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Preventing vascular catheter-associated infection : the next steps
Tapei July 2013
Professor Didier Pittet, MD, MS,
Infection Control Program
&
WHO Collaborating Center for Patient Safety
University of Geneva Hospitals, Switzerland
Lead Advisor, 1st Global Patient Safety Challenge,
World Health Organization (WHO) Patient Safety
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1. Pathogenesis
2. Epidemiology
3. Technology
4. Best practices in CLABSI-reduction
5. Implementation of guidelines & recommendations
6. Summary
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1. Pathogenesis
2. Epidemiology
3. Technology
4. Best practices in CLABSI-reduction
5. Implementation of guidelines & recommendations
6. Summary
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Sources of intravascular catheter infection
Skin Vein
Intraluminal from tubes and hubs
Haematogenous from distant sites
Extraluminal from the Skin
Mermel. Ann Intern Med 2000;132:391
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Focus of infection prevention
Skin Vein
Insertion site
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Focus of infection prevention
Skin Vein
Insertion site
Hubs
Tubes
Catheters
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Schachter. Nature Biotechnology 2005;21:361
A. Attachment
D. Maximal thickness
B. Irreversible attachment, aggregation and formation of extracellular matrix
E. Detachment of planktonic bacteria
C. Maturation
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Co-factors: - Fibrinogen1, Fibronectin2
- Calcium3, Magnesium3, Iron3,4
- Production of extracellular matrix5,6
- DNA7
- Stress8*
*subinhibitory concentrations of aminoglycoside on P. aeruginosa & E. coli
1. Mehall. Crit Care Med 2002;30:908 2. Vaudaux. J Infect Dis 1993;167:633 3. Banin. Appl Environ Microbiol 2006;72:2064 4. Rhodes. J Med Microbiol 2007;56:119
5. Falcieri. J Infect Dis 1987;155:524 6. Sheth. Lancet 1985; 2:1266 7. Qin. Microbiology 2007;153:2083 8. Hoffman. Nature 2005;436:1171
Biofilm formation
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Central venous catheter (CVC) 2.7/1000 catheter-days
Peripherally inserted central catheter (PICC) 2.1/1000 catheter-days
Tunnelled CVCs 1.6/1000 catheter-days
Peripheral catheters 0.5/1000 catheter-days
Implantable port systems 0.1/1000 catheter-days
Maki. Mayo Clin Proc 2006;81:1159
Risk for CRBSI Catheter-related bloodstream infections
Risk for CRBSI
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1. Pathogenesis
2. Epidemiology
3. Technology
4. Best practices in CLABSI-reduction
5. Implementation of guidelines & recommendations
6. Summary
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HELICS/ECDC – ICU-data
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422 ICUs from 36 countries in Latin America, Asia, Africa, and Europe
Rosenthal. Am J Infect Control 2012;40:396
International Nosocomial Control Consortium - ICU
Pooled mean CLABSI rate
Type of ICU ICU’s, n Patients, n
6.8/1’000 catheter-days
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Zingg. J Hosp Infect 2009;73:41
Non-ICU wards
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Central Venous Catheter (CVC) Utilization and Catheter-Associated Bloodstream Infection (CA-BSI) Rates for 4 General Medicine Wards at a Teaching Hospital in St. Louis, Missouri:
Marschall. Infect Control Hosp Epidemiol 2007;28:905
Non-ICU wards
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ICU vs. non-ICU
Zingg. J Hosp Infect 2009;73:41 Zingg. J Hosp Infect 2011;77:304
ICU Non-ICU
CVC-utilization, % 29.5 4.6
CVC dwell-time, median (IQR) 4 (2-7) 8 (3-14)
Catheter-days, % 40 60
CVC: Central venous catheter
