Transcript Guidelines to Prevent Central Line-Associated Blood Stream Infections Why do I need to complete this orientation? • Problem – – Vascular access device-associated infections increase morbidity, mortality, hospital.

Guidelines to Prevent
Central Line-Associated
Blood Stream Infections
Why do I need to
complete this orientation?
• Problem
–
–
Vascular access device-associated infections increase
morbidity, mortality, hospital length of stay, and costs.
Education of health care workers decreases healthcareassociated infections.
• Intervention
– Mandatory course to achieve standardization of infection
control practices during central vascular access device
(C-VAD) insertion.
Why do I need to
complete this orientation? (cont.)
• Outcome
– Education in another center achieved a 28 percent
relative reduction in central line infections and saved
$800,000. *
– Since implementing this orientation, that center’s central
line-associated related blood stream infection (CLABSI)
rates have decreased below the national average.
*Sherertz, et al. Ann Intern Med. 2000;132(8):641-648
Statistics for CLABSIs
• 90 percent of all blood stream infections are associated with
C-VADs.
• 400,000 CLABSIs occur each year in the United States.
• CLABSIs are —
– Associated with increased morbidity
– Associated with mortality rates of 10 percent to 20 percent
– Associated with prolonged hospitalization (mean of 7 days) and
increase in medical costs >$28,000
National Nosocomial Infection
Surveillance Rates
• In 2003, National Nosocomial Infection Surveillance from the
Centers for Disease Control & Prevention reported the
number of CLABSIs per 1,000 catheter days based on
nationwide intensive care unit (ICU) surveillance.
• Table 1 compares ICUs from one academic medical
center to national benchmark CLABSI rates.
CLABSI Rates
per 1,000 Catheter Days
NHSN 90th
Percentile
NHSN 50th
Percentile
Pre-VAD
Training
Post-VAD
Training
SICU
9.1
5.3
6.7
0.6
PICU
11.9
7.7
5.5
5.4
CVICU
4.9
2.8
7.6
2.7
MICU
9.8
6.1
7.8
3.3
CCU
7.9
4.6
5.0
1.2
NCCU
8.3
4.9
6.6
3.7
OncICU
9.3
4.7
N/A
1.6
Risk Factors for CLABSI
• Site of insertion — Subclavian vein poses less risk than
internal jugular or femoral vein.*
• Multiple lumen catheters —
– Increased tissue trauma predisposes to CLABSI
– More manipulation and contamination of multiple ports/hubs
• Total parenteral nutrition and/or lipids
• Low nurse to patient ratio
*Merrer, et al. JAMA. 2001;286:700-7
Risk Factors for CLABSIs (cont.)
• Infection elsewhere (remote, i.e., urinary tract
infection or wound) — secondary source
• Colonization of catheter with organisms
• IV catheterization longer than 72 hours
• Inexperience of personnel inserting the C-VAD
• Use of stopcocks
Process of
Catheter-Related Infections
Five Evidence-Based Steps to
Prevent CLABSI
1. Use appropriate hand hygiene.
2. Use chlorhexidine for skin preparation.
3. Use full-barrier precautions during central
venous catheter insertion.
4. Avoid using the femoral vein for catheters in
adult patients.
5. Remove unnecessary catheters.
Hand Hygiene
Wash hands with soap and water or use a
waterless hand sanitizer —
–
Before and after invasive procedures
–
Between patients
–
After removing gloves
–
Before eating
–
After using the bathroom
–
If contamination is suspected
Hand Hygiene Works!
Year
Author
Setting
Comparison
Group
1982
Maki
ICU (U.S.)
Crossover
↓ Nosocomial Infection
1984
Massanari
ICU (U.S.)
Crossover
↓ Nosocomial Infection
Pittet
Teaching
Hospital,
Switzerland
Observational
↓ Nosocomial Infection
↓ MRSA Rates
2000
Results
Waterless Hand Hygiene Steps
• Coat all surfaces of your hands thoroughly
with waterless hand sanitizer, including
palms, in between fingers, under
fingernails, backs of hands, and around
wrists.
• Rub your hands briskly until they feel
comfortably dry.
• It takes about 15 seconds, and no water or
towels are needed.
