 Because it's trash hard to do, really. It does, but you wouldn't believe how loud the window is. Well, no. It was. It's a truck train. I don't have a very long life span. Right? None. I thought you meant maybe here? I thought you meant here. He's like, no, but I told my classmates that. No. They can hear, though. Yeah. We can try that out. I think I have five right now. You'd have to have. We'd have to have. Real animals. No, you'd have to have like a white, not a decorative one. Hi, everyone. We appreciate all of you who have joined in early. We are about 10 minutes away from getting started. So just wanted to say hello and we'll be getting started in about 10 minutes. Hi, everyone. This is Ariana from the patient safety movement foundation. We're five minutes away from starting. You may have noticed that we've muted everyone on entry just to make sure that there is low interference. So we will take questions at the end and we'll get started in about five minutes. So thanks again for all of you who are joining early. All right. Good morning to everyone who is on the line today. It may be afternoon your time. So welcome. This is our webinar. The patient safety movement foundation is presenting getting to zero central line associated bloodstream infection. And we have some wonderful speakers today from two organizations. So I would like to get started. I'm sure by the time I get to the next slide, it'll be nine o'clock Pacific time. So as we talk through our agenda for the day, I will start out introducing you all to the patient safety movement foundation and our actionable patient safety solutions, which we call our app. I will be brief because we do have two sets of speakers today. So we're planning about 40 minutes of expert presentation. And then we'll leave 10 minutes at the end for questions and answers. So to get started, we are the patient safety movement foundation and our goal is to eliminate preventable deaths in hospitals by the year 2020. We often call that zero by 2020. And that's what you see on the screen now. And we focus on the very bold and audacious goal of zero because we truly believe that one preventable patient death is one too many, especially when we have initiatives and protocols for understanding the problems and presenting solutions. So the patient safety movement foundation again is fostering new efforts by building on to existing patient safety programs through commitments to zero. So the patient safety movement foundation was started in 2012. We had our first meeting in 2013. And we were founded by Joe Keane. He's also a well-known entrepreneur and engineer who started the medical device company called Massimo. And it was at that time that the Institute of Medicine created the report to Eris Human. And that time estimate was that between 44 and 98,000 Americans were dying preventably. This obviously caused a lot of people to start focusing on patient safety. And for that we're really glad. It took us until 2012 to really start honing in on it and launching the patient safety movement foundation. And that was mainly because in 2010 the Office of the Inspector General produced a report that said that about 182,000 beneficiaries of Medicaid and Medicare were being adversely affected in hospitals. And so between that 1999 and 2010 that estimate of preventable deaths in the hospital spiked from about 98,000 to about 182,000 just for that population within CMS. And so at that time Joe started thinking, you know, it's been a decade since that initial report. What can I do in order to bring together the healthcare ecosystem? And so we determined that the best way to do that was to take action and create opportunities for organization to participate in the patient safety movement to get closer to zero preventable deaths by 2020. So the first group that we work with our hospitals and healthcare organizations, we encourage them to make public commitment around how they're improving patient safety within their institution. This can be an existing program that they're really proud of and have been successful reducing instances of harm and death. It can also be an opportunity for goal setting in a lot of developing countries that we receive commitments from. They use our platform as a way to share what they plan on doing and learning from those organizations who have committed through our foundation. At this time we have 4,598 hospitals and healthcare organizations across 44 countries who are participating. The second group, our partner, we ask them to sign commitment to action letters. These can be organizations like associations, professional societies, advocacy groups, and other nonprofits who are helping to push the same message forward, patient safety. And so we come up with customized ways that partners can work with us and we post those publicly on our website as well. At this time we have about 55. The third group that we work with which makes us very unique is working with healthcare technology companies. We ask them to sign a letter. It's a pledge. We call it our open data pledge. And we encourage healthcare technology companies that are producing patient data through the devices and products that hospitals purchase. Or systems that are interconnecting those like electronic health record companies to sign a pledge that says that they will not knowingly interfere or charge for data sharing in order to improve patient safety. To date we have over 83 companies who sign that open data pledge and we're really proud that we're making progress to get more types of healthcare technology companies to join us. The fourth group that we work with are patients and family members. We not only encourage