Evidence-based Practices to Prevent Catheter-related Bloodstream Infections: Seeking Zero Tolerance

Community and Hospital Infection Control Association (CHICA) February 24, 2009

William R. Jarvis, M.D.

Jason and Jarvis Associates www.jasonandjarvis.com

Several Reasons Why YOU Should Want to Prevent Catheter-Related Bloodstream Infections

Impact of Primary BSI

Crude mortality 10% to 40% Attributable mortality 2% to 15% Prolongation of hospitalization 5 to 20 days Attributable cost $34,000 to $56,000

Wey et al. Arch Intern Med 1988; Voss et al. Infection 1997 Pelz et al. J Int Care Med 2000; Blot et al. Am J Med 2002

The Cost of CVC-BSIs in U.S. ICUs

•80,000 CVC-related BSIs occur in U.S. hospital ICUs causing an estimated 28,000 deaths annually.

•Annual cost to the healthcare system

$296 million-$2.3 billion

(U.S.)

CDC IV Guideline-2002

Healthcare-associated Infections in Canadian Adult Acute Care Hospitals

• • •

Study design

: Point prevalence survey, February 2002.

Results

: 5750 adults surveyed. 667 HAIs detected in 601 patients (prevalence: 10.5% of patients infected; 11.6% HAI prevalence). Urinary tract infections were most common (3.4%), followed by pneumonia (3%), surgical site infections (2/5%), and bloodstream infections (1.6%).

Conclusion

: HAIs are prevalent in adult patients, similar to other developed countries.

Gravel D et al. J Hosp Infect 2007;66:243-8.

• • •

Central Line-associated Bloodstream Infection (CLA BSIs) Surveillance, Canadian Pediatric Hospitals Methods

: Telephone survey of infection control practitioners (ICPs) at 15 university-affiliated Canadian Pediatric hospitals.

Results

: Surveillance: 14 (93%) hospitals conduct surveillance for infections associated with CLAs (11 comprehensive; 3 selected patients; 3 include outpatients). One conducts surveillance for mechanical complications. Numerator: A positive blood culture was sufficient for CLA-BSI in eight centers; the rest use CDC definitions. Denominators: Four centers collect CLA days on all patients; four use per 100 discharges; four report absolute number of infections (2 use >1 denominator). Surveillance methods: chart and micro records; none used electronic records. Standardized protocols: All 15 either had or were developing hospital-wide protocols for CLA use.

Conclusions

: Insufficient personnel exist to meet recommended data collection. Inter-hospital comparisons are not possible because of variation in definitions, denominators, and patients surveyed. Langley JM et al. Can J Infect Control 1995;10:80-1

• • •

Healthcare-associated Infections in Canadian Acute Care Hospital Pediatric Populations

Study design

: Point prevalence survey, February 2002 at 25 hospitals across Canada.

Results

: 997 children surveyed. 91 HAIs detected in 80 patients (prevalence 91 per 1,000 patients. Bloodstream infections were the most common HAI (3% of patients; 34% of HAIs). The HAI prevalence was 8% and ranged from 0% in trauma/burn units to 19% in PICUs to 27% in transplant units. Multivariate analyses identified a central venous catheter (OR 2.54), mechanical ventilation (2.59, and receiving antimicrobials (OR 9.27) as independent risk factors for HAI.

Conclusion

: HAIs are prevalent in pediatric patients and CLA-BSIs are the most common HAI.

Gravel D et al. Am J Infect Control 2007;35:157-62

Infection Control Resources in Canadian Acute Care Hospitals in 1999 and 2005 (pre- and post-SARS)

• • •

Study design

: The Resources for Infection Control (RICH) project assessed infection control programs (ICPs) in Canadian acute care hospitals in 1995. In 2006, a similar RICH survey was mailed to ICPs in all acute care hospitals with >80 beds.

Results

: Response rate: 1995: 72.3%; 2006: 60.1%. The number of infection control professionals (mean: 0.5 to 0.8 per 100 beds), surveillance intensity index score (mean: 61.7 to 68.1), and control intensity index score (mean: 60.8 to 64.1) increased from 1995 to 2006. MRSA (2.0 to 5.2 per 1,000 admissions) and CDAD (3.8 to 4.7) rates, and proportion of hospitals with VRE infections increased (34.5% to 61.0%).

