Organizational Self Assessment - The Joint Commission

Bloodstream Infections: Useful Tools, An International Perspective. Nov 20, 2013. Accessed [user please fill in access date].

http://www.jointcommission.org/CLABSIToolkit

Organizational Self Assessment

Question Tools

Does the organization have the

tools to champion change?

CUSP Barrier Identification and Mitigation Tool - See Appendix N

Overview of Factors Affecting the Success of Improvement Initiatives

(corresponding to Table 4-1 of CLABSI Monograph Preventing Central

Line–Associated Bloodstream Infections: A Global Challenge, A Global

Perspective, page 73)

CUSP Engage the Senior Executive Tools

CUSP Back to the Basics Document - See The CLABSI Elimination

Toolkit – Appendix 9

AHRQ Surveys on Patient Safety Culture

Michigan Keystone intensive care unit (ICU) project: Six-step

Comprehensive United Based Safety Program (CUSP) process to

assess and improve the safety culture

o CUSP How to Conduct a Culture Check-up - See

Appendix G

o NCABSI Team Check-Up - See Appendix I

Accountability of Health Care Personnel in Preventing CLABSIs

Johns Hopkins Quality Safety Research Group – Nurse Empowerment

(PPT Slides)

Sustainability Rating Scale (from The Joint Commission’s Multidrug-

Resistant Organism (MDRO) Toolkit, What Every Health Care

Executive Should Know: The Cost of Antibiotic Resistance)

Project Prioritization Matrix (from MDRO Toolkit)

Develop a Culture of Safety - IHI Website

Bloodstream Infections: Useful Tools, An International Perspective. Nov 20, 2013. Accessed [user please fill in access date].

http://www.jointcommission.org/CLABSIToolkit

Organizational Self Assessment

Question Tools

Does the organization have the

tools for an active, well

resourced surveillance

program?

2013 CDC Central Line-Associated Bloodstream Infection (CLABSI)

Event Definition

WHO Assessing and tracking patient harm – A methodological guide

for data-poor hospitals

Pooled Cumulative Incidence Densities for CLABSI in Adult ICU

Patients, WHO Data 1995–2010 (corresponding to Table 6-2. of

CLABSI Monograph, page 105)

CLABSI Rates per 1,000 Central Line–Days in Limited-Resource

Countries (2002–2011) (corresponding to Appendix B of CLABSI

Monograph, pages 115–118)

Egyptian Surveillance forms

o Surveillance Form 1

o Surveillance Form 2

SICU Monthly Survey

Outcome and Process Performance Measures (adapted from CLABSI

Monograph)

Examples of National and International HAI Surveillance Systems

(corresponding to Table 5-1 of CLABSI Monograph Preventing Central

Line–Associated Bloodstream Infections: A Global Challenge, A Global

Perspective, pages 87–89)

Benefits, Essential Components, and Limitations of Electronic

Surveillance Systems (corresponding to Table 5-2 of CLABSI

Monograph, page 91)

Steps in Evaluating Electronic Surveillance Systems for Potential

Incorporation into a Facility

Bloodstream Infections: Useful Tools, An International Perspective. Nov 20, 2013. Accessed [user please fill in access date].

http://www.jointcommission.org/CLABSIToolkit

Organizational Self Assessment

Question Tools

Does the organization have

access to current guidelines for

the prevention of CLABSIs?

Examples of International Clinical Practice Guidelines That Include

CLABSI Prevention Strategies (corresponding to Table 2-1 of CLABSI

Monograph Preventing Central Line–Associated Bloodstream

Infections: A Global Challenge, A Global Perspective, pages 13–15)

Examples of Clinical Practice Guidelines or Practice Standards

Developed by Organizations or Professional Societies Regarding

Aspects of CLABSI Prevention or Diagnosis (corresponding to Table 2-

2 of CLABSI Monograph, pages 15–21)

Position Papers Related to CVCs, CLABSIs, and Their Prevention

(corresponding to Table 2-3 of CLABSI Monograph, pages 21–22)

Society for Healthcare Epidemiology of America/Infectious Diseases

Society of America Compendium of Strategies to Prevent Healthcare

Associated Infections

o Chapter on CLABSIs

Does the organization use

improvement in CLABSI rates to

bolster licensure of

accreditation?

Review of Joint Commission and Joint Commission International

Requirements That Address the Prevention and Control of CLABSI

Does the organization educate

clinicians about the incidence,

prevalence, reasons for and

avoidance of CLABSI?

HAI Causes in US by DHHS (corresponding to Sidebar I-1 of CLABSI

Monograph, page vi)

Prevalence of HCAI in Developed Countries (corresponding to Figure

I-1 of

CLABSI-Monograph Preventing Central Line–Associated

Bloodstream Infections: A Global Challenge, A Global Perspective,

page viii)

Prevalence of HCAI in Developing Countries (corresponding to Figure

I-2 of

CLABSI-Monograph, page ix)

Intrinsic and Extrinsic Risk Factors for CLABSI (corresponding to Table

1-2 of CLABSI Monograph, page 4)

Intrinsic Risk Factors for CLABSIs and Susceptible Populations

(adapted from CLABSI Monograph)

Routes for Central Venous Catheter Contamination with

Microorganisms (corresponding to Figure 1-1 of CLABSI-Monograph,

page 5)

CUSP Vascular Access Device Training Slides and Quiz

Potential Educational Delivery Methods and Reduced CLABSI Rates

(adapted from CLABSI Monograph)

Bloodstream Infections: Useful Tools, An International Perspective. Nov 20, 2013. Accessed [user please fill in access date].

http://www.jointcommission.org/CLABSIToolkit

Organizational Self Assessment

Question Tools

Does the organization have an

effective hand hygiene

program?

