Transcript Data a Information a Action: Preventing Nosocomial Infections Technical Aspects

Data a Information a Action:
Preventing Nosocomial Infections
Technical Aspects
David D. Wirtschafter, MD
Chair, Perinatal Quality Improvement Panel, CPQCC
Dept of Pediatrics/Neonatology
Kaiser-Permanente Medical Center, Los Angeles
[email protected]
Janet Pettit, R.N., M.S.N., N.N.P.
Doctors’ Hospital
Modesto, CA
Member, Perinatal Quality Improvement Panel, CPQCC
[email protected]
The Message:
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The “BIG” Picture
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Where are we?
Where can we go?
Reading the road signs (aka Diagnosis)
Finding our position on the map (aka Trending)
Tour Guide
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Hand Hygiene
Lines and hubs
Getting organized
GRADING THE EVIDENCE
Muir Gray 1997
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RCTs from multiple centers (Meta-Analysis)
 (Class I)
RCTs from a single center
 (Class II)
Pre-/Post or case-control studies from single/multiple
centers
 (Class III)
Evidence from well-designed non-experimental
studies, preferably from more than one center
 (Class IV)
Opinions of respected authorities, expert committees
 (Class V)
Reducing Nosocomial Infection in the NICU
CPQCC Toolkit 2003
and 2006 Revision
(Class V)
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Writing Committee for 2003 Edition (on behalf of the PQIP)
Courtney Nisbet, RN, MSN
Janet Pettit, RN, MSN, NNP
Richard Powers, MD
Shukla Sen, RN, MSN
David Wirtschafter, MD
TOOLKIT AVAILABLE AT CPQCC.ORG
2006 Revision: California Children’s Hospital NICU NI Prevention Study Group
Search for “Potentially Relevant Publications” (PRPub) (JP, DW)
Members to contribute other ”potentially relevant publications” and
experiences
Members assess revision(s) to 2003 CPQCC Toolkit’s “Best Practice”
statements and seek consensus on Revised “Best Practices” statements
Members to present proposals to PQIP later
The NI Challenge: How Much Is Preventable?
Unchanging NI Rates, Highly Variable Rates and
Clearly Distinguishable “Good” Performers
% Bacterial NI
VON VLBW NOSOCOMIAL BACTERIAL
INFECTION RATE 1997-2004
30
75th %tile
Median
25th %tile
20
10
0
1997
1999
2001
Year
2003
NI:Defining GoalsIndicate Your Preference
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Best 10th percentile
Best Quartile
Best Half
Not beyond the second standard
deviation
Other
EXPLANATIONS FOR
“SUPERIOR PERFORMANCE”
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CHANCE
FAVORABLE CASE-MIX
FAVORABLE ENVIRONMENT
UNDER-REPORTING OF ADVERSE EVENTS
HIGH QUALITY CARE
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* William Edwards, MD/ VON/NIC/Q Phase I Report
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NIC/Q PROJECT-Phase I
INFECTION OUTCOME (Class III)
HORBAR JD, et al. Pediatrics, 2001
25
20
15
NIC/Q Grp (N=6)
CONTROL(N=66)
10
5
0
1994
1995
1996
1997
NIC/Q 2000 Program Effect In 6 NICUs:
CONS Rates Before and After Interventions Described (Class III) Kilbride Pediatrics 2003
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
1997
2000
A
B
C
D
E
F
ALL
CPQCC Member
(Class III)
Infections/1000 line
days
CLBSI in 500-1000 gm Infants: Point Size
Indicates Annual Line Days
20
15
783 1191
10
CLBSI
5
0
1996
1264713 864
1998
2000
2002
Year
999 1059
2004
903
2006
2008
But Clearly Rates Can Change!
VON-CPQCC CENTERS-CA #1
(Class III)
60%
50%
40%
CONS
FUNGAL
ANY LATE NI
30%
20%
10%
0%
2000
2001
2002
3.1
2.4
2.3
2.2
2.1
1.4
1.3
1.2
1.1
0.4
0.3
0.2
0.1
99.4
99.3
99.2
40
35
30
25
20
15
10
5
0
99.1
NI RATE (%)
VON DEFINED NI RATE BY YEAR/QUARTER
YEAR/QUARTER
NI Rates before and after implementation of hand hygiene
(light blue column indicates quarter) and vascular access
device (initial-chartreuse, repeated-striped quarters) cqi
processes in VON-CPQCC CA#2 NICU
Closed Medication System Associated
with reduced BSI rate.# (Class III)
Aly Pediatrics 2005
18
16
14
12
10
8
6
4
2
0
03
20
02
20
01
20
00
20
99
19
19
98
Infection/1000
line days
Data points estimated from their original Figure 2. CH Wash DC
# PRPub=Potentially Relevant Publication
Prospective Evaluation of a Multi-Factorial
Prevention Strategy# (Class III)
Andersen J Hosp Infect 2005
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Changes in hand washing solutions, Melbourne NICU
Standardized deep line insertion packs
Change to 2% acqueous CHG and 1% CHG in
alcohol for skin antisepsis
Mandatory removal of PIVs @ > 48 hrs & feeds > 120
ml/hr/d
RESULTS
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N= 174 newborns; N= 1359 devices
Pre: 21% BSI
Post: 9% BSI
Problems with 2% CHG
# PRPub
“Proactive” Management of PICC results
in decreased NI in ELBWs# (Class III)
Golombek J Perinatology 2002
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PICC Maintenance Team, Westchester NY NICU
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MD/NNP team that managed catheters daily (both
placement and removal)
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Team inspected dressings daily
“Proactive” removals if:
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Maximal barrier protection; Tegaderm dressings
For catheters (if feasible) q 6 wks
Unexplained CBC abnormality even if BC neg
> 3 repairs for leakage or breakage
CRIs i from 15.8 to 5.1 CRI/1000 line days
#PRPub
Sustained Reductions in Neonatal NI
Rates Following A Comprehensive
Intervention Program (Class III)
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Physician and nursing education, UAB NICU
Common improvement goals
Hand hygiene and environment care
Specialty nursing team for PICC placement, limits on
umbilical catheter duration, increasing BM feeds,
hastening feeding advancement
Baseline infection rate: 8.5/1,000 hospital days
Post-intervention: 1st year- i 26% (p=0.002)
2nd -3rd year-i 29% (p=0.001)
Much of decrease associated with CONS, but other
bacteria/fungi also fell significantly
Schelonka. J Perinatology 2006
Meta-Analysis: Review of Risk Factors
and Control Factors for Catheter-Related
BSI caused by PI CVC#
(Class I) Safdar Medicine 2002
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Inexperienced, marginally skilled operator