Conclusions

: Canadian ICPs continue to fall short of expert recommendations for human resources and surveillance and control activities. Rapid rise on infection control personnel has not translated into marked improvement ICP surveillance and control of MDRO control. Zoutman DE et al. Am J Infect Control 2008;36:711-7

• •

Central Line-associated Bloodstream Infections (CLA-BSIs) in Canadian Intensive Care Units (ICU)s

Study method

: A prospective, active, 6-month cohort study with a nested case-control study in 41 ICUs in 19 Canadian hospitals. All patients with a CL for >48 hrs.

Results

: 182 CLA-BSIs associated with 3696 CLs in 2531 patients. Mean CLA-BSI rate per 1,000 CL-days were: 6.9, 6.8, and 5.0 in adult, neonatal ICU, or pediatric ICU patients. Coagulase-negative staphylococci accounted for 73% of CLA-BSIs. Risk factors for BSI were: CL insertion (OR 1.2), total parenteral nutrition (OR 4.1), and having >1 CLs (OR 3.1). In the case-control study logistic regression model, 80% of variance was explained by: duration of CL insertion (OR 1.2 per day), receiving chemotherapy (OR 6.1), >1 CL insertion (OR 3.5), insertion of a CL with >2 lumens (OR 2.3), using the CL for TPN (OR 1.6), or having a non-clean surgical wound (OR 1.6).

Holton D et al. Can J Infect Dis Med Microbiol 2006;17:169-76

Nosocomial Bloodstream Infections (BSIs) in Intensive Care Units (ICUs), Calgary

• • •

Study design

: Population-based (ICUs) prospective cohort. All adults admitted to Calgary Health Region multidisciplinary ICUs, May 1999-April 2000.

Results

: 1,158 admissions of 1,017 patients; mean APACHE 23.4 + 7.7. Fifty-one BSIs (4.4%); incidence density 5.2 per 1000 ICU-days. Risk factors: younger age, longer ICU stay, lower HCT. ICU-BSIs were associated with increased LOS (2.9 days), increased ICU mortality (AOR 2.03, 95%CI 1.03-4.0, p=0.04).

Conclusion

: 1/20 patients admitted to Calgary ICUs develops a BSI.

Laupland KB et al. CCM 2002;30:2426-7

• • •

Mortality Associated with Bloodstream Infection (BSI)-associated Sepsis or Septic Shock in Intensive Care Unit (ICU) Patients

Study design

: Population-based cohort of adult multidisciplinary and cardiovascular ICUs in Calgary Health Region from July 1999-March 2002.

Results

: 4,845 adults with >1 ICU admission; 251 (5%) had BSI-associated sepsis on admission and 159 of these had septic shock. Risk factors for late mortality: surgical DX, BSI associated sepsis, increasing age.

Conclusion

: BSIs are associated with risk of mortality persisting >28 days.

BSI w/o shock w/ shock Overall 28 day 23 51 18 Mortality (%) 90 day 30 57 21 1 year 36 61 24 Laupland KB et al. Intensive Care Med 2005;31:171-3

Mandatory Reporting of Healthcare-associated Infection Rates - 2009

* www.APIC.org

Ontario Ministry of Health and Long-Term Care Patient Safety Indicators

Patient Safety Indicator Start Date of Public Reporting • • • • • •

Clostridium difficile (C. difficile)

Methicillin-resistant

Staphylococcus aureus

Sept. 30, 2008 (MRSA) Dec. 31, 2008 Vancomycin-resistant Enterococci (VRE) Dec. 31, 2008 Hospital standardized mortality ratio (HSMR) Dec. 31, 2008 • Rates of ventilator-associated pneumonia April 30, 2009 • Rates of central line infections April 30, 2009 Rates of surgical site infections April 30, 2009 Hand hygiene compliance among health care workers April 30, 2009

U.S. Deficit Reduction Act

As of October 1, 2008, Medicare will stop paying hospitals for treating the following conditions, if they are not present on admission: - Catheter-associated urinary tract infections - Pressure ulcers (decubitus ulcers) Vascular catheter-associated infections Mediastinitis after coronary artery bypass graft surgery -Fractures, dislocations, or other hospital acquired injuries - Objects left in during surgery - Air embolisms - Blood incompatibilities

The Majority of CLA-BSIs Occur Outside of the ICU

300,000 250,000 200,000 150,000 100,000 50,000 0 70% 30%

Annual CLA-BSIs (n=250,000) 1,2

170,000 80,000 Non-ICU Patients ICU Patients

Infections A significant opportunity exists to reduce CLA BSI incidence in non-ICU settings.

