INSIDE THE CURRENT ISSUE January 2013

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1 Inside the Current Issue CLINICAL INTELLIGENCE FOR SUPPLY CHAIN LEADERSHIP INSIDE THE CURRENT ISSUE January 2013 Cover Story Honoring 3 Cs pushing supply chain momentum, progress Self Study Series White Papers Purchasing Connection Resources Show Calendar HPN Hall of Fame Classifieds Issue Archives Advertise About Us Home Subscribe Sign up for our Newsletter GO For Marketing you can trust Special Event Photos Contact Us KSR Publishing, Inc. Copyright 2012 Infection Prevention IV-site care Improved practices, advanced technology reap optimal outcomes by Susan Cantrell, ELS If pathogenic organisms could love, they would l-o-v-e catheters. What better could they ask for to accomplish their mission of infection than to be routed directly into the source of life? "Central line associated blood stream infections (CLABSIs) are important and deadly HAIs [healthcare-acquired infections], with reported mortality of 12% 25%," the CDC tells us.1 That is the bad news, but fortunately there is also really good news on that front. "In 2001, an estimated 43,000 CLABSIs occurred among patients hospitalized in ICUs [intensive care units] in the United States. In 2009, the estimated number of ICU CLABSIs had decreased to 18, an estimated 25,000 fewer CLABSIs... than in 2001, a 58% reduction. This represents up to 6,000 lives saved and $414 million in potential excess healthcare costs in 2009 and approximately $1.8 billion in cumulative excess health-care costs since 2001." The reduction in CLABSIs is a product of state and federal agencies coming together to develop recommended practices in catheter care and of healthcare workers across the nation conscientiously and diligently implementing these best practices. The resulting success is so astounding that "The model of federal, state, facility, and health-care provider collaboration that has proven so suc cessful in CLABSI prevention should be applied to other HAIs and other healthcare associated conditions,"1 said the CDC. Phenelle Segal, RN, CIC, President, Infection Control Consulting Services (ICCS), Delray Beach, FL, talked in more detail about use of catheters and what can be done to mitigate related infections. "Intravenous therapy is infused via many routes, including peripheral and central catheters. Selecting a catheter is dependent on many factors, but the most important factor is selecting the smallest gauge and length, as few lumens as possible, and the least invasive device. Peripheral catheters are the number one choice, if possible, for infusing medications, as the risk of HAIs is far less than central catheters, which have the potential to become infected at the time of insertion and during site maintenance." An approach that includes all caregivers involved with catheter insertion and care is the best, noted Segal. "IV-insertion and site-care best practices preferably should be a multidisciplinary approach, as studies have shown repeatedly that a team of diligent healthcare workers striving for the common goal of patient safety, including prevention of HAIs, is far more effective than a single effort." Segal also talked about best practices for IV-site care. "Peripheral and central catheters require aseptic technique insertion with hand-hygiene and glove practices enforced. Skin preparation should occur using an antiseptic such as chlorhexidine (not to be used in patients under 2 months of age), povidoneiodine, or 70% alcohol. A no-touch technique should be used: insertion site should not be palpated after the skin is cleaned unless sterile gloves are worn;; IV-site care, including dressing changes, must be performed aseptically with the emphasis on hand-hygiene, wearing of gloves (donned before removing the old dressing and donned again before replacing the old dressing with the new one);; and prevention of contamination of the new dressing. Central-catheter dressing changes should occur on a regular schedule and immediately if the integrity of the dressing is compromised or signs of infection are present. Peripheral IV catheter dressings are not changed routinely unless the dressing is soiled or no longer intact." Antimicrobial-impregnated catheters Technique is vital, but technology plays an important role, too. Industry has responded to the quest for fewer infections and other complications related to Infection Prevention Update New IDSA guidelines aim to reduce death, disability, and cost of prosthetic joint infections Of the one million people each year who get hips and knees replaced, as many as 20,000 will get an infection in the new joint, a number that is expected to skyrocket in the next 20 years. Multispecialty physician teams need to work together to reduce disability, death and costs associated with the ever-growing number of these prosthetic joint infections, note the first guidelines on the topic being released by the Infectious Diseases Society of America (IDSA). Hips, knees and other joint replacements such as shoulders and elbows can become infected during the surgery or months or even years later. The guidelines, which were published in the journal Clinical Infectious Diseases, outline the evidence and opinions regarding methods that are appropriate to diagnose the infections early and treat them most effectively, according to patients specific situations. Most infections require long courses of antibiotics and surgery, which can range from washing out the infected area to removal and replacement of the joint to permanent removal of the prosthesis to amputation. Multidisciplinary teams should include an orthopedist and an infectious diseases specialist, as well as other specialists on a case-by-case basis. In rural areas with few specialists, doctors should consider consulting with infectious diseases specialists or orthopedists at referral centers. Among the recommendations in the guidelines: Physicians should suspect a prosthetic joint infection in a patient who has any of the following: persistent wound drainage in the skin over the joint replacement;; sudden onset of a painful prosthesis, or ongoing pain after the prosthesis has been implanted, especially if there had been no pain for several years or if there is a history of prior wound healing problems or infections. In patients with prosthetic joint infections: Those with a well-fixed prosthesis without an open wound to the skin who had surgery less than 30 days previously are likely candidates for debridement, which means re-opening the incision and cleaning out the wound.