people in the public space to share their stories with us, instances of harm that they may have survived or family members survived, or potentially the tragic cases of those people who lost their lives due to a preventable medical error. We also encourage and ask actively for patient and family perspectives in every area that the Patient Safety Movement Foundation works, including our board levels, the workgroups that we have around the actionable patient safety solutions that we're gathered here around today. And really helping us identify resources that could be helpful to other patients and family members. So with that I'm going to focus real briefly on our actionable patient safety solutions. So these are the 16 evidence based best practice documents that we've put together over the last six years. And as you can see there's some small print on the right hand side. I hope you can read it. But we have 16 overarching challenges which are healthcare-associated infections, medications, neonatal safety, obstetric safety, embolic events, just to name a few of those. And then if you see underneath there are sub apps as we call them where for instance today we're focusing on two S, our central line associated bloodstream infection. So kind of a sub topic over the overarching healthcare-associated infection. Not yet in mobile form. They are PDFs that you can download and encourage your leadership to look at. If you are in a leadership position we encourage you to download these freely off of our website and use the executive summary checklist which is the first page of each document to really determine if your organization is positioned to get close to and hover around zero for any of these topics. So with that I will just share briefly. I mentioned this before. The number of hospitals that we have committed to the patient safety movement foundation, again those are the groups that are the hospitals that are sharing publicly what initiatives they're working on and how they have a plan to achieve zero. We have 4,598 across 44 countries which has grown steadily since our inception in 2013. What I wanted to focus on is that these hospitals by sharing how their improving safety can help others emulate their successes. Just those 4,598 hospitals in our network they claimed over 81,533 lives were saved in 2017 alone. This was reported in February earlier this year. And this shows that by putting in place processes we truly can save lives together. So with that I hope that was a helpful introduction to the patient safety movement foundation if you are just learning about us for the first time. I am now pleased to pass over to the University of Vermont Children's Hospital. We have two distinguished speakers, Sarah Burton and Rebecca Bell who will lead us through their set of slides around getting to zero. And then we will also have Susan Azarian from Tri City Medical Center follow shortly after with their perspective. So Sarah and Rebecca you can take us away. Thanks and thanks for having us. So I'm Becca Bell. I work in the pediatric ICU at the University of Vermont Medical Center and with Sarah Burton who is our neonatal nurse educator. And the University of Vermont Medical Center is located in Burlington, Vermont. We are near Lake Champlain and sort of are near the border of New York so we take care of patients both from Vermont and from Northern New York. And we are the major academic medical center. We have the College of Medicine here as well as the College of Nursing. Next slide. For our pediatric patients we are Children's Hospital within a hospital. We have a general pediatric floor which includes our neonatal transitional unit as well. We have a neonatal intensive care unit and then a pediatric intensive care unit which is a little bit of a unique model we share space with a surgical ICU group with nurses trained in both and so we have the flexibility to go up to 15 beds if needed although our average census is closer to five or six. Next slide. So we have looked at the Children's Hospital at many different hospital acquired conditions or infections and this is a chart of our CLABSIS and as we were having a increased incidence of CLABSIS in 2015 we decided as the department that we really needed to take a look at this so formed a team there and since that time we've had two periods where we've had no CLABSIS. Next slide. Hi, this is Sarah Burton now. So we, around that time we have a wonderful woman named Kathy Brown she's our quality program coordinator for the Vermont Children's Hospital and she reached out to us and said what can we do and we joined forces with people around the hospital to form a committee on focusing on CLABSIS prevention and what we really wanted to do is get representatives from all key pediatric areas. We really wanted to try to get different roles involved to make it very interdisciplinary and include those that may not be so obvious we have people from the IV team quality nursing and provider reps, bedside nursing as well as educators from the different pediatric units and we also had a family advisor join forces with us for a little while and just calling on others as needed such as our EPIC team to help with making some improvements with our electronic health record system. Next slide. So we determined at that point that it would be a good direction for us to take by joining forces with the solutions for patient safety and much like the patient safety movement this is geared toward children's hospitals specifically and it's a network of 130 plus children's hospitals that share the goal to urgently reduce and then eliminate serious harm for children being cared for in our facilities. So they