4589 Preventing Central Line- Associated Bloodstream Infections Study Guide
Preventing Central Line-Associated A CK NOW L E DG EM E NTS We would like to express our sincere appreciation to the following individuals Dennis G. Maki M.D. Ovid O. Meyer Professor of Medicine University of Wisconsin School of Medicine and Public Health Rita McCormick, RN Senior Infection Control Practitioner University of Wisconsin Hospital and Clinics Keith A. Rains, RN, BSN, CIC Infection Prevention Professional ECHCS Denver Medical Center April Tracy, RN BSN IP Infection Prevention/Control Coordinator T. J. Samson Community Hospital Jeanne E. Zack, PhD., RN, CIC Manager, Infection Prevention and Control Missouri Baptist Medical Center Association for Vascular Access www.avainfo.org Envision, Inc. 2009 Video produced and distributed by: Envision, Inc. 644 West Iris Drive Nashville, TN 37204 1-866-321-5066 www.envisioninc.net 2
Table of Contents Instructions for Continuing Education Credit...................................................................... 4 I. Introduction................................................................................................... 5 II. Objectives.................................................................................................... 5 III. Central Lines and Their Uses................................................................................... 6 IV. Central Line Infection Definitions............................................................................... 6 V. Pathogenesis................................................................................................. 7 VI. How Do We Create Change and Prevent Central Line Infections?................................................... 8 VII. Catheter Selection............................................................................................. 9 VIII. Site Selection................................................................................................. 9 IX. Infection Prevention Basics................................................................................... 10 X. Catheter Insertion Practices................................................................................... 10 XI. Care and Maintenance........................................................................................ 11 XII. Patient Education............................................................................................ 12 XIII. Surveillance................................................................................................. 12 XIV. Enhanced Interventions....................................................................................... 13 XV. Conclusion.................................................................................................. 13 XVI. References.................................................................................................. 14 XVII. Post Test.................................................................................................... 18 XVIII. Tools........................................................................................................ 20 A. Nursing Checklist: Central Venous Catheter Insertion............................................................. 20 B. Save That Line Poster and Note Card........................................................................ 21 XIX. Continuing Education Application.............................................................................. 22 XX. Program Evaluation Form...................................................................................... 13 XXI. Post Test Answers............................................................................................ 14 Kimberly-Clark Health Care Education 3
Instructions for Continuing Education Credit This program has been approved by Envision, Inc. for 1.0 Contact Hour, Program Number 006CLABSI10. Envision, Inc. is an approved provider by the California State Board of Registered Nursing, Provider Number CEP 15437 To obtain continuing education credit: View video presentation Review study guide Complete CE application form, including applicant information, test answers and evaluation section Forward the application form and $10 processing fee to: Envision, Inc. 644 West Iris Drive Nashville, TN 37204 1-866-321-5066 Certificates will be mailed within 4 weeks. 4
I. Introduction Central venous catheters (CVCs) are often essential when caring for patients in the acute, ambulatory, home care and long term care settings. For instance, it is estimated that 48% of ICU patients have central venous catheters, accounting for 15 million catheters days per year. 1 And yet their use may be associated with bloodstream infections that produce life-threatening illnesses in millions of patients every year, and cost millions to treat. 1,2 It is clear that central venous catheters (CVCs) are more likely to cause infection than peripherally inserted lines. One study estimates approximately 90% of catheter-related bloodstream infections occur with central lines. 3 Other studies indicate they are responsible for a 10% to 30% increase in mortality in ICU patients. 4-6 This may be because the use of CVCs are almost exclusively inserted in this area, frequently placed in emergent situations, needed for extended periods of time, and accessed repeatedly throughout the day. 7,8 However, the majority of patients with central lines are actually outside the ICU where lines tend to remain longer and there is substantial risk for infection. 