Site of insertion: internal jugular & femoral v
Placement in old site over guide wire
Limited use of sterile barriers
Heavy colonization of insertion site
Contamination of catheter hub
Catheter placement > 7 days
# PRPub
Meta-Analysis: Review of Risk Factors
and Control Factors for Catheter-Related
BSI caused by PI CVC#
(Class I) Safdar Medicine 2002
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Maximal sterile barriers at the time of CVC insertion
Use of CHG rather than povidone-iodine for
cutaneous site disinfection
Use of topical anti-infective ointments on the insertion
site
Impact of transparent polyurethane film dressings
The use of multi-lumen rather than single-lumen
CVCs
The efficacy of anti-septic or silver impregnated
cuffs/coatings
# PRPub
Applying the Science to the Prevention of
CRI# (Class I)
O’Grady J Crit Care 2003
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Educating and training of operators who
insert and maintain catheters
Using full barrier precautions during CVC
insertion
2% CHG for skin antisepsis
Eliminating scheduled replacement of CVCs
Using antiseptic/antibiotic impregnated shortterm CVCs
# PRPub
Data to Effect Change:
A Tale of Two Views
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“Science Facts”-The Science of Nosocomial
Infection Prevention
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Data: What to measure and how
Information: What messages are there in these
data
Action: What works to effectively change rates
“Arti-Facts”-The Organizational Art of Bringing
About Change
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Data: What to measure and how
Information: What do these measure tell
Action: How can you effectively change yourself
Baseball: Right or Left-Handed Pitching?
Managing Change: Technical or Social
Aspects
Managing Change: Address
Both The Technical and Social
Aspects
So How To Proceed?
The Manager’s Game Plan
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Use data to define your unit’s
challenges
Use quality improvement cycles
Proceed through the sequence of:
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Data a Information a Action
Act Plan
Study Do
Data a Information a Action:
PLAN: Technical Aspects
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Nosocomial Infection Facts In Your Unit
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What to measure
How to measure
How to display
Facts About Nosocomial Infection
Prevention
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Travelers’ Tales
Evidence-based recommendations
Technical Aspects re Selected NI
Prevention Practices-1
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Diagnosis (central line blood stream infection):
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Hand Hygiene Observations:
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Peripheral blood cultures and/or line cultures?
Volume of blood cultured?
Pre-intervention: typically 50 %- 70 % compliance
Line Management Observations:
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Line set-up practices: no metric available
Utilization of ‘closed systems”: anecdotal only
“Hub care” practices: 57 %-100 %
Diagnosis-1
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Vermont-Oxford Network NI Definition:
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All but CONS: bacteria/fungus recovered from blood or
CSF after DOL 3
CONS: recovered from blood or CSF after DOL 3, signs of
generalized infection and antibiotic treatment for > 5d
Note: this definition does not exclude the presence
of other infectious foci.
Diagnosis -2
National Nosocomial Infection
Surveillance (NNIS) Definition of Primary
Bacteremia (Garner Am J Infect Control 1988)
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No other infectious focus
All but common skin contaminants: at least one
positive blood culture or
Common skin contaminants:
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signs of generalized infection AND
one + Bld Cult OR
at least two + Bld Cults OR
IV line present and antibiotic treatment instituted
“Clinical Sepsis”- Rx instituted, no other site and
negative (or absent) blood culture.
Diagnosis-3
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NICHD Neonatal Research Network:
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Stoll J Pediatr 1996
One positive blood culture drawn after 72 hrs
of age plus presence of signs of infection
UCSD Proposed Definition for CoNS Sepsis
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Craft J Perinatology 2001
“True” CoNS infection. Simultaneously + BC
(>1 ml) from central line and peripheral site.
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If colony counts are available, > 50 cfu/ml
Diagnosis 4
Evaluation of 1 vs 2 Blood Cultures to
Diagnose Neonatal Sepsis:# (Class III)
Sarkar J Perinatology 2006
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Peripheral blood cultures (> 1 ml) from 2
different sites cleaned with povodine-iodine
186 culture pairs for EOS & 83 for LOS
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22 episodes of culture + sepsis (20 infants)
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All episodes had concordant positive BCs
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Differs from Jawaheer Arch Dis Child 1997 who
showed that 0.5 ml sufficient to detect CONS.
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Only 1 Early Onset Sepsis (Listeriosis)
Smaller volume may be insufficient to detect other species
One peripheral BC of > 1 ml can detect sepsis
#PRPub
Additional Methods for Determining and
Defining CRI# (Class IV)
Bouza Clin Mirobiol Infect 2002
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Quantitative cultures: peripheral vs catheter drawn
Timing of culture positivity: peripheral vs catheter
drawn
Cytocentrifugation and acridine orange staining of
blood drawn from catheter
Moreover, the use of antimicrobial-coated catheters
may alter the definition of CRI
#PRPub
Prevention of Contaminated Blood
Cultures#
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Skin Antisepsis Kits containing either alcoholic CHG