really take an all teach all learn collaboration I really see a lot of similarities between this group and the patient safety movement they help provide benchmark data give guidelines on best practice they have many QI audit tools there are webinars and there's great ability to network on their website with other units both on a regional level as well as a national level and they do conferences as well. Next slide. So we're not going to go into great detail but we have a couple the next couple slides show the prevention bundles that they have specifically on CLABSIS they do have different ones for different hospital acquired conditions but this is the insertion bundle for CLABSIS prevention and then there's another one for maintenance which is on the next slide and then Becca is going to talk more about the auditing process Next slide. So we split our team up into those who would look at insertion and those who would look at maintenance in terms of preventing CLABSIS So for the insertion piece the first thing we did was look at the SPS best practices and then we looked at our own documentation in our EHR to make sure that those were the same and they were and so then our next step was to actually audit all of the central line insertions from pediatric patients in the hospital regardless of where they were placed whether it was the ER, the PICU, the NICU the operating room interventional radiology and we made sure that every central line insertion was associated with documentation of the best practices We did identify in the NICU the nurse practitioners who were placing the lines had their own note template that didn't include all of these practices and we did do some education with that group so then they began to use the central line navigator in our EHR Then the next piece was looking at maintenance and so we had nurse champions on each unit do some sort of random auditing looking at dressings looking at the dressing change process and that was really helpful for us in the sense of what things we were following and what things folks were having trouble with so that we can make a plan for intervention We noted that dating of the dressing was an issue so there was some education around that and then we felt in general that dressing changes deserve more attention and work together to make an educational tool which there we'll talk more about Next slide And then we also wanted to look at what we were doing well One of the big pushes is to make sure that any provider placing a central line is really proficient and this is something that we do well in the pediatrics department so we feel strongly that the most senior provider place a central line and we have a core group of people doing that so we feel that any trainees that need to place central lines because they're going into a field field because they're going to a field where they'll need to do that then they would learn that in their fellowship but otherwise residents and certainly medical students don't need to place central lines and so in the PICU we just have PICU attending placing central lines and the NICU it's just the NMPs and the PAs and that way they're doing many lines and have become really proficient in that as far as maintenance the NICU has a core group of experienced nurses that do the line changes and then we had been in all the units doing a pretty good job of assessing and documenting need for a line and when the line can be removed The other piece that was a little bit unique was that we have a built-in system in our EHR for the NICU patients where once they reach full there's a prompt that reminds the person to consider removal of the line if it's not needed anymore and then we felt that our group was a pretty motivated group and we met pretty frequently and that helped us kind of move things along and implement changes and then we also credited just our hospital-wide culture of safety in making some of these changes and we're going to talk about the educational tool that we implemented. Next slide. So around the same time that we were working on all of this one of our nurses was in his master's program and he joined forces with us to create a pow-toon video that we could use for education and roll out to our staff on kind of emphasizing these key points of the bundle and so this is just a picture of the we didn't want to show the whole video but this gives you a sense of what was in the video going through all of the steps and then you can see in the next slide. So just a fun way to capture people's attention and then we also included this with our annual nursing competency process on how to, you know, improve our workings with Central Line. Next slide. Then we thought we would just cover some things that were kind of unique that we implemented in the NICU and one thing was that we purchased procedure cards that were meant specifically for doing line changes. I think one thing that is a challenge for us and probably in other NICUs is that currently we're an open-day model until we move to our new unit there's always an issue for us so there's not always at the bedside to have a nice clean, clutter-free place to do line changes and so these carts can be moved around the unit and they have an IV pole and the drawers have all the supplies needed to do their line changes. We also started using KerosPAPS as a standard for all of our lines whenever they were packed off and we also have a disinfection unit which uses UV light and that is right by the entrance where staff and family can put their phones in and clean while they're washing their hands because we know that they're going to be using their phones to take pictures and things like that in