I mean by that? I mean as the blood stream infection team on your unit, this CUSP team, we recommend getting a group of your team together, and this should be nurses, doctors, whoever is on your team, and we suggest walking that process from line placement to how that line is being maintained. And we recommend doing this to make sure all of the basic recommendations are being followed each and every time, before you go and throw new technologies at the problem.

As you may know, the CDC recommends getting these basic interventions down and then if you are still having infections when you know those basic interventions, you are compliant with those, then there’s an opportunity to add new technologies. But, at Johns Hopkins we actually haven’t added Bio-Patch or some of the other technologies simply because our goal is to always provide those basic recommendations, and we’ve found that we can be quite successful with those basic interventions.

So next slide, I’m going to hand it over to David here to talk on these next few slides.

David Thompson: So, one of the things that started when I was doing this with Aventis, was we were looking at a way to systematically review this as all scientists would do. At the patient level, we wanted to look at several things about the evidence that Melinda talked about, the basic science of the five pieces of evidence. Was the checklist used? And if it wasn’t used, was that breaking policy and procedure or was that because the nurses didn’t feel empowered about speaking up? Was the protocol followed? Were they placing the central line consistently each and every time? And did everyone wear appropriate clothing? I had physicians refusing to wear hats, that were bald, because after all they didn’t have any hair and why did they need the hat? I had fellows that were assisting with line placement that felt that they were standing behind the resident so they actually didn’t need to have on the sterile gown and all of that stuff. Once I said there was no exception and when they did the original trials, there was no randomization for hair or no hair and all of those kinds of things, people kind of bought into it and then they allowed them to move forward. The other thing that we did was – did someone speak up? And we found that often a nurse would speak up, and then they would document on the checklist that indeed, they did speak up, but they were ignored. And they wrote, “Made suggestions to Dr. So and So and was ignored” rather than being able to stop them from, as Peter would say, taking take off. What that meant was that we had to get middle management involved because we had to have the nurse empowered in order to do that. Was the dressing secured? And more often than not, we found that the dressing was not placed in a very particularly strong fashion, and within a couple of days, the dressing had been coming off. Was the site cleaned and maintained per protocol? Most of the teams had switched to the chlorhexidine, which is recommended. But what we found was that chlorhexidine wasn’t being used per manufacturer’s recommendation. And then did you use a preferred site for placement? And this brought about a lot of different things, and we’ll talk more about it later. But, it meant that some people, some of the nurse practitioners and the physicians placing the line, actually had to have some remedial education because they weren’t used to placing IJ and subclavian. Did the line stay in longer than necessary? And this happened an awful lot, and there were a lot of nurses that would stand up at our face-to-face meetings and even some physicians had said, “Well, you know, my patient is an elderly woman or an elderly man, and they really hate having their blood drawn.” And I said, “How often is the blood being drawn?” And they said, “Once a day.” And I said, “Well, you have to explain to them the risk, and it’s really up to you.” By that time, if that’s the only reason a line is in, certainly the line doesn’t need to stay.

Some of the other lessons that I’m going to talk about are things that we’ve learned to date are all from true stories that hospitals that I’ve worked with either within Johns Hopkins or across the State. So, attributable infection definition is misunderstood. One of the things that I saw in a big spike in infections, we saw three in 1 month, two in another month, and I was talking with them on one of our coaching calls on the definition for placement, and they weren’t aware if the line was placed in the ED, that even if the infection occurred within 72 hours that it was not their infection. One of the things that they did after that was they moved the bundle or they spread the intervention out to the emergency department, so they knew that.

One of the other things that we’ve learned since doing this is the data has really showed that if the infection occurs within 5 days, chances are it is because of how the line was placed. If it occurs after 5 days, it has to do with maintenance. So that is something to keep in mind as you look at your own processes.

Checklist used, but nurses documenting the noncompliance, as I said, instead of stopping the procedure. Again, this was a big issue in some of our smaller hospitals. They had to get sign off from the chief medical officer, the chief operating officer and learn their hierarchy. They never needed to use their hierarchy, never needed anybody to stand up for them, but this time they did and they did have the chief medical officer, who just like we did here, where our dean of the school of medicine, Ed Miller and Peter Pronovost, told the nurses that you can call me anytime, day or night, if a physician is noncompliant, and that’s exactly what we had to do there. Nurses did not feel they had leadership support to stop the procedure. And again, they were faced with their nurse managers not feeling comfortable enough to go to even their nursing director to talk about this. So this is something that can’t stay within the silo of nursing -- this has to go outside the silo of nursing. You have to have your chief nursing operator, nursing officer, and the chief operating officer working together in tandem to make sure those people are supported. And in our experience here, even when the dean gave his business card to one of the nurses, he didn’t really know whether the nurse would call him. In listening to his story as he was talking about quality and safety, the same nurse called him on three occasions with three different residents that he said, “What do you mean?” And I can’t even imagine wanting to risk that, but after that, that was the end on that unit and that was a general inpatient unit where they couldn’t get the nurses to be compliant.