2 catheters with improved, advanced products. One trend in catheter care is to employ the catheter itself as a weapon against infection. Teleflex offers catheters impregnated with antimicrobials to fight against potential infections. Kathy Conner, Vice President, Global Marketing, Vascular Access, Teleflex Inc., Limerick, PA, described how their catheters help to thwart related complications. "More than 30 studies and reviews prove ARROWg+ard catheter technology s ability to decrease the incidence of catheterrelated BSI, reduce costs, and save lives. For example, ARROWg+ard reduces bacterial colonization of the catheter by 60% and catheter-related infection by 80%. ARROWg+ard Blue PLUS provides proven infection-fighting ability both outside and inside the catheter. Chlorhexidine and silver sulfadiazine continuously prep the subcutaneous catheter tract and kill organisms in places that you simply can t reach." Conner also recommends a bundled approach, which has an excellent track record for assisting in reducing rates of infections. "Arrow uses an ErgoPack System for our central venous catheters (CVCs) and peripherally inserted central catheters, providing 31 essential tools systematically organized for procedural ease. Use of a bundled approach for insertion of central lines is proven to significantly reduce procedural time and the risk of CRBSI." Cook Medical's Spectrum catheters, with minocycline and rifampin, protect patients against CLABSI. The ARROW ErgoPack from Teleflex provides procedural efficiency and defense against BSI. Conner related an experience of a hospital that attributes a lowered rate of CLABSIs to their products. "Patients receiving care in a West Texas 400-bed county hospital are now facing less risk of CLABSIs. After an internal analysis of their reported medical intensive care unit and burn-unit CLABSI rates, they converted to ARROWg+ard Blue Plus CVCs. This hospital now follows the recommendation of the CDC, using antimicrobial catheter technology as part of their HAI reduction plan." Cook Medical also offers antimicrobial-impregnated catheters. "Cook Medical s Spectrum catheters are impregnated with minocycline and rifampin to protect patients against CLABSI, a common and potentially fatal hospital-acquired infection," said Dan Sirota, Vice President, Interventional Radiology and Critical Care, Cook Medical, Bloomington, IN. "In a challenging clinical environment, a hospital that switches to a minocycline+rifampin-impregnated catheter can expect to see a decrease in CLABSI rates, attributable mortality, and CLABSIrelated costs." "What might not be so apparent," said Sirota, "is that highperforming hospitals can switch to Spectrum to drive incremental improvements in CLABSI rates and still achieve substantial reductions in mortality and cost. For example, in a hospital that places 100 CVCs per month with an average dwell time of 7 days2 and an infection rate of 3.3/1,000 catheter-days, a reduction by 50% would save that hospital 112 bed-days and $231,700 annually." "Twenty-one peer-reviewed studies confirm process," said Sirota. "Spectrum is the most effective tool available to reduce the incidence of BSIs, including gram-positive, gram-negative, and fungal infections in both short- and long-term use. It s evidence of protection no other process or technology can match. Ten years of clinical use and a study of more than 500,000 catheter-days confirm no evidence of bacterial resistance associated with Spectrum use." out the wound. Those who have more extensive infection that has affected the bone and tissue may need to have the prosthesis replaced, either in the same surgery in which the prosthesis is removed, or in a later surgery. Patients who cannot walk and who have limited bone stock, poor soft tissue coverage and infections due to highly resistant organisms may need to have the implants permanently removed. In some cases the joint may need to be fused. Amputation of the limb may be necessary, but only as a