So we're going to talk about the technical work for line insertion, which is how we got started as part of the overview for the Michigan Keystone Project. And really this was to inform them about a lot of things that maybe had been done differently within some of the many organizations. And one of the first things that we did, was had to clarify what we were including and what needed to be included in the CLABSI Intervention. So as you know, there are many different kinds of central lines. So we were looking at percutaneous central lines, tunnel pick lines, all different kinds of things. What we found was that for those hospitals that lack policies and procedures, they treated a lot of their different lines and even some of their equipment the same. So one of the things that we found was we had to definitely exclude some of the other things that we were looking at such as pacemakers and those kind of things, because they were not what we were here to prevent infections of. We were here basically for central lines. And I think that what this did, was enable people to develop very specific protocols for the central line population, and then other protocols for some of these other things. And really the bottom line was what we said was that, anything line that ended in a great vessel would be what we were looking at. So the order of the pulmonary artery et cetera. And really that was the extent of what we were talking about. So for some of the hospitals, they did not include pick lines and pick lines were definitely included for lines that were placed. Some of the people that placed IJs and things like that that didn't meet the central line criteria. It did not end in the great vessel. Those were excluded from the data. So very important that people had a good understanding of what was included in CLABSI prevention and what was not included in the CLABSI prevention. So one of the other things that we had to do, because some of the organizations use different rates. And I can remember one hospital say," oh we use the CDC guidelines." And when we went to the cardiac unit, we found that they really didn't track because they were a cardiac unit and they had very short length of stay. And so, they use the STS data. The Society of Thoracic Surgery the data that they collected, and they did not have a definition for CLABSI. And remember, we were using the surveillance definition of CLABSI, so not the infection CA data. So we were looking at surveillance data only, and making sure that everybody was on board so that some people weren't doing the infection definition versus the surveillance definition so everybody was on the same page. And working very closely with our hospital epidemiology infection control departments to make sure that we definitely had an organism that was definitely considered always a pathogen, and that they deemed definitely a CLABSI from no other source. The other thing that we had to make sure of was that they really understood the denominator. So we had looked at hospitals from you know, all over Michigan. Some of them were very small and rural, some of them were just small community hospitals, some more teaching some were academic. And what we really had to make sure was finding a way in the hospitals that didn't have electronic medical records for them to identify what their line days were. So we'd settled on 12 noon everyday. You counted the number of lines. We also had to make sure that they understood that when you counted the number of central lines, that it didn't include patients that had multiple lines or triple lumens. That did not mean that they counted as more than one central line. So if a patient had a triple lumen, a swan ganz catheter, and a single lumen IV, that they were not counted as having three central line days, that included one central line day. And I think that was very important too because it had been done in very different ways. And you can see that when you're working with 103 hospitals that really never talked to each other until this program, that people would be doing this very very different. And that not everybody had an HIC Department that was really involved with what the frontline staff were doing. So finally our metrics were the number of actually confirmed CLABSIS divided by the number of central line days times a thousand, and that gave us our rate, CLABSI rate per 1000 central line days. Mechanisms of CLABSI. So we were really looking at how we got the CLABSI. So I think the easiest way to explain this, is contaminated infusate. So is your Iv contaminated? Is your IV fluids contaminated? Is the IV contaminated because of how you've handled it or is it contaminated before you even place it, like you have broken aseptic technique before you've done that? And then, the pathogens that we have on our arm that can cause localized infection. Those kind of things were also very important to be aware of. So we really wanted them to understand that there was going to be a time limit to how long everything could be kept in use, and that there was a shelf life. So everything that came in contact with the Central Line was going to be for limited time, and that meant the IV fluids, that meant both the mini bags, anything that was hooked to it. So if you had a propofol drip, if you had blood components, everything had a time limit. And each one of those things had to be changed within that time limit so that you actually were reducing the risk of contaminating your central line. So the other thing that I think was really important was, we were dealing with a situation where there's a lot of evidence out there. And there are some articles that are very small in size and they're not generalizable. So we really wanted to take the time to let the frontline providers both the physicians and the nurses know what the level of evidence was that supported some of the work that we were doing. So everything was labeled as 1A, 1B, and 1A for instance strongly recommended. And this was because it was either from a very highly powered randomized control trial, an observational trial, but enough information to say that this was categorically the way that this should be done. Many of these were epidemiology studies where patients were followed over time. But categorically 1A was something that was considered to be necessary to be done in order to prevent those infections. And 1B strongly recommended for implementation, and this was for lots of different reasons. It could have come from an epidemiological study that was maybe a little bit smaller, maybe not big enough to be generalizable, but really strong in the fact that the rationale was well accepted and it was supported by expert evidence and those kind of other supporting groups. So something that was done maybe like a meta analysis when you looked at four or five smaller studies with the same variables that when compared together, that you actually had enough evidence to support this should be done. Level 1C required by state and federal guidelines. And then, level to suggest for implementation and supported by the clinical and epidemiological studies and or there's a theoretical basis for it. So theoretically it makes sense. These studies usually are not powered as high. There might not be as much evidence but the evidence that is there, is strong enough to support that it should be done. And then there were some things that we came across at that time that really were unresolved. Both unresolved from our perspective and unresolved from the CDC because either it hadn't been studied before, there were very limited studies to support any of it, there was no meta analysis completed, no literature reviews that were done, not enough evidence to say that one way or the other whether or not this would be validated and could be used to support CLABSI reduction. So one of the first things I think hand hygiene. And the reason I have this and be getting our technical works where, you can't believe how hard it is to get everybody to wash their hands. I think the frontline providers are really good about it. I think people that are there to do Consults, pass by the sink awful lot. But really no matter who or what you're doing, washing your hands is shown to restrict or prevent infection or contamination of our patients no matter what type of infection you're looking at. So from CLABSI to VAP to contaminating a surgical site infection, you should be washing your hands before and after you see your patients. And if not, you should be using alcohol prep.