1. Mermel L, Farr B, Sheretz R. Guidelines for the management of intravascular catheter-related infections. Clinical Infectious Diseases. 2001;32:1249-1272. 2. Centers for Disease Control and Prevention. Guidelines for the prevention of intravascular catheter related infections. Morbidity Mortality Weekly Report. 2002;51:1-29.

Pathophysiology of Catheter-Related Infection

All sources of infection are potential targets for prevention catheter hematogeneous hub/lines Dressing skin Infusates/ drugs Critically ill patient: 2-4 vascular access devices

The Institute for Healthcare Improvement (IHI) CVC-BSI Prevention Bundle-----Evidence-Based Measures to Reduce Infections Associated with Catheter Insertion.

• • • • • • • • Hand hygiene Maximal sterile barrier precautions Chlorhexidine skin antisepsis Optimal site care (device selection and site of insertion) Education Catheter removal Monitoring of practices Leadership

Effect of Hand Hygiene on Resistant Organisms*

Year

1982 1984 1990 1992 1994 1999

Author

Maki Massanari Simmons Doebbeling

Setting

adult ICU adult ICU adult ICU adult ICU

Impact on organisms decreased decreased no effect decreased with one versus another hand hygiene product

Webster Pittet NICU

MRSA eliminated

hospital

MRSA decreased

ICU = intensive care unit; NICU = neonatal ICU MRSA = methicillin-resistant

Staphylococcus aureus

*All interventions included multifaceted intervention programs; Most quasi-experimental or observational, not randomized trials.

No randomized trial of hand hygiene vs. no hand hygiene has been conducted.

Source: Pittet D: Emerg Infect Dis 2001;7:234-240

Effect of Maximal Barrier Precautions* during Insertion on CVC Infections

8 7 6 5 4 3 2 1 0 p=0.03

p=0.01

Total Infection Infections First 2 Mo.

Precautions N=176 No Precautions N=167

*All interventions included multifaceted intervention programs; Most quasi-experimental or observational, not randomized trials.

No randomized trial of maximum barrier precautions vs. no maximum barrier precautions has been conducted.

Raad I. et al. ICHE 1994

Education-based prevention of CVC-BSI

Education-based strategy applied to the medical staff (students + residents + fellow) in of 6 U.S. ICUs Infection control (1h): - hand hygiene - isolation/barrier techniques - handling of patients 1h-training stations: - blood draws through lines - arterial punctures - catheter insertion vascular guidelines: - skin: povidone-iodine - no antibiotic ointment - clear plastic dressing - change dressing/tubing 1x/3 days - no scheduled change of CVCs

Sherertz Ann Intern Med 2000

Education-based prevention of CVC-BSIs

Exit-site infection Primary BSI

Cost saving: $800,000 over 18 months for 6 ICUs.

Sherertz Ann Intern Med 2000

Impact Of Dedicated IV Device-Care Teams

P-Value Study No. Patients IV-Related Sepsis

•

Concurrent but non-randomized: Nehe, Ward Care JAMA (1980) TPN Team

•

Randomized: Tomford et al. Ward Hos Arch Int Med (1984) PIV Team Edlin et al.

Arch Int Med (1998) Ward HOs IV Team 391 284 427 433 463 412 26.2% 1.3% 2.1% 0.2% 1.5% 0% <.001 .02

<.05

Evidence-Based Measures to Decrease the Risk of Infection During Maintenance of the Intravascular Catheter

• • • • Minimize catheter site skin bioburden.

Aseptic manipulation of catheter connectors--

Scrub the hub

!

Antibiotic lock.

Device selection.

Microbiology of the Skin

• 80% of the resident bacteria exist within the epidermis • • 20% are found in biofilms within hair follicles and sebaceous glands Complete re-colonization can occur within 18 hours of antiseptic application 8 Ryder, MA. Catheter-Related Infections: It's All About Biofilm.

