Where does it state that the patients face must be covered to be compliant with full max barrier?....... Only one manufacturer makes a drape that covers the entire patient. The others make a drape to place over the patient (chin to toe), and include a mask for the patients face and a half drape and the fenestrated drape for the arm. What are you doing and are we being compliant if we dont cover the patients face with the drape?
Â
Can anyone provide anything that supports going away from a signed consent? I realize that informed consent is still and allways needed. I am working with risk management, they need something more than little old me telling them that this is a
Michelle Todd, CRNI--Head PICC Nurse, Vibra Specialty Hospital of Portland [email protected]
I have the same question because most of my patients have trachs and vents and I have their face and vent behind the drape but not necessarily on top of their face. It is more that half of their face is covered by the drape. I can see their eyes over the drape. They are definitely not breathing over my sterile field, but am I compliant since they are not breathing under it. Since they can not talk, I need to monitor their facial expressions for any sign of needing more local. If they are alert, and if they can lift their arm, I can have them raise their hand if they are in pain. But many can not do this.
Michelle Todd, CRNI--Head PICC Nurse, Vibra Specialty Hospital of Portland [email protected]
Michelle Todd, CRNI--Head PICC Nurse, Vibra Specialty Hospital of Portland [email protected]
When you look at the original studies on maximal barriers, they did not define the specific length of the drape nor the amount of the patient's body that should be covered. I agree that it is confusing.
Lynn Hadaway, M.Ed., RN, BC, CRNI
www.hadawayassociates.com
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
We have a custom kit built for us which covers the entire sides of the bed and over the foot of the bed. We do not pull it over the patient's face as it is not fenestrated but cover their face with a mask in our PICC insertion kit. We have other drapes that we provide a barrier against the head/face on the insertion side.
Yesterday my PICC rep. states that Joint Commission is requiring that the PICC be bundled with the max barrier? I question this as we have refused to spend $20 for their max kit (they are making PICCs and full barriers as a bundle and we said no thanks). The kits we have made cost less than $9.
Have you heard of this?
2010 National Patient Safety Goals do include 1 whole section about preventing CVC related infections. 1 of the subsets of this goal does include that a central line kit include everything, including maximum barrier precaution. I remember that the date of implementation is 1/10. I think this will have all of us looking at the cost of kits!
Gwen Irwin
Seton Family of Hospitals
Austin, Texas
There is a definition of Maximum barrier. The IHI, the Institute for Healthcare Initiatives, the group who created the Central Line Bundle that was part of the successful save 100,000 lives campaign and the ongoing save 5 million lives campaign is specific in stating that the drape should cover the patient "from head to toe"
There are many PICC companies and kit packaging companines who have drapes long enough to do so, some have a fenestration, some have a separate, smaller drape specific for the arm. The upcoming AVA conference is a good place to see what every manufacture has to offer in one place, or I am sure your local rep for each company would be happy to come in to demonstrate for you.
JCAHO and SHEA both recommend using a complete kit that includes cap, gown, mask, and maximum drape. In lieu of a complete kit, a cart containing all needed supplies that can be brought "close to the bedside" is recommended. The problems with having a cart: someone has to stock and restock it, no guarentee that inserter will use all items needed, tracking multiple SKUs in inventory and no ability to charge for the items used.
When you use one kit that contailns everything, you are able to charge for the kit, and everything it contains, complaince improves because the inserter has to move the PPE to get to the insertion supplies, and it is one SKU to inventory and stock.
Chris Cavanaugh, CRNI
Chris Cavanaugh, RN, BSN, CRNI, VA-BC
Kathy Kokotis
Bard Access Systems
This is not a sales pitch and I do know what I am talking about as I have heavily researched this topic to present at AVA this year. The Joint Commission as it is not longer the old name has introduced NPSG's for 2010 which are the national safety patinet goals and you are not going to like them but you do not have to comply with The Joint commission recommendations as it is not mandatory to get their approval. They are no longer tied to Medicare or Medicaid funding as of Jan 1 2009. Take that up with your hospital CEO and see what they want to do. I bet The Joint wins or JC as I am now calling them.
Yes you have to have a drape that covers the head like it or not. That is the IHI definition in the tool kit. In fact IHI (www.IHI.org) states that if you do not have such a draoe than you are to contact you operating room to locate a one piece drape with a fenestration. Pull the tool kit as you will have to read it to match their other 10 recommendations as well. If the patient is claustaphobic I suggest asking the OR how to handle this (tenting the drapes is what I am seeing done). You may not realize but skin sheds (facial skin). Eyelashes are loaded with bacteria. I am an infection control RN. The MD's also have to comply with this. In fact JC states right at the top that PICC lines are not excluded as they realized we would try to argue out of this one.
