Reducing Infection Risk At All Access Points

PORT PROTECTORS IN CLINICAL PRACTICE CUROS TRADEMARK OF 3M COMPANY AND DISTRIBUTED IN THE UK BY VYGON UK LTD Corinne Cameron - Watson Senior Infection Prevention & Control Nurse Barking Havering & Redbridge University Hospitals NHS Trust

Overview Introduction Study rational Methodology Results Conclusions

Introduction Intravenous catheter Needle-free port cleaning Current active disinfection or scrub the hub technique relies on the clinician to adequately disinfect the IV port prior to IV access using a alcohol based prep pad 15 seconds scrub (Epic 3) 30 seconds or until dry (Kill time) Passive disinfection using an luer lock cap pre loaded with 70% isopropyl alcohol (Curos ) which then stays in situ until the next IV access Requires 3 minutes to deliver a 5 LOG reduction / disinfection Stays on for up to 7 days or until next access

Introduction The international guidance on effective device disinfection relies broadly on three key factors: Cleaning technique of the clinician (To ensure all key access parts of the needle-free port are cleaned) The duration of the physical cleaning (minimum of 15 sec) The duration of the disinfectant drying / Kill time (minimum of 30 sec)

Study Rational Knowing that we have higher than average BSI s Aware that there was non compliance of scrub the hub Curos is designed to engineer out human variation The only British evidence for Curos was home parenteral nutrition outpatients (Mia Small) despite USA peer reviewed studies. We wanted to know if using Curos would improve compliance with port cleaning Would there be a positive / negative affect on line related bacteraemia rates with passive port decontamination

Methodology 6 month cross site study utilising 4 wards Oncology Acute Care of the elderly Adult Intensive care Surgical Ward All had medium to high use of Intravascular lines Users completed a questionnaire on usability

Methodology Retrospective review of the wards BSI data for 6 months prior to, during and 6 months post study. Port cleaning ( scrub the hub ) survey pre intervention Training of staff in the use of Curos prior to the intervention period Removal of intravascular disinfection wipes. Monthly compliance audits during the study

Study Results Survey of conventional port cleaning Compliance rates for the use of Curos IV catheter Infection rates Financials User experience Patient experience

Survey of conventional port cleaning This survey had 104 responses from a variety of different departments: Women's and Children's Services Medical Surgical Renal Cancer Services Emergency Medicine Critical Care and Anaesthetics Diagnostics

Cleaning Time National N = 1237 Trust N = 108 23% 30% 5 Seconds or Less 24% 28% 0% 7% 10 Seconds or Less 15 Seconds or Less 20 Seconds or Less 0% 5% 16% 24% 25 Seconds or Less 30 seconds 15% 26% 10 Sec or less =54% 10 Sec or less =54%

Drying Time National N = 1237 2% Trust N = 108 1% 37% 20% 0 Seconds 5 Seconds or Less 10 Seconds or Less 25% 27% 1% 7% 13% 20% 15 Seconds or Less 20 Seconds or Less 25 Seconds or Less 30 seconds 1% 9% 8% 27% 25 Sec or less =63% 25 Sec or less =75%

Compliance rates for Curos Department Curos compliance Oncology 81% Acute Care of the elderly 79% Adult Intensive care 80% Surgical Ward 81% Total (Average) 80% Curos demonstrated a compliance rate of 80%. Curos demonstrated 53% higher compliance rate with trust disinfection policy than scrub the hub (27%).

IV Catheter Infection Rates Pre Intervention Department CRBSI s for 6 months pre intervention Oncology 14 Acute Care of the elderly 0 Adult Intensive care 9 Surgical Ward 3 Total 26 CRBSI s on the 4 departments were measured for 6 months (Oct -March) pre intervention. Total of 26 CRBSI s.

IV Catheter Infection Rates Curos Intervention Department CRBSI s for 6 months pre intervention Total CRBSI s for the Curos intervention period Oncology 14 5 Acute Care of the elderly 0 0 Adult Intensive care 9 3 Surgical Ward 3 0 Total 26 8 CRBSI s reduced from 26 pre intervention to 8 post intervention, delivering a 69% reduction in CRBSI s

Curos Use Compliance Rate (%) Number of Line Related Bacteraemia Results CRBSI s Vs Compliance Comparison of Compliance Vs Incidence of Line Related Bacteremia 100% Pre Intervention Period Curos Intervention Period 8 90% 80% 70% 6 6 7 86% 80% 74% 87% 81% 79% 82% 72% 7 6 60% 5 50% 4 4 40% 30% 20% 10% 1 2 3 1 2 1 3 2 1 0 0 0 0 0 0 0 00 0 0 0% 08.2013 10.2013 11.2013 01.2014 03.2014 04.2014 06.2014 07.2014 09.2014 11.2014 Time in Months Total Port Compliance All 4 departments Line Related Bacteremia (LRB) All 4 departments

Statistical Analysis Variable Accounted For Slit Start Oct 2013 April 2014 UCL = 12.3 Mean = 4.3 1.5

Data With Washout Phase Number of Line Related Bacteremias

Financials Time saving calculation Bed days saved calculation Product comparison CRBSI saving calculation

Time Saving Calculation Using Curos has delivered a calculated time saving during the 6 month intervention on the four wards of 330 clinical hours. Volume of product used Time Saving per Curos Total Time Released to Care Clinical Days Released to Care (8hr Day) 26,374 45 seconds 329.7 Hours 41.2 Days The time saved by not needing to scrub the hub (15 sec) and let it dry (30 sec) before every access is 45 seconds per Curos used.

