Transcript Presentation Title

Mitigating Pediatric Central Vascular
Access Device Complications
Carol Heiser Rosenberg, ND RN
Children’s Hospital Association
Associate Director, Clinical Quality Improvement
Deborah R. Campbell, RN-BC, CCRN, MSN
Children’s Hospital Association
National Faculty
Dallas, TX • November 2–4, 2012
Mitigating Pediatric CVAD Complications
Session Code: 103 Contact Hours: 0.8 CRNI Units: 2
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Handouts for this session are available online at www.ins1.org.
Session recordings will also be available post-meeting courtesy of
B.Braun Medical/Aesculap Academy.
As a courtesy to both presenters and attendees, please turn off all cell phones and refrain
from talking during the session.
Tonight’s Event:
Industrial Exhibition and Networking Reception
3:30-5:30pm
Dallas, TX • November 2–4, 2012
Objectives
1. Review the need for specialized knowledge and technology
in the care of children with Central Venous Access Devices
(CVAD)
2. Identify the risk factors and complications associated with
use of CVADs having greatest impact in the pediatric
population
3. Describe the strategies for addressing complications related
to infection and occlusion developed by the Children’s
Hospital Association
(formerly National Association of Children’s Hospitals and Related Institutions – NACHRI)
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Dallas, TX • November 2–4, 2012
Children Are Not Little Adults
Dallas, TX • November 2–4, 2012
“Although in some
aspects, pediatric
patients may be regarded
as ‘little adults,’ there are
many important
differences regarding
CVC use between adults
and children.” (Rogier 2005)
Dallas, TX • November 2–4, 2012
We Know as Nurses That Children Require
Specialized Knowledge and Technology
 Yet, compared to adults, very few studies address the unique
needs of children with CVADs.
 Pediatric care involving infusion therapy should be
individualized, collaborative and age appropriate. (INS 2011;
American Nurses Association 2004)
 In children, more so than adults, age, weight and
height/length are key factors in CVAD device selection. (Rogier
2005)
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Dallas, TX • November 2–4, 2012
Most Significant Complications of
CVADs in Children
The necessity of permanent venous
access is even more important in
children. CVADs can also put a child at
risk for severe and life-threatening
complications. Most serious include:
 Mechanical/Device Related
 Infection
 Occlusion/Thrombosis
(Blatny 2004; Rogier 2005; Barnacle 2008,
Doellman 2011)
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Dallas, TX • November 2–4, 2012
Overview of
Pediatric Mechanical Risk Factors
Higher risk of displacement in percutaneously inserted catheters related to
frequent movement in children (Rogier 2005)
Mechanical and displacement risk is lowest with
tunneled implanted ports in children
(Munro,1999; Wiener, 1992; Holylyoak, 1997)
Insertion in right subclavian resulted in significantly higher risk for
malpositioning compared with left subclavian placement
(Casado-Flores, 2001)
Jugular vein recommended in sedated children for short-term (≤ 5 days) as
associated with low risk mechanical complications
(Rogier 2005)
While not recommended in adults, femoral vein resulted in lower
mechanical risks in children; preferred for short-term (≤ 5 days) use
(Casado-Flores, 2001; Durbee, 1997; Maissicotte 1998)
Dallas, TX • November 2–4, 2012
Overview of
Pediatric CLABSI
CLABSIs are a significant cause of mortality in pediatric patients.
(Mermel, L, 2000; Richards, 1999; Miller, 2010)
According to the CDC, pooled data from PICUs reported that
between 1992-2003, the rate for infections per 1000 line days was
7.3% (CDC Nosocomial Infection Surveillance System 2003)
Several studies, summarized by Kline, put CLABSI as the most
common (28%) of all hospital acquired infections in PICUs.
(Kline 2005)
Estimates of the cost of attributable to CLABSI are over $40,000
per infection (Slonim, 2001; Elward, 2005)
Dallas, TX • November 2–4, 2012
Overview of
Pediatric Thrombosis
Prophylactic heparin decreases catheter-related venous of central
venous catheters and may decrease catheter-related bacteremia
(Randolph, 1998)
An association between thrombosis and bloodstream infection
was found in neonates with peripherally inserted catheters
(Thornburg, 2008)
The use of urokinase in pediatric patients is supported by findings
in a study that show it is safe and cost-effective as an alternative
to catheter replacement
(Wachs, 1990)
In children with cancer, because CVCs are in use for an extended
length of time, they are associated with mechanical, infectious and
Dallas, TX • November 2–4, 2012
thrombolytic complications
Risk Factors for Central Line-Associated
Bloodstream Infection (CLABSI) in Children
At Boston Children’s Hospital, in a
study of over 600 pediatric ICU
patients, Wylie et al identified the
following risk factors:

Catheter duration

Line utilized for parenteral nutrition

Line utilized for blood transfusion

Presence of gastrostomy tube

Non-operative cardiovascular disease

Placement of central line in ICU
(Wylie, 2010)
Dallas, TX • November 2–4, 2012
Risk Factors for Central Line-Associated
Bloodstream Infection (CLABSI) in Children
Yogaraj and colleagues found
these risk factors for children with
central lines and note they are
different than adults when it comes
to CLABSI:




