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4/3/2014
1
Causes, Prevention andBest Practices
Nancy Moureau, BSN, CRNI, CPUI, VA-BC
Catheter-Related Bloodstream Infection
Disclosure
� Nancy Moureau has the following disclosures:� Consultant for PICC Excellence � Speakers Bureau for:
� 3M� Excelsior� Teleflex
Learning Objectives
At the end of this presentation the learner will be able to:
� Identify types and complications associated with central
venous catheters (CVC’s)
� Identify causes and pathogens of CR-BSI
� Describe best practice recommendations from various
organizations
� Discuss clinical application of best practice components
on prevention of CRBSI
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Classifications OfVascular Access Devices
Classes of Vascular Access Devices
� Peripheral Catheter� Central Venous Catheter� Arterial� Subcutaneous port� Dialysis Catheter� Umbilical Catheter
CVC Complications
� Catheter occlusion� Phlebitis� Catheter-related vessel
thrombosis� Catheter tip malposition� Catheter fracture� Air embolism� Infiltration and extravasation� CRBSI
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Where do Catheter Related Bloodstream Infections occur?
� What patient care units?
� What patient populations?
TABLE 2. Pooled means and key percentile of the distribution of central-line associated bloodstream in infection rates among hospitals participating in the in the National Healthcare Safety Network, CDC, 2006 –2007.
Percentile
Type of Intensive
care Unit
No.
Units
No.
CABSIs
Catheter-
days
Pooled mean Incidence/
1,000 catheter-days
10%
25%
50%
75%
90%
Burn 22 239 42452 5.6 0 1.5 3.8 8.2 13.5 Trauma 32 435 107620 4.0 0.3 1.5 4.0 5.7 7.7 Pediatric medical/surgical
71 404 140,848 2.9 0.0 0.0 2.1 3.8 6.0
Neurosurgical 39 173 68550 2.5 0 0 1.9 3.8 6.2 Medical 144 1073 454839 2.4 0 0.6 1.9 3.6 5.3 Surgical 128 881 383126 2.3 0 0.5 1.7 3.1 5.1 Coronary 121 373 181079 2.1 0 0 1.3 2.8 5.3 Medical/surgical Major teaching
104 692 342214 2.0 0 0.5 1.5 3.0 4.2
Inpatient medical ward
40 111 60257 1.8 0 0 0 2.2 3.4
Med/Surg All others
343 972 662489 1.5 0 0 0.6 2.0 3.6
Surgical cardiothoracic
97 397 275194 1.4 0 0 1.2 1.9 3.4
Inpatient medical/surgical ward
82 169 132133 1.3 0 0 0 1.6 4.0
Neurologic 15 31 25440 1.2 - - - - -
Edwards JR, Peterson KD, Andrus ML, Dudeck MA, Pollock DA and Horan TC. National Healthcare Safety Network (NHSN) Report, data summary for 2006 through 2007, issued November 2008. Am J Infect Control 2008;36:609-26
TABLE 3. Most common pathogens isolated from nosocomial bloodstream infections, SCOPE
Pathogen Total ICU Non-ICU
Coagulase-negative staphylococci 31.3 35.9 26.6
Staphylococcus aureus 20.2 16.8 23.7
Enterococcus spp 9.4 9.8 . 9.0
Candida spp. 9.0 10.1 7.9
Gram-negative rods
Escherichia coli
Klebsiella spp
Enterobacter spp.
Pseudomonas aeruginosa
Acinetobacter baumannii
Serratia spp.
