vascular access - reducing clbsi rates to zero. helen loudon independent infection prevention...

Vascular Access – Ways to Bring Line Infection Rates to Zero

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HANDBOOK OF ANAESTHESIA

Sr H LoudonRN UDNE (UKZN) CIC (NMMU) Independent Infection Prevention and Quality Management Specialist

Intravascular access devices are now commonplace in the management of patients in acute and chronic care settings – however, catheter-related bloodstream infections (CR-BSIs) associ-ated with the insertion and maintenance of these devices are potentially the most dangerous complications associated with health care. Seventy percent of health care-acquired blood stream infections are catheter-related and one in five patients will die.1,3,4,12

Additionally, health care funders are now enforcing punitive measures on service providers by withholding reim-bursement for health care associated bloodstream infections.

This article will highlight the current and internat ional ly recognised c l in ical methods for the prevention of CR-BSIs.

THE PATHOGENESIS OF CATHETER-RELATED BLOODSTREAM INFECTIONS The skin cannot be sterilised. Vascular catheters disrupt the integrity of the skin, making infection with bacteria and/or fungi possible (see Figures 1 and 2).

The most common route for contamina-t ion of vascu lar access dev ices i s


Figure 1. Scanning electron microscopy depicting a hair shaft extruding from the stratum corneum

Figure 2. Pathogenesis of catheter-related blood stream infection

�brin sheath catheter wound

contaminateddisinfectants

hands of medical personnel

external spread

auto-infection

patient’s micro�ora

haematogenous seeding

ANAESTHESIA2


migration of skin organisms at the insertion site into the cutaneous catheter tract and along the surface of the catheter with subsequent colonisation of the catheter tip and formation of biofilm.

Other causes of catheter-related blood-stream infections (CR-BSIs) include direct contamination of the catheter hub by contact with hands or contaminated fluids or devices – less common causes include haematogenous seeding of the intravascular device from another focus of infection or infusate contamination.5

There are approximately 1 000 species of micro-organisms on human skin; the average human being has an estimated number of skin bacteria of 1012 (1 trillion).6

Much research has been undertaken to examine the resident skin flora or ‘human microbiome’. It appears to be mostly bacterial, and more commonly Staphy- lococci and Coryneforms. These micro-organisms are found in the superficial layers of the epidermis and upper parts of the hair follicles (see Figure 3).

SKIN PREPARATION AT THE INTRAVASCULAR INSERTION SITE 1,2,3,7,8,12

n The minimum measures to be taken prior to vascular access include adequate site coverage and at least 30 seconds ‘contact time’ with a 0.5% chlorhexidine in 70% alcohol solution; applied with firm swabbing strokes using multiple swabs (preferably gauze, or gauze covered) and the avoidance of palpation once vessel selection has been made.

n The routine use of 70% isopropyl or ethyl alcohol alone is not recommended for skin antisepsis, unless the use of chlorhexidine contra-indicated. Although rapidly bacteriocidal on contact, alcohol has no residual effect on skin micro-organisms once it has evaporated.

n Data from multiple, rigorous and large randomised-controlled studies have informed clinical infection control practice for some time that

chlorhexidine in 70% alcohol is superior to povidone iodine.

n Povidone iodine may require up to four minutes contact time in order to exert a bacteriocidal action. Chlorhexidine is bacteriocidal after 30 seconds, binds irreversibly with the stratum corneum and demonstrates residual efficacy for up to seven hours after application.

I The activity of an antimicrobialsolution is affected by:n Burden and type of micro-

organism/s presentn Inherent microbial resistance n Concentration of solutionn Contact time n Environmentalinfluencesn Skin integrity

CATHETER MATERIAL, LUMENS AND ACCESSORIES1,3 n Intravascular catheter material may

be an important determinant in the development of catheter-related infection (see Figure 4). Teflon and polyurethane catheters have been associated with fewer infections

Figure 3. Cross section of the skin illustrating the location of microbial colonisers

Skin surface

Epidermis

Dermis

FungusBacterium MiteVirus

Sebacious gland

Hair shaft

Sweatpore

Sweat gland


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than catheters made of polyvinyl chloride (PVC) or polyethylene.

n Studies suggest that bacterial biofilms (which form on the extra-luminal and intra-luminal surfaces within hours of catheter placement) are less likely to form and/or adhere to the former.

n A central venous catheter (CVC) should have the minimal number of ports or lumens essential for patient treatment. Catheters with multiple lumens present increased opportunities for manipulation and contamination, whilst the use of stopcocks has also been implicated in increased CR-BSI rates.