Moving on to slide seven, ICU was not asking daily if the central line could be removed and added the question to daily goals worksheet. They had taken it out early because they assumed they would be able to identify when a patient no longer needed fluid boluses, blood transfusions, or multiple antibiotics. But again, what came in to play here was the patient who was alert sometimes and oriented would say, “I really don’t want to be stuck.” And again, we owe it to our patients to be open and explain the risk of having that central line for one more day just for the convenience of not having to have a blood draw.

And then, inconsistent compliance with scrubbing the hub prior to accessing line. We’ve had some units that use a scrub the hub campaign in the unit, and we did that while we were in Aventis. We also empowered the patient and we told the patients if anybody comes in here and tries to hook up a mini bag or apply any type of IV tubing to what’s already there and you see that they don’t pull out their alcohol pad to scrub, you have a right to tell them that you need to wipe that off with alcohol, very effective. Vascular access team and infection control provided training to all the staff who accessed the line, and they come up with some of their own policies, so very effective in reducing that. Standardization: One of the things we hear, even a year after some of the interventions were started, some of the sites still had not standardized. So use of that cart so that people didn’t have to go around. In the cart they had everything that they needed for line insertion, but they also had everything that they needed for the dressing change, which really improved the patient flow. The line cart contents, the four drawers, setting those up and then finding a mechanism because even if you do this, if something’s not there, you might go ahead and skip it. A new policy and procedure or you gave the supply clerk a list of the inventory with the number that was supposed to be there and you had them supply early in the morning and in the afternoon to make sure the supply cart was always filled. We did find if it wasn’t there, people weren’t going to go looking for it. You have to remember people are really busy, and anything that we can do to reduce the number of steps they take and make things simpler, the more likely that they will do the right thing.

And then on slide 10, the process auditing where we begin to look at what happens at the unit level, especially if you see a lot of different infections over time. The percent of the time the IV administration set was replaced per policy: I teach in the school of nursing here as well as in the school of medicine. I can’t tell you how many times I find administration sets that are out of date, sometimes by only a day but sometimes much older. The percent of femoral lines versus IJ and subclavian: Again, that had to do with physicians feeling comfortable placing those lines, and it meant remedial training for some of them. Percent of the time the checklist was used: I asked sites if they had no record of how often the checklist was used to write down the number of lines that went in that month and then to look at the number of checklists that corresponded to see exactly what their compliance was. The percent of the time that protocol was followed: Again, so you are looking at that checklist to make sure that protocol was followed so the nurse can say they redirected if they were beginning to steer away or whether or not they just documented that the physician was not compliant. Percent of lines that could have been removed: Now this happens in the form of an audit, and we’re talking about auditing now, and there are two tools that Melinda and I have worked on that are there for everybody to use in order to look to see where in the process things are falling by the wayside. The percent of nurses that are comfortable stopping a procedure and did they stop it when it was necessary: What I found was for some of the sites, I needed to go back and do some teamwork and communication training because they didn’t feel comfortable. They had no formal training or education in appropriate assertion. So, I’m going back and making sure that they were appropriately assertive and that they would have the support of the hierarchy within their hospital, and that meant the nurses and physicians. We did still have problems with some of the sites, and with that we added the code of conduct so when people blatantly failed to do things to protect the patient from harm, that that was something that was incorporated in some of the hospitals that we had recently adopted here at Johns Hopkins, the code of conduct. And percent of lines that are changed after emergent placement: If you cannot guarantee that that line was placed using the protocol, following sterile techniques such as in an emergency room where a patient comes crashing from the floor into your ICU or your step-down unit, that line technically should be changed out within 24 hours of placement -- not just rewired but a whole new site picked and that line should be replaced.