5.6
4.8
4.3
3.9
1.7
1.3
3.7
4.0
4.7
4.7
2.1
1.6
7.6
5.5
3.8
3.1
1.3
0.9
Percentage of BSIs
1. Wisplinghoff H, Bischoff T, Tallent SM, Seifert H, Wenzel RP and Edmond MB. Nosocomial bloodstream infections in US hospitals: analysis of
24,179 cases from a prospective nationwide surveillance study. Clin Infect Dis 2004;39:309-17
2. Gaynes R, Edwards JR. Overview of nosocomial infections caused by gram-negative bacilli. Clin Infect Dis 2005;41:848-54
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CDC Criteria for CRBSI
� Positive semi quantitative (>15 colony-forming units
[CFU]/catheter segment) or quantitative (>103 CFU/catheter
segment) cultures whereby the same organism (species
and antibiogram) is isolated from the catheter segment and peripheral blood
� Simultaneous quantitative blood cultures with a ≥5:1 ratio CVC versus peripheral
� Differential period of CVC culture versus peripheral blood culture positivity of >2 hours
CDC, 2011
Sources of CRBSI: Intraluminal
ContaminationContamination
Non-aseptic manipulations to hub and tubing Contaminated Infusate
Hub Contamination
Hub contamination infections� Seen in long-term catheters
(cuffed, surgically implanted or tunneled)
� Occur 2 or more weeks after insertion
10%Other
60% Skin
30% Hub
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Sources of CRBSI: Extraluminal
Contamination
Skin Contamination
Infections related to skin flora regrowth:
� Occur when organisms from the skin travel along the intercutaneous segment of the catheter
� Occur usually within first 2 weeks of insertion
� Are seen more often with short-term, non-tunneled, non-cuffed catheters
� Reduced with the use of maximum barrier precautions
60% Skin
10%Other
30% Hub
Biofilm
� When the catheter becomes contaminated, biofilm forms
� Biofilm-forming bacteria secrete a sticky carbohydrate coating to protect themselves from antibiotics and disinfectants
� Because of this coating, biofilm bacteria are unique from planktonic bacteria making biofilms notoriously difficult to kill
“The rule of thumb is that 1,000 times more of an antimicrobial agent is needed to kill a biofilm than a planktonic bacteria.” (William Costerton)
� A best practice is to prevent bacteria regrowth on the skin before biofilm can form
Candida albicans biofilm after 24
hours of development. Catheter wall
and intraluminal biofilm
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Microorganisms Commonly Associated with Biofilms on Central Venous Catheters
• Candida albicans
• Coagulase-negativeStaphylococcus
• Enterococcus species
• Klebsiella pneumoniae
• Pseudomonas aeruginosa
• Staphylococcus aureus
Ryder, M.A. Catheter-Related Infections: It's All About Biofilm. Topics in Advanced Practice Nursing eJournal.2005;5(3)
37%
14%13%
5%
5%
4%
3%
2%
17%Coag Neg Staph
Enterococcus
S aureus
Candida
Enterobacter
Pseudomonas
Klebsiella
E coli
Other
Most Common Pathogens Causing CRBSI
Impact of Skin Flora
� Location matters� Skin of the neck and thorax is oily and houses
approximately 1,000–10,000 CFUs per site
� Skin of the antecubital space is dry and cool and houses approximately 10 CFUs per site
� Even with stringent cleansing and prepping, up to 20% microbes remain on and within the skin after prepping – the skin can never be sterilized
What is Best Practice?
Best Practices are defined as:
Strategies, activities or approaches that have been shown through research and evaluation to be effective and/or efficient. Also known as evidence-based practice.
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Organizational Evidence for Best Practices
Examples:
� Centers for Disease Control 2011 Guidelines for Prevention of Catheter Related Infections– USA
� Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA ). 2008 Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals, 29(Supp 1):S22.
� Institute for Healthcare Improvement (IHI) www.IHI.org - USA
� Agency for Healthcare Research and Quality (AHRQ) - USA
� Registered Nurses Association of Ontario (RNAO) 2008 Best Practice Best Care – Canada; Infusion Nurses Society Standards of Practice (INS) - 2011,;Royal College of Nursing Standards of Practice 2010
� National Institute for Health and Clinical Excellence (NICE) – UK
� EPIC and EPIC2 2007 Guidelines for Preventing Hospital Acquired Infections –UK
� Infusion Nurses Society, Infusion Nursing Standards of Practice, www.ins1.org ,
� Association of Vascular Access (AVA) Position Statements, iSAVE THAT LINE Campaign
Best Practices
Vascular
Access
Education for
reducing
complications
and
infections
� Provide consistent and repeated education on management and prevention of complications with IV/CVADs.
� Education results in reduced infection and other complications.
� The principles and practice of infusion therapy should be included in the basic IV education curriculum, be available as continuing education, be provided in orientation to new employees and be made available through continuing professional development opportunities.
