Strategies to Reduce theIncidence of

Central Line-AssociatedBloodstream Infections

Wendy Kaler MPH, CICManager of Infection Control

Saint Francis Memorial HospitalSan Francisco, CA

Saint Francis Memorial Hospital

Team involvement…..

ICU Rounding

• Active daily interaction of IC as partof the ICU PI team

– Focus on NEED for indwelling central line– D/C of femoral lines– Catch early indications of infection

ICU Rounding Photo here Feedback to staff

Cheerleading

# Days since last infection ascalculated by Infection Control

Updated weekly

Celebrate milestones

Process Improvements…….

Insertion of Central Lines

• Bundles– IHI– Provonost (NEJM Dec 28, 2006)– Joint Commission NPSG#7– CA SB 739

• Early use of PICC in neonates

Link to: NNIS Online at CDC

Fact:Catheters and other invasive devicesare the # 1 exogenous cause ofhospital-onset infections.

Prevent InfectionStep 2: Get the catheters out

12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults

Central Line Needs Assessment

• During daily rounding

• Sticker in Physician Progress Notes

• EMR mandatory field

Maintenance Bundlefor

Central Lines• Most CL-BSI occur > 5 days after insertion• Stabilized lines• Timely dressing changes per policy-

dressings dated• Skin antisepsis at insertion site• Dressings dry and intact• Cleaning of port prior to accessing

Successful Disinfection ofNeedleless Mechanical Valve

Access Ports: A Matter of Timeand Friction

Kaler, W., Chinn, R. JAVA 12(3) Fall 2007Rady Children’s HospitalSharp Memorial Hospital

Conclusion We provide evidence that when

access ports are subjected to theindustry recommendeddisinfection time of 15 secondswith friction, alcohol alone orchlorhexidine/alcohol wereequally effective in sterilizing MVports inoculated with a 105 CFUssuspension of microorganisms,regardless of whether the MVswere constructed using positive,negative, or neutral displacementtechnologies.

IV Access Port Protection Caps

• Alcohol-impregnated caps-remain on theports between use

Iveramed- Curos

Excelsior Medical

Port Protection CapsAdvantages

• Decreases nursing time required to comply with“port disinfection policy” (NPSG#7)

• Allows for monitoring of compliance with portdisinfection policy (NPSG #7)

• Potential reduction of contaminated line-drawnblood cultures– Appropriate antibiotic use– Accurate CLABSI rates for PUBLIC REPORTING/CMS

Reporting

Nursing Attitude & Focus on InfectionControl Practices

• Barriers to following good infectioncontrol practices include:– Not enough time– Not enough resources– Not enough information– It is really not that important– Not able to focus on task at hand due to

many distractions

Nursing Attitude & Focus on InfectionControl Practices

• Possible solutions:

- Get staff level nurses involved in designingsolutions

- Make it personal - Provide evidence of effectiveness of

methods - Provide local data/risk

- Feedback of poor outcomes

Culture of a patient’s port surface

Staff EDUCATION

Re-usable Post-It® poster on each nursing unit…

messages changed as needed

Making it Personal…

Our IV TEAM Leadposing as a patient

Infection ControlIt’s an ATTITUDE…

Provide care as if it were YOU in that bed……

How do you know it’s aCLA-BSI?

Are you involved in the RCAs?

Specimen Collection

•Garbage in = Garbage out

Public Reporting Antibiotic Resistance

LCBISurveillance Definitions

CRITERION 3

Patient <1 yr has at least one of the following signs orsymptoms: fever, hypothermia, apnea, bradycardia

ANDSigns and symptoms and lab data not related to infection

at another siteANDA common skin contaminant cultured from 2 or more blood

cultures drawn on separate occasions (within 2 days).

For QUANTITATIVE blood cultures

Ascher et al Diag Microbiol Infect Dis 1992 Aug 15(6) 499-503

≤10 CFU not significant (Bradley, J. et al)

Non-ambiguousBlood Culture Results

• Peripheral vs line draw• Line-draw technique

– DISCARD 1-3 ml

• Labeling of bottles• Full info in lab report• NO Catheter tip cultures

LCBISurveillance Definitions

CRITERION 1• Patient has a recognized pathogen

cultured from one or more blood culturesANDOrganism cultured from blood is NOT

related to an infection at another site

LCBISurveillance Definitions

CRITERION 3

Patient <1 yr has at least one of the following signs orsymptoms: fever, hypothermia, apnea, bradycardia

ANDSigns and symptoms and lab data not related to infection

at another siteANDA common skin contaminant cultured from 2 or more blood

cultures drawn on separate occasions (within 2 days).

ZERO is the goal…..

Processand

teamwork(good relationships)

get you there…..