How well are we doing with CVC’s in EBMT? London 5th October 2012 Arno Mank, Nurse Researcher,

The European Group for Blood and Marrow Transplantation

How well are we doing with CVC’s in EBMT?

London 5th October 2012

Arno Mank, Nurse Researcher, Past President, EBMT-NG Academic Medical Centre, Amsterdam



Overview

• Why?• About CVC’s• Guidelines/ Protocols • Care aspects• Collaborative survey/ EBMT guideline


Why

• Medication • TPN• Chemotherapy• Blood sampling

“Where are you infusing into?• Patient diagnosis/medical

condition• Patient compliance to

therapy

“How long are infusing?• Duration of therapy• Length of therapy• Number/frequency of infusions• Alternative site infusion

“What are you infusing?• Drug (s) to be administered• pH/ Osmolarity


Not like this!


Venous Access

• PI• Midline• Subclavian/

jugular• PICC• Tunnelled

catheter• Implanted port

• + 3 days• 3 days to 4 weeks• 1 week to 8 weeks• 1 week to 4 month• 3 weeks to 6 month• > 6 weeks and

intermitted


Subclavian/ jugularis catheter

• Long term / Short term• (Non) tunnelled


Placement

• Vena Jugularis • Vena

Subclavia• Vena

Femoralis• Vena

Brachialis


Complications CVC

• Insertion: perforation bleeding pneumothorax arrhythmias • During treatment: extravasations thrombosis catheter related infections


PICC line

Upper arm/ Vena cava superior– Under ultra sound guidance inserted– Not invasive– No pneumothorax


Differences/ Discussion points

Alternative peripheral IV, subclavia and jugular• History/Development• Length• Suitable for infusion agents• Can it be used for a medium till long period?• For hospital and home infusion• Single, double and triple lumen• Thrombosis • Cost saving• Patient’s comfort• Decreasing Infection rate


Guidelines and Protocols

Documents which supports decisions and following actions.


Differences

Protocol• Specific• Detailed• Compulsory• Acts: Who, What, How,

Which Order• Legal framework

Guideline • General• Not/less detailed• Advisory• More informing/ evidence• Supportive

Guideline : what should be doneProtocol: how certain transactions should be carried out


Diagnosis of acute fever for patient suspected short-term cvc infection

Obtain samples for blood culture prior to the initiation

of antibiotic therapy (A1 evidence)

Mermel LA et.al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America.Clin Infect Dis. 2009;1;49(1):1-45.


Conclusion: there is room for improving European nurses’ knowledgeof central venous catheter-related infections prevention guidelines. We recommendincluding supplementary support from current evidence-based guidelinesin their educational curricula and continuing refresher programs.

Labeau SO et.al. Centers for Disease Control and Prevention guidelines for preventing central venous catheter-related infection: results of a knowledge test among 3405 European intensive care nurses.Crit Care Med. 2009;37(1):320-323.


Educational intervention

Warren DK et.al. A multicenter intervention to prevent catheter-associated bloodstream infections. Infect Control Hosp Epidemiol. 2006;27(7):662-9.

An educational intervention that uses evidence-based practices can be successfully implemented in a diverse group of medical and surgical units and reduce catheter associated bloodstream infection rates


Summary of Recommendations

• Education, Training and Staffing • Selection of Catheters and Sites • Peripheral Catheters and Midline Catheters • Central Venous Catheters. • Hand Hygiene and Aseptic Technique • Maximal Sterile Barrier Precautions • Skin Preparation • Catheter Site Dressing Regimens • Patient Cleansing • Catheter Securement Devices • Antimicrobial/Antiseptic Impregnated

Catheters and Cuffs • Systemic Antibiotic Prophylaxis • Antibiotic/Antiseptic Ointments • Antibiotic Lock Prophylaxis, Antimicrobial

Catheter Flush and Catheter Lock Prophylaxis

• Anticoagulants • Replacement of Peripheral and Midline

Catheters • Replacement of CVCs, Including PICCs and

Hemodialysis Catheters • Umbilical Catheters • Peripheral Arterial Catheters and Pressure

Monitoring Devices for Adult and Pediatric Patients

• Replacement of Administration Sets • Needleless Intravascular Catheter Systems • Performance Improvement

• Indications for catheter insertion• Choice of catheter• Patient care prior to catheter insertion• Antibiotic prophylaxis• Catheter insertion• Immediate patient care after catheter insertion• Long-term catheter care• Patient information• Management of problem patients• Prevention and management of catheter

complications– Malfunction– Infection– Thrombosis

• catheter removal

O'Grady et al.Clin Guidelines for the prevention of intravascular catheter-related infections. Infect Dis. 2011;52(9):e162-193

Bishop L, et.al. Guidelines on the insertion and management of central venous access devices in adults. Int J.Lab Hematol. 2007;29(4):261-78.


