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Guidelines to Prevent Central Line Guidelines to Prevent Central Line Associated Blood Stream InfectionsAssociated Blood Stream Infections

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Why do I Need to Why do I Need to Complete this Orientation?Complete this Orientation?

• Problem – Vascular access device (VAD) associated infections increase

morbidity, mortality, hospital length of stay (LOS) and costs – Education of health care workers decreases health care

associated infections

• Intervention– Mandatory course to achieve standardization of infection

control practices during central vascular access device (C-VAD) insertion

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Why do I Need to Why do I Need to Complete this Orientation? (Cont.)Complete this Orientation? (Cont.)

1 Sheretz et al. Ann Intern Med. 2000;64:1-8

• Outcome– Education in another center1 achieved a 26% relative

reduction in central line infections & saved 1.3 million dollars

– Since implementation of this orientation, JHH central line related bloodstream infection (CLABSI) rates have decreased below the national average

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STATISTICS for CLABSIsSTATISTICS for CLABSIs

• 90% of all blood stream infections are associated with C-VADs

• 400,000 CLABSIs occur per year in U.S.

• CLABSIs are

– 1) Associated with increased morbidity

– 2) Associated with mortality rates of 10% to 20%

– 3) Associated with prolonged hospitalization (mean of 7 days)

and increase in medical costs > $28,000

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National Nosocomial Infection National Nosocomial Infection Surveillance (NNIS) RatesSurveillance (NNIS) Rates

• In 2003, NNIS (from the Centers for Disease Control & Prevention {CDC}) reported the number of CLABSIs per 1000 catheter days based on nationwide intensive care unit (ICU) surveillance

• Table 1 compares ICUs from one academic medical center to the national benchmark CLABSI rates

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Table 1: CLABSI Rate Table 1: CLABSI Rate per 1000 Catheter Daysper 1000 Catheter Days

 

NHSN 90th Percentile

NHSN 50th Percentile

Pre-VAD Training

Post-VAD Training

SICU 9.1 5.3 6.7 0.6

PICU 11.9 7.7 5.5 5.4

CVICU 4.9 2.8 7.6 2.7

MICU 9.8 6.1 7.8 3.3

CCU 7.9 4.6 5.0 1.2

NCCU 8.3 4.9 6.6 3.7

OncICU 9.3 4.7 N/A 1.6

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Risk Factors for CLABSIsRisk Factors for CLABSIs

• Site of insertion; subclavian vein poses less risk than internal jugular or femoral vein2

• Multiple lumen catheters-– increased tissue trauma predisposes to CLABSI– more manipulation and contamination of multiple ports/hubs

• TPN and/or lipids

• Low nurse to patient ratio

2 Merrer et al. JAMA. 2001;286:700-7

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Risk Factors for CLABSIs Risk Factors for CLABSIs (Cont.)(Cont.)

• Infection elsewhere (remote, ie UTI or wound) – secondary source

• Colonization of catheter with organisms

• IV catheterization longer than 72 hours

• Inexperience of personnel inserting the C-VAD

• Use of stopcocks

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Process of Process of Catheter Related Infections Catheter Related Infections

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Evidence Based JHH 5 Steps to Evidence Based JHH 5 Steps to Preventing CLABSIPreventing CLABSI

• Clean hands (waterless alcohol based hand sanitizer or wash hands with soap and water)

• Select best insertion site

• Use proper skin preparation (chlorhexidine)

• Use maximal barrier precautions

• Remove catheter as soon as possible

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Hand Hygiene:Hand Hygiene:When and Where?When and Where?

Wash hands with soap & water or use a waterless hand sanitizer

Before and after invasive procedures

Between patients

After removing gloves

Before eating

After using the bathroom

If contamination is suspected

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Hand Hygiene Does Work!Hand Hygiene Does Work!

Year Author SettingComparison

GroupResults

1982 Maki ICU (US) Crossover ↓Nosocomial Infection

1984 Massanari ICU (US) Crossover ↓Nosocomial Infection

2000 PittetTeaching Hospital,

SwitzerlandObservational

↓Nosocomial Infection↓MRSA Rates

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Infection PreventionInfection PreventionWaterless Hand Hygiene Steps:Waterless Hand Hygiene Steps:

• Coat all surfaces of your hands thoroughly with waterless hand sanitizer, including your palms, in between fingers and under fingernails, backs of hands and around wrists.

• Rub your hands briskly until they feel comfortably dry.

• It takes about 15 seconds, and no water or towels are needed.