Some of the things that I’ve noticed from our mid-course meetings, in fact, some fascinating things, there was one team that set up in their simulation lab. They asked their nurses to go in and do the dressing change on a model patient, a dummy, whatever you’d like to call them. The patient already had a dressing that was applied, and they were asked to take down the dressing and reapply the dressing, and they were being filmed. Again, it was to assess whether or not they were compliant to see whether or not they needed to add a competency training to their yearly certification. The majority of nurses -- and these were senior clinical nurses a lot of them with years of experience -- some of them had extra components in their kits that they used for their dressing changes. Some of them had pieces of the equipment they didn’t even know what they were for, so they weren’t that familiar, and in the majority, and this goes across a lot of hospitals and a lot of nurse educators that I talk with, when they watch, they find that the chlorhexidine is not being applied appropriately. It’s being applied just like we learned in nursing school, to start in the middle and work their way out, but the thing about chlorhexidine is that in order for it to be effective, you have to apply friction, back and forth with kind of a “Z” motion. You can do the other way, and I’ve seen nurses effectively provide friction, but we’re taught to be very gentle and work in a circular fashion, but if you’re just painting the chlorhexidine on, it’s not really being effective at its job as being an antimicrobial.

The other things that we’ve learned is that some of the hospitals that I’m working with are already jumping to advanced technology, and that’s because their rates were already high and their infectious disease department had already recommended advance technology like impregnated catheters or impregnated dressings -- kind of jumping ahead of the game because what they didn’t realize was that they weren’t already doing everything that they should do. They weren’t using a full barrier precaution. They had physicians that were still using sterile drapes or sterile towels to drape off just that section of the patient. They had people providing care that didn’t have their mask on, so they definitely didn’t have full barriers. They had people that weren’t washing their hands before the procedure. They had assistants in there without the full barriers on. So there was a lot that we learned, not only the inappropriate use of the chlorhexidine, the fact that people weren’t competent, and that a lot of the nurse educators were telling me they need to go back to the basics, and they’re doing yearly competencies with their nursing staff to make sure that they can do the dressing change appropriately.

So we’ve moved from just line insertion to looking at the effect of maintaining the dressing. And with the audit tool, there were a lot of teams that I’ve talked with who’ve said that they’ve gone, they’ve done the audit to assess whether the dressing was adherent and a couple of days into it, it’s supposed to last for 7 days, if you’re using the clear dressing, and at day 3 or day 4, it was no longer adherent, and rather than taking it down and starting over like you’re supposed to, they just tape it down after we’ve already had the patient drooling into the dressing or the ventilator becoming disconnected and spraying the area with that lovely water in the ventilator tubing that all of us would be appalled by if it was on us. So a lot of things that have been happening that we just didn’t realize, so you can’t put the dressing on and just think, “Okay, you’re good to go,” because you’ve done the dressing change right. The other thing I’ve noticed is that when the patient has a lot of drainage, especially if their co-ags are off, they don’t switch back to a gauze dressing. They are leaving it. And if the dressing is still attached, they are leaving that to stay in there, and the CDC clearly recommends that if there’s drainage, that you use the gauze dressing. And after the gauze dressing comes off, that you take the sterile saline and catheter kit, and you clean that before you begin to clean with chlorhexidine. So you should be starting with a clean skin surface before you even begin using the chlorhexidine, and once the drainage stops then to go back to the clear dressing.

I think there are a lot of things that we’ve been finding in clinical practice, either by the senior clinical nurses, nurse educators, or just our own observations, and people are beginning to pick this up that we need to spend a lot more time on the basics.

I’m going to turn this back over to Melinda and let her continue.

