"Practice maintenance."

The words sound boring, but the change they portend may change patient outcomes.

When change was required for the Sutter Roseville Medical Center (SRMC) in Roseville, CA, to achieve a 37-month zero catheter-related bloodstream infection in 6,000 peripherally inserted central catheter (PICC) lines, we tried to make it sound more exciting. We used words like "sustaining excellence," "hardwiring success" and "safeguarding quality."

We recognized that providing a safe environment for our patients is not only creating solutions to our clinical challenges, but also maintaining them day in and day out.

A Desire for Excellence

In 2005, our medical center experienced 11 catheter-related blood stream infections (CRBSI), and the vascular access device (VAD) of choice was the peripheral IV and the centrally inserted central catheter (CICC).   

We are a very busy medical center, a designated level II trauma center with 32 ICU beds, a busy OR, immunosuppressed patients and many patients with multisystem disease. We compared ourselves with similar institutions, but we wanted excellence and thought we had it.

In November 2005, SRMC hired a clinical manager, who had a passion for vascular access, for its infusion services department. The passion quickly became contagious as the team and its leader started to question everything.

Making Change a Reality

We asked ourselves, "Did we have the right products, the right procedures; did we use the products correctly; train our employees the correct way?"

We learned while our goal was excellence, our policies and procedures did not reflect a standard of practice that supported better, safer, care with all VAD insertions and maintenance. In order to accomplish this, we had to change practice throughout our entire facility with the insertion and management of all VADs. We recognized this would improve patient safety and satisfaction and become the cornerstone of our CRBSI-reduction bundle.

In early 2006, after extensive research and careful review of all the products in use, as well as new products on the market, the center's PICC team developed a new central line bundle consisting of seven components that address insertion, maintenance and daily monitoring of all central lines.

This bundle included changes in practice, product and use of technology.

Seven Steps to Success

Each of these bundle steps carried detailed processes:

Step 1: Maximum barrier precautions. This included designing a maximum barrier kit by negotiating with the materials management department. We faced many challenges: buyer groups' limitations, getting practitioners to "give up" products they were familiar with, and mandating all practitioners to use the kit for every central line insertion.

Step 2: Ultrasound-guided PICC placement. This involved transitioning from a practice of inserting PICC lines using the traditional smaller vein in the antecubital bend of the arm to utilizing 100 percent ultrasound guidance, upper arm basilic vein of choice for all PICC placements. Complete retraining of our PICC team was necessary; they had to "give up" the way they had inserted central lines for years.

Step 3: Antimicrobial interventions. We implemented a two-step process of cleansing the skin with alcohol, followed by an antiseptic and the placement of a chlorhexidine gluconate (CHG) impregnated foam disc on the insertion site. A securement device is added. We eliminated the 24-hour gauze pressure dressing change, and instead placed the CHG foam disc directly on the site after insertion.

Step 4: Neutral fluid displacement device adoption. This required a connector to support a saline-only flushing protocol, septum disinfection and eliminating the clamping sequence.  

Step 5: Septum disinfection. Observations of practitioners revealed varied length of cleansing and inconsistent application of pressure to the hub during disinfection. Our bedside-training program involved review of correct septum disinfection technique. We set a standard of 15 seconds of vigorous cleansing using 70 percent isopropyl alcohol, better known as an alcohol pad.