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1. Wet hands

2. Obtain soap

3. Lather for 10-15 seconds

4. Rinse hands

5. Turn off faucet handles with paper towel

Infection PreventionInfection PreventionHandwashing Steps:Handwashing Steps:

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C-VAD Site SelectionC-VAD Site Selection

• Use the SUBCLAVIAN site unless medically contraindicated (e.g. patient has an anatomic deformity, coagulopathy, or has renal disease that may require dialysis)

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C-VAD Site Selection:C-VAD Site Selection:Special ConsiderationsSpecial Considerations

• For patients on hemodialysis, National Kidney Foundation 2000 Guidelines recommended against the use of the subclavian vein for any VAD unless use of the IJ vein is absolutely contraindicated. This is due to the risk of subclavian vein stenosis

• If the IJ vein is chosen, use the right side to reduce risk of non-infectious complications

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C-VAD Line Selection C-VAD Line Selection

• Use a single lumen C-VAD, unless multiple lumens are absolutely necessary

• Consider a tunneled or implanted C-VAD for patients

requiring long-term access (> 30 days), or a PICC or cuffed C-VAD for patients requiring therapy for >1 week

• Evaluate daily the need for C-VAD and remove when not needed or change to a single lumen C-VAD when possible

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Aseptic Technique: GoalsAseptic Technique: Goals

• Remove transient organisms and soil from the skin

• Reduce number of resident microbial flora and inhibit their rebound growth

• Create a sterile working surface that acts as a barrier between the insertion site and any possible source of contamination

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Aseptic TechniqueAseptic Technique

• Prepare skin with antiseptic/detergent Chlorhexidine 2% in 70% isopropyl alcohol

• Pinch wings on the “Chloraprep” applicator to pop the ampule. Hold the applicator down to allow the solution to saturate the pad. Press sponge against skin, apply chlorhexidine solution using a back and forth friction scrub for at least 30 seconds. Do not wipe or blot

• Allow antiseptic solution time to dry completely before puncturing the site (may take 2 minutes).

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Evidence supporting use of Evidence supporting use of Chlorhexidine: Skin Prep−Meta Chlorhexidine: Skin Prep−Meta

AnalysisAnalysis

Pooled RR for BSI

Ann Intern Med. 2002;136:792-801

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Maximal Barriers Required Maximal Barriers Required for C-VAD Insertionfor C-VAD Insertion

• Use face mask, cap and sterile gloves

• Wear a sterile gown with neck snaps and wrap-around ties properly secured

• Instruct anyone assisting you to wear the same barriers

• Drape the patient with a LARGE sterile drape that covers the entire patient

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Maximal Barrier Precautions (MBR) Maximal Barrier Precautions (MBR) Decrease CLABSI InfectionsDecrease CLABSI Infections

OR=odds ratio MBR= inserter washes hands and wears mask, sterile gown, sterile gloves and patient’s head & body are covered with a large, sterile drape

Author Design Catheter Type OR for Infection without MBR

Mermel / 1990Prospective

Swan-Ganz2.2

Cross-Sectional (p<0.03)

Raad / 1994Prospective

Central6.3

Randomized (p<0.03)

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Caveats: Catheter InsertionCaveats: Catheter Insertion

• IV antimicrobial prophylaxis does not reduce CLABSI1

• Insertion of C-VADs through open techniques/cutdown increases the risk of CLABSI

• Ensure adequate room to perform the procedure without risk of contamination

1 Ranson. J Hosp Infect. 1990;15(1):95-102.

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Post Insertion: C-VAD CarePost Insertion: C-VAD Care

• Antimicrobial ointments do not reduce the incidence of CLABSI

• Apply a sterile dressing to the insertion site before the sterile barriers are removed

• Transparent dressings are preferred to allow visualization of the site

• If the insertion site is oozing, apply a gauze dressing instead of a transparent dressing

• Replace C-VAD dressings when the dressing becomes damp, loosened, soiled or after lifting the dressing to inspect the site

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Replacing CVADsReplacing CVADs• Remove the line as soon as possible

• Routine C-VAD guidewire exchange or site rotation is not recommended1

• Guidewire exchange is acceptable for replacing a malfunctioning catheter or downsizing a PA catheter to a CVC

• Patients who clearly have a CLABSI should not undergo guidewire exchange

• Selected patients with suspected BSI and limited venous access may have their catheter exchanged over a guidewire and the catheter tip should be cultured

• Switch to a new set of sterile gloves before handling the new catheter

1Eyer et al. Crit Care Med. 1990;18(10):1073-9 .