the unit. We also have these sterile procedure signs that we can mount by the bedside when they're doing a line insertion and that just helps raise awareness that this is going on and to give the space needed to do that. Next slide. So we felt that one way to get to promote awareness and buy in from all staff members because everyone plays a part in emergency prevention was to celebrate our successes and so when we had those two periods or we had zero pediatric CLABSIS, we celebrated. So each unit had a lunch or dinner depending on whether it was day or night shift. We had signs up. We presented some of our work at quality forums and this was just a really nice way for everyone to be aware of the work that we're doing and the need to work hard every day to prevent CLABSIS. Next slide. And then we're continuing to find new ways to maintain low CLABSIS rates and to continue with our success. So we felt as a group that the auditing piece was difficult and we're trying to find a better way to formalize this which Sarah will talk about in a bit. We do partner with a company that makes Biopatch and they do quarterly audits at our hospital among our pediatric patients but also adult patients and then they give a report to our CLABSIS hospital-wide committee on what issues we've been having any failures and then what specific units might be having trouble with and that's a way to get pretty good real-time feedback and then representatives from the units can go back to the units and give those results and work on improvement. The central line insertion piece we've decided as a hospital that any provider placing a central line really needs to show competency not just in the technique of placing the line but in the sterile aspects related to that and so we're using we've partnered with our simulation center and every provider is going to need to go through a course where they show competency and then before placing the line they'll show the bedside nurse that they've completed this competency. As I mentioned we in the pediatric department we don't have residents placing lines but in the in our hospitals that certainly some of the adult specialties the residents are placing lines so they're going to start with the trainees going through the simulation and then move up to all the attendings who are placing lines. And then for the maintenance piece the dressing change was really an area that we could could use a little bit more work and so some of our nursing leaders have looked into improving the kit the sterile kit used for dressing change identifying the fact that sometimes some pieces were missing and we were having to pull out different pieces and so they are piloting a few different types of sterile maintenance kits and we're going to use those on the unit and get some feedback and move forward with getting those in the kit. Next slide. So we actually learned about this through SPS and it's we call them K cards but it's Kamishi by cards and what it is is a visual audit tool and it's meant to be peer to peer and then going you can use it for different hospital acquired conditions and use like a rack holder as a way to display your results. So one side of the card is green and the other side can be red or orange meaning that you did not meet all the elements of the bundle and essentially you can pick a couple staff for each shift and then say okay I would like you to go around and audit on this particular hospital acquired condition so CLABSI for example and then they look at all the elements of the bundle with the nurse who's caring for that patient and then it's a way to make sure they're following all the elements and make corrections on the spot and also help identify reasons for when elements are not there and identifying what are the systems issues or what can we do better and make improvements. It's also a way that could potentially engage patients and families so if they're there they can also help by get involved and make sure that the nurses and themselves are following these elements to keep their child safe. So we know that you know getting to zero is a journey it's not a straight line there's always room for improvement and this is a way that we can try to continue to get the momentum to go forward by using K-Cards. That's it from us. Thank you. Great. Thank you, Sarah. Thank you, Rebecca. We really appreciate your perspective from your facility up in Vermont. So with that I'd like to pass it on to Susan to carry us on. All right, thank you. We're welcome and thank you for joining the webinar this morning. I am Susan Azarian. I know it says Annette Reed-Lily as well on our slide but she is ill today so you're stuck with me. I'm a staff nurse and also have a major role in the NICU at Tri-City as the PIC team coordinator. I formulated the beyond the bundle plan for cloud-tooth prevention over eight years ago and since then we have had a zero rate in pick line infection. Hopefully some of this information will be of use to you and I'm happy to share it today. Tri-City just for background is an acute care hospital located in California which is in northern San Diego County. We're a community hospital and have a level three NICU which has 20 licensed beds. We accommodate about 500 internal admissions and 100 external admissions each year. Moving on. Moving on, sorry, okay. This graph is Plappedi data prior to the NICU developing our own central line team and the takeaway is that our numbers really vary greatly because we didn't have a consistent methodology for addressing all lines all the time. You can see in 2008 our Plappedi rate was 9% per 1,000 central line days and it dropped to zero in 2009 and back up to 2010 at 