9-12 This is why the Centers for Medicare and Medicaid Services (CMS), the Department of Health and Human Services (DHHS), The Joint Commission, the World Health Organization (WHO), and the Association for Vascular Access (AVA) among others have all targeted central line-associated bloodstream infections to be eliminated in healthcare settings. Specifically, Preventing central line-associated bloodstream infections is a 2009 Joint Commission Patient Safety Goal 13 The DHHS has included CLABSI in their 5 year Action Plan to Prevent Healthcare-Associated Infections 14 CMS will not pay for vascular catheter-associated infections unless documented as present upon admission 15 WHO has presented Patient Safety Solutions to address the challenge of CLABSI 16 This program will highlight prevention techniques outlined in The Guidelines for the Prevention of Intravascular Catheter-Related Infections by the Centers for Disease Control and Prevention (CDC), 17 A Compendium of Strategies to Reduce Healthcare Associated Infections In Acute Care Hospitals by HICPAC/SHEA/IDSA/APIC [the Healthcare Infection Control Practices Advisory Committee (HICPAC)/ Society for Healthcare Epidemiology of America (SHEA)/ Infectious Diseases Society of America (IDSA)/ Association for Professionals in Infection Control (APIC)], 18,19 Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies by the Agency for Healthcare Research and Quality (AHRQ); 20 intervention bundles by the Institute for Healthcare Improvement (IHI) Protecting 5 Million Lives From Harm campaign; 21 and other best practice research. II. Objectives After viewing this program and completing the Study Guide, the learner will be able to: Define Central Line-Associated Identify the various types of central lines and their uses Discuss how catheter and site selection can affect the development of CLABSI Discuss measures to prevent the development of CLABSI during insertion, care and maintenance of central lines Kimberly-Clark Health Care Education 5
III. Central Lines and Their Uses The National Healthcare Safety Network (NHSN) defines a central line as a catheter that terminates at or close to the heart or in one of the great vessels. These great vessels include the aorta, pulmonary artery, superior vena cava, inferior vena cava, brachiocephalic veins, internal jugular veins, subclavian veins, external iliac veins and common femoral veins. 22 Central lines also include peripherally inserted central catheters or PICCs. A PICC is inserted in a peripheral vein, such as the cephalic, basilic, or brachial vein, and then advanced toward the heart until the tip terminates in either the distal superior vena cava or cavoatrial junction. 23 Central lines may be short or long term devices, and include catheters, ports, tunneled and nontunneled devices. Central lines are placed for various reasons: 23,24 To provide venous access for administration of IV therapies, such as antibiotics and chemotherapy agents The infusion of parenteral nutrition To facilitate high-flow access for plasmapheresis and hemodialysis When there are no peripheral sites available or when multiple lines are needed To provide access for the insertion of intracardiac catheters for hemodynamic monitoring IV. Central Line Infection Definitions CLABSI are measured by the CDC and the NHSN Manual: Patient Safety Component Protocols by the following criteria as laboratory-confirmed bloodstream infection (LCBI) for surveillance: 20,22 Criterion #1: The patient has a recognized pathogen cultured from 1 or more blood cultures, And The organism cultured from blood is not related to an infection at another site. Criterion #2: The patient has at least 1 of the following signs or symptoms: fever (>38 C), chills or hypotension, And Signs and symptoms and positive laboratory results are not related to an infection at another site, And Common skin contaminant (e.g. diphtheroids [Corynebacterium spp.], Baccilus [not B. anthracis] spp., Propionibacterium spp., coagulase-negative staphylococci [including S. epidermidis], viridans group streptococci, Aerococcus spp., or Micrococcus spp.) is cultured from two or more blood cultures drawn on separate occasions. Criterion #3: Patient 1 year of age has at least one of the following signs or symptoms: fever (>38 C rectal), hypothermia (<37 C, rectal), apnea, or bradycardia, And Signs and symptoms and positive laboratory results are not related to an infection at another site, And Common skin contaminant (e.g. diphtheroids [Corynebacterium spp.], Baccilus [not B. anthracis] spp., Propionibacterium spp., coagulase-negative staphylococci [including S. epidermidis], viridans group streptococci, Aerococcus spp., or Micrococcus spp.) is cultured from two or more blood cultures drawn on separate occasions. 6
Clinical Sepsis (CSEP): CSEP may be used only to report a primary BSI in neonates and infants. To report a CSEP, the following criterion must be met: Patient 1 year of age has at least one of the following clinical signs and symptoms with no other recognized cause: fever >38 C, rectal), hypothermia (<37 C, rectal), apnea, or bradycardia, And Blood culture not done or no organisms or antigen detected in blood and no apparent infection at another site and physician institutes treatment for sepsis. V. Pathogenesis The most common pathogens identified with CLABSI are Staphylococcus aureus, coagulase-negative staphylococci, enterococci, gram-negative organisms including Extended Spectrum Beta Lactamase (ESBLs) and Candida species. 11 Some patients are more likely to develop central line infections than others. These include patients with: 19 Co-morbidities or existing infections Prematurity and partially developed immune systems Neutropenia or insufficient mature white blood cells Total Parenteral Nutrition or TPN indicating malnourishment or severe underlying disease Patients who have had a prolonged hospital stay before insertion and may be colonized with hospital-associated or drug-resistant organisms Other risk factors include: 19 Prolonged duration of catheter use Insertion of multiple catheters Emergency insertion of catheters with less than ideal aseptic conditions Repeated access to catheters Femoral and internal jugular catheterization Substandard care of the catheter Most catheter-related BSI are due to microbes that colonize catheter hubs and the skin surrounding the insertion site in various ways: 25,26 By migrating inside the lumen from colonized hubs, and occasionally from contaminated infusate By migrating along the outside of the lumen from colonized skin By travelling via blood from distant infection sites and seeding the catheter By adhering to fibrin sheaths or thrombus (clots) and developing mature biofilm Kimberly-Clark Health Care Education 7