Melinda Sawyer: On slide 11, I’m going to just give you an example of when I started with my CUSP team back in 2001, looking at how we can try to improve outside of our ICUs and our progressive care unit our central line-associated blood stream infections. As you all know, step two of CUSP is identify defects, and when we ask the staff how the next patient was going to be harmed and what we could do to prevent that harm, some of the staff on my unit said, “We’re going to give patients a blood stream infection because we don’t change our IV administration sets according to protocol.” I was surprised by this because I knew we had a policy and that everyone knew the policy. It wasn’t a knowledge deficit. It was that the system in which they were required to work was difficult to be compliant with the policy. So, before I ever tried to put an intervention into place, we decided to do some process audits at the unit level and say, “What percentage of IV administration sets or IV tubing was not compliant?” And we defined not compliant as it was outdated, meaning that it was older than 96 hours or that it didn’t have a date on it all because then we couldn’t verify when the IV tubing was last changed. And to my surprise, actually as I look here, we actually started working on this particular process in 2004, to my surprise, we were between 25 and 27 percent not compliant with this policy. I was stunned to say the least. So what we did was we used the Learning from Defects tool to try to understand the contributing factors that were underlying why it was hard to comply with the policy because we knew it wasn’t that the staff didn’t know that it needs to be changed. So we needed to figure out what it was. What we realized was that we required our nurses to change the IV tubing at night. And when they changed it, they put a sticker up there that has the date they hung the IV tubing, and what we realized was that every night when the nurses were on and they had their patients to take care of, they had to go and calculate in their head, do this mental math, they had to calculate 96 hours ahead of when that date was on that tubing and it honestly got put to the bottom of their priority list every night. As a result, we were seeing a lot of noncompliance with this policy. It was difficult to comply with. It was too much to ask them to do this 96-hour calculation on all their IV tubing every night that they worked. So we went back to them and we said, “What would be better?” And they said, “Well, if we had a way to know when we went in there and just looked that it needed to be changed today.” But we needed to be careful because we didn’t want to shift the mental math to the person hanging the tubing, meaning the person hanging the tubing had to say, “Today’s Monday, I need to think 96 hours ahead and put that date on there.” So what we figured out, we came up with a better system and that was we created a new labeling system where you hang a sticker which tells which day to bring the tubing down, but to save the mental math on the person hanging the tubing, what we did was create a chart next to those labeling stations which said if today is Monday, you hang a “change Thursday” sticker. If today is Tuesday, you hang a “change Friday” sticker. So it was easy for the nurse hanging and when the night shift nurse went in to her shift that night she could look for all the “change Thursday” stickers and quickly change those tubing out so the mental math, we made sure that no one had to do it anymore. A few months into it, we realized that we were still a little bit not compliant, not at our goal, and we realized that we had IV labeling stations only on one end of the unit, yet nurses could get IV tubing from both ends of the unit. So we had to add a labeling station to the other end of the unit, and we continued to follow up with our nurses to give them lots of reminders when we were doing the audits if they were not compliant. Eventually, soon after, we got down to our goal which was to have zero to five. We really didn’t want any, but if we were less than five percent, we were very happy but zero was always our goal. So that’s just one example of not only having a process audit, but then using CUSP and using the steps in CUSP, using their identifying defects and Learning from Defects tools to put really strong interventions into place to fix the broken process, to fix the system so that it’s easier to comply with the policies.

So next side, on slide 12, so what are some other lessons that we’ve learned when we’ve done process audits? In one clinical area, we realized that the central line infections were all associated with one particular provider, and we had to get that provider on board and try to figure out what were the areas that needed additional training or improvement. We had to offer that to them to get them more comfortable, for example, with putting in subclavian lines over IJs or femoral lines. Recently, in my own department, we identified that our interns were learning from their senior residents how to put in IJs over subclavians, so what we had to do was provide additional training in our simulation center before the interns started so that they could be provided education from experts on how to put subclavian lines in. Same with groin lines over the IJ or subclavian. We have to make sure that we are providing equal training to our providers who are inserting these lines in addition to the nurses who are maintaining them.

So next slide, another lesson that we had with that, we found one charge nurse found a dozen full barrier drapes in a storage drawer, and she was curious as to why they were there instead of being used. What they realized was that the providers weren’t using the full barrier drapes; they were using another type of drape. So we had to go back and put interventions into place to correct that. We identified in another ICU central line cart that three-quarter length drapes were in place, and that we had to initiate routine training on what the equipment was, in fact, that was required in the cart and that that person who was responsible for supplying the cart had the training that they needed because from their perspective -- it was not a clinical person -- there was very little difference to them in knowing why a full barrier drape over a three-quarter barrier drape was important. They thought they could substitute it if they didn’t have it, and that one way we found we could do that easily was that we label each cart with the required equipment and then train that person that all of those things must be in there -- we can’t substitute -- and if they have any problems with meeting that need, they need to talk to their appropriate person.

Another lesson that we learned was that we realized in some ICUs and step downs, we had a central line cart. The providers on the floor were forced to use a bundle, and that bundle wasn’t complete -- it was part of a bundle. Once the providers were really frustrated with that because they were still having to gather the supplies, they came back and gave us that feedback and they had to develop a new bundle, which was more comprehensive, more complete.

