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Elimination of Central-Line Associated Bloodstream Infections

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					 Elimination of
  Central-Line
   Associated
  Bloodstream
   Infections:
Application of the
    Evidence
    Central-Line Associated
    Bloodstream Infections:
          (CLA-BSIs)
• Estimated 250,000
  cases occur annually
• Mortality rate of 12%
  to 25% for each
  infection
• Marginal cost to
  hospital can be as
  high as $25,000 per
  episode
    Surveillance for Hospital-
      Acquired Infections
• Surveillance is employed in
  healthcare facilities
  worldwide
• Comparison of hospital-
  acquired infections rates is
  made possible through
  various national surveillance
  networks that allow
  surveillance findings to be
  used for quality
  improvement and
  benchmarking efforts
• Largest database in US:
  National Healthcare Safety
  Network
          Risk Factors
• Four major risk factors are
  associated with increased catheter-
  related infection rates:
  – Cutaneous colonization of the
    insertion site
  – Moisture under the dressing
  – Prolonged catheter time
  – Technique of care and placement of
    the central line
 Evidence-Based Strategies
Selected to Reduce CLA-BSIs

1. Central line-associated bloodstream
   infections bundle
2. Hand hygiene
3. Maximal sterile barriers
4. Chlorhexidine for skin asepsis
5. Avoid femoral lines
6. Avoid/remove unnecessary lines
                Hand Hygiene
• Cornerstone of any infection
  prevention program
• Many studies have shown
  that improvement in hand
  hygiene significantly
  decreases a variety of
  infectious complications
• Insufficient or ineffective hand
  hygiene contributes
  significantly to a greater
  bacterial burden and
  subsequent spread of
  microorganisms within the
  environment
               Hand Hygiene

• Use of waterless alcohol-
  base hand rub
  – Most effective and efficient
    method for hand antisepsis
    against bacterial pathogens
• When hands are visibly
  soiled, they should be
  washed with soap and
  water
 Efficacy of Hand Hygiene
  Preparations in Killing
          Bacteria
 Good          Better          Best




Plain Soap   Antimicrobial   Alcohol-based
             soap            handrub
   Technological Advancements
• Electronic
  monitoring and
  voice-activated
  prompts to remind
  caregivers to
  perform hand
  hygiene resulted in
  improved
  compliance

     Swoboda SM, Earsing K, Strauss K, et al. Electronic
     monitoring and voice prompts improve hand hygiene and
     decreased nosocomial infections in an intermediate care
     unit. Crit Care Med. 2004;32:358–363.
         Maximal Sterile Barriers

• Maximal sterile barriers
  improve sterile technique
  during catheter insertion
• The person inserting the
  central line wears a head
  cap, face mask, sterile body
  gown, and sterile gloves, and
  uses a full size drape to
  cover the patient from head
  to toe
     Maximal Sterile Barriers

• One study found a 6-fold
  higher rate of catheter-
  related septicemia when
  minimal sterile barriers
  (sterile gloves and small
  drape) were used instead
  of maximal sterile barriers

Raad II, Hohn H, Gilbreath J, et al. Prevention of central venous
catheter-related infections by using maximal sterile barrier precautions
during insertion. Infect Control Hosp Epidemiol. 1994;15:231–238.
           Chlorhexidine for Skin
                 Asepsis

 • Studies have compared chlorhexidine
   gluconate (CHG) versus povidone iodine
   as a skin antiseptic for catheter insertion
   and routine insertion site care
      – Recent meta-analysis, the use of CHG rather
        than povidone iodine was found to reduce
        the risk of CLA-BSIs by approximately 50%
        in hospitalized patients who required short
        term catheterization
Chaiyakunapruk N, Veenstra, DL, Lipsky BA, Saint S. Chlorhexidine
compared with povidone-iodine solution for vascular catheter-site care: a
meta-analysis. Ann Intern Med. 2002;136:792–801.
 Benefits of CHG

• 2% CHG in tincture of isopropyl alcohol
  has rapid bactericidal activity and is
  effective within 30 seconds after
  application versus 2-minute period for
  povidone iodine
• CHG provides persistent bactericidal
  activity on the skin and maintains its
  activity in the presence of other organic
  material
• Minimal systemic absorption
        How to Use CHG

• Back and forth, up and down motion
• Motion promotes penetration of the
  cleanser within multiple layers of the
  epidermis
• Clear solution
• Orange tinted solution now available
Site Selection: Avoid Femoral
             Lines

• Insertion of CVCs can lead to serious
  and sometimes life-threatening
  complications, whether of mechanical,
  infectious, or thrombotic origin
• Higher rate of infectious complications in
  study comparing femoral lines versus
  subclavian lines
  – 19.8% vs 4.5%
       Avoid and Remove
       Unnecessary Lines

• Once placed, there should be
  periodic, if not daily assessment, of
  its continued need, with emphasis
  on prompt removal
 Empowerment of Nursing


• One of the most important steps in
  preventing CLA-BSIs is to empower
  the nursing staff to stop the central
  line insertion procedure if the
  guidelines were not followed
       Line Care and Tubing
             Changes

• A transparent, semi permeable polyurethane
  dressing has many advantages over gauze but
  both have shown no difference in infection rates
  as long as they are used appropriately
• Benefits of a transparent dressing
   – Ability to evaluate the insertion site while the dressing
     is in place
   – Wicking of moisture away from the skin
   – Less frequent dressing changes compared with
     standard gauze and tape dressings
             Line Care

