Out of Sight Out of Mind

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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        Site                      Organism
   1    Peripheral       Foot     Methicillin Resistant Staphylococcus aureus
   2     Central       Hickman       Coagulase negative staphylococcus
   3    Peripheral     Femoral              Pseudomonas aeruginosa
   4     Central       IJ/SVC               Pseudomonas aeruginosa
   5     Central       Hickman                 Acinetobacter spp
   6    Peripheral      ACF                  Staphylococcus aureus
   7     Central       IJ/SVC                 Serratia marcescens
   8     Central       Hickman       Coagulase negative staphylococcus
   9     Central       Hickman                 Klebsiella oxytoca
  10     Central       Hickman       Coagulase negative staphylococcus
  11    Peripheral      Wrist     Methicillin Resistant Staphylococcus aureus
  12     Central       IJ/SVC        Coagulase negative staphylococcus
  13     Central       Broviac       Coagulase negative staphylococcus
  14     Central       Hickman    Methicillin Resistant Staphylococcus aureus
  15    Peripheral       Arm                 Staphylococcus aureus
  16    Peripheral       Arm      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 ante-
cubital 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.
   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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