So, next slide, once you get your processes in place and you know you are 100 percent compliant with those, there may be a time where you go long periods of time without any infections, and then all of a sudden one pops up and what should you do? On slide 15, one of the things that we really stress is that you need to consider each infection a defect worthy of a full analysis, and as David mentioned before, we have developed both auditing tools to measure your processes but also a blood stream infection investigation tool which will help you understand the defects and what possibly could have gone wrong with that particular central line that led to that particular central line infection. And then, you may go through that blood stream infection investigation tool and identify some system-level defects that you need to improve, and that’s where we recommend you then use your Learning from Defects tool just like I did with my IV tubing compliance. Use that Learning from Defects tool to develop some system-level interventions that are focused on the contributing factors that are causing those system defects and then develop a plan to prevent those system defects in the future. A part of that Learning from Defects tool is identifying the interventions you are going to put in place, assigning a project leader, and assigning a project completion date, and making sure in your CUSP team you follow up and make sure those projects and interventions are being implemented.

Next slide, so in conclusion, we just want to make sure that you ensure your unit is implementing the recommendations for central line maintenance and, in addition to that, the recommendations for central line insertion. David pointed out that if the infection’s occurring early after the line was inserted, typically about 5 days is a general rule of thumb, you want to focus on the central line insertion practices. But if your line infections are occurring 10, 15, 20 days out, you really need to be focusing on your central line maintenance practices. Do those process audits both at the patient level and at the unit level to identify areas that could possibly need improving. Really make your goal 100 percent compliance with all of those recommendations. Develop a plan with your interdisciplinary team that includes your infection control staff because they are experts. They are going to be able to help you make sure you’re meeting all of the recommendations, you are implementing them as expected. Make an implementation plan and keep an eye out for your results, and then only if you know you are 100 percent compliant with all of those basic recommendations and you are seeing little or no improvement in your infections should you consider adding the new technology. Again, there’s a lot of institutions out there, including us, who have been able to get our infection rate down to zero and have not had to implement those technologies because we really focus on the basics.

On the next slide, just briefly, are just some references if you have any questions, but with that why don’t we open up the lines to questions because I heard we’re now over 300 participants on the line. So I imagine there may be some questions.

Operator: Ladies and gentlemen, if you have a question at this time please press star then one on your touchtone telephone. If your question has been answered or you wish to remove yourself from the queue, please press the pound key. Our first question comes from Patti Bull from Hendrick Medical Center. Your line is open.

Patti Bull: Yes, ma’am. The only question I have, and I’m not in disagreement with you, but with the advanced technologies, per se, what about the new recommendations from the CDC concerning the Bio-patch or the CHG disk?

Melinda Sawyer: That’s a great question. The recommendations were that those were to be implemented if you were 100 percent compliant with all of the basic interventions and you still had a problem with infection, just like we outlined. At that point, it’s important to add, it is a recommendation, just like we said, that you add advanced technology.

Patti Bull: Okay.

Melinda Sawyer: But they definitely highlight the importance of those basic recommendations.

Patti Bull: All right, thank you.

Operator: And our next question comes from Rose Chavez from Roseland Community Hospital. Your line is open.

Rose Chavez: Hi, how are you? An excellent presentation. I have a question regarding your “Scrub the Hub” campaign. That’s one of the things we want to embark upon now. I definitely foresee some difficulty because I know the recommendation is that they should scrub the hub for at least 30 seconds. So what did you guys do to implement that and have the staff embrace that practice?

Melinda Sawyer: That’s a great question. So, in fact the literature is silent and the CDC recommendations are silent with regard to how long to scrub the hub. They just tell us to scrub the hub with either alcohol or chlorhexidine and that it’s up to an institution to determine what their policy and practice is going to be with how long to scrub the hub. So I can tell you that the practice at Johns Hopkins was vastly different, depending on the type of unit and nurses and their comfort. I can tell you that some units didn’t have great practice. They did a quick swipe with the alcohol. Other units scrub with two or three different chlorhexidines for a total of 2 minutes each. I mean it was way overboard, I would say. But, I think that’s where it’s important to have this type of campaign to set what your hospital’s policy is. We decided that 15 seconds was sufficient, and if you actually sit down and scrub a hub for 15 seconds, it seems like a pretty long time. But, one of the things we really highlight -- and I just did this education with all of my department nurses recently -- was that if you look at the claves of central lines, it’s a very uneven surface and a quick swipe is not going to clean that surface. And it really needs to be a thoughtful scrub, and it needs to be 15 seconds. We also say that one of the sources of infection during for central line maintenance practices is this. The reason is that we all know patients have skin flora all over them. We’ve done studies that have shown that everything in the environment is dirty, and that clave that we use is touching everything. It’s touching the patient’s skin. It’s touching their gown. It could be touching side of the bed. It could be touching the linen. And all of that we need to consider to be contaminated, and thus the hub has been contaminated. We do not want to be the ones responsible for hooking up, for not scrubbing it, leaving possible bacteria on that surface, and then hooking up an IV fluid and pushing that right into the patient. So we just focus on the education: What are the sources of infection, why it’s important, and what the expectation is that we’ve decided as an institution.