Topics in Advanced Practice Nursing eJournal

. 2005;5(3) ©2005 Medscape Posted 08/18/2005 .

Randomized Controlled Trial Evaluating a Chlorhexidine-Impregnated Patch (BIOPATCH) and Conventional Dressing

Intervention

BIOPATCH Dressing Control

% local infections (N=1,401 lines)

16.4

29.3

% CR-BSIs (N=589 subjects)

2.4

6.1

•

Comparative efficacy findings :

–

44% reduction in the incidence of local infection

–

60% reduction in the incidence of CR-BSIs

–

Statistically significant reduction in skin colonization Maki D et a ICAAC, Toronto, Canada, 2000

Does Vancomycin Lock or Flush Reduce CVC-BSIs?

• • •

Study design: Meta-analysis of prospective randomized studies, 1966-2006. Results: Seven studies with 463 patients; cancer (n=5), NICU (n=1), cancer/TPN (n=1).

–

Summary risk ratio for vancomycin-heparin lock or flush = 0.49 (95% CI: 0.26-0.95, P=0.03).

–

Summary risk ratio for vancomycin-heparin lock: 0.34 (95% CI: 0.12-0.98, P=0.04) Conclusion: Use of vancomycin lock in high risk patients with long-term IVDs reduces the risk of BSI.

Sadfar N et al. CID 2006;43:474-84

Meta-analysis of CA-BSI Rates with Antiseptic Catheters

Tennenberg Maki Hannan Bach Heard Collin Ciresi Pemberton Ramsay Trazzera George

Summary OR 0.56, 95% CI (0.37-0.84)

0.0

0.5

1.0

Odds Ratio

2.0

3.0

(Veenstra, Saint, Saha, et al. JAMA 1999)

Prevention: Impact of Coated Catheters

Meta-analysis of published studies N° of studies 0.03 0.1

0.3 1.0 RR (95% CI) NNT 18 colonization 16 bloodstream infections 6 >1 week 9 <1 week 0.60 (0.49-0.74) 0.64 (0.46-0.88) 8 55 0.35 (0.16-0.67) 0.82 (0.56-1.21) 28 122

Walder, Pittet, Tramer CCM 02

Device Selection

Split Septum Needleless Devices

Split septum surface Blunt cannula insertion

Mechanical Valves

CLC2000 ® SmartSite Plus ® Clearlink TM SmartSite ® Clave ® Posiflow TM

Flostar TM MaxPlus TM

Ultrasite ®

For illustrative purposes only. Does not imply association with increased BSIs.

Increased BSIs Temporally Associated With the Introduction of A Mechanical Valve (MV) Needleless Device (ND)

• • Hospital: University of Virginia (hospital-wide) Problem: Increased BSI rate after introduction of a MV ND in May 2002 – By June 2002, nosocomial BSI rate increased 61%; – January-May 2002 vs. May-December 2002: BSI rate: 2.2 vs. 3.5 per 1000 pt-days (RR=1.6, p<.0001) – 2.9-fold increase in CR-BSI with common skin organisms.

– 1.8-fold increase in CR-BSI with non-skin organisms.

Hall K et al, SHEA Annual Meeting 2004

Increased BSI Rate Temporally Associated With Switching From A Split Septum to Mechanical Valve Needleless Device in a Long-Term Acute Care Hospital

• • •

Study location

: 40 bed long-term acute care hospital.

Split septum (SS) period: January 2002-December 2003.

Mechanical valve (MV) period: January 2004-October 2005. BSI Rate* GNB-BSIs

SS Period MV Period

1.79

8% 5.41

39.5%

RR 95% CI

3.02 2.62-3.39

4.93 1.27-19.19

P-value

<.0001

.0006

*BSI rate per 1,000 catheter days; BSI rate has decreased since returning to a split septum needleless device.

Salgado C et al. ICHE 2007;28:684-8 .