Hand Washing Steps
1. Wet hands.
2. Obtain soap.
3. Lather for 10 to 15
seconds.
4. Rinse hands.
5. Turn off faucet handles
with paper towel.
C-VAD Site Selection
• Use the subclavian site unless medically
contraindicated (e.g., patient has an anatomic
deformity, coagulopathy, or has renal disease that
may require dialysis).
C-VAD Site Selection:
Special Considerations
• For patients on hemodialysis, the National Kidney
Foundation’s 2000 guidelines recommended
against the use of the subclavian vein for any VAD
unless use of the internal jugular vein is absolutely
contraindicated. This is due to the risk of subclavian
vein stenosis.
• If the internal jugular vein is chosen, use the right
side to reduce the risk of noninfectious
complications.
C-VAD Line Selection
• Use a single lumen C-VAD, unless multiple lumens are
absolutely necessary.
• Consider a tunneled or implanted C-VAD for patients
requiring long-term access (>30 days) or a PICC or
cuffed C-VAD for patients requiring therapy for
>1 week.
• Evaluate the need for C-VAD daily.
– Remove it when not needed or change to a single lumen
C-VAD when possible.
Aseptic Technique: Goals
• Remove transient organisms and soil from the skin.
• Reduce the number of resident microbial flora and
inhibit their rebound growth.
• Create a sterile working surface that acts as a barrier
between the insertion site and any possible source of
contamination.
Aseptic Technique
• Prepare skin with antiseptic/detergent
chlorhexidine 2 percent in 70 percent
isopropyl alcohol.
• Pinch the wings on the “ChloraPrep” applicator to pop
the ampule. Hold the applicator down to allow the
solution to saturate the pad. Press the sponge against
skin and apply chlorhexidine solution using a back-andforth friction scrub for at least 30 seconds. Do not wipe or
blot.
• Allow the antiseptic solution time to dry completely
before puncturing the site. This may take 2 minutes.
Evidence Supporting Chlorhexidine Use:
Skin Prep−Meta Analysis
Pooled RR
for BSI
Ann Intern Med. 2002;136:792-801
Maximal Barriers Required
for C-VAD Insertion
• Use face mask, cap, and sterile gloves.
• Wear a sterile gown with neck snaps and wrap-around
ties properly secured.
• Instruct anyone assisting you to wear the same barriers.
• Cover the patient entirely with a large sterile drape.
Maximal Barrier Precautions
Decrease CLABSI Infections
•
•
Author
Design
Catheter Type
OR for Infection
Without MBR
Mermel/1990
Prospective,
cross-sectional
Swan-Ganz
2.2 (p<0.03)
Raad/1994
Prospective,
randomized
Central
6.3 (p<0.03)
OR = odds ratio
MBR = maximal barrier precautions. Inserter washes hands and wears
mask, cap, sterile gown, and sterile gloves. Patient’s head and body
are covered with a large, sterile drape.
Caveats: Catheter Insertion
• IV antimicrobial prophylaxis does not reduce CLABSI.*
• Insertion of C-VADs through open techniques/cut
down increases the risk of CLABSI.
• Adequate room is needed to perform the procedure
without risk of contamination.
*Ranson. J Hosp Infect. 1990;15(1):95-102.
Post Insertion: C-VAD Care
• Antimicrobial ointments do not reduce the incidence of
CLABSI.
• A sterile dressing should be applied to the insertion site before
the sterile barriers are removed.
• Transparent dressings are preferred to allow visualization of the
site. However, if the insertion site is oozing, apply a gauze
dressing instead of a transparent dressing.
• When the C-VAD dressing becomes damp, loosened, or soiled
or after lifting the dressing to inspect the site, replace the
dressing.
Replacing C-VADs
• Lines should be removed as soon as possible.
• Routine C-VAD guidewire exchange or site rotation is not
recommended.*
• Guidewire exchange is acceptable for replacing a
malfunctioning catheter or downsizing a pulmonary artery
catheter to a central venous catheter.
• Patients who clearly have a CLABSI should not undergo a
guidewire exchange.
• Selected patients with suspected blood stream infections and
limited venous access may have their catheter exchanged
over a guidewire and the catheter tip should be cultured.
Before handling the new catheter, switch to a new set of sterile
gloves.