VI. How Do We Create Change and Prevent Central Line Infections? The key to preventing CLABSI is to educate clinicians on how to change or eliminate practices that create risk of infection in patients, while avoiding interventions that may encourage the emergence of antimicrobial resistance. Staff should be educated on: 17-19,27 Guidelines and best practices to prevent CLABSI Indications for CVC use Insertion and maintenance of catheters to ensure knowledge and competency Proper infection control measures to prevent CLABSI Using a catheter insertion checklist Education programs that emphasize CVC insertion, care and maintenance result in decreases in cost, morbidity and mortality. Consistent reinforcement through ongoing education will remind clinicians of best practices and will continue to decrease CLABSI rates. 17,28-31 The use of infection prevention bundles are highly encouraged for lowering infection rates. Bundles are a group of individual practices drawn from best evidence research that when implemented together result in better patient outcomes. For example, along with a reduction of CLABSI rates per 1,000 device days, the DHHS announced a national 5 year prevention target of 100% compliance with central line bundles for non-emergent insertions. 14 The key components of the IHI s Central Line Bundle are: 21 Hand hygiene Maximal barrier precautions upon insertion Chlorhexidine skin antisepsis Optimal catheter site selection, with the chest site (axillary, cephalic and subclavian veins) vein as the preferred site for non-tunneled catheters Daily review of line necessity with prompt removal of unnecessary lines The Association for Vascular Access s SAVE That Line campaign to prevent catheter-related bloodstream infections promotes four basic principles: 32 S Scrupulous hand hygiene A Aseptic technique during catheter insertion and care V Vigorous friction to catheter hub prior to entry E - Ensuring patency of the device We will discuss bundle elements as well as other recommended practices in this study guide. 8
VII. Catheter Selection The following interventions can be applied to the selection and insertion of a catheter. First, consider whether the catheter is completely necessary, or whether there are any other alternatives. Will the catheter be short or long term? Long term catheters can be surgically implanted ports, or have a cuff on the catheter which acts as a barrier to invading skin organisms. Insertion requires additional skill and is often done in a procedure or operating room. 17 PICC lines are being used more and more in the acute setting since specially trained nurses may now insert them at the bedside. The use of ultrasound equipment ensures easy access to the vessel for good results. Many nurses prefer PICCs as the care and maintenance of the device may be easier and preferable to other central lines. However, comparative studies are lacking as to whether PICC lines actually reduce rates of infection. One study suggests PICCs have comparable infection rates to conventional CVC s placed in the internal jugular and subclavian veins and are more vulnerable to thrombosis and dislodgement. 33 Catheter material selection may also reduce infections. Silicone or polyurethane catheters appear to be associated with fewer infectious complications than catheters made of other materials. 17 In addition, there are antibiotic-impregnated and antimicrobial-coated devices that have shown good results in clinical studies. The use of these types of catheters may be considered by facilities to enhance their infection prevention efforts. 17,25 However, this technology should not be a substitution for educating staff on insertion and site care maintenance of the CVC. Central venous catheters should have the least number of lumens necessary for care. 17 PICCs may have single, dual or triple lumens; while tunneled and non-tunneled CVCs may have one to five lumens. VIII. Site Selection Ideally, you should choose insertion sites with the lowest density of flora or colonization rates, as well as sites with the lowest risk of non-infectious complications such as deep vein thrombosis, bleeding or mechanical complications. 34 However, it is important to weigh the risks and benefits of placing a device at a site to reduce infectious complications against the risk for mechanical complications, which include pneumothorax, subclavian artery puncture, subclavian vein laceration, subclavian vein stenosis, hemothorax, thrombosis, air embolisms, and catheter misplacement. 17,34 The chest (subclavian, axillary and cephalic veins) site is recommended for adult patients to minimize infection risk for non-tunneled CVC placement, but has potential for the greatest mechanical complications. 21,34 The femoral site has the highest risk of infection and deep vein thrombosis in adults and should be avoided in adult patients, but may be a necessary option for children. 18,19,21 In addition, patient factors may also dictate the insertion site and type of catheter, such as: 34 Pre-existing catheters, history of complications, or treatments such as mechanical ventilation and anticoagulation therapy The comfort of the patient and anticipated duration of the catheter How well the catheter can remain secured and maintained aseptically Kimberly-Clark Health Care Education 9
IX. Infection Prevention Basics Basic but vital infection prevention practices should be followed by all healthcare professionals involved in the insertion, care and maintenance of the central venous catheter. This includes practicing scrupulous hand hygiene according to CDC and WHO guidelines at the following times: 18,19,27 When hands are visibly soiled Before and after: Patient care activities Palpating the insertion site Inserting, replacing, accessing, repairing, or dressing a catheter Before donning gloves After glove removal Hand hygiene should be a part of the central line placement checklist. 21 Follow Standard Precautions at all times, and Isolation Precautions when indicated. Ensure that Environmental Services and Equipment Processing personnel follow guidelines for optimal cleaning of surfaces and sterilization of equipment. X. Catheter Insertion Practices 1. Have a credentialed healthcare professional insert the central line. 19 The more highly trained and specialized the professional, the less likely the potential for infection or other complications. 2. Maintain aseptic technique during the insertion of central line catheters. 17,34 3. Use maximal barrier precautions for the insertion of CVCs, including PICCs and guidewire exchanges. 17-19,21,27 CVCs carry a substantially higher risk of infection than peripherally inserted catheters; therefore, the level of precautions must be greater to prevent infection. This means using a cap, mask, sterile gown, sterile gloves, and a full body sterile drape, just as with any other surgical procedure that carries a risk of infection. 17,21,34-36 If a full size drape is not available, use two drapes to cover the patient. 