2.3 per 1,000 central line days. But we have tributar success to combine intervention of a Plappedi prevention bundle and really a dedicated central line team which we refer to as our bundle implementation. The process was developed in late 2010 and we implemented it in 2011. Moving on. There you go. Prior to 2007, our central lines were placed and guided at physician discretion. The neonatologists decided which patients qualified for central lines, educated families, and they determined when the lines would be discontinued. The NICU initially started training nurses to place picks mostly for the doctors to be more flexible in their other duties in labor and delivery. So training of the pick nurses was really in response to interruptions in the NICU patient care flow when they get a call from L&D to go to delivery and not about Plappedi prevention in the early years between about 2007 to 2010. There were some bundle elements in place but they were not strictly enforced and we ran into the problem of who do you hold accountable if a central line stays in too many days. Or how could the physicians monitor how a central line tubing change was performed or how a medication was attached because it really weren't at the bedside. We noticed a major disconnect but weren't exactly sure how to fix the issue at the time. It wasn't until August 23, 2010 when an X26 six-weeker named Isaiah had embolk lines contracted a central line infection. The NICU nurses had grown very close to Isaiah and we knew his family intimately so we really took it to heart. And that was a wake-up call for all of us. That was the moment that we knew we had to change the culture in the NICU with regard to central line care and infection prevention. Moving on. We knew we had to own the entire process. The decision was made to take over the entire Plappedi process because one Plappedi is too many. And the cost of not just financial is too great. But our answers were trained already, band together to control this process. We most closely followed NAN guidelines and that's the National Association of Neonatal Nurses and their bundle elements. At the start of this endeavor we did an evidence-based literature review which revealed that utilizing a team approach was most effective in reducing Plappedi rates. So in 2010 our RN-based PIC team became fully formed. Introduction of this dedicated nurse-based Plappedi team has been successful in our NICU and is probably the single most important change to keeping our Plappedi rate at zero for PIC lines for more than eight years. Our founding principle is one Plappedi is too many. We all know Plappedi's affect many individuals on many levels. The baby has to endure increased pain and suffering, antibiotic therapy, probable increased length of stay. The family may endure increased anxiety, issues with bonding, and a greater financial burden while the NICU staff is also negatively impacted. Moral and workload can be affected and the hospital may be affected by increased financial burden, mandatory reporting to healthcare agencies and more. Our NICU is proud of our accomplishments today and are working diligently to keep zero going. Moving on. So when we first got together in 2010 our NICU team fully formed and focused our prevention processes on these four areas. Education, insertion, maintenance, and removal. We wanted to look at the details of every single one of these to see what we could do and how to form our process. So first we'll look at education. Moving on. The first focus is education. We had to develop an entire educational process basically from scratch. Education includes initial training and ongoing competencies for PICC team members. We ensure a competent proctoring and expect each PICC nurse to maintain quarterly minimums for successful insertions. By annual leave or every two years PICC team members go through an eight hour course that contains both didactic and hands-on elements. Recently we found that we had a need for training of a subset of nurses to active mentors for the night shift because our PICC team is taking day shift positions. So and there's a lot of new staff on night shift. Because of this need we developed a central line super user designation and new course to correspond. These super users are given a more in-depth hands-on course and education on bundle elements and it's seen as the super users and expertise in that night shift. All staff have had didactic training courses for several competencies and they vary. Sometimes we do dressing changes, tubing changes, line discontinuation, etc. We also look at education of ancillary staff and family education. We did develop new educational handouts in English and Spanish for our parents because Spanish is the main secondary language of our patient population. Moving on. We looked at prevention from the insertion view point. We asked ourselves so what can we do regarding insertion to decrease our class B rate. First we decided that all procedures needed to be two persons to increase awareness of breaks in any serial procedure. We changed the culture of Tri-City so the bedside nurse will advocate for central lines for their patients in need during rounds. Most babies requiring seven or more to visit at Tri-City and the bedside nurse is empowered to advocate for that line so this is no longer physician driven it's really collaborative. Insertion checklist needed to be developed and we use NAN as our guideline as a resource for this checklist. We use time out posters as a reminder to do the time out prior to the procedure and we really empower all staff to stop if there's a break in and we have big stop signs around the unit as well as time