n Administration sets in continuous use do not need to be changed more frequently than every 96 hours.

n Parenteral feeding – it is preferable to use a designated single lumen catheter to administer TPN and other lipid based solutions. Change lipid solution administration sets every 24 hours.

n Blood and blood products – change administration sets when the transfusion episode is complete or every 12 hours (whichever is sooner)

CENTRAL VENOUS CATHETERS – INSERTION SITES1,3,5,9,12

n The site at which any vascular access catheter is placed can influence the subsequent risk of CR-BSI because of variation in both the density of local skin flora and the risk of thrombophlebitis.

n CVCs are generally inserted in the subclavian, jugular or femoral veins, or peripherally inserted into the superior vena cava via the cephalic or basilar veins in the antecubital space of the upper arm.

n Catheterisation of the subclavian vein is associated with a reduced risk of catheter-related bloodstream infection.1 There are several reasons for this – the subcutaneous course of the subclavian catheter before entry into the vein is generally

longer than for jugular and femoral insertion sites. In addition, the subclavian insertion site has the lowest bacterial bioburden and is relatively protected against dressing disruption.3,9

n However, the risk of pneumothorax with the subclavian route is an important consideration – a pragmatic approach to site selection, the expertise and skill of the operator and the relative risks inherent with each insertion site.

n The use of real-time two-dimensional ultrasound is recommended where possible for the placement of CVCs as it has proven to reduce the incidence of mechanical complications, compared with the standard ‘landmark’ placement technique.

n Avoid using the femoral vein for CVCs in adult patients.

See Figure 5 for the distribution of noso-comial bloodstream pathogens.

MAXIMAL STERILE BARRIER PRECAUTIONS1,3,10,12

Infection prevention clinical standards require maximal sterile barrier (MSB) precautions during CVC insertion:n high level hand hygiene prior to

undertaking the proceduren wearing sterile gloves and gown,

cap and mask n using a full-body sterile drape

during catheter insertion.

Figure 4. Staphylococcus sp. biofilm in the lumen of a central venous catheter

ANAESTHESIA4


VASCULAR CATHETER SECUREMENT, DRESSINGS AND CATHETER SITE CARE1,3

n Use 0.5% chlorhexidine gluconate in 70% isopropyl alcohol (or povidone iodine in alcohol in patients sensitive to chlorhexidine) to clean the catheter insertion site during dressing changes, and allow to air dry (approximately two minutes).

n Suture-less securement devices lower CL-BSI risk.

n Use a sterile, transparent, semi-permeable polyurethane dressing to cover the intravascular insertion site. Change the dressing every four to seven days, or sooner, if it is loose or moisture has accumulated under the dressing.

n Use a sterile gauze dressing if a patient is perspiring profusely or if the insertion site is bleeding or leaking. Change the dressing when inspection of the insertion site is necessary or if the dressing becomes damp, loose or soiled. (Replace with a transparent semi-permeable dressing as soon as possible thereafter.)

n Dressings used on tunnelled or implanted catheter insertion sites should be replaced every seven days until the insertion site has healed,

unless there is an indication to change them sooner. A dressing may no longer be required once the insertion site has healed.

n The selective use of chlorhexidine impregnated dressings in ‘at risk’ adult patients as a strategy to reduce CR-BSI should be considered.

n Consider using antimicrobial CVCs in ‘at risk’ patients, where catheter duration is prolonged or if CLA-BSI rates remain high.

Figure 5. Distribution of nosocomial bloodstream pathogens

Crude mortality

0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0%

Pathogens

Frequency

Coag Neg Staph

S.Aureus

Enterococcus spp.

Candida spp.

E. coli

Klebsiella spp.

Enterobacter spp.

Pseudomonas spp.

Serratia spp.

Viridans strep

Other

(Data from Edmond MB, Wallace SE, McClish DK, et al. Nosocomial bloodstream infections in United States hospitals: a three-year analysis 1995-1998. Clin Infect Dis 1999; 29:239–44.)

I Poor and controversial practicesn Local hair removal by shaving vs

clippersn Antimicrobial prophylaxis after

catheter insertion or during use to prevent colonisation

n Use of topical antimicrobial ointments at insertion site (exception – femoral haemodialysis catheters)

n Routine use of - heparin, disinfectant, antibiotic

or ethanol ‘locks’ - arterial or venous cut-down for

CVC insertion - in-lineIVfilters


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n Daily patient full-body cleansing with a chlorhexidine based liquid soap has also demonstrated improved outcomes.