Now for the checklist and you will hate this part. It is mandatory to have a individual trained in sterile technique observe every central line insertion and be able to stop the procedure. You think I am kidding I am not. I had JC in a hospital last week and they watched PICC insretions with the team. I am not kidding. This team covers head to toe. But they got cited for not having a policy on how to change caps sterily. I am not sure how to do this yet myself. Maybe Hadaway knows that one.
There is lots more but the message is too long already
kathy
Kathy Kokotis
Bard Access Systems
I have read your response here and on another thread about the NPSG for 2010 stating that no longer can one person place a picc line (you suggested having a PAT in the room who is trained on sterile procedures). I am bringing this up to my administration so that we can add the appropriate team members, but can't seem to find this goal. So far, this is what they are telling me:
I have copied and pasted a statement from TJC. I have viewed some proposed revisions to the NPSGs for 2010, but mostly standards are being moved from the NPSGs to other chapters. Karen, can you give me the exact NPSG being referenced?
From TJC website
"NPSGs being reviewed during 2009......During 2009, The Joint Commission is undertaking an extensive review of the current National Patient Safety Goals and the process for their development. As a result, there will be no new NPSGs developed for 2010. The review is being undertaken in response to concerns about the challenge some Goals represent and the need for additional information about effective approaches to addressing these challenges."
Can you provide me a link to find this info. thanks bunches
Karen
The second person is for the checklist (See the joint commission compendium oct 2008). The goals for 2010 were really for 2009. They are not new as they were not implemented in 2009 so the joint kept them for 2010 implmentation. That is why they say there are no new goals for 2010 cause you did not implement the 2009 goals. They want the 2009 goals for 2010 implemented.
B. At insertion
1. Use a catheter checklist to ensure adherence to infection
prevention practices at the time of CVC insertion (B-II).23,29
a. Use a checklist to ensure and document compliance
with aseptic technique.
i. CVC insertion should be observed by a nurse, physician,
or other healthcare personnel who has received
appropriate education (see above), to ensure that aseptic
technique is maintained.
b. These healthcare personnel should be empowered to
stop the procedure if breaches in aseptic technique are
observed.
2. Perform hand hygiene
Kathy, I have read your thread on this and I have not been able to find in the NPSG's for 2010, any statement in regards to having a second person in the room for placement. I am trying to put a budget together for staffing and supplies and I need this support. Can you email me the specific link?
Thank you, Robin
[email protected]
10. As of January 1, 2010, use a catheter checklist and a standardized protocol for central venous catheter insertion. C
Above is the direct statement fromthe Joint Commission NPSG 2010. In it is says USE a checklist. How does one USE a checklist with one individual. The purpose last I heard for the checklist was to actually observe and break the process if technique was compromised. I would have your administration ask infection control how to implement a checklist with one individual and have it be documented (2 signatures like the one on IHI's website) and have it be measured. Is Infection Control going to measure the ones checked by the lone PICC RN on their own. Great, there will always be 100% compliance. The individual placing is not going to check the box that they did not do something on the list.
For an explanation of how to implement the checklist you can go the IHI website (www.ihi.org) or go the The Joint Commission website and type in compendium to prevent catheter associated bloodstream infections which was written in Oct 2008 and the quote I presented below you will fine. You are right about should and shall. However, I want to be in the room when the Joint Commission says use checklist and they see no-one acturally checking that person off. As far as the second person goes that is the need for the second person. It is to do the checklist not to help you insert the line. That second person can be anyone. staff RN, MD, nursing assistant. Find out the process in your hospital as to who will check off the MD's and use the same process. Talk to infection control and find out who will check off the MD's placing a line?
kathy
kathy
thank you so much for the information, it is very helpful to me; however, my organization wants to argue with the word "should" (I am so tired of arguing the point of should and shall with them) anyway, they say that because it says should, doesn't mean that we "absolutely have to do it" but it comes as a strong recommendation. I look forward to hearing your talk at AVA so that I can bring more to the table to prove my point. thanks for all of your help
karen
They are correct. Those words do carry different legal meanings. Shall means that it is required while should indicates the preferred method. If you notice in the INS standards of practice, the word "shall" is used in the standards statements while "should" is the verb used in the practice criteria. I have also run into this in legal documents in other avenues totally unrelated to healthcare. I do realize how hard this is do deal with though.
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I do picc line insertions alone. If there is anytime I suspect or know that I have contaminated myself or any item I stop and resolve the issue and then resume procedure. When I document my checklist ( computer generated list that goes along with my insertion documentation) I document "yes" to sterility maintained, because I maintained it and did not proceed with anything without assuring its sterility. In this event are they looking for documentation of breaks in technique and efforts to resolve?