or tincture of Iodine# (Class II)
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Contamination rate differences (1/215 vs 3/215): N.S.
Trautner Infect Control Hosp Epidemiol 2002
Comparison of four antiseptic preparations for skin in
the prevention of contamination of percutaneously
drawn blood cultures-RCT# (Class II)
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2.6% (333/12,692 blood cultures) were contaminated. No significant
differences between: a) povidone-iodine; b) tincture of iodine; c) isopropyl
alcohol; and d) Persist® (i.e. povidone-iodine with ethyl alcohol).
“… isopropyl alcohol may be the optimal antiseptic for use prior to obtaining
blood for culture, given its convenience, low cost and tolerability.”
Calfee J Clin Microbiol 2002
# PRPub
DATA: Pre-meeting exercise
NI diagnostic process
Patient
1
2
3
Day of life
at time of
work-up
Check All
Applicable
Lines
Cultures
Drawn
From Lines
U P N
A/ I o
U C n
V
e
L
Record #
and Volume
of Blood
Culture(s)
#
ml
Cultures Drawn Peripherally
Record if
Line
Culture Pos
or Neg
Record #
and Volume
of Blood
Culture
#
ml
Record if
Line
Culture Pos
or Neg
Record
Duration
(days) of
Antibiotics if
peripheral
culture NEG
Understanding and Trending
Your NI Data: Plan, Do, Study, Act
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Case ascertainment
Denominator ascertainment
Interval between cases
Cases per line days
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Stratified by birth weight
Statistical process control charting
Stratified by type of organism
Risk-adjusted rates
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CPQCC, VON, other
STUDY: Interval (in days) Since Last CRIThe NICU Equivalent to “Accident Free”
Days at the Worksite!
30
25
20
15
Days since last
infection
10
5
0
1st
Qtr
2nd
Qtr
3rd
Qtr
4th
Qtr
STUDY: SPC (Statistical Process
Control) Charting Illustrated:
CLBSI in the NICU
CLBSI in the NICU
Jan 1997 - 2000
<1000 Grams
80
50th
NNIS
12.1
60
40
Avg
20
1 Qtr
2000
3rd Qtr
1Qtr.99
3 Qtr.
1Qtr.98
3 Qtr.
0
1Qtr.97
U-SPC Chart
Rate per 1000 Central Line Days
Good
UCL
STUDY: Look At The Data
Four Different Hospital NI “Profiles”
25%
20%
15%
CONS
FUNGI
OTHER
10%
5%
0%
Hosp A
Hosp B
Hosp C
Hosp D
ACT: Obtain and Augment Your
Nosocomial Infection Knowledge Base
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Facts About Nosocomial Infection
Prevention
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Travelers’ Tales
Evidence-based recommendations
Vermont Oxford Network (VON)
Neonatal Intensive Care
Collaborative
Quality Improvement Collaboratives:
NIC/Q 1996 and 2000
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VON: (inter)-nation al NIC U n etw ork
– Ran domized controlled trials
– Outcomes research
– Literature review
– Collab orative learning
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NI C/Q 1996: VON s ubs et– 10 collaborating N ICUs
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NI C/Q 2000: VON s ubs et– 34 collaborating N ICUs
VON
N~3 00
NIC/ Q
N=34
Vermont Oxford Network-NIC/Q 2000
Habit for
Change
Habit for
Evidence
Based
Practice
KNOWLEDGE
BANK
•NETWORK DATABASE
•BETTER PRACTICES
•CLINICAL
•ADMINISTRATIVE
Habit for
Collaborative
Learning
Habit for
Practice as
Process
CHANGE IDEAS
Internal and External
Published Process Analysis
BENCHMARKING with
Superior Performers
Evidence
Round Robin
Site Visits
Your Own Thinking
and Experience
Clinical
Operational
Organizational
Act Plan
Study Do
“BETTER PRACTICE” AREAS
NOSOCOMIAL INFECTION
1998 Report: NICQ Phase I (Class V)
Horbar Pediatrics 2001
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HANDWASHING
NUTRITION
SKIN CARE
DIAGNOSIS
RESPIRATORY CARE
VASCULAR ACCESS
UNIT CULTURE
Fight Bacterial Infections
Key Milestones and Lessons Learned
NIC/Q 2000-Phase II (Class V) Kilbride Pediatrics 2003
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Prevention with an Attitude:
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Important Categories of Practice
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Nosocomial Infection is not an entitlement
Fewer and more experienced providers draw
fewer cultures
Skin of the patient
Skin of the health care worker
Lines and Hubs
Accuracy of diagnosis
Contamination of IV solutions
PBP Prioritization
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22 Overall PBP’s
8 PBP’s chosen as most relevant
Final Synthesis: 3 Group Consensus Statements
Eight Prioritized Potential Best
Practices: (Class V)
Kilbride Pediatrics 2003
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Increase compliance with hand hygiene
standards
Improve accuracy of NI diagnosis
Reduce line and “hub” contamination
Maximize barrier protection when inserting
central lines
Decrease the number of skin punctures
Decrease duration of IV lipid infusions
Decrease duration of central venous line use
Reducing Nosocomial Infection in the NICU
CPQCC Toolkit 2003
and 2006 Revision
(Class V)
Writing Committee for 2003 Edition (on behalf of the PQIP)
Courtney Nisbet, RN, MSN
Janet Pettit, RN, MSN, NNP
Richard Powers, MD
Shukla Sen, RN, MSN
David Wirtschafter, MD
TOOLKIT AVAILABLE AT CPQCC.ORG
 2006 Revision: California Children’s Hospital NICU NI Prevention Study
Group
Search for “Potentially Relevant Publications” (PRPub) (JP, DW)
Members to contribute other ”potentially relevant publications” and
experiences
Members assess revision(s) to 2003 CPQCC Toolkit’s “Best Practice”
statements and seek consensus on Revised “Best Practices”
statements
Members to present proposals to PQIP later
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Handwashing a Hand Hygiene
Science and background
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Transient Microflora:
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recently acquired pathogenic organisms
Can be removed with friction and ordinary
detergent
Resident Microflora:
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Prolonged presence
Resistant organisms
Colonization of fissures and deeper squamous
layers
Can only be removed with antiseptic agents
Controlled Trials of
Handwashing
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Failure of bland soap to eradicate resistant