21 4. Use a catheter kit or cart containing all necessary items for aseptic insertion. 18,19 Items in a catheter insertion kit should be packaged sterile, and processed items cleaned and sterilized properly. 19 5. Prior to the insertion, apply an appropriate antiseptic to the insertion site and allow to completely air dry. 19,21,34 Use a chlorhexidine-based antiseptic for skin preparation in patients older than 2 months of age. 18 Use a concentration of at least 0.5% chlorhexidine gluconate. 18,19 2% chlorhexidine gluconate or CHG is the preferred skin antiseptic, but tincture of iodine, an iodophor, or 70% alcohol can be used. 21,27,34 6. For patients with hemodialysis catheters and a history of recurrent Staphylococcus aureus CLABSI, apply povidone-iodine or polysporin ointment to the insertion site. 19 7. Dress the insertion site using sterile gauze or sterile transparent, semi-permeable dressings to cover the catheter site. 17-19 While the type of dressing is a matter of facility preference, gauze dressings are desirable if there is blood oozing from the site. Be sure to use aseptic technique to open dressing packages and apply the dressing. 10
In addition, some facilities may elect to use CHG sponges routinely during the dressing of the site to prevent infections, while others may use them as an enhanced precaution if infection rates are higher than desired. This is based on studies that show CHG impregnated sponges as part of the dressing over the insertion site may reduce catheter related infections. 37,38 8. Avoid the use of antimicrobial prophylaxis during the insertion of short term or tunneled catheters, or while catheters are in place. 19,25 This practice may prevent future resistance of antimicrobials. In addition, do not apply mupirocin ointment to insertion sites due to the risk of mupirocin resistance and damage to polyurethane catheters. 18,19 9. Use a catheter checklist to ensure and document compliance with aseptic practices and related processes performed during the placement of the catheter. 18,19,21 The Compendium and SHEA/IDSA recommendations also include having the insertion observed by an appropriately trained clinician, and empowering healthcare personnel to stop a procedure if breaches in aseptic technique are observed. 18,19 XI. Care and Maintenance During the care and maintenance of the catheter site, there are several important actions to keep in mind. 1. Always maintain aseptic technique during catheter site care and maintenance in order to prevent catheter-related infections. 17,34 2. Minimize hub manipulation. 25 The greater the frequency of hub manipulation, the higher the risk for contamination, as every contact with the catheter or hub can introduce microorganisms that can cause infection. 25 3. Before accessing catheter hubs, needleless connectors and injection ports, disinfect them. 17-19,25 Scrub them for at least 15 seconds with an alcohol and CHG preparation or 70% alcohol, according to manufacturer recommendations, and allow to air dry to prevent entry of microorganisms and biofilms. 19 4. Evaluate central lines daily for necessity, and remove the catheter as soon as no longer essential. 18,21,34,39 The longer a catheter is left in place, the greater the risk for infection. Staff should consider removal when therapy is concluded or if there is reason to suspect a malfunction, infection or other catheter-related complication. A daily review of the line will help clinicians prevent unnecessary delays in removing a line that is no longer necessary to the patient s care. 21 The IHI bundle recommends stating the line day during rounds to remind all clinicians how long the line has been in place. For example, today is line day 6. However, daily review may not be appropriate for catheters that are in place for long term use. 21 5. Do not routinely replace CVCs or arterial catheters. 17,21 Routine replacement has not been shown to lower rates of infection; and is not necessary as long as the integrity of the catheter polymer is stable for the expected use and duration of catheterization, and as long as catheters are functioning and have no evidence of causing local or systemic complications. 17 6. Do not routinely use positive-pressure needleless connectors with mechanical valves before a thorough assessment of risks, benefits, and education regarding proper use. 19 The routine use of these devices have been associated with increased risk of CLABSI. 41-44 7. Do not routinely use guidewire exchanges for non-tunneled catheters to prevent infection. 17-19 However, guidewire exchanges may be used to replace a malfunctioning nontunneled catheter if no evidence of infection is present. Be sure to change gloves before handling the new catheter when performing a guidewire exchange. 17 Kimberly-Clark Health Care Education 11
8. Change dressings aseptically, and on scheduled intervals. 17,19 When changing dressings: Always practice good hand hygiene first and wear sterile gloves. 17,18 Change transparent dressings on non-tunneled catheters and perform site care every 5 to 7 days, or more frequently if the dressing is soiled, loose or damp, or when inspection of the site is necessary. 17,18,34 For patients who cannot tolerate transparent dressings, use gauze dressings on non-tunneled catheters and change them every 2 days unless soiled, loose or damp. 17,18 Change dressings on tunneled or implanted sites no more than once per week, unless soiled, loose or damp, until the insertion site has healed. 1 Use an appropriate antiseptic solution preferably chlorhexadine gluconate - to clean the site during every dressing change. 17,18 9. Follow flushing protocols for the specific type of line. Follow manufacturer instructions and established guidelines such as those by the Infusion Nurses Society (INS), available at www.ins1.org. 10.Replace administration sets at the proper intervals. 17-19 Replace administration sets that are used for fluids other than blood, blood products or lipids at intervals not longer than 96 hours. 18,19 Sets should also be replaced if there is blood in the tubing that cannot be flushed through, as this provides a breeding ground for bacteria. Replace tubing used to administer blood products or lipid emulsions within 24 hours of initiating the infusion. 17 11.Use antimicrobial ointments for hemodialysis catheter insertion sites. 