Home' The Source : First Quarter 2011 Contents First, HCA developed a template for what was es-
tablished in the literature as best practices. It wanted
to build on the Michigan project and take the initia-
tive to the next level by applying the procedures not
only in the ICU, but also to patients on the floors.
"That meant addressing not only insertion, but also
maintenance. The literature indicates maintenance
may be as important, if not more
important, than how the line is
inserted," Septimus says.
The discussions included spe-
cifics such as which products,
like caps, gloves and drapes, were
required to meet the evidence-
based guidelines and caregiver
workflow needs. "It's important to
engage the end users on the front
end and find out what their needs
are instead of deciding for them
and getting the 'no one asked me'
reaction," Septimus says.
It took a lot of time, thought
and research to define the central-
line kit components. For instance,
there were di erent opinions on
how big a "full drape" should be,
Septimus says. They also had to
define and agree on the proper
roles of assistants and even of the
Some physicians were unfa-
miliar with the emerging role
of two-dimensional ultrasonography---using sound
waves to image internal structures in order to im-
prove line insertion accuracy. They needed education
on the advantages of this new technology.
Education Is Key
Central-line insertion and maintenance are proce-
dures physicians learn in their training. Best practices
have changed in recent years as a result of the focus
on fighting infections. For example, chlorhexidine has
replaced iodine-based solutions as the recommended
antiseptic prep. The evidence also demonstrates the
e cacy of using a full drape to provide a larger ster-
ile environment around the patient. As a result of
these new practices, HCA now requires a refresher
course, or "privileging," for physicians before they can
perform the procedure in an HCA hospital.
"We developed an educational module that detailed
the level of morbidity and mortality and explained
why the new procedures are important," Septimus
explains. "We went over the peer-reviewed literature
about processes shown to reduce infections. Next we
outlined the kinds of cultures to obtain if a physician
suspects there is a central line infection, how to collect
the cultures and how to interpret the results."
For instance, a positive result might indicate the
presence of a contaminant rather than a true infection;
misreading the results could lead to over-treating,
which is ine ective and costly.
Because hospitals must now report CLABSIs to the
CDC in order to receive their payment update from
CMS, it's important that physicians know and use the
specific definitions required for reporting infections,
so that reports are accurate and consistent.
There are also monetary incentives to reduce
CLABSIs: Medicare no longer pays the added re-
imbursement for treating patients who develop
infections after admission to a hospital, says Steve
Tarkington, assistant vice president, supply chain
management, and executive leader of SolutionsTrust.
Though the supply bundles cost somewhat more
than the individual items themselves, the anticipated
reduction in infections will likely drive down other
costs, such as the time and medications needed to
treat infections, Tarkington notes.
Always Follow Best Practices
"Thanks to Keystone, the evidence is very clear-cut
that using all-inclusive prepackaged kits or standard-
ized carts significantly decreases infections, saves
time and improves caregiver satisfaction," says Julia
Moody, MS, SM (ASCP) clinical director of infection
prevention, Clinical Services Group, HCA.
Moody stressed that it's not enough just to use
the standardized kits; the sta must also adhere to
the steps in the standardized procedures each and
every time. A recent study of ICUs showed decreased
CLABSI rates when insertion best practices were con-
sistently performed at least 95 percent of the time.
To help personnel follow and track the recom-
mended procedures, HCA developed a visual six-step
reminder for the insertion and documentation screens
in its electronic medical records: perform hand hy-
giene; wear cap, mask with eye protection, sterile
gown and gloves; avoid the femoral site when possible;
prep the site with CHG plus alcohol; use a sterile full
body drape; and apply sterile dressing.
"Documentation is important and not only for
reporting to the CDC. You can't improve what you
can't or don't measure, so it is important to measure
compliance against the standard, every time, on every
patient," Septimus says.
New literature supports the importance of mainte-
nance practices after insertion to prevent infections.
Maintenance of the central lines after insertion in-
cludes regular changes of the dressing covering the
stands for antimicrobial steward-
ship---the best use of antibiotics to
treat infections e ectively without
overuse, which can run up costs and
encourage the evolution of more
refers to the list of insertion
practices and procedures that have
been shown to prevent CLABSI as a
result of insertion.
stands for proper maintenance
of the site to reduce infections
at that stage.
24 First Quarter 2011 | The Source
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