From the 2021 HVPAA National Conference
Robin Williams (Henry Ford Health System), Kelsey Hebel, Fred Giertz, Swati Verma
P2 is a 40-bed unit, specializing in Oncology, stem cell transplant and cellular therapy for patients with primary and metastatic malignant solid tumor and hematologic disease. P2 is the highest user of Peripherally Inserted Central Catheter (PICC) lines at the hospital, outside of Intensive Care Units. PICC Team here consists of 8 nurses and 3 nurse-assistants providing support 365 days a year. Our project was initiated in June of 2020.
In the year prior, P2 had 16 central line blood stream infections (CLABSI) of which 8 were linked to PICC line insertions. Our team assessed pre-and-post-procedure processes and discovered that there wasn’t an integrated standard procedure at either end of PICC insertion. There was a lack of communication between care teams including Physicians, bedside Nurses, PICC team and patients. Patients were often not aware of the need for PICC placement. Bedside nurses had no idea when the PICC team would arrive. Chlorhexidine gluconate (CHG) baths were never done prior to procedure and were hit and miss after the line was placed. PICC and P2 Team collaborated to develop a standard process. When PICC team receives an order for PICC placement, a thorough chart review is completed to assess for contraindications and appropriateness for bedside PICC placement. PICC team then calls P2 nurse and gives them a 4-hour window to complete CHG bath and notify the patient of the pending catheter placement. P2 nurse also educates the patient about line maintenance, infection prevention and care which includes daily CHG baths.
PICC team arrives at the bedside and uses 2 more CHG wipes to ensure a thorough CHG barrier at the insertion site. Standard sterile maximal barrier precautions are used during insertion procedure. After insertion PICC nurse reinforces the patient education. PICC team conducts independent audits to monitor procedure compliance. P2 nurses perform daily CHG baths and monitor and audit for compliance. From July 2020 to January 2021 85 PICCs were inserted and only 1 reported CLABSI on P2. 4 patients refused pre-procedure CHG bath. The one reported CLABSI refused his pre-procedure bath, was non-compliant with post-procedure bathing and left AMA(Against-Medical-Advice).
Impact of this project is multi-faceted. It has empowered patients and their families by giving them an understanding of care required to safely live with a PICC. It has reduced number of CLABSIs on P2 and therefore reduced length of stay and any potential harm caused by prolonged hospital stay including antibiotic therapy, line removal and replacement, and mortality. It is estimated by the AHRQ* that 12-25% of CLABSIs are fatal. The project also has a significant cost avoidance for HFH. Each CLABSI could cost the hospital on average $48,101. Physicians, nurses, and PICC team have developed better communication and teamwork and have reduced delays in care due to mixed messages. Everyone on the care team knows when line placement will be done, in effect creating a seamless continuity of care. The project success spurred the development of a taskforce to roll out the process to the entire hospital. The project was shared with another hospital in the system who are considering a pilot. There are plans to integrate the process into nursing orientation at HFH. This project has become a part of the culture of safe care at HFH in our journey towards becoming a High Reliability Organization.