18,19 Apply povidone-iodine or polysporin ointment to hemodialysis catheter insertion sites in patients with a history of recurrent Staphylococcus aureus CLABSI. However, mupirocin ointment should not be applied to the catheter insertion site due to the risks of mupirocin resistance and damage to polyurethane catheters. 19 XII. Patient Education If the patient is to be discharged home with a central line, the patient should be involved in the active prevention of infection. 13 Consider providing the patient and family with the following information: Instructions as to proper care and maintenance of the insertion site How CLABSI occur Home health follow up if advised How caregivers should be preventing infections whenever accessing the line XIII. Surveillance Despite the release of guidelines by the CDC and other evidence based research, and high rates of CLABSI, reports suggest that adherence to best practices remains low in US hospitals. 22 Surveillance works hand in hand with aims that are set by the unit or facility for reducing CLABSI, as goals reflect true attempts at improvement. 21 In order to determine whether these best practice recommendations are being adhered to and are preventing infection 12
in your patient population, facilities should perform surveillance for CLABSI. 17-19,22 The NHSN recommends surveillance in any type of patient care location where central lines are inserted. 22 The NHSN would like reporting on using maximal barrier precautions during insertion, avoiding the femoral insertion site if possible, and avoiding guidewire exchanges when CLABSI is suspected, among other information. 40 This data should be compared with historical data as well as national rates. Be sure to provide feedback to clinicians in order to promote what s working, as well as identify areas that need improvement. 19 In alignment with National Patient Safety Goal #7, The Joint Commissions Elements of Performance #4 (EP4) will require surveillance and prevention efforts throughout the healthcare facility starting in January 2010. 13,45 EP8 requires hospitals to measure CLABSI rates, monitor compliance with best practice or evidence-based guidelines, and evaluate the effectiveness of current progress. 45 XIV. Enhanced Interventions According to the SHEA/IDSA practice recommendations, 19 if the rates of infection continue to be high despite compliance with basic CLABSI infection prevention practices, then the following enhanced interventions may be considered. They may be especially beneficial for patients with limited venous access, a history of recurrent CLABSI, at heightened risk for severe sequelae from CLABSI, and for hospital units or patient populations with higher infection rates. 19 1. Bathe ICU patients older than two months of age with a chlorhexidine preparation daily. 19 The Food and Drug Administration has not approved the use of chlorhexidine products for children younger than 2 months of age; therefore, use a povidone-iodine preparation on the insertion site for younger children, especially low birth weight neonates. 2. Consider the use of antiseptic or antimicrobial impregnated CVCs. 19 There are various catheters either impregnated with antiseptics such as chlorhexidine-silver sulfadiazine, or antimicrobials such as minocycline-rifampin that show clinical promise. 46-50 3. Place chlorhexidine-containing sponge dressings at the insertion site in patients older than two months of age. 19 4. Use antimicrobial locks by filling the lumen of the catheter with antimicrobial solution and leaving in place until the hub is re-accessed. 19 This practice has shown great promise in clinical studies, 51 but there are some studies that show concern regarding the potential for systemic toxicity from leakage of the solution into the bloodstream, and for emergence of resistance in exposed organisms. Therefore, antibiotic lock solutions should be reserved for special circumstances. 17,19 XV. Conclusion Central line-associated bloodstream infections can be devastating to patients, family, and the healthcare system. But by implementing simple and practical infection prevention practices and best practice interventions, we can prevent CLABSI. Kimberly-Clark Health Care Education 13
XVI. References 1. Soufir L, Timsit JF, Mahe C, Carlet J, Regnier B, Chevret S. Attributable morbidity and mortality of catheter-related septicemia in critically ill patients: a matched, risk-adjusted, cohort study. Infect Control Hosp Epidemiol. 1999 Jun;20(6):396-401. 2. Saint S, Savel RH, Matthay MA. Enhancing the safety of critically ill patients by reducing urinary and central venous catheter-related infections. Am J Respir Crit Care Med. 2002 Jun 1;165(11):1475-9. 3. Mermel LA. Prevention of intravascular catheter-related infections. Annals of Internal Medicine. Mar 7 2000;132(5):391-402. 4. Warren DK, Kollef, MH. Prevention of hospital infection. Microbes Infect. 2005 Feb;7(2):268-74. 5. DeGaudio AR, Di Fillippo A. Device-related infections in critically ill patients. Part I: Prevention of catheter-related bloodstream infections. J Chemother. 2003 oct;15(5):419-27. 6. O Grady NP. Applying the science to the prevention of catheter-related infections. J Crit Care. 2002 Jun;17(2):114-21. 7. Maki DG, Kluger DM, Crnich DJ. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc 2006;81:1159-1171. 8. Esteve F, Pujol M, Limon E, et al. Bloodstream infection related to catheter connections: a prospective trial of two connection systems. J Hosp Infect 2007;67:30-34. 9. Climo M, Diekema D, Warren DK, et al. Prevalence of the use of central venous access devices within and outside of the intensive care unit: results of a survey among hospitals in the prevention epicenter program of the Centers for Disease Control and Prevention. Infect Control Hosp Epidemiol 2003;24:942-945. 10. Vonberg RP, Behnke M, Geffers C, et al. Device-associated infection rates for non-intensive care unit patients. Infect Control Hosp Epidemiol 2006;27:357-361. 11. Marschall J, Leone C, Jones M, Nihill D, Fraser V, Warren D. Catheter-Associated in General Medical Patients Outside the Intensive Care Unit: A Surveillance Study. Infect Control Hosp Epidemiol. August 2007, Vol. 28, No. 8. 12. Trick WE, Vernon MO, Welbel SF, Wisniewski MF, Jernigan JA, Weinstein RA. Unnecessary use of central venous catheters: the need to look outside the intensive care unit. Infect Control Hosp Epidemiol 2004;25:266-268. 