I do agree that our checklists are going to be 100% on compliance because that is the only way to insert a central line with those standards and we do all to uphold them. If I feel at anytime in the procedure I have breeched that I stop and resolve it. I dont really think I need someone over me to police me to be sure I am doing that, nor document everytime I did something to maintain it.
Our computer generated checklist , also asks us about all the other bundles or steps to
decrease infection taken and we document them upon completion of procedure. I am not sure , but, it sounds like they want it documented as it happens and to use the checklist as a "reminder " of sorts to be sure all items are done is that correct?
Gina Ward R.N., CPAN
Gina Ward R.N., VA-BC
That is the purpose of these checklist - to monitor as the procedure is being done. I am sure your technique is great, however I would also expect there to be times when you may have a breach in sterility and not realize it. The checklist idea actually originated from the methods of Crew Resource Management in the airline industry. Many years ago, 2 planes collided on a runway in the Canary Islands, the largest accident in aviation history. The reason this occurred was because the captain did not listen to the concern and warning of a crew member. That revolutionized the aviation industry and now those proven methods are making their way into healthcare. I have always believed that PICC insertion should be no different from a regular CVC insertion. A physician requires an assistant. So why should nurses take on PICC insertion without an assistant to meet the patient's needs during the procedure. These checklist empower the person observing to stop the procedure if any step in the process is not done or done incorrectly. This means that an assistant of any professional level can stop even the chief of staff if there is a breach in technique. This is all part of the patient safety movement.
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
would anyone be willing to provide a copy of their central line checklist for us to review. I use a checklist, but it is a pre-op checklist and I want to re-vamp it into a central line insertion checklist like Kathy suggested. thanks
Arrow has had a central line bundle and time out checklist included in their maximum barrier kit configurations for Central lines and PICCs for a few years now. It is based on the IHI central line checklist created in 2004 (I believe). I am happy to send a pdf copy to any who would like it. Contact me directly at [email protected]
Chris Cavanaugh, RN, BSN, CRNI, VA-BC
(can't seem to make the random iv-therapy.net/allsites/themes.....stuff to disappear)
http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Tools/CentralLi...
and then, below is the list of items on our checklist - combined effort of our intensivists, quality, ICU director, and vascular access dept. It has some extras on it, and because we're a teaching facility, some choices that wouldn't apply for every facility. This is used for all CVAD insertions.
Emergency ProcedureConsent Obtained
Perform time out/final moment
Disinfect table
Perform hand hygiene
Disinfect procedure site (state type/amount of antiseptic used; instructions for use have specific area of coverage)
30 sec or 2 min for moist sites (femoral) (for the antiseptic we use, chlorhex with IPA - chlorhexidine is bundle standard)
Allowed procedure site to dry
All persons in room wear a cap and mask
Patient barrier head to toe
Clinician used sterile gown and gloves
Sterile technique maintained by all
Sterile Dressing applied and dated
less than or equal to 3 passes with hollow needle (this is for MDs; our policy for RNs is r/t our SOP, less than or equal to 2. We document exactly how many attempts in the procedure note)
Attending notified after 3 passes
Attending directs team to continue
Attending performs procedure
IR notified
Done under Ultrasound Guidance
(and then more, belonging to procedure note and not the checklist)
See you in about a week!
Mari
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
Me again, Karen:
If it helps you feel any better, our hospital directors also resisted my suggestion that all healthcare personnel assisting with the checklist/central line procedure have documented training specific to the central line insertion/bundle checklist.
We require it of all of our IV RNs and are able to do so, but it is not yet required for the nurses in the ICUs or ED. The ICU director feels strongly that sterile procedure establishment, maintenance, and corrective measures are already taught. I disagree; I do think that nurses get some training in establishing a sterile field for wound dressing changes, central line dressing changes, but even those basic best practices are not being followed. I think the education/training required for CLABSI prevention/CVAD insertion/Bundle checklist is much more specific, which is why I made it mandatory for our staff - PICC RNs and non-PICC RNs. We also will be training our resource staff (float pool) so that we have other options if our IV staff are unable to assist a PICC RN (for those occasional 10pm-a-PICC-really-is-the-best-option-non-emergent-but-somewhat-urgent cases).
When looking at the JC Oct. 2008 Compendium (also known as the SHEA compendium) - be sure you have the full document. One supplemental version doesn't list the subsets that Kathy posted.
I'll share with you the objectives we use for our sterile technique mandatory (a one hour presentation, with return demonstration required), and the competency assessment checklist we added this summer.
FYI: We use head-toe drape, we prep the entire upper arm to a point distal to the antecub/elbow (keeping in mind the coverage area of the antiseptic device and adding as needed). The drape we use is stiff enough that we can either tent it, or tape the non-procedure side to a portable bar we had made, or a light fixture on a stiff movable arm (light turned off!), or small TV with stiff movable arm (one patient was able to watch TV during PICC insertion). If you use devices like that - be careful that they aren't hovering over your sterile drape at any time (dust, etc.) - they can only be UNDER the drape.