gram negative organisms
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Ehrenkrantz et al,
Inf Control Hosp Epidemiol
1991;12:654-62
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Antiseptic soaps shown to be superior to
bland soap in hand antisepsis
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Boyce et al Inf Control Hosp Epidemiol 2000;21:438-41
Doebbeling et al, NEJM 1992;327:88-93
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Kjolen et al, J Hosp Infect 1992;21:61-71
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Effectiveness of Hand Antiseptic
Agents
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Triclosan and Chlorhexidine gluconate
provide an advantage by virtue of their
immediate spectrum and residual effect
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Ayliffe et al, J Hosp Infect 1988;11:226-43
Larson et al, Infect Control 1987;8:371-5
Emergence of Alcohol as a
Superior Hand Antisepsis Agent
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Alcohol is an effective antiseptic agent
At least as effective or more effective than
antiseptic soap
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Girou et al, BMJ 2002;325:362
Morrison et al, Infect Control 1986;7:268-72
Handwashing compliance improves with
waterless alcohol gel products
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Bischoff et al, Arch Intern Med 2000; 160:1017-21
Pittet et al, Lancet 2000;356:1307-12
Impact of Alcohol Gel on DrugResistant Bacteria# (Class III)
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Gordin Infect Control Hosp Epidemiol 2005
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3 yr: i MRSA and VRE; no r Clostridia
Boyce Infect Control Hosp Epidemiol 2006
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3 yr: h Gel Use to 85%; no r Clostridia
#PRPub
Hand Hygiene Realities
Hand Hygiene Misses
DATA: Pre-Meeting Exercise
Hand Hygiene Observations
Hand Hygiene Observation Tool
(Suggest one observation session by one observer)
Date of Observation __________
Person Observed
RN, RT, NNP, MD,
Surgeon, OT/PT, etc.
Opportunity
Assessed
A. Before patient care
B. During patient care
C. After patient care
Title of Person Observed
1
2
3
4
5
6
Time Observed _____ - _____
Adequacy of Cleaning
Potential Break in Compliance
A. Adequate (10-15 sec)
B. Inadequate (<10-15 sec)
C. Noncompliant (not done)
1=Initial 2 min scrub 2=Using phone
3=Using beeper
4=Diaper change
5=Chart use
6=Computer Use
7=Scale use
8=One touch
9=Use of supplies 10=Touch glasses
11=Touch face
12=Touch hair
13=Other
Opportunity
Assessed
Method
Hand
Wash
Gel
Adequacy of
Hand Hygiene
Break in
Compliance if
Observed
The HUB of the Problem
The Deep Line’s Hub
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Association of organisms colonizing the hub with
bloodstream infection
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Bloodstream infection in < 7 days: catheter site
Bloodstream infection > 7 days: hub colonization
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Maki et al, Infect Control Hosp Epidemiol 1994;15:227
Sitges-serra and Girvent, World J Surg 1999;23:589-95
Mahieu et al. J Hosp Infect 2001; 48:108#
Bakr. J Trop Pediatr 2003; 49:295#
Culture of same organism from bloodstream as well
as catheter hub and skin around catheter entry site
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#PRPub
Salzman et al, J Infect Dis 1993;167:487-90
Sitges-serra, Nutrition 1997;13:30S-35S
Mahieu et al. J Hosp Infect 2001; 48:108#
Mahieu et al. J Hosp Infect 2001; 48: 20#
Disinfect Connections When
Opened
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Swab connection sites with antiseptic solution
when connections are opened
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Salzman et al, J Clin Microbiol 1993;31:475-9
Sitges-serra et al, Nutrtion 1997;13:30S-35S
Needleless Systems
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Reduce risk of needle stick injuries
Do not require break in system to access
Can be adequately disinfected with isopropyl alcohol
swabbing
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Arduino, et al, Am J Infect Control. 1997 Oct; 25(5):37780.
Brown, et al, . J Hosp Infect. 1997 Jul; 36(3):181-9.
Hub Contamination
Areas where
hub was
placed on agar
dish
Not Cleaned
with Alcohol
Cleaned with
Alcohol
After two days growth
Prevention of Microbial Contamination of
CV Catheter Luers: Needleless vs
Standard Caps# (Class II)
Casey J Hosp Infect 2003
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Needleless vs Standard caps
Isopropyl alcohol vs 0.5% CHG/IPA vs IPA/povidoneIodine
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Luer contamination rates at 72hr
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6.6% NDL vs 18% STD (p<0.0001)
Contaminated NDL: 69% IPA vs 31% CHG vs 42% P-I (p<0.0001)
Needleless-external compression seals
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To disinfect IV connections
To disinfect skin prior to insertion
7.3% were internally contaminated
Bottom Line: Posi-Flow® NDL connectors disinfected
with 0.5%CHG/70%IPA had only a 1% contamination
#PRPub
rate.
Increased CRBSI with Change in
Type of Access Port# (Class III)
Maragakis Infect Control Hosp Epidemiol 2006
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Children’s Center (PICU, NICU, ped onc)
Baseline: CRBSI 1.55/1000 line days-while using a Clave®
Needleless
New Line: CRBSI 2.79/1000 line days after change (p=0.01) to
a positive pressure mechanical valve: SmartSite plus Needlefree
Valve®
Return: CRBSI 1.43/1000 catheter days after reverting back
to original injection port (12/04-3/05) p=0.06
NICU experience: CRBSI h from 0.51/1000 line days to
1.34/1000 catheter days. p=0.17
Low baseline rates of CRBSI in all ICUs made detection of
statistical significance difficult unless rates were pooled.
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h polymicrobial BSIs from 6.5% to 14% after change
h gram negative bacilli from 17.7% to 28.1%
Others reported similar problems, resolved by returning to splitseptum (MV) technology.
#PRPub
Prospective Trials of Open vs Closed
Systems# (Class II)
Bouza J Hosp Infect 2003