Presence of multiple CVADs
Presence of arterial catheter
Chronic stress
Immobility
(Yogaraj, 2002)
Dallas, TX • November 2–4, 2012
Risk Factors for
Thrombotic Complications
INS Standards and Practice Criteria
Include young age in addition to these
factors for assessment:



Presence of chronic disease
such as cancer, diabetes,
ESRD, Irritable Bowel
Syndrome
Known genetic coagulation
issues
Multiple CVADs
(Infusion Nurses Society 2011)
Dallas, TX • November 2–4, 2012
“Neonates and
children differ from
adults in physiology,
pharmacologic
responses to drugs,
epidemiology and
long-term
consequences of
thrombosis.”
(American College of Chest
Physicians 2012)
Dallas, TX • November 2–4, 2012
Strategies for Mitigating Complications:
The Children’s Hospital Association
Quality Transformation Network
Targeting Improved Pediatric Outcomes
for Infection and Thrombosis
Dallas, TX • November 2–4, 2012
Largest Quality Improvement Network
in Pediatrics: 93 Hospitals and 172 Teams
Dallas, TX • November 2–4, 2012
Dallas, TX • November 2–4, 2012
Impact of the QTN Collaboratives:
Infections
Prevented
Deaths
Prevented
Cost
Savings
PICU CLABSI Collaborative
(across 4 cohorts: 2006, 2008,
2009, 2011)
3454
414
$120,890,913
Hem/Onc CLABSI Collaborative
(across 2 cohorts: 2009, 2011)
293
35
$10,249,068
Totals
3747
449
$131,139,981
Data as of 6/2012
Dallas, TX • November 2–4, 2012
PICU Collaborative Aggregate Data
75% Reduction in Infection Rate
Pre-study and Study Monthly CLABSI Rate
Feb 2004 to July 2012
Dallas, TX • November 2–4, 2012
Hematology/Oncology Aggregate Data:
25% Reduction in Infection Rate
Pre-study and Study Monthly CLABSI Rate
Jan 2006 to July 2012
Dallas, TX • November 2–4, 2012
PICU Process Measures for
Improvement Success
Bundle Compliance January 2010 – July 2012
Dallas, TX • November 2–4, 2012
Hem/Onc Process Measures for
Improvement Success
Bundle Compliance January 2010 – July 2012
Dallas, TX • November 2–4, 2012
What is a Care Bundle?
• Care bundles are groupings
of best practices with respect
to a disease process.
• Each practice has been
shown to improve care but
when “bundled” together
result in substantially greater
improvement.
Dallas, TX • November 2–4, 2012
How Were the Bundle Components
Determined?
• Guided by success of PICU CLABSI
Collaborative
• Discussions with pediatric critical care,
hematology/oncology, nephrology and
infection control central line experts and
bedside nurses
• Review of the literature and evidenced based
practice
• Guidelines from the CDC, INS, ONS, Pedivan
• Expert consensus from NACHRI faculty and
collaborative members
Dallas, TX • November 2–4, 2012
Care and Maintenance Bundle
1. Daily Assessment of Line
Necessity
2. Daily Assessment of Line Dressing
3. Line Entry
4. Dressing Change Procedure
5. Cap Change Procedure
6. Tubing Change Procedure
7. Implanted Port Needle Care
Dallas, TX • November 2–4, 2012
“CLABSIs are a
preventable cause of harm
for critically ill children.
Our 3-year quality
transformation effort
shows that focused
consistent adherence to
insertion and maintenance
bundles produces
sustained and continually
decreasing CLABSI
rates.”
(Miller, 2011)
Dallas, TX • November 2–4, 2012
New Efforts Aimed at Thrombosis:
“CLOT” Bundle
Prescriptive Surveillance
1. Check for blood return every 12 hours if line has an
infusion that can be safely interrupted; for lumens
that are locked and not being entered for any
purpose, check for blood return when lumen is
heparin flushed at least every 24 hours.
2. Do not aspirate lines for which manufacturer
prohibits aspiration. If implanted port is not
accessed, does not need routine blood return check
Dallas, TX • November 2–4, 2012
Prevention
1. Multiple attempts at same site avoided if possible.
2. Blood waste not returned unless self contained
blood conservation system in use.
3. Flush line with preservative free 0.9% saline before
and after each use.
4. Positive fluid displacement should be maintainedeither by using a positive displacement device pe
manufacturer directions or by employing the
"flush-clamp" technique (clamping while still in the
process of flushing) which prevents reflux of blood
into the line.
5. Lock line with heparin at least 10 units/ml
6. Frequency for flushing locked lines at least every
24 hrs if not accessing for any other purpose.
Dallas, TX • November 2–4, 2012
Thrombosis Suspected
1. If line sluggish when flushed and/or if blood
return absent or sluggish, TPA administered.
2. Consider ultrasound of line, if available.
3. If clot visualized and/or TPA unsuccessful, line
removed if possible.
Dallas, TX • November 2–4, 2012
Update on CLOT Findings
Dallas, TX • November 2–4, 2012
Questions ?
Dallas, TX • November 2–4, 2012