• • •

Increase in BSIs Temporally Associated with Switching From A Split Septum to a Positive Displacement Needleless Valve Device Study location

: Academic medical center Split septum (SS) period: January 2003-February 2005 Positive displacement needleless valve (PDV) period: March-August 2005

BSI Rate* Unit

Critical Care/ Transplant 9 other inpatient

SS Period PDV Period

3.87

3.47

10.43

7.51

P-value

<.0001

<.0001

Post-PDV SS Period

7.62 2.36

Cooperative care (OPD TX) 5.80

*BSI Rate per 1,000 CVC-days 15.18

.0005

4.30

Rupp M et al. CID 2007;44:1408-14

Participants’ Hospital, Needleless Devices (ND), and ND Use or Comparison Periods

Hospital

Hospital A Hospital B Hospital C Hospital D Hospital E

ND Period 1

Interlink Interlink Clave Interlink Interlink

ND Period 1

1-3/03 1-5/02

ND Period 2

SmartSite Ultrasite

ND Period 2

4-6/03 6/02-4/03 1-3/04 10-12/03 7/00-6/03 SmartSite Plus Clave Clearlink/ Posi-flow 7-9/04 2-4/04 7/03-6/04

Bloodstream Infection Rates

#

Temporally Associated With Change In Needleless Devices

Hospital

Hospital A 1* Hospital B*

Location

HW-Peds HW

ND Period 1

1-3/03

BSI Rate

1.8

ND Period 2

4-6/03 1-5/02 2.3

6/02-4/03

BSI Rate

3.9

3.5

Hospital C^ Hospital D* PICU HW 1-3/04 10-12/03 5.4

1.5

7-9/04 2-4/04 17.3

5.1

Hospital E* ICU 7/00-6/03 5.7

7/03-6/04 8.5

# BSIs per 1,000 CVC- or patient-days; HW=Hospital-wide; BSI=Bloodstream infection; * change from split septum to mechanical valve; ^ change from neutral to positive pressure mechanical valve

How May the Mechanical Valves Lead to BSIs?

• • •

Location

: Wake Forest University School of Medicine.

Study Design:

Quantitative cultures of blood from ICU patients drawn through MV ND from December 12, 2004 to January 21, 2005 (initial syringe pull back of morning blood draw).

Results:

– 226 “discards” obtained from 83 patients.

– – – 39/226 (17%; range 8% to 50%, by unit) culture positive.

Colony forming units (CFU/ml): median=0.3, range 0.1->100.

Pathogens: 25 CNS, 5 yeast, 2

S. aureus

Enterococcus spp., 1 each

S. maltophilia

, 2 each Serratia or or Acinetobacter spp.; 31% would be considered pathogens in a blood culture.

– 31% of nurses did not disinfect the MV before accessing system.

Karchmer TB et al. SHEA 2005, Abstract #307

Disinfection of Needleless Catheter Connectors

•

Study design

: In vitro study. – 3 luer-activated valved connectors (Clearlink [Baxter Healthcare], PosiFlow [Becton-Dickinson], and Micro CLAVE [ICU Medical]) were studied.

– 36 connectors from each tested concurrently.

– One device as control, the rest inoculated by immersing the membranous surface in a suspension of

E. faecalis

containing >10 8 colony forming units (CFUs) per ml. Septum allowed to dry for 24 hours (final inoculum 10 5 CFU/ml).

– Accessed by sterile syringe containing 3ml of sterile tryptocase soy broth and flushed with broth. Menyhay and Maki ICHE 2006;27:23-27

Results of Simulation Study Variable

# connectors showing microbial transmission across the membrane/total # connectors studied Approx. # CFU traversing membrane * P<.001

No Disinfection Disinfection With 70% Alcohol Disinfection with Antiseptic Barrier Cap (CHG)

15/15 (100%) 4,500 28,000 20/30 (67%) 1/60 (1.6%)* 442-25,000 0-350 Menyhay and Maki ICHE 2006;27:23-27

Disinfection of Mechanical Valves

• •

Study design

: 300 MVs (4 types from 3 manufacturers) were tested. Each septum inoculated with 10 5 CFUs/ml of

S. epidermidis

cultured. , (Chlorascrub

S. aureus

 ,

P. aeruginosa

, and/or

C. albicans.

Membranous septum disinfected for 15 seconds with friction, using 70% alcohol or 3.15% chlorhexidine/70% alcohol ). 0.9% non-bacteriostatic saline flush solutions were collected downstream and quantitatively

Results

: Disinfection of the membranous septum for

15 seconds with friction

accessing the ports. , using either 70% alcohol alone or 3.15% chlorhexidine/70% alcohol (Chlorascrub  ) was equally effective in preventing the transfer from the membranous septum downstream in the process of Kaler W et al. JAVA 2007

Mechanical Valves and Bloodstream Infections

• • •

Study design

Seattle, WA.