A needleless closed sytsem device (CLAVE®)
protects from intravascular catheter tip and hub
colonization.
Post-CV surgical ward.

N=352 pts; 1774 catheters inserted




N=178 Clave®; N= 174 COS (Conventional open system)
Cath Tip Colonization/1000 line days: 59 vs 84 (p=0.003)
Hub colonization/1000 line days: 7.6 vs 24.7 (p=0.002)
CRBSI: 3.78 vs 5.89 (p=0.4) *insufficient power
#PRPub
DATA: Pre-Meeting Exercise
line set-up/blood draw Kilbride Pediatrics 2003
CLOSED SYSTEM BLOOD SAMPLING SET-UP
USING THE MANIFOLD
Three-way Stop-cock (L) port Lever Lock Cannula  Three-way Stopcock Top port syringe for drawing specimen (one ml TB syringe for
ABG and/or three ml syringe for other lab specimen)  Three-way
Stop-cock (R) port three ml syringe for withdrawn blood that will be
returned back to patient  Detach manifold after blood sampling is
done. Note the “cue” for complying with the hub care process.
Prevention of CRI Using a New
Disinfectable,Needleless Connector: RCT#
(Class II) Vebenes Am J Infect Control 2004


RCT of 243 pts & 278 CVCs; 420 bed Univ H
Control: usual 3-way stopcock


CRBSI: 5.0/1000 line days
Study: SmartSite® Disinfectable, Needleless
Connector swabbed with 70% IPA.