13. The Joint Commission 2009 National Patient Safety Goals. http://www.jointcommission.org/nr/rdonlyres/ D619D05C-A682-47CB-874A-8DE16D21CE24/0/HAP_NPSG_Outline.pdf 14. U.S. Department of Health and Human Services. Action Plan to Prevent Healthcare-Associated Infections: Introduction. www.hhs.gov/ophs/initiatives/hai/introduction.html 15. Dept of Health and Human Services, Centers for Medicare and Medicaid Services. 42 CFR Parts 411, 412, 413, 422, and 489 [CMS-1390-F]; [CMS-1531-IFC1]; [CMS-1531-IFC2] [CMS-1385-F4] RIN 0938-AP15; RIN 0938-AO35; RIN 0938-AO65. Medicare Program; Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2009 Rates; Payments for Graduate Medical Education in Certain Emergency Situations; Changes to Disclosure of Physician Ownership in Hospitals and Physician Self-Referral Rules; Updates to the Long-Term Care Prospective Payment System; Updates to Certain IPPS-Excluded Hospitals; and Collection of Information Regarding Financial Relationships Between Hospitals. http://www.cms.hhs.gov/acuteinpatientpps/downloads/cms-1390-f.pdf 16. World Health Organization. WHO Collaborating Centre for Patient Safety. http://www.euro.who.int/healthsystems/service/20070828_1 17. O Grady N, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki DG, Masur H, McCormick RD, Mermel LA, Person ML, Raad II, Randolph A, Weinstein RA, HICPAC Advisory Committee. Guidelines for the Prevention of Intravascular Catheter-Related Infections. Infect Control and Epidemiol 2003, Vol. 23, No. 12. 14
18. Yokoe DS, Mermel LA, Anderson DJ, Arias KM, Burstin H, Calfee DP, et al. A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals. Infect Control and Hospital Epidemiol, October 2008, Vol.29, Suppl 1. 19. Marschall J, Mermel LA, Classen D, et al. Supplemental Article: SHEA/IDSA Practice Recommendations. Strategies to Prevent Central Line-Associated in Acute Care Hospitals. Infect Control and Hospital Epidemiol, October 2008, Vol.29, Suppl 1. 20. AHRQ Evidence Report/Technology Assessment Number 9. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Volume 6- Prevention of Healthcare-Associated Infections. AHRQ Publication No. 04(07)-0051-6. January 2007. 21. Institute for Healthcare Improvement. Protecting 5 Million Lives From Harm campaign. Getting Started Kit: Prevent Central Line Infections, How-To Guide. Cambridge, MA, 2008. www.ihi.org 22. Centers for Disease Control and Prevention. The National Healthcare Safety Network (NHSN) Manual. Patient Safety Component Protocol. Last updated January 2008. 23. Central Venous Catheters Topic Overview from WebMD. www.webmd.com/a-to-z-guides.central-venouscatheers-topic-overview 24. Center Venous Catheter Placement Department of Surgery, Baylor College of Medicine, Texas, Houston. www.debakeydepartmentofsurgery.org/ 25. Mermel LA. Prevention of Intravascular Catheter-Related Infections. Ann Intern Med. 2000;132:391-402. 26. Safar N. Maki, DG. Inflammation at the insertion site is not predictive of catheter-related bloodstream infection with short-term, noncuffed central venous catheters. Critical Care Medicine. 30(12):2632-2635, December 2002. 27. American Association of Critical-Care Nurses. AACN Practice Alert: Preventing Catheter Related Bloodstream Infection. www.aacn.org/wd/practice/docs/preventing_catheter_related_bloodstream_infections_9-2005.pdf 28. Gnass SA, Barboza L, Bilicich D, Angeloro P, Teriver W, Grenovero S, Basualdo J. Prevention of central venous catheter-related bloodstream infections using non-technologic strategies. Infect Control Hosp Epidemiol. 2004 Aug;25(8):675-7. 29. Sherertz RJ, Ely EW, Westbrook DM, et al. Education of physicians-in-training can decrease the risk for vascular catheter infection. Ann Intern Med. 2000;132:641:648. 30. Coopersmith CM, Rebmann TL, Zack JE, Ward MR, Corcoran RM, Schallom ME, Sona CS, Buchman TG, Boyle WA, Polish LB, Fraser VJ. Effect of an education program on decreasing catheter-related bloodstream infections in the surgical intensive care unit. Crit Care Med. 2002 Jan;30(1):59-64. 31. Berenholiz SM, Pronovoist PJ, Lipsett PA, Hobson D, Ersing K, Farley JE, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004 Oct;32(10);201-20. 32. Association for Vascular Access: SAVE That Line! Campaign. www.avainfo.org 33. Tariq M, Juang DT. PICCing the best access for your patient. Critical Care 2006, 10:315doi:10.1186/cc5031. 34. U.S. Department of Health and Human Services. Action Plan to Prevent Healthcare-Associated Infections: Prevention Prioritized Recommendations. 2008. www.hhs.gov/ophs/initiatives/hai/prevention.html 35. Chaiyakunapruk N, Veenstra DL, Lipsky BA, et al. Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: a meta-analysis. Ann Intern Med. 2002 Jun;4;136(11):792-801.t 36. Hu KK, Lipsky BA, Veenstra DL, et al. Using maximal sterile barriers to prevent central venous catheter-related infection: a systemic evidence-based review. Am J Infect Control. 2004 May;32(3):142-6. Kimberly-Clark Health Care Education 15
37. Jean-François Timsit, et al. Chlorhexidine-Impregnated Sponges and Less Frequent Dressing Changes for Prevention of Catheter-Related Infections in Critically Ill Adults. JAMA. 2009;301(12):1231-1241 38. Perencevich EN, Pittet D. Preventing Catheter-Related : Thinking Outside the Checklist. JAMA. 2009;301(12):1285-1287. 39. Eggiman P, Sax H, Pittet D. Catheter-related infections. Microbes Infect. 2004 Sep;6(11)1033-42. 40. Centers for Disease Control and Prevention/NSHN. National Healthcare Safety Network. Central Line Insertion Practices (CLIP) Training Course. http://www.cdc.gov/nhsn/wc_clip.html 41. Maragakis LL, Bradley KL, Song X, et al. Increased catheter-related bloodstream infection rates after the introduction of a new mechanical valve intravenous access port. Infect Control Hosp Epidemiol 2006;27:67-70. 42. Field K, McFarlane C, Cheng AC, et al. Incidence of catheter-related bloodstream infection among patients with a needleless, mechanical valve-based intravenous connector in an Australian hemotology-oncology unit. Infect Control Hosp Epidemiol 2007;28:684-688. 43. Salgado CD, Chinnes L, Paczesny TH, Cantey JR. Increased rate of catheter-related bloodstream infection associated with the use of an intravascular needleless valve. Clin Infect Dis 2007;28:684-688. 44. Rupp ME, Sholtz LA, Jourdan DR, et al. Outbreak of bloodstream infection temporarily associated with the use of an intravascular needleless valve. Clin Infect Dis 2007;44:1408-1414. 45. The Joint Commission. 