Transcript AAP Things That Work: Prevention of Catheter Related Bloodstream Infections Marlene R. Miller, M.D., M.Sc. Christopher T.

AAP Things That Work:
Prevention of Catheter Related
Bloodstream Infections
Marlene R. Miller, M.D., M.Sc.
Christopher T. McKee, DO
Ivor Berkowitz, M.D.
Claire Beers, R.N., M.S.N.
Johns Hopkins Children’s Center
Hospital Epidemiology and Infection Control
Center for Innovations in Quality Patient Care
Introduction
• Review Epidemiology
• Define Standard of Care
– Hand Hygiene
– Maximal Barrier Precautions
– Proper Antisepsis
– Insertion Sites of Choice
• Describe our intervention and results to
date
The Problem
• 250,000 cases of central venous
catheter related bloodstream
infections (CR-BSI) per year in US
• 80,000 cases per year in ICU’s
• Attributable mortality: 12-25%
• Attributable cost: $25,000 per episode
Strategies For Prevention:
Adult Experience
•
•
•
•
•
Hand Hygiene
Use of Maximal Barrier Precautions
Chlorhexidine for Skin Antisepsis
Subclavian Site as First Choice
Remove Unnecessary Lines
MMWR. 2002;51:RR-10
What Is Pediatric Best Practice?
• No studies published in pediatric literature
• Assume adult data holds for children
– Exception is optimal site of line insertion
BSI Intervention
•
•
•
•
Education on best practices
“Line cart”
Nursing check list for CL insertion
Empowerment of nurses to stop
procedures if best practices breached
Hand Hygiene: The Data
Since 1977, 7 of 8 prospective
studies have shown that improvement
in hand hygiene significantly
decreases infection rates
Clin Infect Dis 1999;29:1287-94
Alcohol-Based Hand Cleansers
Soap and
Water
Alcohol
Solution
# of HCWs
n = 43
n = 43
Reduction
in CFUs
50%
88%
Non-medicated soap used; alcohol was mixture of n-propanol and isopropanol;
hands contaminated under clinical conditions
Am J Infect Control 1999; 27:258-61
Hand Hygiene: Be A Role Model
• HCWs in a room with a senior medical
staff person or peer who did not wash
their hands were significantly less likely to
wash their own hands (OR = 0.2, p <
.001)
• Use of gloves does not obviate the need
for hand hygiene
Emerg Infect Dis 2003; 9:217-23
Hand Hygiene Best Practice
• Purell for routine hand cleaning
• Soap and water when hands are soiled
and at start of day
• One of these types of cleanings should be
done before inserting a central line
Maximal Barrier Precautions
Do I Really Need Maximal
Barrier Precautions ?
Author Study Design
& Year
Type
OR for
of Line infection
without MBP
Mermel Prospective
SG
1991
Cross-sectional
Raad
1994
Prospective
Randomized
2.2 (p=0.03)
Central 3.3 (p=0.03)
Am J Med 1991;91(3B):197S-205S
Infect Control Hosp Epidemiol
1994;15:231-8
What Are Maximal Barrier
Precautions?
• For You
– Hand hygiene
– Non-sterile cap and mask
• All hair should be under cap
• Mask should cover nose and mouth tightly
– Sterile gown and gloves
• For the Patient
– Cover patient’s head and body with a large
sterile drape
Who Needs To Be Dressed In MBP?
• The operator
• The assistant
• Anyone else who crosses the sterile
field
• NOT people in the same room who
are not involved with the procedure
Skin Prep
• Chlorhexidine 2% is more effective than
povidone iodine (Betadine) because it
dries quickly and has longer residual
action
Skin Prep
• If you must use Betadine
– Allow Betadine to dry completely (at least 2
minutes)
– Do not blow on, fan, or blot the site to make it
dry faster!
Dressing The Line
• Apply dressing immediately after
placement when site is still sterile
• Use transparent dressing (Sorbaview)
unless site is oozing or pt is allergic
Maintaining The Line
• Change transparent dressing weekly,
gauze dressing daily, and any dressing
that is damp, bloody, or non-occlusive
• Do not use topical ointment or cream at
insertion site
• Do not leave a line undressed
• Lines examined daily by medical staff
What Site Is Best?
• “No randomized trial satisfactorily has
compared infection rates for catheters
placed in jugular, subclavian, and femoral
sites.” MMWR, 8/9/02
What Site Is Best?
• The Hopkins Experience—retrospective
analysis of SICU IJ & SC catheters that
grew  15 cfu
– IJ position was the only predictive factor of 
15 cfu (OR 1.83, p < .001)
What Site Is Best?
• RCT of femoral and SC lines in the ICU
– 145 pts femoral/144 pts SC
• Outcomes
– Similar rates of mechanical complication:
17.3% vs 18.8% (p = NS)
– Higher rate of infectious complications
(colonization and BSI combined) in femoral
grp: 19.8% vs 4.5% (p < .001)
– Higher rate of thrombotic complications in
femoral grp: 21.5% vs. 1.9% (p < .001);
complete thrombosis 6% vs 0%
JAMA; 2001,286:700-7
What Site Is Best?
• Based on these and other studies, the
JHH VAD policy recommends that the
preferred order of line placement is
SC IJ F
• Other factors to consider in site choice
– Anatomic deformity
– Coagulopathy
– Operator experience
What Site Is Best For Children?
• Traditionally femoral vein is site of first choice for
all pediatric patients
– Operator experience is determining factor for
placement of lines elsewhere
• Infectious data does not hold true in children
– Site of insertion does not correlate with infectious
complications
• Same or fewer mechanical complications noted
with femoral line placement
• No thrombotic risk with femoral line placement
Summary of Best Practices
• Wash your hands or use waterless hand
cleaners
• Use sterile technique and maximal barrier
precautions when placing central lines
• Use chlorhexidine for line insertion and
dressing changes
• Use femoral site if possible
• Don’t put in lines that are not needed and take
out lines that are not needed
BSI Intervention
•
•
•
•
Education on best practices
“Line cart”
Nursing check list for CL insertion
Empowerment of nurses to stop
procedures if best practices breeched
Time S e r ie s P lot P IC U B S I
3.0
BSI
effort
starts
2.5
BS I c o u n t
2.0
1.5
1.0
0.5
0.0
M onth
Ye a r
Ja n
2002
Jul
Ja n
2003
Jul
Ja n
2004
Jul
Ja n
2005
BSI Intervention
• Education on best practices
–
–
–
–
–
Hand Hygiene
Use of Maximal Barrier Precautions
Chlorhexidine for Skin Antisepsis
Femoral Site as First Choice
Remove Unnecessary Lines
• “Line cart”
• Nursing check list for CL insertion
• Empowerment of nurses to stop procedures if
best practices breeched
Lessons Learned
• Actual and reported practices vary
• People may not know what you think they
know
• Team work helps
• Maximized preparation helps (line cart)
• Need to be on alert for ‘next best thing’ in
new equipment