CATHETER REPLACEMENT STRATEGIES1,3

n Do not routinely replace peripheral or central venous access devices to prevent catheter-related infection.

n Do not use guide wire-assisted catheter exchange for patients with CR-BSI.

n Peripheral vascular catheter insertion sites should be inspected six-hourly, and a visual infusion phlebitis score should be recorded.

n A catheter should be removed as soon as it is no longer required or when complications occur.

I Safe injection practices11

n Follow appropriate infection control practices during the preparation and administration of injected medications.

n Disinfect catheter hubs, needleless connectors, and injection ports before accessing vascular catheters

n Never administer medications from the same syringe to more than one patient, even if the needle is changed.

n After a syringe or needle has been used to enter or connect to a patient’s IV it is contaminated and should not be used on another patient or to enter a medication vial.

n Never enter a vial with a used syringe or needle.

n Assign medications packaged as multi-dose vials to a single patient whenever possible.

n Do not use bags or bottles of intravenous solution as a common source of supply for more than one patient.

‘BEST CARE ALWAYS’ CAMPAIGN Based upon the highly successful and innovative international programmes such as The Institute for Healthcare Improvement (IHI) 100K Lives Project, Canada’s ‘Safer Healthcare Now’ and the World Health Organization’s World Alliance for Patient Safety, the ‘Best Care Always’ Campaign has been designed to support the efforts of hospitals to reduce patient morbidity and mortality caused by hospital-acquired infections, by sharing best practices around the measurement and implemen-tation of simple quality improvement practices known as ‘bundles’.

WHAT IS A ‘BUNDLE’?12

n A ‘bundle’ is a grouping of best practices with respect to a disease process that individually improves care, but when applied together result in substantially greater improvement

n The evidence-based science behind the bundle is so well established that it should be considered a standard of care

n Compliance should be measured to ensure consistency

n An “all or none” approach is used (e.g., Yes/No checklists).

THE CL-BSI ‘BUNDLE’12

n High level hand hygienen Maximal sterile barrier precautions

- Non-sterile cap and face mask (all hair should be under cap) and mask should cover nose and mouth tightly

- Sterile gown and gloves- Cover patient’s head and body

with a large sterile drapen Skin disinfection and catheter care

with 0.5% chlorhexidine in 70% isopropyl alcohol

n Optimal catheter site selection, with subclavian vein as the preferred site for non-tunneled catheters in adults

n Daily review of line necessity and prompt removal of unnecessary lines

ANAESTHESIA6


I Practice point n The positive culture of a catheter tip

is not indicative of CR-BSIn In the absence of clinical features

of CR-BSI, routine culture of the catheter tip when the line is removed is unnecessary.

CLINICAL GOVERNANCE AND QUALITY ASSURANCE13,14

IPC reporting and surveillance is a key quality assurance performance measure.CR-BSI is a clinical definition, used for diagnosis and treatment, which requires specific laboratory testing that more accurately identifies the catheter as the source of the BSI.

The CDC/NHSN reporting criteria for CR-BSI require laboratory confirmed blood stream infection, that must meet at least one of the following criteria:n A recognised pathogen (e.g., Staph.

aureus, Klebsiella, Candida sp.) and not resident skin flora (e.g., Corynebacterium, Micrococcus) is cultured from more than one culture and - The organism cultured is not related

to infection at another site- The patient also has at least one of

the following: - Fever >38°C, chills, hypotension

- Symptoms are not related to an infection at another site

- The same common commensal (i.e., diptheroids [Corynebacterium snot C. diphtheriae], Bacil lus s[not B. anthracis], Propionibacterium spp., coagulase-negative staphylococci [including S. epidermidis], viridans group streptococci, Aerococcus spp., and Micrococcus spp.) i s cultured from two or more blood cultures drawn on separate occa-sions. Criterion elements must occur within a timeframe that does not exceed a gap of one calendar day between two adjacent elements.

THE BOTTOM LINECR-BSI preventive measures are non- negotiable.

Desire to improve outcomes does not necessarily translate into action – it is a mental attitude with a sense of urgency – improvement is required now.

To be consistently successful, our efforts require not only uncompromising leader-ship, but also a multidisciplinary approach to improve standards – involving all health care professionals who order the insertion and removal of intravascular catheters, those who insert and maintain intravas-cular catheters, infection prevention specialists as well senior health care management who allocate financial and equipment resources.

REFERENCES1. CDC/HICPAC (Healthcare Infect ion

Control Practices Advisory Committee) 2011 Guidelines for the Prevention of Intravascular Catheter-related Blood Stream Infections.