2009 Standards. Elements of Performance EP4 and EP8. 46. Raad I, Darouiche R, Dupuis J. Central venous catheters coated with minocycline and rifampin for the prevention of catheter-related colonization and bloodstream infections: a randomized, double-blind trial. The Texas Medical Center Catheter Study Group. Ann Intern Med 1997;127:267-274 47. Veenstra DL, Saint S, Saha S, Lumley T, Sullivan SD. Efficacy of antiseptic-impregnated central venous catheters in preventing catheter-related bloodstream infections: a meta-analysis. JAMA 1999;282:261-267. 48. Darouiche RO, Raad II, Heard SO, et al. A comparison of two antimicrobial-impregnated central venous catheters: Catheter Study Group. N Engl J Med 1999;340:1-8. 49. Hanna HA, Raad II, Hackett B, et al., M.D. Anderson Catheter Study Group. Antibiotic-impregnated catheters associated with significant decrease in nosocomial and multidrug-resistant bacteremias in critically ill patients. Chest 2003;124:1030-1038. 50. Hanna H, Benjamin R, Chatzinikolaou I, et al. Long-term silicone central venous catheters impregnated with minocycline and rifampin decrease rates of catheter-related bloodstream infection in cancer patients: a prospective randomized clinical trial. J Clin Oncol 2004;22:3163-3171. 51. Garland JS, Alex CP, Henrickson KJ, McAuliff TL, Maki DG. A Vancomycin-Heparin Lock Solution for Prevention of Nosocomial Bloodstream Infection in Critically Ill Neonates With Peripherally Inserted Central Venous Catheters: A Prospective, Randomized Trial. Pediatrics. Vol. 116 No. 2 August 2005, pp. e198-e205 (doi:10.1542/peds.2004-2674) 16
Kimberly-Clark Health Care Education 17
XVII. Post Test 1. The following can be said about central lines except: A A central line is a catheter that terminates at or close to the heart or in one of the great vessels B Central lines are always long term devices C Central lines include peripherally inserted central catheters (PICCs) D The majority of patients with central lines are actually outside the ICU 2. Patients who are more likely to develop CLABSI include: A Those with prolonged hospital stays before insertion and who may have MDROs B Those receiving Total Parenteral Nutrition (TPN) or have neutropenia C Patients with multiple catheters or prolonged catheter use D All of the above 3. When selecting insertion sites: A Choose insertion sites with the lowest density of flora or colonization rates and with the lowest risk of non-infectious complications B Avoid the femoral site whenever possible C Consider patient factors and preferences D All of the above 4. Maximal barrier precautions include: A A cap, mask, sterile gloves and partial sterile drape B A cap, mask, sterile gloves, sterile gown, and full body drape C A mask, gown, clean gloves and sheets D A mask, sterile gown, clean gloves and full body drape 5. Considerations during catheter insertion include: A Using a catheter kit or cart containing all necessary items B Applying povidone-iodine or polysporin ointment to all insertion sites C Using a chlorhexidine antiseptic on the insertion site after insertion D Dressing the insertion site with clean dressings 6. During care and maintenance of the insertion site, perform the following except: A Maintain aseptic technique B Disinfect hubs, needleless connectors and injection ports with 70% alcohol or chlorhexidine solution and allow to air dry C Routinely replace CVCs in order to prevent infection D Minimize hub manipulation 18
7. The following can be said about keeping a line in place: A The longer a catheter is left in place, the greater the risk of infection B Consider removing the catheter when therapy is concluded or there is reason to suspect a complication C A daily review of the line will help clinicians prevent unnecessary delays in removing a line that is no longer needed D All of the above 8. When changing dressings the following should be considered: A Always practice good hand hygiene and wear clean gloves B Perform site care and change dressings on nontunneled catheters every 5-7 days C Change gauze dressings on nontunneled catheters every 5-7 days D Change dressings on tunneled catheters every 2-3 days 9. Surveillance is used for all except: A To work hand in hand with goals set by the facility to reduce CLABSI rates B To spy on clinicians to make sure they are performing infection prevention measures C To compare facility rates with national rates of infection D To provide feedback to clinicians in order to promote what s working, and identify areas that need improvement 10. The following are enhanced interventions that can be used if rates of infection continue to be high despite compliance with basic CLABSI infection prevention practices: A Using antiseptic or antimicrobial impregnated CVCs or antimicrobial locks B Bathing all patients with a chlorhexidine preparation daily or placing chlorhexidine-containing sponge dressings on all patients C None of the above D All of the above Kimberly-Clark Health Care Education 19
XVIII Tools Nursing Checklist: Central Venous Catheter Insertion Department: CCU MICU TICU NSICU SICU BICU PCCU NICU Other MR#: Date: / / Time Start (1st needle stick): : a.m. p.m. Time End (catheter sutured): : a.m. p.m. Type of Catheter: Insertion Site: Side: Indications for use: Check if: Double lumen Internal Jugular Right Pressors Consent obtained Triple lumen Subclavian Left Hemodynamic mont. Pt/Family teaching done Introducer Femoral Fluids/blood products Guidewire exchange Swan-Ganz Other (specify) Frequent lab draws Vascath List all sites where insertion was attempted: RIJ LIJ RSC LSC RF LF Other (specify) The provider inserting this line: A. Handed-off his/her pager before the procedure? Yes No Didn t ask B. Washed hands immediately prior to procedure? Yes No Didn t ask C. Has previously placed at least five (5) central lines? Yes No* Didn t ask * If No, was this procedure supervised by someone with at least five (5) central lines experience? Yes No Didn t ask Barrier precautions (check any used): Sterile gloves Sterile gown Mask Sterile towels Full body drape Describe the level of training of the person who actually inserted the line? Medical student Intern (PGY-1) Resident (PGY-2+) Fellow Attending Nurse Practitioner How many different needle sticks did the patient receive (number of skin breaks)? 1 2 3 4 5 6+ Unknown Was the sterile field maintained throughout the entire procedure? Yes No Pre-insertion skin prop (check any used): Alcohol Betadine (povidone-iodine) Chlorhexidine Other (specify) Describe the circumstances under which this line was placed: Non-emergent Emergent (life-threatening or code situation) Pre-existing infection Follow-up CXR: Ordered Not ordered (specify reason) CXR findings (check all that apply): No pneumothorax Pneumothorax (describe action taken) Catheter in good position Catheter position adjusted (describe) Type of dressing: Bio-occlusive Gauze Other (specify Dressing applied by: Nurse Proceduralist Other (specify) Patient tolerated the procedure well? Yes No Comments: Complications? None Placement unsuccessful Other (describe) Note: Please make 2nd copy and file in Patient Chart, and return original copy to the designated location in the ICU. Signature: Date: / / Used with permission from Vanderbilt University Hospital, 2009. 20