last resort. Prior to amputation, the patient should be referred to a center with specialist experience in prosthetic joint infections, if his or her condition allows. Four to six weeks of intravenous or highly bioavailable oral antibiotic therapy is almost always necessary to treat prosthetic joint infections. January 2013 Featured advertisers: 3M Health Care B Braun Medical Berchtold Corp CareFusion/ChloraPrep ChemDAQ Corp Covidien Covidien Detecto Healthcare Logistics Healthcare Logistics Healthmark Industries HealthTrust Purchasing Group Honeywell IAHCSMM IMS Innovative Healthcare Maquet Medical Systems USA Modern Medical Systems PDI Prezio Health Propper Manufacturing Co. Ruhof Corporation Spartan Chemical Co. Spectrum Surgical Instruments Corp. STERIS VHA Xenex Products that reduce blood-exposure risks Inserting catheters puts healthcare workers at risk for blood exposure. Paul Walker, Marketing

3 Communications Manager, Medical Surgical Systems, BD Medical, Sandy, UT, talked briefly about the safety features of their catheters that reduce the risk of a blood exposure. "BD has a broad range of peripheral IV catheter technologies designed to limit the exposure of blood during catheter insertion by the healthcare worker. These include BD Insyte Autoguard with Blood Control Technology, BD Nexiva Closed IV Catheter System, and BD Nexiva Diffusics catheter systems. The BD Nexiva family of catheters all feature pre-attached extension tubing, reducing BD's peripheral IV catheter technologies limit blood exposure the number of during insertion. connections that the clinician is required to make." Cheryl Wozniak, Product Manager, Vascular Access Systems, B. Braun Medical Inc., Bethlehem, PA, talked about safety features of the Introcan Safety IV catheter and the new Introcan Safety 3 Closed IV Catheter. "From insertion to disposal, B. Braun s new Introcan Safety 3 closed peripheral IV catheter is designed to protect clinicians and patients while helping facilities save time and money," said Wozniak. Advantages include advanced stabilization, which minimizes catheter movement, helping to reduce irritation and restarts;; less plastic, which means less waste;; saving money by not needing to throw away unused components;; a passive safety mechanism requiring no user activation and that cannot be bypassed;; design that minimizes needlestick injuries, promoting compliance with recommended safety guidelines;; a sharp universal needle bevel and double flashback vein-access confirmation for greater first-stick success;; plus, the Introcan Safety 3 Closed IV Catheter offers an added safety feature with a multiaccess blood-control septum that prevents blood exposure after withdrawing the needle and every time the hub is accessed. "Anecdotal evidence of passive technology does exist," explained Wozniak. "A landmark French multicenter study (61 hospitals) conducted by GERES (Groupe d Etude sur le Risque d Exposition des Soignants) over a 2- year period evaluated the Introcan Safety 3 Closed IV Catheter, B. Braun Medical Inc. incidence of needlestick injury among different types of safety engineered devices (SEDs), concluding passive, automatic safety devices perform 2 to 3 times better than alternative choices, such as active safety devices.3 The study concluded that passive SEDs are more effective than active SEDs for needlestick injury prevention." Safer connectors Depending on the design, connectors have the potential to enable an infection to take hold. CareFusion, San Diego, CA, offers needleless connectors that are clear, which operates as a visual reminder to clinicians of the need to prime, disinfect, and flush. Alison Sanders, Senior Product Marketing Manager, described the MaxPlus Clear Needleless Connector. "Features include a flat, solid, sealed surface to decrease disinfection time, reduce the risk of contamination, and allow for more efficient disinfection. The advanced dual seal design reduces the risk of bacterial ingress, and the visible fluid path helps clinicians confirm proper flushing. The connector does not have interstitial (or dead) space, reducing accumulation of blood and fluid that is known to foster bacterial growth, and the positive-displacement technology reduces the risk of catheter occlusions when used with best clinical practices. The clear housing of the MaxPlus Clear Needleless Connector allows

