We're going to continue with Insertion-Related Prevention. So I think I first talked about one of the pieces of evidence of washing your hands. So now we're going to things that are just specific to how do we prevent inserted insertion-related central line-associated bloodstream infections. There is a lot of evidence out there, so one of the things that we wanted to support and this is one of those meta analysis that I talked about and this is am turned out to be level 1A. So it was supported when we put all of these studies together. And what we see is that we have definitely a 50% reduction in colonization at the site and Chlorhexidine has turned out to be one of the best things for decontaminating the skin whether it be for surgical reasons, or for central line-associated bloodstream infections. In fact, we say because of this is a procedure, you should pretend this is just like any other surgical procedure. And how you see that is if you look at the squares, the squares are to the left of the vertical line meaning that they either had a reduction or that there was limited change. But collectively, we saw that Chlorhexidine was definitely going to limit our ability to colonize and to have an infection. The second piece that was related directly to central line insertion was the choice of the Prep which was the Chlorhexidine. And with the Chlorhexidine, not only did we have to call some of the senior executives within the organizations in order to get them to buy this because it meant difference supply change and some changes to how they did things, but we had to explain why. We also had to explain how to use this. So Chlorhexidine had to be placed and it was a little bit different than what we were used to so instead of betadine going from inner to outer, we were looking at Chlorhexidine which was a vigorous scrubbing back and forth for 30 seconds, so in two minutes for the groin. So if you had a femoral and you would do that, and depending on where you read at least one minute to dry. What we encourage people to do was to use their organizational representative from the Chlorhexidine who provided the Chlorhexidine to come and do demonstrations for the staff because it really was different for some of the providers that have been placing dressings and using betadine for all of those years, have been very different on how we did it. The next one, if you had a Chlorhexidine allergy was Tincture of Iodine, one minute to dry and Tincture of Iodine was also for infants less than two months of age. And then lastly, a last result Povidone Iodine, two minutes to dry and also for people that couldn't tolerate either the iodine were the Chlorhexidine, and there were some patients that we saw that did develop Chlorhexidine allergies but it was very minimal over time. And level 1B. So there were a couple of big studies and they are identified in the lower left hand quarter. And really what maximal barrier precautions says is that we have to take great strides in order to protect our patients from bacteria. So not only do they have a full barrier drape, and we're covered appropriately but it showed a 2-3 fold reduction depending on which study you looked at in the CLABSI that we were looking at. So maximal barrier precautions for the provider meant sterile gowns, sterile gloves, hat mask, etc., and for anybody else in the room, it meant that we covered the patients head from top to bottom with a large sterile drape and the drape should be long enough that it covered from the top to the bottom to the side to the side. So it should have been hanging over the side rails. We got a lot of push back on this. People have been doing it the way they've been doing it for many years. We found a lot of different drapes being used and that was one of the things that we decided to do was to keep the checklists that we later developed to see how many people were not following the full barrier drape component. And then, for anybody else in the room non-sterile cap and mask and that was all for barrier precautions were. This is what your patient should look like when you're using a full barrier drape as you see it goes above the patient's head, all the way to the bottom behind the bottom of the bed and it covers both edges of the mattress all the way down to the side. The only part exposed is that part that you're working on and I can't really see that well. But it looks like this is looks like it's going to be a subclavian and this is how the foliage barrier drape was to be utilized. Choice of site. There was a really large study that showed the femoral site should be avoided at all costs. And really what we had was a significant increase if we didn't use the subclavian site, we had an increase in thrombolitic events but we also had like 19% compared to 3% in infection rate. So really it was pretty significant. There were no studies looking at femoral site versus IJ. There were some providers that were uncomfortable with the subclavian site because of the potential for pneumothorax. What we ended up saying was that if you followed the checklist and you use the IJ or subclavian, as long as you avoided the femoral site, that was okay. What we later deemed to be a little bit more appropriate was that if you were thinking about long-term placement of a percutaneous central line that may be an IJ wasn't a good place for a male patient where they had beard growth every day because it made it very hard for the dressing to stay on. And the more times the dressing had to be changed, the increased frequency that we thought of the potential for the central line