Save That Line Poster and Note card Poster This Poster is also included on the Resource CD as a PDF document which may be downloaded to your computer and printed. The document size is 8.5 x 11, and has been designed in full color. It may also be printed in black & white. This is an excellent resource to hang in your office and other public areas within your facility. Note Card This Note Card is also included on the Resource CD as a PDF document which may be downloaded to your computer and printed. The document size is 4.25 x 5.5. It is 2-sided, full color. Ideally, the note card is designed to be printed on thicker paper (card stock). However, if printed on standard paper, it may be trimmed to size. This is an excellent resource to hand out as a pocket reference. Card Front Card Back Kimberly-Clark Health Care Education 21
XIX. Continuing Education Application Please print clearly and fill in all data to ensure accurate record-keeping. Preventing Central Line-Associated : LEARNING OBJECTIVES 1. Define Central Line-Associated 2. Identify the various types of central lines and their uses 3. Discuss how catheter and site selection can affect the development of CLABSI 4. Discuss measures to prevent the development of CLABSI during insertion, care and maintenance of central lines CE CREDITS BY MAIL This program has been approved by Envision, Inc. for 1.0 Contact Hour, Program Number 006CLABSI10. Envision, Inc. is an approved provider by the California State Board of Registered Nursing, Provider Number CEP 15437 Please complete this form in its entirety and submit to Envision, Inc. along with the $10.00 CE processing fee. Please mail completed forms and fee to: Envision Inc., 644 West Iris Drive, Nashville, TN 37204. CE certificates will be mailed within four weeks after receipt of this completed form. Thank you. Name: Address: City: State: Zip: Daytime Telehone: E-mail: Date of Application: / / RN/LPN License #: State: TEST ANSWERS Circle only one choice for your answer to each question. 1. A B C D 6. A B C D 2. A B C D 7. A B C D 3. A B C D 8. A B C D 4. A B C D 9. A B C D 5. A B C D 10. A B C D 22
XX. Program Evaluation Form Please circle the number that reflects your extent of agreement with each statement: Evaluate this program in each of the categories by using the following rating scale: Poor Satisfactory Good Excellent 1. Program content resulted in achievement of the stated learning objective #1 1 2 3 4 2. Program content resulted in achievement of the stated learning objective #2 1 2 3 4 3. Program content resulted in achievement of the stated learning objective #3 1 2 3 4 4. Program content resulted in achievement of the stated learning objective #4 1 2 3 4 5. The content met my expectations 1 2 3 4 6. Information presented can be applied to my practice 1 2 3 4 7. Information provided is helpful in achieving my professional goals 1 2 3 4 8. Content was organized and easy to follow 1 2 3 4 9. The information presented is current and relative 1 2 3 4 10. This method of delivery met my learning needs 1 2 3 4 11. The content in this course was presented without bias of any commercial product or drug 1 2 3 4 12. To complete this self paced program, which includes watching the video presentation and reviewing the study guide, it took me minutes/hours. Kimberly-Clark Health Care Education 23
XXI. Post Test Answers 1. B. Central lines are always long term devices. Central lines may be short or long term devices and include catheters, ports, tunneled and nontunneled devices. 2. D. All of the above. Other risk factors include emergency insertion of catheters under less than ideal conditions; patients with comorbidities or existing infections; patients with repeated access to catheters; and patients with prematurity and partially developed immune systems. 3. D. All of the above. In addition, the risks and benefits of placing a device at a site to reduce infectious complications may need to be weighed against the risk for mechanical complications. 4. B. A cap, mask, sterile gloves, sterile gown, and full body drape. 5. A. Using a catheter kit or cart containing all necessary items. B is wrong as you should only apply povidone-iodine or polysporin to patients with hemodialysis catheters and a history of recurrent S. aureus CLABSI. C is wrong in that you use a chlorhexidine preparation before insertion of the catheter. D is wrong in that you dress the insertion site using sterile gauze or transparent dressings. 6. C. Routinely replace CVCs in order to prevent infection. This is incorrect, as routine replacement has not been shown to lower rates of infection, and is not necessary as long as the catheter integrity is stable and the catheter is functioning with no evidence of complications. 7. D. All of the above. 8. B. Perform site care and change dressings on nontunneled catheters every 5-7 days. A is incorrect as you should wear sterile gloves to work aseptically on the insertion site. C is incorrect as gauze dressings should be changed every 2 days; and dressings on tunneled catheters should not be changed more than once per week, unless soiled, loose or damp. 9. B. To spy on clinicians to make sure they are performing infection prevention measures. Surveillance is a positive measure that should never be construed as spying or a negative measure, and in fact results in the reduction of infection rates that improve patient care. 10. A. Using antiseptic or antimicrobial impregnated CVCs and antimicrobial locks. B is incorrect as chlorhexidine preparations should not be used on patients under 2 months of age. 24