SHEA/IDSA 2008 HAI Prevention Compendium
Sherertz R, et al. 2000 Ann Inter Med
Coopersmith C, et al. 2002 Crit Care Med
Warren D, et al. 2003 Crit Care Med
O’Grady N, et al. 2011 CDC Guidelines
Best Practices
Establish
Teams for
IV/PICC/
CVAD
placement
� A specialized team of individuals educated on insertion and care of devices will result in fewer complications
� Team management of CVAD selection, placement, dressing changes and monitoring has the greatest effect
Hawes M. 2007 JIN
INS Standards of Practice 2011
Robinson M, et al. 2005 JPEN
Hornsby s, et al. 2005 JIN
Soifer N, et al. 1998 Arch Intern Med
Alexander M, et al 2002 Nursing Spectrum
O’Grady N, et al. 2011 CDC Guidelines
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Best Practices
Preferred
antisepsis
2%
Chlorhexidine
with 70%
Alcohol
� Chlorhexidine used for prepping prior to CVC placement through the skin reduces skin flora and maintains a residual effect up to 48 hours
� Chlorhexidine with Alcohol has faster killing action and shorter dry time. Use back and forth frictional scrub for 30 seconds, allow to dry up to 3 minutes
� Consistent use of Chlorhexidine has a cumulative effect to prevent skin flora regrowth
Chaiyakunapruk N, et al. 2003 Clin Infect Dis
O’Grady N, et al. 2011 CDC Guidelines
Maki D, et al. 1991 Lancet
Daily
Bathing
� For critically ill patients with a CVC,
consider daily bathing with
chlorhexidine gluconate/alcohol
combination washcloths to reduce
colonization and CRBSI (IB)
� Excludes head, mucous membranes,
and non-intact skin
� In a 6 month study of adult ICU
patients: reduction of MRSA by 25%,
VRE by 45%
Climo et al.,2009
Best Practices
© Sage Products, Inc.
Best Practices
Chlorhexidine
Impregnated
Dressings
� Studies show reduction of CRBSI with CHG impregnated dressing.
� Impregnated dressings show effective reduction of skin flora up to and beyond 7 days.
� Catheter –skin junction site should be visualized daily.
Bhende S, Rothenburger S. 2007 JAVA
INS Standards of Practice 2011.
Chambers 2005 Journ Hospital Infec
Safdar N, Maki D. 2004 Intens Care Med
O’Grady N, et al. 2011 CDC Guidelines
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Best Practices
Antimicrobial
Catheters� Use of antimicrobial catheters reduces
CRBSI by as much as 40%� Minocycline/Rifampin� Chlorhexidine and Silver Sulfadiazine� Use for high risk patients or when
infection rate exceeds goals despite implementation of bundle.
Alonso-Echanove J, et al. 2003 Inf Contr Hosp Epid
O’Grady N, et al. 2011 CDC Guidelines
Marik P, et al. 1999 Crit Care Med
Darouiche R, et al. 1999. NEJM
Raad I, et al. 1997 Ann Inter Med
Maki D, et al. 1997 Ann Inter Med
What is the Central Line Bundle?� …is a group of interventions related to patients with
intravascular central catheters that, when implemented together, result in better outcomes than when implemented individually
� The science behind the bundle is so well established that it should be considered standard of care
� The key components of the IHI Central Line Bundle are:1. Hand Hygiene 2. Maximal Barrier Precautions Upon Insertion 3. Chlorhexidine Skin Antisepsis 4. Optimal Catheter Site Selection, with Avoidance of the
Femoral Vein for Central Venous Access in Adult Patients
5. Daily Review of Line Necessity with Prompt Removal of Unnecessary Lines
Best Practices
Intentional
Catheter
Selection
� Assess the patient for appropriateness of catheter, size and lumens.
� Use single lumen catheter unless multi-lumen device is essential for therapy
� Consideration for the condition of the patient, need, duration and treatment help to guide selection
� Certain access areas on the body carry less risk with insertion related to skin flora. Use device and area with least risk.
EPIC 2007
Grinspun D. 2008 RNAO Guidelines
Barton A, et al, 1998 Jour Nurs Care Qual
O’Grady N, et al. 2011 CDC Guidelines
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Best Practices
Maximum
Sterile
Barriers
� Use of strict sterile procedure with maximum barriers reduces infection
� Incorporation of full body drapes improves sterile procedure when ultrasound is used for CVC insertion
� Personal protective equipment is standard with mask, head cover, sterile gown and sterile gloves
� Incorporation of a Central Line Checklist will aid compliance with sterile technique and best practices
O’Grady N, et al. 2011 CDC Guidelines
Pratt R, et al. 2007 EPIC2
Pronovost P, et al. 2006 NEJM
Saver C. 2006 Nurs Man www.IHI.org
Maki D. 1994 Inf Contr Hosp Epid
Raad I, et al. 1994 Infect Contr Hosp Epid
DAILY CHECKLIST FOR CVC CARE AND MAINTENANCE
Date:
Every day, evaluate the following:
Need for continued use of CVC
Can current IV medications be given orally?
