Transcript Reduction in CL-BSI and VAP Strategies for the ICU

Strategies to Reduce the
Incidence of
Central Line-Associated
Bloodstream Infections
Wendy Kaler MPH, CIC
Manager of Infection Control
Saint Francis Memorial Hospital
San Francisco, CA
Saint Francis Memorial Hospital
Team involvement…..
ICU Rounding
• Active daily interaction of IC as part
of 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
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
Inserter: Complete BEFORE line insertion
{Patient Label}
Central Line Insertion Checklist
The components on this checklist are being used while
inserting this central line
Education on central line-associated bloodstream infection
prevention has been provided to the patient/family
Line: CVC
PICC
SVO2
Site: IJ
SC Fem PICC
Date/time__________ Inserter Signature ______________________
 Hand hygiene is performed before and after assessing for catheter
insertion sites as well as before and after inserting a catheter.
 Maximal barriers are utilized including sterile gloves, sterile gowns,
masks, caps, and large sterile drapes.
 Disinfect clean skin with a Chlorhexidine/alcohol preparation and allow
it to dry completely before inserting the line.
 Do not use topical antibiotic ointment or creams on insertion sites
(except when using dialysis catheters) because of their potential to
promote fungal infections and antimicrobial resistance.
 Placement of catheters in the femoral vein should be avoided unless
subclavian or jugular site is not an option due to patient circumstances.
Document reason for using femoral site in procedure note.
 Secure the catheter with sutures and/or securement devices (Statlock)
whenever necessary to ensure that lines are not dislodged.
 Use sterile gauze and/or transparent, semi-permeable, dressing to
cover the catheter site. If the site is oozing or the patient is diaphoretic
a gauze dressing is preferable.
 Dressings on all new lines should be labeled with the date of insertion
***PLACE IN PATIENT CHART (behind MISC Tab)
(TO BE PART OF PERMANENT RECORD)
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
Prevent Infection
Step 2:
Get the catheters out
Fact:
Catheters and other invasive devices
are the # 1 exogenous cause of
hospital-onset infections.
 Link to: NNIS Online at CDC
Central Line Needs Assessment
• During daily rounding
• Sticker in Physician Progress Notes
• EMR mandatory field
Maintenance Bundle
for
Central Lines
• Most CL-BSI occur > 5 days after insertion
• Stabilized lines
• Timely dressing changes per policydressings dated
• Skin antisepsis at insertion site
• Dressings dry and intact
• Cleaning of port prior to accessing
Successful Disinfection of
Needleless Mechanical Valve
Access Ports: A Matter of Time
and Friction
Kaler, W., Chinn, R. JAVA 12(3) Fall 2007
Rady Children’s Hospital
Sharp Memorial Hospital
Conclusion
We provide evidence that when
access ports are subjected to the
industry recommended
disinfection time of 15 seconds
with friction, alcohol alone or
chlorhexidine/alcohol were
equally effective in sterilizing MV
ports inoculated with a 105 CFUs
suspension of microorganisms,
regardless of whether the MVs
were constructed using positive,
negative, or neutral displacement
technologies.
IV Access Port Protection Caps
• Alcohol-impregnated caps-remain on the
ports between use
Excelsior Medical
Iveramed- Curos
Port Protection Caps
Advantages
• Decreases nursing time required to comply with
•
•
“port disinfection policy” (NPSG#7)
Allows for monitoring of compliance with port
disinfection policy (NPSG #7)
Potential reduction of contaminated line-drawn
blood cultures
– Appropriate antibiotic use
– Accurate CLABSI rates for PUBLIC REPORTING/CMS
Reporting
Nursing Attitude & Focus on Infection
Control Practices
• Barriers to following good infection
control 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 Infection
Control Practices
• Possible solutions:
- Get staff level nurses involved in designing
solutions
- 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 Lead
posing as a patient
Infection Control
It’s an ATTITUDE…
Provide care as if it were YOU
in that bed……
How do you know it’s a
CLA-BSI?
Are you involved in the RCAs?
Specimen Collection
•Garbage in = Garbage out
Public Reporting
 Antibiotic Resistance
LCBI
Surveillance Definitions
CRITERION 3
Patient <1 yr has at least one of the following signs or
symptoms: fever, hypothermia, apnea, bradycardia
AND
Signs and symptoms and lab data not related to infection
at another site
AND
A common skin contaminant cultured from 2 or more blood
cultures drawn on separate occasions (within 2 days).
For QUANTITATIVE
blood cultures
≤10 CFU not significant (Bradley, J. et al)
Ascher et al Diag Microbiol Infect Dis 1992 Aug 15(6) 499-503
Non-ambiguous
Blood 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
LCBI
Surveillance Definitions
CRITERION 1
• Patient has a recognized pathogen
cultured from one or more blood cultures
AND
Organism cultured from blood is NOT
related to an infection at another site
LCBI
Surveillance Definitions
CRITERION 3
Patient <1 yr has at least one of the following signs or
symptoms: fever, hypothermia, apnea, bradycardia
AND
Signs and symptoms and lab data not related to infection
at another site
AND
A common skin contaminant cultured from 2 or more blood
cultures drawn on separate occasions (within 2 days).
ZERO is the goal…..
Process
and
teamwork
(good relationships)
get you there…..