World Health Organization’s “My 5 Moments for Hand Hygiene”

(corresponding to Figure 3-1 of CLABSI Monograph, page 43)

WHO Guidelines on Hand Hygiene in Health Care

o Handwashing Technique with Soap and Water (See

Figure II.2, p.156)

o Hand Hygiene Technique with Alcohol-Based Hand

Rub (See Figure II.1, p.155)

Complimentary Hand Hygiene Educational Resources

2011 CDC Hand Hygiene Guidelines to Minimize CLABSI Risk

Does the organization make

multiple types of catheters

available?

Comparison of the Major Types of Central Venous Catheters (CVCs)

(corresponding to Table 1-1 of CLABSI-Monograph Preventing Central

Line–Associated Bloodstream Infections: A Global Challenge, A Global

Perspective, page 3)

Pediatric Vascular Access Devices

CDC – FAQ About Catheters

Visual Depiction of Each Type of CVC

Antimicrobial- or Antiseptic-Impregnated Catheters Utilization

Algorithm

Article:

“Device Selection: A Critical Strategy in the Reduction of

Catheter-Related Complications,” with chart on Vascular Access

Device Selection.

Reprinted from Nutrition vol. 12, no. 2, M Ryder, Device Selection: A

Critical Strategy in the Reduction of Catheter-Related Complications,

Inc.

Does the organization have

standardized insertion

procedures?

Aseptic versus Clean Technique

CUSP Line Cart Inventory

CVC Insertion Checklist Sample Documents:

o Virginia Mason Medical Center – Central Line Bundle

Insertion Checklist

o Virginia Mason Medical Center – Surgical Safety

Checklist

o Johns Hopkins Hospital Insertion Checklist

o Beth Israel Medical Center – Central Line Checklist

o BJC Vascular Catheter Insertion Checklist

o Scotland - CVC insertion checklist

Central Line Insertion Checklist—Template | Word Document

Bloodstream Infections: Useful Tools, An International Perspective. Nov 20, 2013. Accessed [user please fill in access date].

http://www.jointcommission.org/CLABSIToolkit

Organizational Self Assessment

Question Tools

CVC Insertion Bundles

CDC Dialysis Bloodstream Infection Prevention Collaborative

audit

tools, protocols, and checklists

• CDC’s dialysis checklists portfolio

• CDC’s dialysis audit tools portfolio

Open Versus Closed Intravenous Systems (corresponding to Sidebar

3-1 of CLABSI Monograph, page 49)

CDC Hemodialysis Scrub the Hub Protocol

NHSN Central Line Insertion Practices (CLIP)

Does the organization have

standardized maintenance

procedures?

CVC Maintenance Bundles

Daily Central Line Maintenance Checklist - Template | Word Document

CUSP Central Line Maintenance Audit Form

CUSP Event Report Template

CUSP Care of Patient with Peripheral Line

CUSP Care of Patient with PICC Line

CUSP Care of Patient with Short Term CVC

CUSP Care of Patient with Tunneled CVC of Implanted Port

CUSP Care of Patient with Hemodialysis Catheter

CUSP Care of Patient with Hemepheresis Catheter

CUSP Blood Drawing from a Hemodialysis and Hemepheresis

Catheter

CUSP Care of Patient Receiving PPN/CPN

CUSP Accessing/Deaccessing Implanted CV Access Port

Does the organization have an

active evaluation program for

CLABSI?

2013 CDC Central Line-Associated Bloodstream Infection (CLABSI)

Event Definition

CLABSI Fact Sheet (Source: Quality and Safety Research Group,

Johns Hopkins University)

Examples of National and International HAI Surveillance Systems

(corresponding to Table 5-1 of CLABSI Monograph Preventing Central

Line–Associated Bloodstream Infections: A Global Challenge, A Global

Perspective, pages 87–89)

WHO Assessing and tracking patient harm – A methodological guide

for data-poor hospitals

Pooled Cumulative Incidence Densities for CLABSI in Adult ICU

Patients, WHO Data 1995–2010 (corresponding to Table 6-2. of

CLABSI Monograph, page 105)

Bloodstream Infections: Useful Tools, An International Perspective. Nov 20, 2013. Accessed [user please fill in access date].

http://www.jointcommission.org/CLABSIToolkit

Organizational Self Assessment

Question Tools

CLABSI Rates per 1,000 Central Line–Days in Limited-Resource

Countries (2002–2011) (corresponding to Appendix B of CLABSI

Monograph, pages 115–118)

Benefits, Essential Components, and Limitations of Electronic

Surveillance

Steps in Evaluating Electronic Surveillance Systems for Potential

Incorporation into a Facility

Egyptian Surveillance forms

o Surveillance Form 1

o Surveillance Form 2

SICU Monthly Survey

Outcome and Process Performance Measures (adapted from CLABSI

Monograph)

Does the organization have the

tools for involving patients and

families in avoiding CLABSIs?

American Thoracic Society Patient Education Material – Central

Venous Catheter

CDC Central Line-associated Bloodstream Infections: Resources for

Patients and Healthcare Providers

CDC Frequently Asked Questions about Catheters

CDC-SHEA Patient Guides: FAQ’s about catheter associated blood

stream infections

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