Valve mechanism with the access closed by a silicone
endoluminal embolus that becomes permeable when
compressed
CRBSI: 0.7/1000 line days
#PRPub
Umbilical Catheter Tubing
Set-Up
Peripheral Arterial Line
Tubing Set-Up
Umbilical Venous Line
PICC Setup
Prevention of Microbial Contamination of
PICCs: Vancomycin-Heparin Locks#
(Class II) Garland Pediatrics 2005

PICC locked 20-30 min q 2 or 3 x/day



RESULTS:




NS vs Vancomycin 25 microgram/ml
N= 42 vs N= 43
CRBSI: 5% vs 30%
BSI/1000 line days: 2.3 vs 17.8 (RR 0.13, CI o.o1-0.57)
Vanco undetectable in infant’s blood
Complications:

Hypoglycemia at end of lock period

NS- 18 vs Vanco -6
#PRPub
Treatment of Microbial Contamination of
PICCs:#



Haimi-Cohen et al. Vancomycin and ceftazidime bioactivites
persist for at least 2 weeks in the lumen in ports-simplifying
treatment of port-associated bloodstream infections by using the
antibiotic lock technique. Antimicrob Agents Cemother 2001#
Droste et al. Stability and in vitro efficacy of antibiotic-heparin
lock solutions potentially useful for treatment of CV CRI. J
Antimicrob Chemother 2003#
Dannenberg et al. Ethanol-lock technique in the treatment of
bloodstream infections in pediatric oncology patients with broviac
catheter. J Pediatr Hematol Oncol 2003#
#PRPub
Implementation of Guideline for
Lines and Hub Care

Prepping Protocol:

Silicone/latex needless ports:





perform hand hygiene
establish a sterile surface
use alcohol + friction + time for surface to dry.
prep all surfaces to be connected, unless new
Compliance: continued efforts at
adequate initial training and use of tools
to assess compliance
Scrub the Hub Before Each Entry
DMC
Scrub Before Disconnecting
Supplies Readily Available
Clean vs Sterile Surfaces
DATA: Pre-Meeting Exercise
Accessing Lines
TPN CHANGE OBSERVATIONS
RN
#1
1.
2.
3.
4.
5.
YES
Hands antisepsis before IV line manipulations?
Created sterile field (sterile gauze under
connection sites)?
Cleaned injection ports with alcohol not
betadine?
Used friction when cleaning. (For best results,
actually count the number of wiping strokes)
Used Interlink (or equivalent product) lever
lock or blunt plastic cannula to access
port/injection site?.
BLOOD DRAWING OBSERVATIONS
RN
YES
#1
Hands antisepsis before IV line manipulations?
1.
Created sterile field (sterile gauze under
2.
connection sites)?
Cleaned injection ports with alcohol not
3.
betadine?
Used friction when cleaning. (For best results,
4.
actually count the number of wiping strokes)
Used Interlink (or equivalent product) lever
5.
lock or blunt plastic cannula to access
port/injection site?.
NO COMMENTS
Count:____
If no, describe:
NO COMMENTS
Count:____
If no, describe:
Intravenous LinesDeep vs Peripheral?

PICCs vs PIVs in < 1 kg infants



CRI: 3/1138 PICC vs 12/1114 PIV line days (p=.03)
PICCs

Chowhary Pediatr Surg Int 2001 (Class III)
Fewer CRI when inserted in the OR


Liossis J Maternal-Fetal Neo Med 2003# (Class III)
? Better sedation>better control of field avoids contamination
Long-term vs Short-Term Use of Umbilical Venous
Lines. Butler Pediatrics 2006# (Class II)



UVC up to 28 d vs UVC 7-10 d followed by PICCs
CRI: long-7.4 vs short-11.5 CRI/1000 line days (ns)
Limited power, but suggestive that CDC guideline to
limit UVCs to 14 days may need re-evaluation.

CDC based on Durand Pediatrics 1986, Chathas Am J Dis
#PRPub
Child 1990, Cairns Eur J Pediatr 1995
CV CathetersSingle vs Multiple Lumen?