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Zingg. J Hosp Infect 2011;77:304
Number of „indications“
Use central venous lines Types of „indications“
Non-ICU; median dwell-time: 8 (3-14) Non-ICU; median dwell-time: 8 (3-14)
ICU; median dwell-time: 4 (2-7) ICU; median dwell-time: 4 (2-7)
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1. Pathogenesis
2. Epidemiology
3. Technology
4. Best practices in CLABSI-reduction
5. Implementation of guidelines & recommendations
6. Summary
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Ramritu. Am J Infect Control 2008;36:104
Catheter colonization CRBSI1
___________________ __________________
Coating nCVC RR (95% CI) nCVC RR (95% CI) ___________________________________________________________________ CHG/silver-sulfadiazine 2841 0.59 (0.50-0.71) 3016 0.31 (0.06-1.54) (external) CHG/silver-sulfadiazine 1070 0.44 (0.23-0.85) 1070 0.70 (0.30-1.62) (external/internal) Silver, platinum, carbon 720 0.76 (0.57-1.01) 970 0.54 (0.16-1.85) Minocycline/rifampicin 1063 0.40 (0.23-0.67) 840 0.39 (0.17-0.92) Chlorhexidine alone 254 1.11 (0.80-1.55) 254 2.37 (0.63-8.96) Cefazolin 518 0.59 (0.04-7.72) NA Vancomycin 176 0.77 (0.63-0.93) NA
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Ruschulte. Ann Hematol 2008;88:267
Control Sponge n/1’000 CVC-days n/1’000 CVC-days
7.2 3.8 p=0.02 Dwell-times: 15.8 (controls), 16.6 (sponge) - 601 patients; Triple-lumen Ag/CHG-coated catheters for ≥ 5 days - Chemotherapy for haematological malignancies
Chlorhexidine-impregnated sponge
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Control Sponge n/1’000 CVC-days n/1’000 CVC-days
1.3 0.4 p=0.004 Dwell-times: 6 (controls), 6 (sponge)
Timsit. JAMA 2009;301:1231
Chlorhexidine-impregnated sponge
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1. Pathogenesis
2. Epidemiology
3. Technology
4. Best practices in CLABSI-reduction
5. Implementation of guidelines & recommendations
6. Summary
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Multimodal intervention:
- Education/Training
- Standardized processes
- Maximal sterile barrier precautions
- Chlorhexidine
- Hand hygiene
- Catheter care
- etc.
Eggimann. Lancet 2000;355:1864
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Initiative from the ICU
Contact infection control
Detailed protocol based on literature
Teaching on the ward
Bedside teaching
CVC-insertion
Surveillance
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Initiative from the ICU
Key personnel
Written Protocols
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Eggimann et al.
Eggimann. Lancet 2000;355:1864
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Bundle: - Hand hygiene - Maximal sterile barrier precautions* - Skin antisepsis with Chlorhexidine - Avoiding femoral access - Removing catheter when not needed anymore *Mask, cap, sterile gown, large sterile drape, sterile gloves - Targeting catheter-insertion
Pronovost. New Engl J Med 2006;355:2725
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Me
dia
n/1
’00
0
cath
ete
r-d
ays
Mean/1’000 catheter-days: 7.7
Mean/1’000 cathter-days: 1.3
Pronovost. New Engl J Med 2006;355:2725
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Pronovost. BMJ 2010;340:c309
Pronovost et al.
Sustainability? Data from 90 out of 103 participating ICUs
Baseline Implementation 0-3 16-18 34-36
CLABSI1 7.7 2.8 2.3 1.3 1.1
1Central line-associated bloodstream infections; mean incidence densities
(events per 1000 device-days)
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Pronovost. BMJ 2010;340:c309
Pronovost et al.
Variability
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Ishikawa Y. Ann Surg 2010;251:620
MSB-precautions: always effective?