4 the MaxPlus Clear Needleless Connector allows clinicians to assess the efficacy of their flush technique, reinforcing best clinical practice." "The MaxPlus needleless connector can offer time efficiencies for staff through standardization of the product when used throughout the hospital," said Sanders. "With its solid, sealed access port, MaxPlus needleless connectors can be completely scrubbed with an alcohol swab in 3 seconds. In addition to decreased disinfection time, the anti-reflux technology of the MaxPlus helps reduce the risk of occlusions and maintains catheter patency when used with other VasoNova VPS positioning system provides accuracy, consistency, and ease of use in central catheter placement. MaxPlus Clear Needleless Connector from CareFusion clinical best practices. The anti-reflux action of the MaxPlus allows use of saline flushing, reducing heparin use and the risks associated with heparin." Guided insertion of catheters Another trend in catheter care is use of vascular navigation systems with realtime placement guidance. Teleflex offers such a system. "Newest to our portfolio is the VasoNova VPS technology system," said Conner. "VPS is intended to allow first-time placement of a CVC tip in the distal one-third of the superior vena cava by using a combination of Doppler ultrasound and intravascular electrocardiogram." "The VPS system has been cleared by the FDA as a replacement for chest x-ray following the insertion of a CVC, virtually eliminating the subjective interpretation of a catheter-tip position post-insertion. Use of combination technologies controls the environment to reduce injuries to the healthcare provider, expedite placement of a CVC, reduce patient exposure to x-ray, expedite infusion of medication, and reduce risk of catheter-related infection and thrombosis for the patient. The intended net result is a more cost-effective and safer approach to management of CVC insertion and use." "Parkwest Medical Center, Knoxville, TN, has partnered with Teleflex through the adopted use of our VPS system and a variety of our CVCs," said Conner. "They serve as one of our Professional Excellence Reference Centers where interested clinicians may observe procedures in which our VPS system is utilized to place catheters. This allows interested professionals to understand the value of our technology in applied use and to speak with colleagues regarding the clinical value to the patient, vascular access professional, and healthcare system." AxoTrack, from Soma Access Systems, Greenville, SC, recently won the Popular Science 2012 "Best of What s New Award" for medical innovation for their needle visualization technology. AxoTrack, invented by emergency physician Stephen F. Ridley, originally was designed to improve the safety and accuracy of placing CVCs by providing clinicians with specific, real-time knowledge of the needle location throughout the entire procedure. This technology, which employs ultrasound imaging and magnetics, now is being used in a broad range of needle-guided procedures, including central venous access, biopsy, nerve block, cyst aspiration, arthrocentesis, thoracentesis, and paracentesis. For more information on AxoTrack, visit Electronic management of IV sites Infection surveillance may not be the first thing you think of in relation to IV-site care, but it keeps an electronic eye focused on potential infections and identifying opportunities for improved patient care. France Pitera, Vice President, Clinical Information Technology, Hospira, Lake Forest, IL, explained how their system works and its relation to IV-site care.