*Eyer, et al. Crit Care Med. 1990;18(10):1073-9 .
Suspected C-VAD Infections
•
Remove the C-VAD in a patient with proven CLABSI
(i.e., blood culture positive for a recognized pathogen
with no identified secondary source).
•
If a blood stream infection is only suspected, the
C-VAD is not known to be the source, or the C-VAD
cannot be removed, clinical judgment is necessary.
Extensive, evidence-based guidelines exist for the
diagnosis and treatment of catheter-related infections.*
*Mermel, et al. Clin Infect Dis. 2001;32(9):1249-72.
Suspected C-VAD Infections (cont.)
• Draw two sets of blood cultures from a patient with new
episode of suspected C-VAD infection, preferably both sets
peripherally.
• It is not always necessary to remove the C-VAD in a mildly ill
patient with unexplained fever.
• If the catheter is the suspected source of the infection, it can
be changed over a wire and cultured. If the catheter culture
grows 15 colony forming units of organisms, remove it and
place at a different site.
• Tailor antimicrobial therapy to the individual patient based on
severity of illness, suspected pathogen, and presence of
complicating factors.
C-VAD Line Cultures: Indications
•
The utility of catheter cultures is controversial;
nonetheless, proper technique is imperative to evaluate
the data.
•
The catheter tip may be submitted for semiquantitative
culture if there is clinical suspicion of CLABSI.
•
Routinely removed catheters should not be sent for
culture.
C-VAD Line Cultures: Method
• Remove all dressings and cap off all hubs/ports then
paint the site with antiseptic solution and include within
the sterile field.
• Remove C-VAD en bloc. Under no circumstance should
catheters be cut prior to removal.
• Remove the catheter aseptically, avoiding contact with
the patient’s skin and catheter tray.
• Use sterile scissors (not the scalpel used to cut the
C-VAD sutures) to cut a 5 cm segment, including the tip,
and place it in a culture container.
C-VAD Line Cultures:
Interpretation
• A catheter culture yield of 15 colony forming unit,
accompanied by signs and/or symptoms of infection
is consistent with a catheter-related infection.
• Do not give antibiotics based on a positive catheter
culture only. Evaluate the clinical picture.
Blood Cultures
• Patients with a new episode of suspected catheterrelated infection should have two sets of peripheral
blood samples drawn for culture.
• In rare instances where access for peripheral blood
draws is limited, one set may be drawn from the line and
one set may be drawn percutaneously.
Peripheral Blood Cultures:
Method
• Don sterile gloves and observe standard precautions.
• Apply chlorhexidine 2 percent in 70 percent isopropyl alcohol
(ChloraPrep Frepp) using a back-and-forth friction rub for at
least 30 seconds over a 5 cm area.
• Allow the solution time to dry completely before puncturing the
skin.
• Do not touch the venipuncture site after skin prep except with
sterile gloves.
• Insert the needle into the vein and withdraw 20 cc of blood
(adults).
• Distribute the blood evenly between two culture bottles (10 cc
per bottle), taking care not to inject air into the anaerobic
bottle.
• Always send a second set of blood cultures from a separate
venipuncture site.
Arterial Line: Site Selection
• Radial artery is the preferred site.
• Dorsalis pedis is an alternative site.
• Femoral sites have higher infection rates and risk of
thrombosis.
• Brachial/maxillary sites are a last resort because of
the lack of collateral circulation.
Arterial Lines: Aseptic Technique
• As with C-VADs, always:
– Clean your hands with soap and water or waterless
hand cleaner.
– Maintain standard precautions.
– Perform thorough skin preparation.
– Use barrier protection.
Arterial Lines: Barriers
• For radial or dorsalis pedis sites, create a generous sterile
working surface using sterile drapes. Wear sterile gloves
and a mask with face shield.
• Femoral or axillary arterial catheters may increase the risk
of infection and require maximum barriers as with
C-VADs, including mask, sterile gloves, sterile gown, and
large sterile drape.
Special Thanks
Sean Berenholtz, M.D.
Roy Brower, M.D.
Raphe Consunji, M.D.
Sara Cosgrove, M.D.
Pamela Lipsett, M.D.
Trish Perl, M.D.
Peter Pronovost, M.D.
Lisa Cooper, R.N.