Multiple vs Single Umbilical Venous Catheters





Kabra Cochrane Database Syst Rev 2005# (Class I)
“quality of studies…is poor”
PIV use i in first week, but no difference in 1st month.
Catheter malfunction h in ML-UVC
CRIs in Multiple vs Single Lumen CVCs


Dezfulian Crit Care Med 2003# (Class I)
CRIs h (OR 2.15) in all studies, but, when only
higher quality studies analzed, the difference
disappears; catheter colonization was not h
#PRPub
PICC vs PIVs for VLBW IV Rx#
(Class II)
Janes J Ped Surg 2000



RCT of 63 infants, Ontario NICU, at 1 wk of
age between PIV or PICC until no further IV Rx
needed
No difference in sepsis incidence, # antibiotic
courses or duration of IV use.
Significant differences in



Insertion attempts: PICC 8.8 vs PIV 16.1 (p=0.008)
Catheters utilized: PICC 4.8 vs PIV 8.0 (p=0.002)
Conclusion: PICC is less painful. F/U required.
#PRPub
Maximum Sterile Barrier
Precautions
CV Catheter Insertion

Maximal Barrier Precautions


Use of sterile cap, mask, gown, gloves and
drape
Shown to be more effective than sterile
gloves and small drape alone


Mermel et al, Am J Med 1991;197S-205S
Raad et al, Inf Control Hosp Epidemiol
1994;15:231-8
CV Catheter Insertion

Prepping the skin




Chlorhexidine (CHG) vs Alcohol vs Povidone-Iodine
CHG shown to be more effective due to residual
effect.

Garland Pediatr Infect Dis J 1995 (Class III)

Chaiyakunapruk Ann Intern Med 2002# (Class I)
But, in newborns, 2% CHG associated with
complications.

Andersen J Hosp Infect 2005# (Class III)

Garland Pediatr Infect Dis J 1996 (Class III)
CHG recommended by the CDC Guideline
#PRPub
Skin Antisepsis
CV Catheter Insertion#

Maximal Barrier Precautions

Site of Insertion: OR safer than ICU



Bacterial (CONS) contamination common
(1/5) at time of insertion


Hirschmann J Hosp Infect 2001# (Class II)
Chowdhary Pediatr Surg Int 2001# (Class III)
Hall Pediatric Surg Int 2005# (Class II)
Disinfection of hands before gloving is
significantly more efficacious than washing

Hirschmann J Hosp Infect 2001# (Class II)
#PRPub
Catheter Site Care: Dressings

Transparent: allows direct visualization and requires fewer
changes, but no other demonstrated clinical advantage.



Gillies Cochrane Database Systematic Reviews 2003# (Class I)
Gauze: absorbant for oozing blood
Biopatch®: Chlorhexidine impregnated sponge
 Reduces infection rate in adults
 Neonatal study: Garland Pediatrics 2001 (Class II)
 No better than Povidone-Iodine dressing
 15% rate of CHG hypersensitivity


See also: Andersen J Hosp Infect 2005# (Class III)
Infant and children CV Surgery study: Levy Pediatr Infect Dis J
2005# (Class II)
 Biopatch® vs transparent polyurethane site dressing
.
 Biopatch®: iCVC colonization, no effect on CRI
#PRPub
Maintain Clean, Intact Dressing
Contamination of IV Solutions#
(Class II)
Van Grafhorst Critical Care Med 2002

Simulated model of IV solution preparation by
nurses in ICUs versus pharmaceutical
technicians in a satellite pharmacy




6 large hospitals, Netherlands
Syringes prepared from 10 ml ampules and
rubber-compound-capped 50 ml vials
Bacteria (mainly GPC) in 22% of syringes mixed
from vials under ward conditions vs 1% under
satellite conditions
Bacteria (mainly GPC) in 2% of syringes mixed
from ampules under ward conditions vs 0% under
satellite conditions
#PRPub
Reduce the Duration of
Intravenous Lipid Use


Rationale: lipids have been shown to be
immunosuppressive, easily contaminated and
support growth of fungi and bacteria
IV lipid use correlates with CONS bacteremia
in the NICU



Freeman NEJM 1990 (Class III)
Avila-Figueroa Pediatr Infect Dis J. 1998 (Class III)
Must balance the benefits of enhanced caloric
intake with infectious risks
 introduction of early feeds is an important
adjunct

Kilbride Pediatrics 2003a (Class V)
Prefilled Flush Syringes
When to remove a deep line-1
Benjamin Pediatrics 2001

Neonates with central catheters in whom
bacteremia develops:


The outcome for patients in whom the central
catheter was not removed within 24 hours of
organism identification was significantly worse
(46% vs 8% complication risk) than it was for
those whose catheters were removed promptly.
Recommends immediate removal for Staph
aureus, gram negative rods and probably
enterococcus
When to remove a central line-2
Karlowicz Pediatr Infect Dis J 2002

Neonates with CONS bacteremia

Early removal < 3 days vs late removal > 3 days




Rare complications in either group
43% incidence of CONS sepsis of > 3 days in the late
removal group vs 13% in the early removal group
None of the infants with CONS lasting greater than 4
days was treated successfully with the line in place.
Candida