: Intervention study. Changed from an opaque to clear mechanical valve. Change the mechanical valve whenever blood is visible (e.g., after blood infusion or withdrawal). VA Hospital,

Results

: CR-BSI rate: 7.4 to 1.5 per 1,000 line days (p<0.05). Blood culture contamination: 4.4 to 1.8 per 1,000 line-days. Cost savings: $241,000. Valve replacement increased 52%.

Conclusion

: Changing to a clear valve and changing it whenever blood contamination visible reduced CR-BSIs, blood culture contamination, and saved money. 2007 VHA MRSA Prevention Forum, Orlando, FL, Nov 2007

Potential Risk Factors for Bloodstream Infections Associated With Mechanical Valves

Factor Difficulty cleaning access surface Gap around plunger harbors bacteria Opaque housing hides incomplete flushing of media based fluids Internal mechanisms obscure fluid path Potential Impact HCWs may not adequately clean the intricate surface details before access, leading to fluid path contamination.

Gap cannot be accessed for disinfection and can lead to fluid path contamination (esp. with repeated entry-SAS or SASH flushing).

During course of normal manipulation of catheter, small amounts of bacteria and media-like fluids contaminate the valve. If these organisms proliferate, then they can be infused with subsequent manipulations.

Impossible to visually confirm complete flushing.

Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals

.

Marschall J, Mermel LA, Classen D, Arias KM, Podgorny K, Anderson DJ, et al. Infect Control Hosp Epidemiology 2008;29:S22-30.

Rationale for Prevention of CLA-BSIs

– – – – – – – – –

1. Independent risk factors for CLA-BSIs

: Prolonged hospitalization before catheterization Prolonged duration of catheterization Heavy microbial colonization at the insertion site Heavy microbial colonization of the catheter hub Internal jugular catheterization Neutropenia Prematurity Total parenteral nutrition Substandard care of the catheter (excess manipulation or reduced nurse to patient ratio) Marschall J. et al. Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospital. Infect Control Hosp Epi 2008;29:S22-30.

Strategies to Prevent CLA-BSIs

2. Infrastructure Requirements :

– An adequately staffed infection prevention and control program responsible for identifying patients with CLA-BSIs.

– Information technology to collect and calculate catheter-days (denominator) for computing CLA-BSI rates and patient-days to calculate CVC utilization.

– – Resources to provide appropriate education and training.

Adequate laboratory support for timely processing of specimens and reporting results.

Marschall J. et al. Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospital. Infect Control Hosp Epi 2008;29:S22-30.

Strategies to Prevent CLA-BSIs

3. Practical implementation :

– Educate physicians, nurses and other healthcare personnel about guidelines to prevent CLA-BSIs.

– Develop and implement a catheter-insertion checklist. Educate healthcare workers about catheter insertion using the checklist.

– Educate healthcare personnel about the insertion and maintenance of catheters.

– Establish catheter insertion kits/carts containing all necessary items for insertion.

Marschall J. et al. Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospital. Infect Control Hosp Epi 2008;29:S22-30.

SHEA / IDSA Practice Recommendations

– – – – –

Before insertion

: Educate healthcare personnel involved in the insertion, care, and maintenance of CVCs about CLA-BSI prevention (A-III).

Indications for catheter use, appropriate insertion and maintenance, the risk of CLA-BSI and general infection prevention strategies.

Insure all personnel complete an educational program.

Periodically assess knowledge of and adherence to prevention measures.

Insure that all who insert a CVC undergo a credentialing process to insure competency. Marschall J. et al. Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospital. Infect Control Hosp Epi 2008;29:S22-30.

SHEA / IDSA Practice Recommendations

At insertion

: – Use a catheter checklist to insure adherence to infection prevention practices at the time of CVC insertion (B-II).