Can frequency of ordered labs be decreased?
Is there evidence of catheter or site complications?
Can CVC be flushed without resistance and brisk blood return upon aspiration?
Ensure all stopcocks, ports are cleared of blood
Is dressing occlusive and without drainage, blood, or moisture?
Perform dressing change or port access every __ days
Perform needleless connector change every __ days
Perform infusion tubing change every ___ days
Performance measures:
Hand hygiene performed before and after care
Use of clean gloves for all CVC access
CVC maintenance supplies readily available
Disinfection of needleless connectors prior to accessing
For muli-lumen CVC, dedicated lumen for TPN
Daily bathing with CHG
Considerations for continued use of CVC:
• Patient receiving the following therapies: hyperosmolar therapies e.g. TPN, chemotherapy, vesicants, irritants, vasopressive drips, CVP monitoring, and frequent blood sampling
• Patient conditions: hemodynamically unstable, rapid infusion of large volumes of fluid/blood, critical airway, poor access, and need for frequent or long-term access
Type of CVC: ___________________ Location of CVC: ______________
Date of insertion: ________________ CVC tip placement: ____________
Presented at the Association of Vascular Access (AVA) Conference, September, 2009
P Catudal, D Doellmanwww.avainfo.org
Best Practices
Daily
Assessment
of Site
Necessity
�Perform daily assessment of insertion
site with palpation and visualization.
Monitor for complications.
� Institute a systematic process to assess
each central venous catheter for
necessity with prompt discontinuation.
�No delays in discontinuation of devices
when therapy is complete
Pronovost P, et al. 2006 NEJM
O’Grady N, et al. 2011 CDC Guidelines
Saver C. 2006 Nurs Man www.IHI.org
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Maintenance Bundle
� Maintenance Best Practices � Disinfect before access� Remove nonessential catheters� Change dressings weekly and when loose using
CHG skin antisepsis� New tubing for new catheter or every 96 hours,
exceptions apply� Keep piggyback intermittent sets connected to
maintain closed system and reduce contamination� Consider disinfecting caps for tubing and CVC
access points� Perform surveillance for infection and compliance
Halton et al., 2009; Parencevich & Pittet, 2009, ESPEN 2009
Risk Factors for BSI During the Process of CVC Care Maintenance
� Provider knowledge of risk factors� Minimize CVC manipulation� Consolidate blood draws� Daily site inspection (visual & palpation)� Dressing change protocol� Hand hygiene prior to accessing hubs� Hub antisepsis prior to accessing� Tubing replaced after blood product infusions� Hubs replaced after any opening� Nurse-to-patient ratio� Specialized line teams� Protocol for CVC removal
Use of Needless
Connectors
� Utilize a needleless connector at CVC hubs and stopcocks (1A)
� Minimize the use of stopcocks If a stopcock is used, cap port(s) with a needleless connector and disinfect prior to use
� Educate clinicians on appropriate use of needleless connectors per manufacturer’s guidelines
� Consider use of a closed system for infusion, medication administration, and blood sampling
Casey et al., 2003; Yebenes, et al., 2004
Best Practices
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Needleless
Connector
/Hub
Antisepsis
and change
� Vigorously scrub needleless connector (diaphragm and sides) prior to entry with seconds (or manufacturer’s guidelines) and allow to dry (1A)
� Organizational CVC policies to address consistent practice for antisepsis of needleless connectors
� Alcohol or chlorhexidine gluconate /alcohol combination using friction for a minimum of 15 seconds.
� Needleless connectors to be changed at least as frequently as the administration set
� For CVCs that are locked, change no more
frequently than every 96 hours
Kaler & Chinn, 2007
Best Practices
Process
Improvement Plan
� Perform surveillance or processes:
-Hand hygiene
-Sterile or aseptic technique-Proper skin disinfectant andapplication-Catheter access technique-Infusion tubing change technique-Dressing change technique-Complication rates
-Collect data onCRBSI rates
-Identify trends,and potential lapses with infection controlpractices
Best Practices
Putting it all together
� Provide the very best and most effective care for our patients as evidenced by a zero intravenous catheter infection rate and few catheter related complications, by using best practices that have been shown through research and evaluation to be effective and/or efficient
� Is there any reason we cannot apply ALL the best practices?
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Thank you for your attention
Nancy Moureau
nancy@piccexcellence.com
QUESTIONS?
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