Early removal within 3 days of + culture



Duration of treatment 1-14 days (m 3)
Deaths 0
Late removal > 3 days of + culture


Duration of treatment 1-24 days (m 6)
Deaths
When to remove a central line-3

Neonates with Enterobacteriaceae
bacteremia Nazemi Pediatrics 2003(Class III)


Early removal (< 2 d) n=15


Attending choice as to removal time
9 CV lines replaced, with 2 that then
became infected
Late removal (> 2 d) n=38

45% treated successfully w/o removal



85% had only 1 day of bacteremia
24% had >1 day of bacteremia
Suggests 1-2 day attempt to save line
Conclusions:

Most important practices in reducing NI:




Hand hygiene
Line management and hub care
Evidence clinical trials or collaborative
benchmarking must be individualized for
each center if change is to be successfully
implemented
In reducing nosocomial infection,
multidisciplinary behavioral changes are
especially critical
Data a Information a Action:
ACTION-Technical Aspects








Integrating the technical and social aspects of
change
Building the team
Prioritizing the work
Doing the work
Communicating the work
Communicating the work
Communicating the work
Evaluating and providing feedback about the
work
Plan: Look At How Your Practices
Affect Your NI Rates:+
Kilbride Pediatrics 2003;



Diagnosis: Sites of culture, method for
cleaning site, amount of blood drawn
Hand hygiene observations: Agent(s) used,
consistency of use, specific opportunities
identified, artificial nails,
Line Management: minimization of ports,
“closed systems” (piv, deep venous lines,
umbilical lines); access methods (including
hub care):
+ Sample observation forms available at cpqcc.org
Plan: Look At How Related Medical
Practice Choices Influence NI Rates

Feeding practices: they affect your line days!!!



When are feeds initiated and how fast are they advanced?
Feeding success affects when lines are pulled (i risk)
What you feed affects infection risks

BM (at least banked milk for sure) lowers NEC rate
(Lucas Lancet
1990, Hylanau Pediatrics 1998)


BM affects enteric colonization
(Go J Ped Surg 1994, Ford J Ped Surg 1996)
How you process and deliver feeds affects
colonization


bacterial risks: on bacterial contamination of enteral
feeding tubes in neonates (Mehall:J Ped surg 2002)
viral risks: CMV (Red Book 2000; Vochem Peds ID Journal 1998 and Hamprecht. Lancet 2002)
Plan: Look At How Related Medical
Practice Choices Influence NI Rates

Line days (the number of times “at-bat” for hub
access errors)

compare to NNIS data (device days/1000
B WT/%tile
10th 25th 50th 75th
<1000 g
0.19 0.28 0.40 0.55
1001-1500g 0.09 0.15 0.25 0.41

NNIS Report. American Journal Infection Control 2002; 29:458




Line “anatomy”: How lines are “set-up”


patient days)
90th
0.64
0.55
Kilbride Pediatrics 2003
What goes through the lines, e.g. prolonged IL use

Shiro J Inf Dis 1995; Freeman N Engl J Med 1990
Do: Getting Started




Team building:
Priority setting:
Establish your monitoring
methodologies from the outset:
Getting your NI facts:
Plan Before Do: Setting Priorities

For each opportunity for improvement, list its

feasibility:





utility:



scale (one to many individuals involved)
magnitude (little to great time, resources, etc)
dependencies (other services, products)
likelihood that planned change can be achieved
previously demonstrated impact
likelihood to influence NI rates in your unit
summative variable: priority

you now have the information to develop actions!
Typical Action Agendas:

Hospital A:



Hospital D:

Hospital B:



hand hygiene
diagnosis

hand hygiene
line management
Hospital C:



advancing feeds
decreasing IL “exposure”
decreasing line
“exposure”


central line insertion
methods
decrease the number
of skin punctures
Hospital E:

reduce postnatal
steroid use
FBI - HUB CARE IMPLEMENTATION
 Task Force formed and




literature reviewed
Hub Care/ Line Care
guidelines developed
One-on-one inservices/Line Care Skills
Lab/Incentive
program/Product inservices/Storyboard
HUB CARE LOGO
VASCULAR ACCESS/
”HUB CARE” AUDIT
TOOLS
FBI - HUB CARE - BUY-IN
 Raising staff awareness by staff meetings,
visual cues, on-going feedback, in-services,
and literature review
 Staff involvement, recognition and incentives
 Self-audits of change in practice
 A positive attitude that change was possible
FBI - HUB CARE
 BARRIERS:





Resistance to change
Scarce person-power
Transitioning nursing leadership
Inadequate product in-service and supply
Lack of communication
IMPLEMENTATION ADVICE:





Staff involvement in literature review/ In-services (one-on-one)
Visual cues/ Memos/ Updated information/ Positive feedback
Adequate staffing and supplies
Annual competency requirement/ Include in orientation program
Supportive leadership