A recent multicenter randomized controlled trial found that MSB was not effective for CRBSI prevention: CRBSI/1000catheter- days
2.4/1000 vs. 1.9/1000 (RR: 1.2; CI 95%0.43–3.1; P=0.78) - The study was performed among surgical patients in general wards - Median catheter dwell-times in both groups were high (14 days)
For central lines of longer duration, catheter care may be equally important in CRBSI-prevention than optimal catheter insertion
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Interventions: - Hand hygiene - Catheter care
- Exit site dressing - Manipulations on tubes, hubs, stop cocks (non-touch
technique) - Preparation of infusates using an aseptic technique
Zingg. Crit Care Med 2009;37:2167
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Information/Invitation head nurses
Focus groups with
head and teaching nurses
Adjustment of the intervention
Ex-cathedra teaching
Bedside teaching
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Baseline Intervention Incidence density 3.9 1.0 (n/1‘000 catheter-days) Time to infection 6.52 3.48 9.3 6.63 (mean SD) Catheters 974 1015 Total catheter-days 6200 7279 Dwell-time, median days (IQR) 5 (3-8) 6 (3-9)
Zingg. Crit Care Med 2009;37:2167
Zingg et al. – Zurich
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Zingg. Crit Care Med 2009;37:2167
Zingg et al. – Zurich
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Multidisciplinary task force Anesthesiology, infection control, board of nursing
Physicians Nurses Education strategy,
training tools
Simulator training
workshops
Modular E-learning program
Zingg et al. – Geneva
Zingg. 52th ICAAC 2012; San Francisco
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Implementation
Workshops for physicians
Training for nurses
Adoption by school of nursing
Surveillance
Physician training: tools
Nurse training: modular E-learning program
2007 2008 2009 2010 2011
Preparation Training Baseline
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39
Comprehensive insertion kit
Line cart
Availability of and easy access to material and equipment and optimized ergonomics
Zingg. 52th ICAAC 2012; San Francisco
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Simulator training
Half day training course
- Interactive theoretical lecture
- Simulation based practice on a
- Videotape review
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41
“Train the trainer“ Two workshops per clinical service: - Presentation of the E-learning tool - Simulated training sessions
www.carepractice.net
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050
010
00
15
00
01
23
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16quarter
CRBSI/1000 catheter-days CRBSI/1000 catheter-days
Trained nurses (n) Trained physicians (n)
Results
980 nurses 294 nurses
146 physicians
-8.2%; 95% CI -3.9-12.6%; P < 0.001
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Zingg. Curr Opin Infect Dis 2011;24:377
Multimodal or „bundle“ strategies in the prevention of catheter-related or catheter-associated bloodstream infections: publications 2009-2010
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1. Pathogenesis
2. Epidemiology
3. Technology
4. Best practices in CLABSI-reduction
5. Implementation of guidelines & recommendations
6. Summary
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Healthcare
worker Patient Patient care
Space Infrastructure
Medical devices Tools
Ventilation Lighting Noise
Ergonomics
Performance
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Carayon. Qual Saf Health Care 2006;15: i50
Systems Engineering Initiative for Patient Safety
Process of Care
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Adoption
Implementation
Re-Evaluation
Barrier Identification
Sustainability iterative process
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Greenhalgh et al. 2004
“People are not passive recipients of innovations. They seek innovations, experiment with them, evaluate them, find (or fail to find) meaning in them, develop feelings (positive or negative) about them, challenge them, worry about them, complain about them, “work around” them, gain experience with them, modify them to fit particular tasks, and try to improve or redesign them – often through dialogue with other users.”
Implementation
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Implementation
Damschroder. Implementation Sci 2009;4: 50
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Zingg W. Submitted.
The “SIGHT”-project
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PROHIBIT Six hospitals in Europe. Interviews with 65 individuals: 9% CEOs, 11% infection control physicians; of note, 15% ICU front-line physicians; 17% ICU front-line nurses
Theme counts
Sax, Clack, Casillas, Touveneau, Da Liberdade, Pittet, Zingg
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1. Pathogenesis
2. Epidemiology
3. Technology
4. Best practices in CLABSI-reduction
5. Implementation of guidelines & recommendations
6. Summary
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CLABSI prevention has become a network of technology and practice change in an ever changing work environment and increasing public interest in healthcare-associated infections
Summary
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- The recent literature suggests that most success in infection
prevention does not come from a magical device, but
simply by complying with practice recommendations,
which have been available for many years
- Hospitals are confronted with overwhelming evidence that
practice change successfully reduces CLABSI rates
- Unfortunately, practice change is more difficult to
implement than the introduction of a new medical device
Summary
![Page 55: Preventing vascular catheter- associated infection : the ...€¦ · Preventing vascular catheter-associated infection : the next steps Tapei July 2013 Professor Didier Pittet, MD,](https://reader033.vdocuments.us/reader033/viewer/2022051410/603032a7b299c627d561cdac/html5/thumbnails/55.jpg)
- The question today is not ‘what to do’, but ‘how to do it’
- Hospitals are well advised to think how they can implement practice change in their institutions while respecting local barriers
Think implementation and practice!
Summary