Care aspects CVC

• Indication/Choice Catheter/Lumen• Insertion• Hand washing• Sterile or Non touch method/ Gloves• Manipulation• Change Administration sets • Dressing change• Removal• Registration

– General – Infection

• Quality and Education


Indication/Choice Catheter

• For how long• Not necessarily, then remove• Replace not routinely• Each lumen increases the risk of infection


Insertion

• Sterile barrier• Surgery or department• Chlorhexidine or iodine


Hands Washing/ Disinfection

• Cleaning: Washing and Drying• Infection Prevention: Alcohol• Willingness?• Training and checking


Gloves - No touch method

• Use either clean or sterile gloves when changing

• Use the ‘no touch’ method for dressing change and flushing protocol

• Security?


Manipulation

• Opening the catheter– Medication– Blood sampling– Patient preference– Combination

• How often changing the administration sets– 24/72/96 hours?– Different between fluids/ blood products


Dressing change

• Daily inspection (external contamination)– Dry: Transparent dressing every 5-7 days?– Wet: Gauze dressing should every 2 days?

• Well-healed tunnelled CVAD maybe no dressing• Chlorhexidine impregnated dressing (Biopatch ®)


Flushing/ Needleless connector

• Saline, Heparin, other?• Disconnecting/ blood sampling• Lock solution • Volume at least 2 times volume of the lumen • Normal saline between incompatible drugs• Frequency• Use of correct needless connector


Administration/Registration: General and infection

electronic patient record


Quality/ Qualification/ Education

• Registration by the law• Knowledgeable and skilled• Train the trainer• IV/CVC team

– specialisation– surveillance

How well are we doing with CVC’s in EBMT?


Collaboration IDWP with EBMT-NG

• The Infection Disease Working Party aims to promote and conduct educational activities and clinical investigations on all the topics concerning the diagnosis, the prophylaxis and the management of infectious complications following HSCT.

•The Nurses Group also!•Focus on Central Line Associated Blood Stream Infections (CLABSI)


Study design

Aims of the studyTo evaluate self-reported adherence to CLABSI prevention guidelines in EBMT centres and possible

association with HSCT outcome. Analysis endpoints:Primary: Assessment of current practice of CLABSI prevention in HSCT setting in Europe. Secondary: Assessment of possible association between self-reported adherence to bundle of

recommendations in the guidelines for CLABSI prevention and observed outcome of HSCT in terms of 100 day mortality and graft versus host disease.

Study Design cross sectional study, questionnaire for collection of data on guidelines used and self-reported

adherence to international guidelines for prevention of central line associated bloodstream infections.

Inclusion CriteriaAll centres in the EBMT database.TimelinePreparation of the online questionnaire – June 2012Invitation to the study - October 2012Filling the data by centres – December 2012Analysis of the data – January 2013Abstract preparation – February 2013Publication preparation until March 2013Presentation at the EBMT 2013


QuestionnaireA study specific questionnaire has been constructed based on recommendations from international guidelines. two parts: - written guidelines used at the centre. SOP - different aspects of central venous line practice. Current practice

Key areas- Education of healthcare professionals on prevention of CLABSI- The organization of CVC insertions in the department- Type of catheter preferred by centre- Adherence to full barrier precautions during the insertion- Central venous catheter management- Diagnostics of infection

pre tested for content validity by nurses and physicians from selected EBMT centres who will assess the content and relevance of each item for measuring the adherence to the guideline.

Feasibility The data collected in this study should give answer to two questions:To what extent are guidelines of CLABSI prevention in HSCT implemented in Europe.The possible connection with 100 day mortality and GvHD and self-reported practice of CLABSI prevention bundle as judged from questionnaires


Involved people

Infectious Diseases Working Party/EBMT-Nurses Group Investigators• Emilian Snarski Medical University of Warsaw POLAND• Eva Johansson Associate Professor, Senior Lecturer Division of

Nursing | Karolinska Institute Stockholm SWEDEN• Arno Mank, nurse researcher past president EBMT Nurses

Group Academic Medical Centre Amsterdam The NetherlandsStatistician • Simona IacobelliStudy coordinator• Jennifer Hoek

Study Coordinator European Group for Blood and Marrow Transplantation [email protected]


QUESTIONS?