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Patient safety special focus

Reducing harm in critical care

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This intervention focuses on two key areas in critical care – reducing harm from mechanical ventilation and preventing central line infections

Keywords: Critical care, Central venous catheters, Mechanical ventilation

The goal

The aim is to improve the care of patients receiving critical care through the reliable application of care bundles. There are two care bundles in this intervention.

The focus of measurement is the completion of the entire bundle as a single intervention, rather than completion of its individual components. Trusts can choose one bundle to start with.


Central line bundle

Central venous catheters (CVCs) are used increasingly to provide long-term venous access.

CVCs disrupt the integrity of the skin, making infection with bacteria and/or fungi possible. Infection may spread to the bloodstream and haemodynamic changes and organ dysfunction (severe sepsis) may ensue, possibly leading to death.

This bundle has five key components (outlined below). For further details on good maintenance in this care bundle, see The ‘How to Guide’ forReducing Harm in Critical Care.


Hand hygiene

All NHS organisations should be aware of national initiatives to improve hand hygiene and many have implemented measures such as:

  • Proper hand hygiene is required before and after palpating catheter insertion sites, inserting, replacing, accessing, repairing or dressing an intravascular catheter. In addition, the use of gloves does not negate the need for hand hygiene;
  • Keep soap/alcohol-based hand hygiene dispensers prominently placed and make universal precautions equipment, such as gloves, only available near hand sanitation equipment;
  • Post signs at the entrances and exits of patient rooms as reminders;
  • Create an environment where reminding each other about hand hygiene is encouraged;
  • Initiate a campaign using posters including photos of celebrated hospital doctors/employees recommending hand hygiene.

The NPSA issued a new cleanyourhands alert in September 2008.


Maximal barrier precautions

  • Maximal sterile barrier precautions (such as cap, mask, sterile gown, sterile gloves and large sterile drape) during CVC insertion substantially reduce the incidence of central line-associated bacteraemia compared with standard precautions (for example, sterile gloves and small drapes).
  • Keep equipment stocked in a trolley for central line placement to avoid the difficulty of finding necessary equipment to institute maximal barrier precautions.
  • If a full-size drape is not available, apply two drapes to cover the patient. Or consult with the operating room staff to determine how to procure full-size sterile drapes, since these are routinely used in surgical settings.


Use of 2% chlorhexidine (alcoholic 70%) skin antisepsis

  • Disinfect clean skin with an appropriate antiseptic before catheter insertion and during dressing changes.
  • Include chlorhexidine antisepsis kits in trolleys or grab-bags storing central line equipment. If a pre-packed central line kit includes povidone-iodine solution, do not use it. If there is good reason not to use chlorhexidine, such as a patient allergy, you should not feel forced into using it. If there is a good reason for an exception and it is documented, the intent has been met and teams should feel comfortable assigning compliance for that item.
  • Ensure that chlorhexidine solution dries completely before inserting the central line.


Optimal catheter site selection

The subclavian vein is the preferred site for non-tunnelled catheters in adults and the femoral site should be avoided.

The site at which a catheter is placed influences the risk for catheter-related infection and phlebitis. For adults, lower extremity insertion sites are associated with a higher infection risk than upper extremity sites. The subclavian site is preferred for this reason although other factors – such as catheter-operator skill – should be considered when deciding where to place the catheter.

Include the order of preference for site in the line-placement checklist, with an appropriate area for documenting reasons for not using the first choice.


Daily review of central line necessity with prompt removal of unnecessary lines

One of the most effective strategies for preventing central line-associated infections is to eliminate or at least reduce exposure to central venous catheters. However, the decision regarding the need for a catheter is complex and therefore difficult to standardise into a practice guideline. None the less, a local strategy to systematically evaluate daily whether any can be removed should be developed.

A contemporaneous record documenting line placement and site care can help with prompting early removal. The decision on whether the form becomes a permanent part of the medical record, or is simply used as a data collection tool, must be made locally at each hospital. These strategies are particularly effective if used in conjunction with a daily goals assessment sheet. This form can be completed during daily rounds.


Mechanical ventilation bundle

This bundle has four key components:

  • Elevation of the head of the bed to between 30º and 45º;
  • Daily ‘sedative interruption’ and daily assessment of readiness to extubate;
  • Peptic ulcer disease prophylaxis;
  • Venous thromboembolism prophylaxis (unless contraindicated).

Click here for further advice on how to implement this care bundle, including The ‘How to Guide’ for Reducing Harmin Critical Care and a summaryof each care bundle


Case study: York Hospitals NHS Foundation Trust

York Hospitals NHS Foundation Trust has implemented the central line bundle, and seen a dramatic shift in attitude and improvement in relation to central line infections.

What was traditionally regarded as a side-effect of treatment is now understood to be something that can be avoided - simply through reliably implementing the steps needed to reduce the infection rate.

Improvement manager Gillian Younger says: ‘We’ve shown that improvements can be made, and sustained by using the small-scale PDSA (Plan Do Study Act) methodology testing as it allows clinicians the freedom to trial ideas in practice before moving to large-scale implementation. 

‘We are now seeing this methodology being used in more areas across the trust and aim for it to be fully adopted,’ she adds.

Initially the team involved consisted of a consultant anaesthetist, Dr Rinus Pretorius, senior staff nurse Anne Knaggs and consultant microbiologist Dr Neil Todd. However, it quickly became clear that it could not rely on a handful of people. Gradually more volunteers joined the project, each contributing their own experiences and ideas.

After determining the local definition of a central line infection, the team was able to measure the impact of the changes. The team initially focused on insertion of central lines and analysed the current process. This stage found that problems arose with difficulties in finding essential equipment or the under- or overstocking of the trolley. In addition, the unit did not stock 2% chlorhexidine skin antisepsis.

Ideas were tested and modifications made quickly. The outcome resulted in the introduction of the new line trolley and an insertion checklist.

However, Dr Pretorius found that in spite of good compliance rates with the new process, there was no significant reduction in infection rates. Therefore, the process was reviewed, staff views were sought and the team re-examined the whole care bundle. Interestingly, after learning of a similar scenario at nearby South Tees Hospitals NHS Trust, they identified that the critical failure could be care of the lines once inserted. As a result, the team developed a care plan incorporating all aspects of care for central lines.

Since implementing these essential changes across the ICU, infection rates have reduced dramatically from one infection (on average) every fortnight to one in nine months.

Elaine Hunter, lead sister, critical care, says: ‘Patient safety is now openly discussed inside and outside of meetings and the measure - in our case, the number of days since an infection - is on public display. It is a matter of pride for those involved - avoidable central line infections are just not acceptable anymore.’

As a part of The Health Foundation’s Safer Patients Initiative, York was a step ahead when Patient Safety First launched, so the trust is keen to help others learn from its experience. Ms Younger adds: ‘We’ve been proud to share our experiences with other trusts and have benefited from the larger network of support, motivation and experience that Patient Safety First provides.

‘Change can often be a tricky business but we have benefited from the combined efforts from all levels of the organisation. Staff can really see the positive impact that making the changes in critical care has had. We’ve had support from the board and management but it is those on the frontline that really own the change,’ she explains. 

Chris Morris, critical care matron, adds: ‘In the past we thought our practice was OK but we had no measures in place to support this view. Once we examined our practice we obviously found there were improvements to be made and the team embraced this and have successfully embedded changes in practice for the long term. 

‘The culture has shifted. For a nursing team, it is so motivating to see the improvement in infection rates as a direct result of changes you have made. We are always seeking new ways that we can improve and this, along with measurement, is an essential part of creating better systems that will drive to improve the safety of our patients.’


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