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On the CUSP: STOP BSI
Evidence for Best Practices for Placement
and Maintenance of Central Lines
© 2009
Learning Objectives
• Review evidence for the 5 key best practices for
CLABSI prevention
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–
–
–
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Remove unnecessary lines
Hand hygiene
Use of maximal barrier precautions
Chlorhexidine for skin antisepsis
Avoid femoral lines
• Review approaches for central line site care
MMWR. 2002;51:RR-10
© 2009
Hand Hygiene: The Evidence
Since 1977, 7 prospective studies have shown
that improvement in hand hygiene significantly
decreases a variety of infectious complications
Clin Infect Dis 1999;29:1287-94
Lancet 2000;356:1307-1312
© 2009
What are Maximal Barrier
Precautions?
• For Provider:
– 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
© 2009
Maximal Barrier Precautions
© 2009
Maximal Barrier Precautions:
The Evidence
Study Design
Type of
Catheter
OR for
Infection
without MBP
Mermel
1991
Prospective
Non-randomized
Swan-Ganz
2.2 (p=0.03)
Raad
1994
Prospective
Randomized
Central
3.3 (p=0.03)
Lee
2008
Prospective
Non-randomized
Central
5.2 (p=0.02)
Author &
Year
Am J Med 1991;91(3B):197S-205S
Infect Control Hosp Epidemiol 1994;15:231-8
Infect Control Hosp Epidemiol 2008; 29:947-950
© 2009
Skin Prep: Chlorhexidine
Ann Intern Med. 2002;136:792-801
© 2009
What Site is Best?
• RCT of femoral (N = 145) and subclavian (N = 144)
lines in the ICU
• Outcomes
– Higher rate of infectious complications in femoral group:
19.8% vs. 4.5% (p < .001)
– Higher rate of thrombotic complications in femoral group:
21.5% vs. 1.9% (p < .001); complete thrombosis 6% vs 0%
– Similar rates of mechanical complications: 17.3% vs 18.8%
(p = NS)
JAMA 2001;286:700-7
© 2009
Strategies for Prevention:
5 Key “Best Practices”
• Remove unnecessary lines
• Hand hygiene
• Use of maximal barrier precautions
• Chlorhexidine for skin antisepsis
• Avoid femoral lines
MMWR. 2002;51:RR-10
© 2009
Catheter Site and Hub Care
• Clean catheter hubs & injection ports with 70%
alcohol or chlorhexidine/alcohol before accessing
• Change transparent dressings and perform site
care with chlorhexidine
– Routinely every 5-7 days
– If the dressing is loose, soiled or damp
• Replace administration sets not used for blood
products or lipids at least every 96 hours
Infect Control Hosp Epidemiol 2008;29:S22-30
© 2009
Action Items
• Assess compliance with best practices for
catheter insertion
• Assess compliance with best practices for
catheter site care
• Address solutions for barriers to best practice
© 2009
References
•
Guidelines for the Prevention of Intravascular Catheter-Related
Infections; August 2002.
– www.journals.uchicago.edu/doi/abs/10.1086/344188
•
Strategies to Prevent Central Line-Associated Bloodstream Infections
in Acute Care Hospitals; October 2008.
– www.journals.uchicago.edu/doi/pdf/10.1086/591059
© 2009