5 Forest, IL, explained how their system works and its relation to IV-site care. "TheraDoc Clinical Surveillance System helps healthcare organizations integrate data from almost any clinical-source system in near real-time, enabling clinicians to access the exact data they need in a single, configurable platform." "Clinicians determine for themselves what data they want to view, how they want to view it, and what updates in patient status or treatment they want TheraDoc to find and report," said Pitera. "This degree of configurability at the user level enables TheraDoc to help clinicians save time that can instead be used for higher-value clinical duties. TheraDoc can assist clinicians in reducing the time required for surveillance, coordination of data for interventions, and NHSN reporting." Pitera went into a little more detail as to how TheraDoc can assist in IVsite care specifically. "The TheraDoc clinical surveillance systems, from Hospira, simplify information for caregivers. TheraDoc Clinical Surveillance System can assist healthcare organizations in reducing and avoiding costs, including helping to identify opportunities to convert patients from IV to oral medications;; identify de-escalation or discontinuation of drug therapy opportunities;; identify overuse or inappropriate use of antibiotics;; reduce infection rate, time-to-isolation and time-to-confirmation of HAIs;; and execute faster, easier, and more accurate NHSN reporting." "With HAIs representing a significant, unreimbursed expense and drug therapy remaining a primary cost driver for healthcare organizations, TheraDoc s ability to help clinicians meet both infection prevention and clinical pharmacy challenges makes it a highly cost-effective tool," said Pitera. "Currently, HAIs and other adverse events cost the healthcare industry upwards of $33 billion annually. TheraDoc helps hospitals reduce costs by alerting caregivers to potential adverse events, enabling caregivers to take action sooner to help reduce the spread of infection and save lives. For example, one 425-bed community hospital using TheraDoc saw an 81% increase in infection interventions per month and $639,780 saved in the first year of use.4 A 118-bed integrated delivery network reported 53% faster confirmation of HAIs with 98% accuracy."5 Educational resources Vendors are a valuable source of education. They have done much of the legwork for you, so make good use of their investment in research. Here is a rundown of educational resources offered by those vendors interviewed for this article. "B. Braun Medical Inc. provides extensive training to healthcare workers throughout the country via video tutorials and live, in-person training with our nursing staff," said Wozniak. "For more information visit and our micro-site "In addition, B. Braun has developed a 2-day peripheral IV catheter simulationbased mastery learning course that we believe will result in improved nursing practice and patient outcomes. We are currently searching for a hospital partner to help us further validate this important research." "Teleflex offers a variety of CEU and CME accredited education programs compliant with AdvaMed guidelines," noted Conner. "We are committed to proactive vessel health and preservation for every patient. This means teaching healthcare professionals to choose the right catheter for the right patient at the right time. Our educational programs are built on this commitment and are conducted peer-to-peer, both locally and nationally. We also offer web-based education found at VesselHealth.org." Walker pointed to BD s videos on selection and insertion of catheters. "We recently partnered with the nursingcenter.com to provide a comprehensive resource to clinicians related to peripheral-iv site care. It features educational videos on selecting the right IV catheter and proper IV catheter insertion. This is can be found at "CareFusion has a dedicated clinical specialist team nationwide to help educate

6 hospital staff on IV care and best practices," said Sanders. "These sessions are strictly clinical and not sales oriented in nature. For more information on MaxPlus needleless connectors and additional IV sets and accessories from CareFusion, please visit Pitera talked about their online resources. "Hospira has several online resource centers with educational information regarding healthcare-acquired infection and medication-error prevention." Go to and white_papers/index. References 1. Srinivasan A, Wise M, Bell M, Cardo D, Edwards J, Fridkin S, Jernigan J, Kallen A, McDonald LC, Patel PR, Pollock D, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, CDC. Vital signs: central line associated blood stream infections United States, 2001, 2008, and MMWR 2011;;60;;1-6. Early release. 2. Advani S, Reich NG, Sengupta A, Gosey L, Milstone AM. Central line-associated bloodstream infection in hospitalized children with peripherally inserted central venous catheters: extending risk analyses outside the intensive care unit. Clin Infect Dis 2011;;52(9): Tosini W, Ciotti C, Goyer F, Lolom I, L Hériteau F, Abiteboul D, et al. Needlestick injury rates according to different types of safety-engineered devices: results of a French multicenter study. Infect Control Hosp Epidemiol 2010;;31(4): Calloway S, Akilo H, Bierman K, Osburg B. Use of a clinical surveillance system to improve clinical intervention documentation in a 425-bed acute-care community hospital;; Good Shepherd Medical Center;; March 2012;; Longview TX. Poster session presented at Texas Society of Health-System Pharmacists;; 2012 Apr 13-14;; Dallas, TX. 5. Song X, et al. Benefits of using TheraDoc to assist in surveillance for central line associated nosocomial bloodstream infections (CA-BSIs). Abstract SHEA Annual Meeting. March 18-21, Chicago, IL. and