– Perform hand hygiene before catheter insertion or manipulation (B-II) – Avoid using the femoral vein for CVC access in adult patients (A-I).

– – Use an all-inclusive catheter cart or kit (B-II).

Use maximum barrier precautions during CVC insertion (A-I).

– Use a CHG-based antiseptic for skin preparation in patients older than 2 months of age (A-I). Marschall J. et al. Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospital. Infect Control Hosp Epi 2008;29:S22-30.

– – – – – –

SHEA / IDSA Practice Recommendations

After insertion

: Disinfect catheter hubs, needleless connectors, and injection ports before accessing the catheter (B-II).

Remove nonessential catheters (A-II).

For non-tunneled CVCs in adults/adolescents, change transparent dressings and perform site care with a CHG-based antiseptic every 5-7 days (gauze dressing every 2 days) or more frequently if the dressing is soiled, loose or damp (A-I).

Replace administration sets not used for blood, blood products or lipids at intervals not longer than 96 hours (A-II).

Perform surveillance for CLA-BSIs (B-II).

Use antimicrobial ointments for hemodialysis catheter insertion sites (A-I).

Marschall J. et al. Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospital. Infect Control Hosp Epi 2008;29:S22-30.

SHEA/IDSA Recommendations for Implementing Prevention and Monitoring Strategies: Special approaches for the prevention of CLA-BSIs

Recommended for locations and/or populations within the hospital that have unacceptably high CLA-BSI rates despite implementation of the basic CLA-BSI prevention strategies.

– Use antiseptic- or antimicrobial-impregnated CVCs for adult patients (A-I).

– – Use antimicrobial locks for CVCs (A-I).

Use CHG-containing sponge for CVCs in patients >2 months of age (B-I).

– Bathe ICU patients >2 months of age with a CHG preparation on a daily basis (B-II).

Marschall J. et al. Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospital. Infect Control Hosp Epi 2008;29:S22-30.

SHEA/IDSA Recommendations for Implementing Prevention and Monitoring Strategies: Approaches that should not be considered a routine part of CLA-BSI prevention

– – – Do not use antimicrobial prophylaxis for short-term or tunneled catheter insertion or while catheters are in situ (A-I) Do not routinely replace CVCs or arterial catheters (A-I).

Do not routinely use positive-pressure needleless connectors with mechanical valves before a thorough assessment of risks, benefits, and education regarding proper use (B-II).

Marschall J. et al. Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospital. Infect Control Hosp Epi 2008;29:S22-30.

– – – – –

SHEA / IDSA Practice Recommendations

Accountability

: The hospital’s chief executive officer and senior management are responsible for ensuring that the healthcare system supports an infection prevention and control program that effectively prevents the occurrence of CLA-BSI.

Senior management is accountable for ensuring that an adequate number of trained personnel are assigned to the infection prevention and control program.

Senior management is accountable for ensuring that healthcare personnel are competent to perform their job responsibilities.

Direct healthcare providers and ancillary personnel are responsible for ensuring that appropriate infection prevention and control (IPC) practices are used at all times.

Hospital and unit leaders are responsible for holding personnel accountable for their actions. Marschall J. et al. Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospital. Infect Control Hosp Epi 2008;29:S22-30.

– – –

SHEA / IDSA Practice Recommendations

Accountability

: The person who manages the IPC program is responsible for ensuring that an active program to identify CLA-BSIs is implemented, that data on CLA-BSIs are analyzed and regularly provided to those who can use the information to improve the quality of care and that evidenced-based practices are incorporated into the program.

Individuals responsible for healthcare personnel and patient education are accountable for ensuring that appropriate training and education programs to prevent CLA-BSIs are developed and provided to personnel, patients and families.

Personnel from the IPC program, laboratory, and information technology departments are responsible for ensuring that systems are in place to support the surveillance program. Marschall J. et al. Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospital. Infect Control Hosp Epi 2008;29:S22-30.

Interventions That Prove That Implementation of Evidence-Based CVC-BSI Prevention Measures Can Prevent Infections, Save Lives, and Save Money

Institute for Healthcare Improvement (IHI) Initiatives

• •

December 2004: initiated the Save 100,000 Lives Campaign.

June 2006: IHI announced: >3,100 enrolled (80% of all U.S. admissions); most introduced >1 of 6 changes. – IHI estimates that 122,000 lives saved over 18 months.

