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					HOSPITAL ACQUIRED INFECTIONS
BEWARE THE FORGOTTEN OR HIDDEN CANNULA
Hospital Acquired Infections (HAIs) are associated with increased morbidity and mortality. National prevalence surveys of HAI carried out in 1980, 1994 and 2006 have shown that approximately 9% of hospital patients will acquire an infection during their hospital stay. Blood stream infections accounted for between 0.1% and 0.6% of these HAIs. Intra-vascular cannulation is a recognised risk factor for hospital-acquired bacteraemia. Enhanced surveillance of bacteraemia has been carried out in this trust since January 2001 and our results would support this view. A care plan was therefore developed to prevent patients acquiring peripheral vascular access device associated sepsis, including bacteraemia. The care plan was implemented throughout the Trust in the summer of 2006. There have been sixteen episodes of intra-vascular device associated infections in fifteen patients in the six months between August 2006 and January 2007, since the implementation of the care plan. Of the sixteen episodes (Table 1), seven were associated with a tunnelled central vascular device (Hickman or Broviac Line), three with a non-tunnelled central vascular device (Internal Jugular or Superior Vena Cava) and six with peripheral cannulation. Two of the non-tunnelled central vascular device associated episodes were related to critical care and the six Hickman line cases were in patients receiving chemotherapy. A variety of organisms were associated with these infections. Table 1 Episode Line Type 1 Peripheral 2 Central 3 Peripheral 4 Central 5 Central 6 Peripheral 7 Central 8 Central 9 Central 10 Central 11 Peripheral 12 Central 13 Central 14 Central 15 Peripheral 16 Peripheral Site Foot Hickman Femoral IJ/SVC Hickman ACF IJ/SVC Hickman Hickman Hickman Wrist IJ/SVC Broviac Hickman Arm Arm Organism Methicillin Resistant Staphylococcus aureus Coagulase negative staphylococcus Pseudomonas aeruginosa Pseudomonas aeruginosa Acinetobacter spp Staphylococcus aureus Serratia marcescens Coagulase negative staphylococcus Klebsiella oxytoca Coagulase negative staphylococcus Methicillin Resistant Staphylococcus aureus Coagulase negative staphylococcus Coagulase negative staphylococcus Methicillin Resistant Staphylococcus aureus Staphylococcus aureus Methicillin Resistant Staphylococcus aureus

Peripheral Cannula Associated Infections Patient 1 A seventy fours years old female was admitted with a CVA and dehydration. A peripheral cannula was inserted for administration of intra-venous fluids and subsequently for administration of cefuroxime and metronidazole for aspiration pneumonia. She was given supportive care, remained nil by mouth but deteriorated and by Day 8 she was barely rousable. Over the next few days she was considered for the ‘vigil pathway’ and commenced on nasogastric feeding. On Day 18 she was clinically septic and re-commenced on cefuroxime. Staphylococcus aureus (methicillin resistant) was isolated from blood cultures. The source of the bacteraemia was a venflon on the dorsum of the right foot, which was inflamed, and a small blister was present. This had been in for eight days. It had been checked on days one and two and then forgotten. Patient 2 An eighty-eight years old female was admitted with diarrhoea, vomiting and PR bleeding. A peripheral cannula was inserted for intravenous fluids and transfusion. Venous access was lost on Day 6 and four attempts at peripheral venous cannulation were unsuccessful. A femoral vein cannula was therefore inserted but was reported as ‘leaking’ 24 hours later. The cannula was left in situ for two more days and was then removed and replaced at the same site over a guide wire. Pseudomonas aeruginosa was isolated from the removed cannula tip. The line site was now clinically infected and therefore the second femoral vein cannula was removed. Venous access was maintained via a newly inserted internal jugular line. Unfortunately this became colonised with the same organism and resulted in an intravenous catheter related Pseudomonas aeruginosa blood stream infection at a later date. Patient 3 A seventy-five years old male was admitted with epigastric pain, weight loss and acute renal failure. He was prescribed intravenous fluids, which were continued for three days, and on Day 4 he was noted to be ‘doing well’. However on Day 5 he had symptoms and signs of acute sepsis and Staphylococcus aureus was isolated from blood cultures. The source of the bacteraemia was an area of cellulitis in the left antecubital fossa associated with the site of a peripheral intra-vascular cannula, which had been in-situ for five days. Patient 4 A seventy-four years old female was admitted with falls, fits and dehydration. She was noted to have anaemia associated with bowel malignancy and metastases and she was prescribed intravenous fluids. Venous access was lost on Day 3 and a new peripheral cannula was inserted for blood transfusion. It was noted that the peripheral cannula was replaced in the left wrist on Day 4 and again on Day 9 in the right wrist.

Thrombophlebitis was noted on the left wrist on Day 11 at the old cannula site. The cannula had been left in situ for 5 days and only removed when clinically infected. Staphylococcus aureus (methicillin resistant) was isolated from this clinical infection. Blood cultures were not collected. Patient 5 A seventy one years old male was admitted with left ventricular failure. A peripheral venous cannula was inserted for the administration of fluids and diuretics. On Day 7 the patient complained of some soreness at the cannula site. There was no other documentation relating to this cannula which should have been removed four days earlier. The cannula was removed at this point, Day 7, but the patient continued to complain of discomfort relating to the insertion site. When the site was examined on Day 12 it was noted that an abscess had developed from which Staphylococcus aureus was isolated. Patient 6 A sixty years old female was admitted with diarrhoea and abdominal pain. There was no documentation with respect to insertion of a venous access cannula on Day 1 but this can be assumed since intravenous fluids were prescribed. It was noted on Day 3 that a peripheral cannula was ‘flushed’ and that a peripheral cannula was re-sited on Day 5. There was no other documentation relating to this cannula. By inference, the cannula had been in situ for 5 days. On Day 10 phlebitis was noted at the access site. Clinical examination revealed a hot swollen area and the presence of pus. A diagnosis of soft tissue infection was made and Methicillin Resistant Staphylococcus aureus was isolated from a swab of the area. Lessons       The care plan is designed to assist with documentation of the ‘life’ of an intra-venous cannula. If it was not recorded it was not done! The care plan is also designed as a reminder to remove the cannula at 72 hours. There is no facility on the care plan to record the checking process after 72 hours. At 72 hours the ward nurses will advise the medical staff that the cannula will be removed unless a doctor inspects, advises and documents a risk assessment to the contrary. This will thereafter happen on a daily basis. Insertion and removal of an intra-vascular cannula must be recorded in the case notes. Always consider when inserting an intravenous cannula whether intravenous access is really necessary. Consider potential duration of intravenous therapy with a view to requesting peripherally inserted central cannulation (PICC). A patient requiring 7 days of intravenous therapy will need a minimum of 3 peripheral cannulae inserted (assuming they last for 72 hours) If a venflon has been inserted for venepuncture only, do not leave it in situ ‘just in case’. Use an appropriate transparent dressing to allow the site to be inspected.

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Femoral cannulae are appropriate for life threatening resuscitation purposes or haemodialysis only and must not be inserted in ward areas by inexperienced operators. In septic patients with presumed hospital acquired infection, always look for the hidden or forgotten venflon.

Judith Bowley Consultant Medical Microbiologist


				
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