associated bloodstream infection rearing its ugly head. So avoid the femoral mind but also to think about your patient and which is the best site for them. The last thing, and certainly if you don't have a central line, assess the need every day and if you don't need the central line, you're certainly not going to have the risk for infection. So this meant a change in culture for a lot of people. A lot of people kept their central line until the patient was transferred out of the ICU. What it did was have people look at how much volume the patient was getting. Did they actually need it? Could they switch over to a peripheral line? Did they no longer need a percutaneous line? Were there going to be on long-term antibiotics and if so was the percutaneous line appropriate and if not perhaps maybe a pick line that would be followed by a specific pick team in order to maintain that line. At the time the evidence showed that peripherally inserted central lines had an actual reduction in central line-associated bloodstream infections. Some of the things that we did in order to jog our memories as I said numerous times to err is human. Humans are fallible. So one of the things that we developed was the central line checklists so we have one foreign adult and we had a pediatric version. And really, this was done to make sure that this was an interdisciplinary task. So you had the provider whether it be a physician, a nurse practitioner, or a PA placing the line and then you had the bedside nurse who was there to not only hook up the line for you but they were there to fill out the form. And they would check off yes that you were compliant or no that you needed reminded. In the pediatric version, it was a little bit different. One of the things that we found across all pediatric units was that more patients had their lines of access to draw blood. Unlike, the physicians in adult ICUs, they preferred to keep an art line and to draw blood, and we didn't access the central line very much at all. The other thing was is that you want to draw blood cultures from the central line. So the checklists were both there to follow. One of the things that came up while we were working on the collaborative was what happens when you are in procedure areas? So, this really had to do with interventional radiology. It also had to do with emergency room. So if they had the need to get a line in quickly, were they still following the evidence? So we had to go back and do additional education for both the ER and interventional radiology to make sure that they actually adhered to the CDC and the evidence-based best practice standards that were set for in this program. And we developed this tool for them in order to make sure that they were also compliant. Because the issue here was is that non-inpatient units so an interventional radiology unit, an emergency room, an OR even are not accountable for their central line. So they place the central line but they are not attributed based on the CDC guidelines to that unit. They are attributed to within 24 hours to the unit that they go to. So we had a falsely elevated rates when lines were placed elsewhere without following the evidence, and this really helped to reduce that potential for infection by including procedural areas. The other thing that we thought was really important and this is not probably an end or all for competency but, one of the things that was very important was that we have adequate training. So each one of our providers whether they be a nurse, a practitioner, a physician, a PA, they had to make sure that they had adequate training. So the training included work on a module. But then they also had to place five of the central lines in each one of the different areas to be certified to place the central line. Now our procedural list did not really feel that this was adequate because there can be a lot of time that can go by and everybody has their preferences. What we've found overall was that we needed to include additional training for those providers that were not comfortable with subclavians and that provider education had to continue throughout the program so that people had an opportunity to hone their skills and be comfortable with placement of all of the central lines. And actually, hands-on work was so much more beneficial than just the training modules whether it be Central Line insertion and the troop came out should be true for the centralized maintenance that we looked at, because rather than have the nurses just do the maintenance module, it was so much better if we actually got to watch them and see how they went ahead and change them. The other thing that we brought with us from our project here at Johns Hopkins was to make sure that we made this as easy to follow the evidence as possible. So we had the bundled kit where everything that was in the kit that was needed for a central line was there, or that we had a central line card that allowed the physician or NP to pull up the cart and they would find that it was labeled, every draw was labeled with what was in it and it was refilled at least twice a shift, so that there was never missing something. So there would be a place for culture bottles, a place for the different types of central lines, sterile gloves, everything that they could possibly need without having to run around to make sure that they had everything which was very successful. In fact, this was one of the first things that we looked at to see did they have a bundled kit or a central line cart when we did site visits to make sure that they were ready to get started?