Also, if we approach the patient with the attitude that the head-toe draping is necessary for their protection, they usually tolerate it just fine. If we approach them with the attitude of "I'm sorry we have to do this, if you get anxious we can try something else, are you ok?" - then they probably will be anxious. Empowering the patient to be part of best practices for their own safety helps a lot. If you truly have someone that has phobia/significant anxiety, it usually works to tent the drape off their face enough so that there is a barrier between their head/face and the procedure area.
Not sure if we can attach things on the forum now - if I can't, I'll send to Sarah for her to post.
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
Our patient safety coordinator emailed Joint Commission with the following question. The response is below:
07.04.01: Is a second person required to be present during a PICC line insertion for the purpose of observation and tracking adherence to sterile technique and speaking up if sterile technique broken?
Thank you for your inquiry. The National Patient Safety Goal does not require the presence of a person for observation purposes. Please feel free to contact me directly with any further questions or discussion for clarification purposes. Please understand that full compliance with the intent of the standards can only be assessed during an onsite survey. Proprietary note: The information transmitted is intended only for the person or entity to which it is addressed and may contain confidential and/or privileged material. Any review, retransmission, dissemination or other use of this information by persons or entities other than the intended recipient is prohibited. If you receive this in error, please immediately contact the sender and delete the material from any computer.
Wendy Erickson RN
Eau Claire WI
Wendy, thanks for invesitgating this to get the answer direct from JC, instead of us "guessing" at what they are looking for, or instilling fear that we need to increase our staff unnecessarily.
Can you send me a copy of their response so that I can share it with the teams I work with. please? Thanks so much.
[email protected]
Chris Cavanaugh, RN, BSN, CRNI, VA-BC
There are some important changes to the JC (JCAHO) NPSG for 2010, some that are effective immediately. These were just announced in their Sep. 9 newsletter.
Most important to vascular access RNs:
07.02.01--The NPSG was deleted for all programs
07.04.01--The NPSG was deleted for the ambulatory care, home care, and office-based surgery programs
I would encourage you to go to the site and download the NPSG that apply to your work setting. http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/
Many of the device manufactures have developed tools and education that can help you meet these goals. I would encourage you to reach out to them to assist you.
Chris Cavanaugh
Chris Cavanaugh, RN, BSN, CRNI, VA-BC
Chris,
Can you be more specific about the JC site? Where is this info? I have been to the site and clicked on many links and not finding it.
Thanks for any help.
Gwen Irwin
Austin, Texas
Gwen and others,
The link I sited in my post will take you directly to the page were the 2010 NPSG are listed. You then need to choose the setting you are looking for, as they are different for each setting--ambulatory, hospital, long term care....etc.
In addition, I believe Sarah has posted the hospital version in the download section of this site. I hope this helps.
Chris Cavanaugh, RN, BSN, CRNI, VA-BC
Kathy,
JC cited for non-sterile cap change? I never had a sterile cap. Please tell me more.
Thanks,
Nancy
Nancy Rose
the essential points that current health care reforms are looking at, and what we as clinicians all want for our patients: how to keep consumers healthy and safe in a cost-effective manner.
With that in mind, the driver should be evidence, not just requirements from JC or CMS or AHRQ or.....and we as vascular access specialists should be leading the way; we can be the dog wagging the tail. Quote from AHRQ Commentary "Healthcare Quality and Disparities" by Carolyn Clancy, MD: "Health and Human Services Secretary Sebelius has called the status quo with regard to quality and disparities 'unsustainable'......Specifically, she has called for hospitals to reduce central line-associated blood-stream infections by 75% over the next 3 years by making use of a proven patient-safety checklist that can significantly and dramatically reduce the rate of these life threatening infections." - statement based on evidence.
There is plenty of evidence that shows that central line checklists reduce central line associated blood stream infections, and it makes sense. No matter how skilled you are at establishing and maintaining sterile fields, stuff happens. The second person observing during the entire sterile part of the procedure is necessary, because no one can observe themselves, no one can check themselves off after the fact using a checklist.
If a facility doesn't want/is unable to hire enough RNs to have 2 placing PICCs, Nursing Assistive Personnel (NAPs) trained to assist with that portion of the line insertion are a cost-effective method to streamline PICC insertion, and help keep patients safe. NAPs don't provide any direct infusion therapy, but they can assist with tying gown, draping, sterile probe cover application - with training and initial and regular competency assessment. (NAPs can also assist with moving furniture, cleaning procedure tables, inventory, data entry, etc. - all non-nursing functions).
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center