out posters as well. Then we looked at product utilization. Designed our own pick insertion kit. We have had success with the BD introducer but have had changed catheter several times due to increases in phlebitis or other complications. We redesigned our clip form which is Insterner, our electronic record. The clip is a central line insertion monitoring tool for California and it's enabled us to have better data to monitor compliance, complications and class D rates. Moving on to maintenance. We then looked at how we can maintain these lines to reduce the risk of infection. Maintenance encompass the entire staff focusing on how to ensure the serility of the fluid, medication administration, tubing changes as well as appropriate dressing changes. As mentioned before, all staff were required to attend educational classes which focus on appropriate osmolarity and pH of maintenance fluids and medications sites and dressing assessment and proper sterile techniques for all tubing and syringe changes. We also had nurses perform competencies and proper sterile dressing techniques using a customized dressing change kit. We instituted a daily bedside checklist which I will show you later which empowers the bedside nurse to be responsible for the line maintenance bundle elements each shift. So pick our end and a super user and the bedside nurse are assigned every shift to oversee that every line is assessed via this bedside checklist. Moving on. And lastly we took a look at the removal and what challenges that held for our class D rates. Of course it's important to assess for line necessities and you can't minimize the importance of getting that line out as soon as possible. I want everyone to think about it. I want the doctor to think about it. The nurse to ponder it and family to ask about it. Does the baby still need a line? Can an energy suffice for feeding? Are we close enough to full feedings and fortification? Or when is antibiotic therapy complete? All these questions must be asked every single time. The assessment of line necessities needs to be put into our medical records. When we remove the lines we do it as sterile procedure which was different than pre-2010 including a hat mask and sterile glass. And staff need to understand that the sterile removal is important because sometimes the line doesn't come out on the first try and then we need to redress it with sterile dressing so you're not able to do that. We usually then warm extremity and try again at a later time. Moving on. Institutions and websites identify a different claptid bundle elements. The most basic five are these above hand hygiene, maximum barrier precaution for insertion, chlorhexidine skin and deceptus, optimal catheter site selection and daily review line necessities. And these come from the Institute of Healthcare Improvement. Like I said there are a lot of entities NAND, the CDC, joint commission, etc. that have groupings of bundles. Moving on. What we knew that we had to apply and successfully integrate the recommended bundle elements but we also were determined to go directly to a zero claptid rate. And knowing that we decided to implement even further strategies that I'll share with you today and we nicknamed the groupings beyond the bundles. This included several items outlined here but of note is a daily bedside checklist. The baby's nurse and pick nurse formally look at the site, the dressing, the tubing chain sticker, medication port, any add-on devices, the heparin amount and the fluid, the dexterous amount and then the physician assessment of line necessity and complete that checklist together on every single shift, every single day until that line comes out. Worthy of mentioning is that this checklist is not perfect. It has been modified three or four times because we continually reassess what we need to look at, what is working and where we may be falling short in our audits. So this list though gives us the possibility to revamp the process and it's really the bedside checklist is super crucial to us. We also developed bedside placards which provided visual for all staff, family and visitors that the patient has a central line. They are just hanging, placards I'll show you a picture of in a moment, they just hang on the IV pool. So for instance, if our occupational therapist comes over to assess the baby, work on feeding, they notice the placard and they know to ask the bedside nurse for assistance prior to swaddling or lifting or moving the baby with a central line. We have added also different annual competencies for nursing staff whenever the need arises. Last year we required everyone do a return demonstration on discontinuing a central line using sterile technique. The year prior we had checked off each nurse on dressing changes and I know before that we had done tubing changes as well. Moving on. This slide is probably my favorite tool is there a picture of our bedside checklist I hope you can see it well enough it's a two person check again twice per day, one on each chest and the form can easily be customized to enable auditing of your best practice criterion. For instance if your unit is falling short in audits on labeling dressing then a line can be added to the checklist to address that particular issue. We have had problems with stickers, the appropriate sticker being on the add-on devices and so we added an item and one thing that is really important on this, we don't leave it so that it's just checked off, we actually make them right in words so that people don't get in the habit of just check check check check all the way down like we'll ask the first one says the flu is infusing so you have to write in D10 or D5 or