–

12 hospitals have gone 12 months without a single CVC-BSI.

Central Line Insertion Checklist -Adults Operator:________________________________________Date:_______________________ RN Assisting:____________________________________ Room/Location:______________ Safety Pause:

 Correct Patient  Correct Procedure  Correct Site  Verbal agreement from all members of the team.

In order to eliminate central line associated blood stream infections, we will be following the Prior to the Procedure:

1.

Hand Hygiene and

YES 2.

Cleanse Site

with 2% CHG with sponge 1.5mL.

YES 3.

Disinfect Site

with a back and forth friction scrub, utilizing 2% CHG wand 10.5mL for 30 seconds and YES 4.

Maximum Barriers

YES Cap/Bouffant YES Mask YES Sterile Gown YES Sterile Gloves Did the operator wear: YES Patient draped with full body sterile sheet.

During the procedure:

5. YES Operator(s) maintained the sterile field.

6. YES Personnel assisting wore a cap, mask and donned gloves appropriately.

After the procedure:

6.

Sterile dressing

applied immediately by the operator.

YES QUALITY IMPROVEMENT THIS FORM IS

NOT

PART OF THE PATIENT'S PERMANENT RECORD.

Please return the form to your Nurse Manager. If a step has was not followed, please note and the Nurse Manager will follow up with the physician.

Developing a Physician Champion — Prevention Should Be The Focus of Clinicians, Not Just Infection Control Personnel.

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Senior leader support

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Clinical Champion

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Day to day leader

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A multidisciplinary team

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Staff buy-in

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Project sustainability

Eliminating Catheter-Associated Bloodstream Infections in an Intensive Care Unit

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Study design

: Prospective cohort study in a surgical ICU. Johns Hopkins Hospital.

Intervention

: Staff education, catheter insertion cart, daily removal reminders, evidence-based guideline checklist, nurse empowerment. Jan 1998-Dec 31, 2002.

Measurement

: CVC-BSIs and guideline adherence.

Results

: CVC-BSI rate decreased from 11.3 to 0 per 1,000 CVC-days. 43 CVC-BSIs, 8 deaths, and $1,945,922 saved.

Berenholtz SM et al Crit Care Med 2004;32:2014-20.

Keystone Project

• • • • • • Michigan Hospital Association 127 intensive care units (ICUs) in Michigan and five other states.

68 ICUs totally eliminated CVC-BSIs.

For 6 months, they eliminated VAP.

Estimates that they saved >1,578 lives, reduced 81,000 hospital days, and saved $165 million.

Hospitals in Rhode Island, New Jersey and Maryland are replicating the Keystone Project locally and others will follow. Pronovost P. et al NEJM 2006;355:2725-32

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Keystone Project

Study design

: Intervention cohort study in 108 Michigan Intensive care units (ICUs) over 18 months. Comparison of CVC-BSI rates before, during, and after intervention.

Results

: 103 ICUs. 1,981 months of ICU data and 375,757 catheter-days.

Median CVC-BSI Rates per 1,000 CVC-days Baseline 3 Months IRR 16-18 Months IRR

2.7

0 0.62 1.4

0.34

Conclusion

: An evidence-based intervention resulted in a large and sustainable decrease (up to 66%) in CVC BSI rates that was maintained for 18 months. Pronovost P. et al NEJM 2006;355:2725-32

Conclusions

•CVC-Related BSIs are a major cause of patient morbidity and mortality.

•Prevention of CVC-Related BSIs requires a multi-factorial approach, including: •Implementation of CDC CVC-BSI Prevention Guideline Recommendations (2002) and SHEA 2008 Compendium Recommendations.

•Implementing new prevention evidence.

•Implementation of insertion and maintenance bundles.

•Educating staff; Insuring adequate and properly trained staff •Insuring that policy = practice (clinician accountability) •Monitoring CVC insertion and maintenance processes (checklists) and CVC related BSI rates (outcomes). • A comprehensive CVC-related BSI prevention program can dramatically reduce infection rates and improve patient safety.

•A rate of ZERO CVC-BSIs in ICU patients is a reality and should be our goal. If “Prevention is Primary”, then action is essential!

Thank You!