Rose Chavez: Thank you.

Operator: Our next question comes from Shelby Lassiter from North Carolina Hospital Quality. Your line is open.

Shelby Lassiter: Thank you. Melinda and David, thank you for a wonderful presentation. You’ve really given us food for thought about the importance of walking the process. I have a question in reference to slide six, specifically regarding the attributable infection definition misunderstanding. I totally understand for the purposes of performance improvement that it’s important to trace back to see where lines are placed in, spread the bundle, and other interventions into those areas. But, I just wanted to make the point that for those of us that are reporting into NHSN, they do not allow us to attribute infections to the outpatient areas such as ED.

Melinda Sawyer: You are absolutely right. If the patient came from the ED to an inpatient area and that line was infected, that inpatient area would get credited, we’ll say, for that infection. You are absolutely right about that; that is the NHSN requirement.

David Thompson: Right. The only thing that I would say is that at least for your team that they know they’re not the ones that are responsible. I think that’s important as well because people take this very seriously and lives are at stake.

Shelby Lassiter: For performance improvement, it’s critical to know where those lines are being placed.

David Thompson: Right.

Shelby Lassiter: Also, for the 5-day reference that you made, you know that “less than 5 days look at insertion, greater than 5days look at maintenance.” Do you have a reference, a study, on that?

David Thompson: I have heard Peter quote that four times, and I will ask him and if I do, we can have Kristina forward that out.

Shelby Lassiter: That would be super. Thank you very much.

Melinda Sawyer: Just to talk about where those line infections get credited, I’ll give you another example is that I just said one of my units went 52 weeks without an infection and all of a sudden they had three infections. It happened to be starting July 7^th, July 13^th and July 17^th. So as you know, we are an academic medical center, so we really started to look at what were causing these infections. What we realized was that these were lines that weren’t placed in the CCU -- that’s the unit that had these infections -- they were placed in our cardiac cath lab, and they were placed under emergent conditions. So what we had to do, although the CCU got credited for those infections because the cardiac cath lab is not an inpatient bedded unit, we had to go back and realize that it wasn’t the CCU’s practices, per se, that were causing these infections. We had a lot of work to do in the cardiac cath lab and also with regard to the communication about what lines were emergent and what lines were not emergent. So, just a lesson, I think, to think about when you are auditing your processes and looking for breaks in your practices. Any other questions?

Operator: Our next question comes from Nancy Eckstrom from St. Elizabeth Regional. Your line is open.

Nancy Eckstrom: Yes, I just wanted to talk to you guys about what we’ve done at our facility for tubing changes. We went through much the same type of difficulty instituting compliance as you guys did, and then we finally trialed and have gone forth with this practice. We do tubing changes and clave changes every Sunday and Thursday, and if the patient comes in on a Saturday they get all their lines changed on Sunday, their tubing and claves. Same way if a patient would come in on Wednesday, and everybody knows in the whole hospital that our tubings get changed on Sunday and Thursday no matter what, and that really has helped our compliance with tubing changes.

Melinda Sawyer: That is a great, great suggestion. I’ll also echo the fact that when we do our IV tubing changes the claves are considered part of the IV tubing, we do the IV tubing and clave at the same time too. But, that’s a great recommendation to standardize your process.

Nancy Eckstrom: And one other comment I have to make, have you guys looked at those swab caps?

Melinda Sawyer: We have looked at those at our hospital and, you mean the ones that have the cover on them?

Nancy Eckstrom: Exactly, yes.

Melinda Sawyer: So, we decided not to go with these. Again, this was just our individual institution’s decision, and the reason is that we did not want, they do not replace the fact that you still needed to scrub the hub, and as a result, we didn’t want to send the message that this was a substitute. So we decided that we would really just focus on the basic recommendation, which was scrub the hub, and not add that extra technology which we thought could possibly lead the nurses to think that it was a replacement for.