whatever it is the heparin amount you can write either 0.5 or one unit so we don't just let them check in they actually have to spank through and do it like I said with either a super user or a pick nurse. Moving on, this is a photo of our bedside slacks as I said they hang on the IV pole and give a general visual to all that the patient has the central line we also included important reminders on various cards. You can see there's a stack of I guess like four cards there. We have reminders of when dressing should be changed. Reminders to use an auto microplane on all the medication lines and things like that. This placard is particularly for kicks but we also have a central line placard for umbilical lines and moving on then this is one of the cards behind that main one it's a reminder card and initially our ends were asking us for reminder of when sterile gloves need to be used versus exam gloves because this whole process was new to all of us in 2011 so when removing an old dressing we used just exam gloves but if you're applying a new dressing sterile gloves need to be utilized so the bedside placard is easy produced we laminate them put them on the bedside they can be modified based on every unit specific needs moving on teaching then this graph displays our class D rate prior to and after or beyond the bundle implementation it includes all PIC and umbilical lines since introduction of our nurse based PIC team the PIC line infections have remained zero since 2010 while we had one umbilical line in 2017 accounting for a 0.1% per thousand line day rate you can see 2017 bumps up a little bit so we were all over the place prior to 2011 and have been very successful and um with our commitment to beyond the bundle moving on so is our room for improvement um one important theme throughout our AER venture is the need to be flexible and is that the very best practice for the overall patient population moving on so the answer to is the room for improvement is absolutely yes there's always room for improvement you'll need to identify challenges and then realistic achievable solutions which is probably um the hardest part of this whole venture each facility has their own difficulties I know that one challenge just challenge for us is really our new hires we have to show them the culture that we've developed that we're diligent in all matters related to line insertion maintenance and removal and our expectations of them during the orientation have to reflect that culture parent education may be challenging there's different languages educational levels visitation schedule so processes with regard to dressings or tooling changes may have flaws and whatever it is don't be afraid to just continuously reevaluate your processes and your checklist and update them to make them more successful lastly your team must keep up to date with the latest research and incorporate that information into practice moving on uh do we now have the photo I had a photo of our pick team there we go this is the latest photo of our pick team and we want to acknowledge that our success to date is due to our entire team and also all the physician support the NICU staff support and NICU management and the next page are some references and finally we'd like to thank Claire and Ariana of the Patient Safety Movement Foundation for putting this webinar together and inviting me to speak today I appreciate it ladies thank you so much Susan, Becca, Sarah we really appreciate your perspective being out there in the field we wanted to pick a west coast spot and an east coast spot in order to encourage everyone out there who's on the line to obviously see what work is being done out there and I really love the focus on continual improvement because you know while zero is the goal there may be changes and unintended consequences of new technology and new people and new ideas that we'll always have to keep up on so we really appreciate the expertise from you three lovely ladies today and with that we have plenty of time for questions I'm going to turn it over to Claire to see if there's been any questions that have come through on the chat okay so if you all who are out there listening would like to chat on the web version please feel free we are going to attempt to unmute everyone but we may have to very quickly mute again just because there may be interference so just bear with us a second to see how much interference there may be when we unmute I just want to remember there's two numbers so 525 it was we've done college education out in many places to not do any changes okay we're going to okay so I think we're going to be able to do we're all okay so that didn't quite work I think you heard a lot of interference so what we're going to try to do is unmute people that we can see aren't interfering if possible we do have someone who just chatted in on the web and Laura would she be willing to share her checklist so I'm assuming that's for Susan yeah I don't know if you want to give them my email or if you guys want to interface and get emails from people and I can do that easily okay yeah if you're willing to do that what we can do is we'll send out an email to everyone following this with where they can find the presentation afterwards so if we want to just include a link to your checklist we can do that okay we also if people are interested have all the checklist for all our competencies as well we have addressing change competency we have an insertion competency and it's tubing line change competency if they want those great okay that person said thanks okay another question came through and it can either of both facility talk about what is in their addressing change