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Suspected C-VAD InfectionsSuspected C-VAD Infections

• Remove the C-VAD in a patient with proven CLABSI (i.e., blood culture positive for a recognized pathogen with no identified secondary source)

• If a BSI is only suspected, or the C-VAD is not known to be the source, or the C-VAD cannot be removed, clinical judgment is necessary. Extensive, evidence-based guidelines exist for the diagnosis and treatment of catheter-related infections1

1 Mermel et al. Clin Infect Dis. 2001;32(9):1249-72.

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• Draw two sets of blood cultures from a patient with new episode of suspected C-VAD infection, preferably both sets peripherally

• It is not always necessary to remove the CVAD in a mildly ill patient with unexplained fever

• If the catheter is the suspected source of the infection, it can be changed over a wire and cultured. If the catheter culture grows 15 colony forming units of organisms, remove it and place at a different site

• Tailor antimicrobial therapy to the individual patient, based on severity of illness, suspected pathogen, and presence of complicating factors

Suspected C-VAD Infections Suspected C-VAD Infections (Cont.)(Cont.)

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C-VAD Line Cultures: C-VAD Line Cultures: IndicationsIndications

• The utility of catheter cultures is controversial

• Nonetheless, proper technique is imperative to evaluate the data. The catheter tip may be submitted for semi-quantitative culture if there is clinical suspicion of CLABSI

• Routinely removed catheters should NOT be sent for culture

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C-VAD Line Cultures: MethodC-VAD Line Cultures: Method

• Remove all dressings and cap off all hubs/ports, then paint the site with antiseptic solution, and include within the sterile field

• Remove C-VAD en-bloc. Under no circumstance should catheters be cut prior to removal

• Remove the catheter aseptically, avoiding contact with the patient’s skin and catheter tray

• Use sterile scissors (not the scalpel used to cut the CVAD sutures) to cut a 5cm segment, including the tip and place it into a culture container

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• A catheter culture yield of 15 CFU, accompanied by signs and/or symptoms of infection is consistent with a catheter-related infection

• Do not give antibiotics based on a positive catheter culture only, evaluate the clinical picture

C-VAD Line Cultures: C-VAD Line Cultures: InterpretationInterpretation

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Blood CulturesBlood Cultures

• Patients with a new episode of suspected catheter-related infection should have two sets of peripheral blood samples drawn for culture. In rare instances where access for peripheral blood draws is limited, one set may be drawn from the line and one percutaneously

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Peripheral Blood Cultures: Peripheral Blood Cultures: MethodMethod

• Don sterile gloves and observe Standard Precautions

• Apply chlorhexidine 2% in 70% isopropyl alcohol (Chloraprep Frepp) using a back and forth friction rub for at least 30 seconds over a 5 cm area

• Allow solution time to dry completely before puncturing the skin

• Do not touch the venipuncture site after skin prep except with sterile gloves

• Insert needle into vein and withdraw 20cc of blood (adults)

• Distribute the blood evenly between 2 culture bottles (10 cc per bottle), taking care not to inject air into the anaerobic bottle

• Always send a second set of blood cultures from a separate venipuncture site

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Arterial Line: Site Selection Arterial Line: Site Selection

• Radial artery is the preferred site

• Dorsalis pedis is an alternative

• Femoral sites have higher infection rates and risk of thrombosis

• Brachial/maxillary sites are a last resort, due to lack of collateral circulation

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Arterial Lines: Aseptic Arterial Lines: Aseptic TechniqueTechnique

• As with C-VADs, always:

– Clean your hands with soap & water or waterless hand cleaner

– Maintain Standard Precautions

– Perform a thorough skin preparation

– Use barrier protection

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Arterial Lines: BarriersArterial Lines: Barriers

• For radial or dorsalis pedis sites, create a generous sterile working surface using sterile drapes; wear sterile gloves and a mask with face shield

• Femoral or axillary arterial catheters may increase the risk of infection and require maximum barriers as with C-VADs, including mask, sterile gloves, sterile gown and large sterile drape

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With Special Thanks to All the With Special Thanks to All the Contributors to this Effort:Contributors to this Effort:

Sean Berenholtz, M.D.

Roy Brower, M.D.

Raphe Consunji, M.D.

Sara Cosgrove, M.D.

Pamela Lipsett, M.D.

Trish Perl, M.D.

Peter Pronovost, M.D.

Lisa Cooper, R.N.