Bed Days Saved Calculation The number of blocked bed days saved in 6 months was 198. Blocked Bed Day Saving Number of CRBSI s Pre Curos Curos Intervention Saving 26 8 18 Blocked bed days 286 88 198 This was calculated by not having to extend patient stay (11 days) to treat infections

Product Comparison Volume of product used Cost of Current Cleaning pad NHSSC Price (Excl. VAT) Total Spend (Excl. VAT) Curos NHSSC Price (Excl. VAT) Total Spend (Excl. VAT) 26,374 0.025 659.35 0.26 6,857.24 The cost of Curos for 6 months over four wards against current cleaning wipe was an additional 6,198

CRBSI Saving Calculation CRBSI Saving Calculation (GBP) Pre Curos Curos Intervention Saving Number of CRBSI s 26 8 18 Cost to treat PIV CRBSI s ( 6,209) Cost to treat CLA CRBSI s ( 16,000) 161,434 49,672 111,762 416,000 128,000 288,000 Savings do not include the increase in the cost of the product at 6,198

User Feedback On Curos 76 nurses from across the four wards were randomly selected to complete anonymous feedback on Curos of which 70% returned completed questionnaires Question Yes No Easy to use 100% 0% More effective than scrub the hub 100% 0% Improves patient outcomes 100% 0% Visually auditable 100% 0% Received training 100% 0% Will continue to use 100% 0%

Patient Experience 27,000 Curos were applied to 1094 patients. Patients liked the visibility of Curos and knew when the device had to be changed Made them feel safe and they felt in partnership with their care

Conclusions Curos could deliver higher compliance to hospital cleaning policy than scrub the hub. Curos was more easily audited. green means clean Increase in CRBSI was seen after Curos was removed, suggesting scrub the hub is less likely to be complied with verses Curos.

Conclusions Significant financial savings could be achieved with Curos using a spend to save approach. Clinician s time could be freed up, though further research into saving of clinical time is required. High patient and clinician engagement with Curos verses scrub the hub. Curos could deliver a significant improvement over scrub the hub in the fight against CRBSI s and the aim at zero infections. Curos is a small change for a big difference

QUESTIONS?

References Cameron-Watson C(2016) Port protectors in clinical practice: an audit.british Journal of Nursing, (IV Therapy Supplement) Vol 25, No 8 Kaler W, Chinn R (2007) Successful disinfection of needleless access ports: a matter of time and friction. Journal of the Association for Vascular Access 12(3): 140 2. doi:10.2309/java.12-3-9 Loveday HP, Wilson JA, Pratt RJ et al (2014) epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect 86 (Suppl 1): S1 70. doi: 10.1016/S0195-6701(13)60012-2 Marschall J, Mermel LA, Fakih M et al for Society for Healthcare Epidemiology of America, (2014) Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 35(7): 753 71. doi: 10.1086/676533. Republished in: The Society for Healthcare Epidemiology of America, Infectious Diseases Society of America, American Hospital Association, Association for Professionals in Infection Control and Epidemiology, The Joint Commission (2014) Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals: 2014 Update. http://tinyurl.com/hyscsw7 (accessed 11 April 2016)

References Mazher MA, Kallen A, Edwards JR, Donlan RM (2013) An in vitro evaluation of disinfection protocols used for needleless connectors of central venous catheters. Lett Appl Microbiol 57(4): 282 7. doi: 10.1111/lam.12108 Menyhay SZ, Maki DG (2008) Disinfection of needless catheter connectors and access ports with alcohol may not prevent microbial entry: the promise of novel antiseptic barrier cap. Infect Control Hosp Epidemiol 27(1): 23-7 Moore MJ, Gripp K; Cooper H, Almeida R (2013) Impact of port protectors on incidence of central line infections. http://tinyurl.com/hrwd2v3 (accessed 11 April 2016) Rawlinson L (2014) National IV Report Cleaning Survey Results. http://tinyurl.com/zx4glu4 (accessed 12 April 2016) Small M (2014) The effect of 70% isopropyl alcohol port protection on central venous catheter related infection in patients on home parenteral nutrition. 3M website. http://tinyurl.com/zv6xj9a (accessed 1 April 2016)