Nancy Eckstrom: Okay, thanks a lot. You guys were a great help.

David Thompson: Good.

Operator: Our next question comes from Lori White from Westmoreland. Your line is open. Lori White, your line is open; if your line is on mute, please un-mute your line.

Lori White: Hi, I’m sorry. The question has been raised recently at our hospital about arterial lines and whether they should be treated the same as placing a venous line. I’m wondering if you have any data or what your practices are for placing art lines?

Melinda Sawyer: So, I can tell you that at our hospital it depends on the type of arterial line, the location. Again, these practices should be implemented for all central lines, regardless of whether they are arterial or venous. Now with that being said, most places and most units are putting in radial arterial lines, and that’s not a central line. However, a femoral arterial line is typically considered a central line, because the IV line is usually 12 or 13 centimeters long and ends in the aorta, so that would be considered a central line. Other areas that we use, in those cases, the femoral arterial lines we do apply all these recommendations, including the Central Line Insertion Checklist. Another area we’ve recently found that’s putting in a lot of arterial lines that we do need to use this for are in the procedure areas when they’re putting inter-procedural arterial sheaths in. So for example, in neuro-radiology, in interventional radiology, and interventional cardiology, they’re doing a lot of inter-procedural arterial sheaths, and those typically need to have, because they are central by definition, need to have a central line checklist.

Lori White: Great, that was very helpful. Thank you.

Operator: And our next question comes from Suzanne Wells from St. Luke’s East. Your line is open.

Suzanne Wells: Yes, hi, thank you. Have you done any differentiation between central lines and PICC lines, especially in the removal process?  Are you asking daily if the line can come out? Are you replacing central lines with long-term catheters such as PICC lines for patients who still need multiple infusions and lab draws and possibly may go home with one?

David Thompson: There is no formal policy. A lot of our patients, if they are long-term or on general inpatient units, they have a PICC line. We still do everything the same, the same process, and still count line days the same way, we still use the checklist. And those are for patients that may be going home on antibiotics or for patients that are inpatient stay with long-term antibiotic treatment. But, we have no formal recommendations for when the percutaneous line comes out and we place the PICC line. But again, we do everything the same, exactly the same.

Melinda Sawyer: I have to say that the only thing we do differently is that central lines we use sutures on and PICC lines we use the sutureless securement device.

David Thompson: Yes, the fat lock.

Suzanne Wells: Right, right. Great, thank you.

Operator: And our next question comes from Erin Flynn from Fairview Hospital. Your line is open.

Erin Flynn: Thank you. You’ve answered our question already.

Melinda Sawyer: Great.

David Thompson: Thank you.

Operator: And our next question comes from Mary Ellen Furanti from Eastern Connecticut Health. Your line is open.

Mary Ellen Furanti: Hi, Melinda. Can you hear me?

Melinda Sawyer: Yes.

Mary Ellen Furanti: We’ve talked before, and your presentation was great. My question is I’ve done some observations for the nursing staff, and many of them still feel a need for that circular motion even with the chlorhexidine, and I’m looking for either a video or some way even to explain to them the best way to clean it because they get concerned should they be starting in the middle to scrub back and forth and then work outward, but they’re still afraid they’re going to be bringing contaminants and whatnot back over to the center and the insertion site.

Melinda Sawyer: That is an old school nursing practice that’s been ingrained in us since nursing school, I think, a circular motion.

David Thompson: I’ve seen a couple things, it’s friction is what’s really, if you read the insert, they want the chlorhexidine, and if you could picture a skin cell, the front and back of the skin cell so it’s the friction of going back and forth. I know that in the OR, they kind of do the “Z” model of back and forth, they work kind of top down. But, I’ve also seen nurses that were placed on the hyperal team and things like that, other hospitals, that start in the middle, they secure the central line with the left hand, and then they start going around really quickly from the inner to the outer and there’s a lot of friction that they make that way, and they’ll go back and forth because it’s coating the cell both ways. If they really have to do it that way, you can do it, you just have to make sure that you’re securing the central line. I would just suggest that it’s sutured and they still put their hand on there. But what’s important, regardless of how you do it, the “Z” method or around, is to make that friction so that you’re getting the chlorhexidine to coat both sides of the cell, and that’s what it says on the package insert. That gentle thing that we’ve learned and being very careful inner-outer, we have to kind of let that go. It’s the friction that’s important.