kit and that's from Stephanie I can I wish I had one in front of me but it's basically everything except the sterile gloves we have sterile drapes we have suture remover to help we have core prep we have gauze and new Tegarderm is what we use to put over it sterile strips just everything we need is in one as well as um sorry sterile sally wipes everything we need is in one place and we just made them ourselves um through our distribution center downstairs so um Sarah or Becca did you want to add anything around your kit? Sure we have something sort of similar but it doesn't include the gloves it includes the the core prep um the new Tegarderm some gauze um some suture remover removal and um but what we're trying to do I sort of mentioned is get a package that actually has um includes those things plus the gloves plus the drapes and and the way that you actually open up the kit um is sort of piece by piece you open up the first part and you put the gloves on and then there are also um visual instructions on how to do that um and then with the biopatch as well so um we're piloting those products I think one is from from Medline um but we're trying a few different types. Great I have another question from Dee Santos to uh Sarah and Becca and it's how long is your platoon and did you require staff to complete? Hi yes uh I believe it's a couple minutes long and yeah like three minutes and we yes we did require all of our nurses to watch that. Great it's on you too we could probably share the link too. Oh that would be great we can include that and we have another question from Kathleen Bolden and it's what are you doing for bathing patients less than two months old or greater than two months old with a central line pick of CVC. Think pick or CVC. Okay. Just a typo. Oh I don't know what you're asking um what we do is we do swaddle bathing but we just use that one leave the arm or the leg or whatever extremity out of the tub and do the same um just pH neutral soap and bath and then let the parents do it but the nurses there watching and ensuring that the line is safe and dry. Any perspective from UVM? No we do the same great great another follow-up question from Kathleen is are you using the pocket technology for the dressing kit? I do not know what that is what she said pocket technology. Yeah pocket technology I'm gonna have to look that up now yeah I think that's what sorry this is Becca from UVM I think that's what I was referring to so so the I'm using my hands but no one can see this but it is it is sort of a folded pocket kit. So you open it up and you open the first pocket and in that pocket there are gloves with a picture and then you put those on and you open the next pocket so that's that's exactly what we're piloting right now and it seems like a really good product we've all taken a look at it great great we don't have any questions at this time so if anyone wants to write in feel free in the meantime what I'll do as we wait is I do have one other slide that I wanted to show just promoting and making everyone aware of some other events that we have going on so again we if you still want to write in on the chat box on the web if you have any questions that would be wonderful for those of you who are calling in who may have questions and we aren't able to go off of mute because there's interference if you have questions please feel free to send them to us afterwards and we can try to field them as necessary we appreciate your flexibility with the technology that we have so real quick for save the dates from the patient safety movement foundation we have two annual events each year our major planning meeting is actually this coming Monday on September 17th here in Irvine California we're sold out so for those of you who will be attending we look forward to seeing you for those of you who missed out we hope to see you at our meeting next year we also wanted to let you know that we have a patient safety newsletter that is digital and our October issue will focus on our actionable patient safety solution challenge number 16 which is person and family engagement it'll be released the first week of October so if you do not currently get those you can sign up for free to receive that newsletter on our website by following our progress we also want to let you know if you're in California area we have our first annual makes a save soccer tournament fundraiser and so we will be having 12 teams compete to raise money to improve awareness around medical errors and our goal of zero preventable deaths it's October 6th a Saturday at the Orange County Great Park registration is still open so feel free to donate if you're in the area we'd love for you to come by and cheerlead I am not athletic so I will be on the sidelines not playing our next quarterly webinar is a special interest topic on metrics integrity we have a special interest workgroup on the topic and Robin Betz who is at Kaiser Permanente Northern California will be speaking on that topic on December 12th and last but not least our main event of the year is our world patient safety science and technology summit it'll be held this January 18th and 19th which is a Friday and Saturday at the Hyatt Regency Huntington Beach Resort and Spa in Huntington Beach California registration is open so we hope that we will see you all there it doesn't look like anyone else has chatted in so with that we will give you seven minutes back to your day so we really appreciate your time again back to Sarah and Susan thank you so much and we look forward to meeting you all again on a webinar or another event in the future thank you so much for having us thank you take care right bye bye