Evidence-Based Strategies for Cost-Effective Occlusion Management
Guest Author: Lee Steere, RN, CRNI, VA-BC
Eloquest Healthcare is excited to welcome Lee Steere RN, CRNI, VA-BC to the Eloquest Healthcare Blog! Lee Steere, RN, CRNI, VA-BC has been leading the IV Team at Hartford Hospital for nearly 20 years. At his facility, all PIVs are inserted on inpatient units by the VAST team using a bundled approach. Lee has spoken at multiple local and national infusion/vascular access conferences on CLABSI prevention, CVAD occlusion management, and PIV insertions using a vascular access nurse and a bundled approach. Lee is a member of the hospital’s HAI committee and is the chair of the HHC Patient Care Clinical Value Team. He is the author of multiple peer-reviewed publications and is the principle investigator of an on-going randomized controlled trial.
Catheter Occlusion Management
In 2014, Hartford Hospital’s Vascular Access Specialist Team (VAST) began evaluating catheter occlusions and the subsequent administration of tissue plasminogen activator (tPA). We are a LEAN facility and during one of our morning huddles – where idea generation is discussed – our VAST wanted to evaluate the waste associated with tPA usage. Part of this idea was to evaluate the effectiveness of moving from a first- generation neutral needleless connector to an anti-reflux design, the TKO-6P.
Our first main goal, at that time, was to see if we could reduce tPA by 50% from our baseline average of 119 mg’s per month. Our second goal was to eliminate our Heparin flushing protocol of all central lines. Intraluminal thrombotic occlusions can lead to costly interventions – tPA administration at approximately $75.00/mg, catheter replacement and CLABSI, all of which can lead to extended hospital stays that result in increased healthcare costs and poor patient outcomes.
Using Heparin puts patients at risk of Heparin-induced thrombocytopenia (HIT), a life-threatening condition that results in thrombosis that can result in deep vein thrombosis (DVT) and pulmonary emboli. Based on these clinical facts, we felt that eliminating Heparin and reducing tPA usage was the right and safe thing to do for our patients, following two of our 4 Core Values at Hartford Hospital. We felt the only way this would occur is if we evaluated and implemented the TKO-6P.
We choose the TKO-6P for many reasons. It is clear, allowing the nurse to see if blood residual left post flushing. It offers bi-directional blood flow control. It contains a 360-degree compressible seal, preventing bacteria ingress inside the needleless connector housing. Additionally, no clamping sequence is required as the silicone diaphragm opens and closes only when pressure applied to a syringe when flushing or when drawing blood.
Following a successful 3-month trial in our 5 ICU’s, we implemented TKO-6P on all our CVC’s and eliminated our Heparin flushing protocol. In addition, we developed an algorithm for central line assessment and implemented it with our VAST. With this, the VAST now controls the majority of tPA administered for catheter clearance, eliminating the use of tPA before identifying whether catheter patency failure associated with a thrombotic versus a mechanical occlusion.
An incidental finding during our trial with TKO-6P found that ward nurses were ordering tPA prior to assessing the line, essentially using it as a first intervention versus the last after a thorough, careful assessment for mechanical occlusions. The algorithm’s first step is evaluating the need for the line. An additional step in our algorithm was evaluating the tip of the catheter looking at a recent chest x-ray. Many doses have been prevented with a careful analysis of the line prior to ordering the tPA.
Sustained Results (26-Months)
In 2018, we published in JAVA, titled, “Lean Six Sigma for Intravenous Therapy Optimization: A Hospital Use of Lean Thinking to Improve Occlusion Management.” This captured results during a 26-month period. During this time, we achieved a 69% reduction in tPA usage, with a subsequent savings of $107,315.00.1 With a baseline of 119 mg per month for 2014, our reduction in 2015 was an average of 53 mg per month and 47.5 mg per month in 2016. With the elimination of our Heparin flushing protocol, we validated an additional savings of $28,887.00 annually.
Expecting no change in needleless connector consumption, we were pleasantly surprised to achieve a 41% reduction, which represented an annual decrease of 44,493 needleless connectors.1
Despite an increase cost moving from a neutral to anti-reflux needleless connector, with the reduction in usage, we were able to net a savings of $100,670.00 annually. Knowing CLABSI’s are multifactorial and that many interventions may have resulted in a reduction, in 2012, we had a total of 34 CLABSI’s. In 2016, we were able to reduce that number to 9. With one study, CLABSI associated with tPA use was 3 times of that of a patient’s who did not receive tPA.2 By decreasing our tPA usage, we felt it was important to include our CLABSI reduction in the manuscript even though multiple interventions have been instituted since 2007.
On-Going Results (5+ Years)
In 2022, we published a featured article in Clinical Nurse Specialist titled, “CLE3AR Study 5-Year Impact of LEAN Central Venous Catheter Occlusion Management & Quality Interventions.” Sustainability is essential in healthcare, yet not always easy to achieve. This manuscript was produced allowing a 5 year look back at the sustainability of our CVC program. Our study name has a duality; it refers to central line patency and (CLEAR) as well as the “3 E’s” of LEAN Six Sigma methodology (efficiency, effectiveness and economics) and the use of anti-reflux technology.
During the 5-year study period, we achieved a 71.3% reduction in annual tPA. We sustained our decrease in annual average needleless connector consumption of 41%. The 5-year cost savings were estimated to be $356,005.00.2
Unique to this study period was the COVID-19 pandemic, which saw an increase in central line usage across the country with an associated rise in CLABSI rates. Despite a 50.3% increase in central line days between 2017 and 2020, using our algorithm and anti-reflux needleless connector, we still were able to sustain a reduction as outlined earlier, while many hospital’s may have seen the opposite due to the hyper coagulopathy associated with the COVID-19 disease. Applying Lean Six Sigma principles, changing needleless connectors from neutral to anti-reflux and taking control of CVC occlusion management, the VAST at Hartford Hospital has been able to sustain improvements while demonstrating cost savings.
Eloquest Healthcare is committed to providing solutions that can help you reduce the risk of IV complications including occlusions, infiltrations, and catheter-related bloodstream infections. For more information about Nexus TKO-6P or to request an evaluation, please contact your sales consultant or Eloquest Healthcare, Inc. by calling 877‐433‐7626 or by completing this form.
- Lee Steere, Marc Rousseau, Lisa Durland; Lean Six Sigma for Intravenous Therapy Optimization: A Hospital Use of Lean Thinking to Improve Occlusion Management. Journal of the Association for Vascular Access1 March 2018; 23 (1): 42–50. doi: https://doi.org/10.1016/j.java.2018.01.002
- Thakarar K, Collins M, Kwong L, Sulis C, Korn C, Bhadelia N. The role of tissue plasminogen activator use and systemic hypercoagulability in central line-associated bloodstream infections. Am J Infect Control. 2014 Apr;42(4):417-20. doi: 10.1016/j.ajic.2013.11.016. Epub 2014 Feb 20. PMID: 24559598; PMCID: PMC4127324.
- Steere, Lee RN, CRNI, VA-BC. CLE3AR Study: 5-Year Impact of LEAN Central Venous Catheter Occlusion Management & Quality Interventions. Clinical Nurse Specialist 36(2):p 92-98, 3/4 2022. | DOI: 10.1097/NUR.0000000000000655