2. CDC (Centres for Disease Control) 2008 Guidelines for Disinfection & Sterilization in Healthcare Facilities.

3. Loveday HP, et a l . Ep ic 3 : Nat ional evidence-based guidelines for preventing healthcare-associated infections in NHS Hospita ls in England. J Hosp Infect . 2014; 86: S1-70

4. Mermel LA, et al . Guidel ines for the Management of intravascular catheter-r e l a t e d i n f e c t i o n s . C l i n I n f e c D i s . 2001;32:1249-72

5. Walz JM, et al. Prevention of central venous catheter b loodst ream in fect ions . J Intensive Care Med. 2010;6.25(3)131-138

7. Mims A, Playfair DE, Roitt S, et al. Medical Microbiology, 2nd Edition. USA: Mosby. 2003.

8. Chopra V, Saint S. Vascular Catheter Infections: time to get technical. Lancet on line September 18. 2015; DOI: http://dx.doi.org/10.1016/S0140-6736(15)00245-7. Accessed 17.10.2015

9. N.I.C.E (National Institute for Health and Care Excellence). Quality Standard #5 Vascular Access Devices. Available from http://www.nice.org.uk/guidance/qs61/chapter/Quality-statement-5-Vascular-access-devices . Accessed 17.10.2015.

I Monitoring of performance is critical for assessing the effectiveness of qualityimprovement interventions.

Calculating a central line associated BSI rate

Numerator: Number of CLA-BSIs for the period--------------------------------------------------- X 1000Denominator: Number of ‘line days’ for the period

(i.e. The total number of days of exposure to central lines by all patientsin the unit during that month)

Example: 2 CLA-BSI’s ÷ 470 ‘line days’ x 1 000. CLA-BSI rate = 4.3%


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REFERENCES1. CDC/HICPAC (Healthcare Infect ion

Control Practices Advisory Committee) 2011 Guidelines for the Prevention of Intravascular Catheter-related Blood Stream Infections.

2. CDC (Centres for Disease Control) 2008 Guidelines for Disinfection & Sterilization in Healthcare Facilities.

3. Loveday HP, et a l . Ep ic 3 : Nat ional evidence-based guidelines for preventing healthcare-associated infections in NHS Hospita ls in England. J Hosp Infect . 2014; 86: S1-70

4. Mermel LA, et al . Guidel ines for the Management of intravascular catheter-r e l a t e d i n f e c t i o n s . C l i n I n f e c D i s . 2001;32:1249-72

5. Walz JM, et al. Prevention of central venous catheter b loodst ream in fect ions . J Intensive Care Med. 2010;6.25(3)131-138

7. Mims A, Playfair DE, Roitt S, et al. Medical Microbiology, 2nd Edition. USA: Mosby. 2003.

8. Chopra V, Saint S. Vascular Catheter Infections: time to get technical. Lancet on line September 18. 2015; DOI: http://dx.doi.org/10.1016/S0140-6736(15)00245-7. Accessed 17.10.2015

9. N.I.C.E (National Institute for Health and Care Excellence). Quality Standard #5 Vascular Access Devices. Available from http://www.nice.org.uk/guidance/qs61/chapter/Quality-statement-5-Vascular-access-devices . Accessed 17.10.2015.

10. Parienti J, et al. Intravascular complications of central venous catheterization by inser-tion Site. N Engl J Med. 2015;373:1220-9

11. Margot Halm, et al. Blood cultures and central catheters: best practice. Am J Crit Care. 2011;20(4):335-338. © 2011 American Association of Critical-Care Nurses

12. World Health Organization. 2009;WHO Guidelines on hand hygiene in health care: a summary. First global patient safety chal-lenge: Clean care is safer care. Available from http://www.who.int/gpsc/5may/tools/who_guidel ines-handhygiene_summary.pdf . Accessed 17.10.2015

13. Best care always. Available from http://w w w . b e s t c a re . o r g . z a / C L A B S I + % 2 8 Central+line-associated+bloodstream+ infection%29 . Accessed 17.10.2015

14. CDC/National Health and Safety Network (NHSN) 2014 Surveillance Definitions for Specific Types of Infections.

15. Agency for Healthcare Safety and Quality. US Department of Health and Human Services. Available from http://www.ahrq.gov/professionals/education/curriculum- tools/clabsitools/clabsitoolsap2.ht ml . Accessed 17.10.2015

16. Webster J, et al . Cl inically- indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD007798. DOI: 10.1002/ 14651858.CD007798.pub2