Mary Ellen Furanti: Ok, because what we’ve found, our policy had said, you do the friction but then we were using the same chlorhexidine to clean the extension pieces with the claves, so I recommended that we use a second chlorhexidine for the claves when you are cleaning the rest of the line afterward.

David Thompson: Yes, that would make sense.

Mary Ellen Furanti: Okay, I thought that maybe I was wrong, that the clave changes were every 7 days. Or has that been changed?

David Thompson: Well, for our policy, it’s the same days as the IV tubing -- and we consider that part of the IV tubing -- and the CDC recommendations are that IV tubing is changed every 72 to 96 hours.

Melinda Sawyer: That’s correct.

Mary Ellen Furanti: Okay. Thank you very much.

Operator: And our next question comes from Diane Dumigan. Your line is open.

Diane Dumigan: Yes, thank you for a very informative afternoon. Melissa and David, I was wondering what you consider emergent placement. We’ve talked about this, but is it during a code? Is it right after a code? We’re really looking at when we should change lines after emergent placement. So could you define that a little better?

Melinda Sawyer: I have to say we purposely don’t define it in any of our policies because our medical leadership likes to say that it’s the doctor’s call of whether any procedure is emergent or not. So, we do leave the definition of that. We don’t describe that, but I can tell you the practice and what we coach the doctors on and the nurses is that the patient, if they’re coding, it’s emergent. And if they are about to code and they need central access, they do the best that they can. And we help coach our nurses to help the doctors in those situations because what we don’t want is the patient about to code, who we need to get IV access on, for the doctor to stop what they’re doing and go put on all of this equipment and then, as a result, the patient codes. So what we coach in those situations is that the nurse help the doctor get as much of the sterile equipment as they can so that the doctor can provide the best that they can, given the circumstances. But those circumstances are so individual to each patient that we don’t try and define that.

David Thompson: Right. And then what we say is if you cannot guarantee that you followed the protocol, then that line should be changed out within 24 hours. So if you have any question at all that you put it in without sterile techniques that it be rewired or changed out within 24 hours.

Diane Dumigan: Okay. Thank you. That’s really helpful.

Operator: And our next question comes from Toni Roberts from Mercy Memorial Health Center. Your line is open.

Toni Roberts: In response to the one question about somebody with a central line and then they may be keeping that line for long-term use so it goes to a PICC line, would that be considered a separate incident or is it all still the central line part of the measurement there?

David Thompson: So, if they’re still in your unit and you take out a percutaneous line and you put in a PICC line, you would still treat it the same. You would count central line days the same. The only difference is that you’ve just changed out the type of central line that you’ve given your patient.

Toni Roberts: Okay. I don’t have your slides that you’re using. Is this something that we have access to?

Melinda Sawyer: These went out on Friday to all the State leads, so you should have probably gotten it from your State lead. If you didn’t, I’m sure that these are going to be posted on the national Web site today if not within the next day.

Toni Roberts: Okay, thank you.

Operator: Again, ladies and gentlemen, if you have a question at this time, please press star then one on your touchtone telephone. And our next question comes from Jodi Henning from Monongalia General Hospital. Your line is open.

Sharon: Hi, it’s actually Sharon, and I just wanted to state that one of the things that we have done is developed our own central line kit, and we put everything into that kit that we needed for the central line.

Melinda Sawyer: That’s great. Now is that for the central line insertion or central line maintenance?

Sharon: Central line insertion.

Melinda Sawyer: That’s definitely one of the recommendations out of the CDC is to either provide a bundle or a cart, so that’s great.

Sharon: We don’t have a cart. We have everything all into one package in a kit.

Melinda Sawyer: That’s fantastic.

Sharon: Thank you.

Melinda Sawyer: So it is a little bit past 3 p.m., and I want to be sensitive to everyone’s time so if you have any more questions you can forward them on to your State lead to send to us at Johns Hopkins, and we’ll be happy to answer those as best as we can. But, thank you for joining in the call. Obviously this is a call that everyone is interested in and you had a lot of questions and I think, I hope, that we can together learn from each other. I encourage you all if you have audit tools, if you have specific interventions you’ve done to share them and we can all learn together in this. With that, I’ll say thank you very much.

David Thompson: Have a great day everybody.

Melinda Sawyer: Take care.

Operator: Ladies and gentlemen, thank you for your participation in today’s conference. This concludes the conference; you may now disconnect. Everyone have a wonderful day.