• CDC guidelines recommend routine
  changing of transparent dressing every 7
  days and whenever either dressing is
  soiled or nonadherent
• Antibiotic ointment at the catheter
  insertion site should be avoided, as it
  promotes fungal infections and antibiotic
  resistance
              Sorbaview
• Study at UVA in 2005
  revealed that
  Sorbaview is more
  adherent, used less
  nursing time, and
  was better liked by
  patients than either
  tape and gauze
       Tubing Changes


• Current CDC recommendation is to
  replace intravenous administration
  sets, including secondary sets and
  add-on devices, no more frequently
  than a 72 hour interval, unless
  catheter-related infectious is
  suspected or documented
              Summary
• Prevention of
  infection is the
  foundation of any
  CLA-BSIs
  management
  program
• CLA-BSIs are one of
  the most prevalent
  healthcare-
  associated infections
                       References
• Centers for Disease Control and Prevention. Guidelines for the
  prevention of intravascular catheter-related infections. MMWR
  Morb Mortal Wkly Rep. 2002;51(RR- 10):3–36.
• Pittet D, Tarara D, Wenzel RP. Healthcare acquired bloodstream
  infection in critically ill patients: excess length of stay, extra costs,
  and attributable mortality. JAMA. 1994;271:1598–1601.
• Goeschal CA, Bourgault A, Palleschi M, et al. Developing and
  implementing an innovative approach to patient safety: nursing
  lessons from the MHA keystone ICU project. Crit Care Clin N Am.
  In press.
• Lee TB, Baker OG, Lee JT, Scheckler WE, Steele L, Laxton CE.
  Recommended practices for surveillance. Association for
  Professionals in Infection Control and Epidemiology, Inc.
  Surveillance Initiative Working Group. Am J Infect Control.
  1998;26:277–288.
                    References
• National Nosocomial Infections Surveillance (NNIS) system
  report: data summary from January 1992–June 2004, issued
  October 2004. Am J of Infect Control. 2004; 32:470–485.
• Mermel LA. Prevention of intravascular catheter-related
  infections. Ann Intern Med. 2000;132:391–402.
• Institute for Health Care Improvement. Saving 100,000 Lives
  Campaign. Available at: http://www.ihi.org/IHI/
  Programs/Campaign/. Accessed June 30, 2006.
• Larson E. Skin hygiene and infection prevention: more of the
  same or different approaches? Clin Infect Dis. 1999;29:1287–
  1294.
• Kent KH, Lipsky BA, Veenstra DL, Saint S. Using maximal
  sterile barriers to prevent central venous catheterrelated
  infections: a systematic evidence-based review. Am J Infect
  Control. 2004;32:142–146.
• American Association of Critical Care Nurses practice alert:
  preventing catheter related bloodstream infections. 2005.
  Available at: http://www.aacn.org/AACN/practiceAlert
  .nsf/vwdoc/PracticeAlertMain. Accessed June 30, 2006.
                    References
• Centers for Disease Control and Prevention. Guideline for hand
  hygiene in health-care settings: recommendations of the
  Healthcare Infection Control Practices Advisory Committee and
  the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
  MMWR Morb Mortal Wkly Rep. 2002;51(RR-16):1–56.
• Larson EL, Bryan JL, Adler LM, Blane C. A multi-faceted
  approach to changing hand washing behavior. Am J Infect
  Control. 1997;25:3–10.
• Pittet D, Dharan S, Touveneau S. Bacterial contamination of the
  hands of hospital staff during routine patient care. Arch Intern
  Med. 1999;159(8):821–826.
• Swoboda SM, Earsing K, Strauss K, et al. Electronic monitoring
  and voice prompts improve hand hygiene and decreased
  nosocomial infections in an intermediate care unit. Crit Care
  Med. 2004;32:358–363.
• Arroliga AC, Budev MM, Gordon SM. Do as we say, not as we
  do: healthcare workers and hand hygiene. Crit Care Med.
  2004;32:592–593.
                       References
• Chaiyakunapruk N, Veenstra, DL, Lipsky BA, Saint S.
  Chlorhexidine compared with povidone-iodine solution for
  vascular catheter-site care: a meta-analysis. Ann Intern Med.
  2002;136:792–801.
• Merrer J, DeJonghe B, Golliot F, et al. Complications of femoral
  and subclavian venous catheterization in critically ill patients: a
  randomized controlled trial. JAMA. 2001;286:700–707.
• Gillies D, O’Riordan L, Carr D, Frost J, Gunning R, O’Brien I.
  Gauze and tape and transparent polyurethane dressings for
  central venous catheters. Cochrane Database Syst Rev.
  2003;(4):CD003827.
• Zakrzewska-Bode A, Muytjens HL, Liem KD, Hoogkamp-
  Korstanje JA. Mupirocin resistance in coagulase-negative
  staphylococci, after topical prophylaxis for the reduction of
  colonization of central venous catheters. J Hosp Infect.
  1995;31:189–193.
• Gillies D, O’Riordan L, Wallen M, Rankin K, Morrison A, Nagy S.
  Timing of intravenous administration set changes: a systemic
  review. Infect Control Hosp Epidemiol. 2004;25(3):240–250.
                    References
• Veenstra DL, Saint S, Saha S, Lumley T, Sullivan SD. Efficacy
  of antiseptic-impregnated central venous catheters in
  preventing catheter-related bloodstream infection: a meta-
  analysis. JAMA. 1999;281:261–267.
• Bassetti S, Hu J, D’Agostino RB Jr, Sherertz RJ. Prolonged
  antimicrobial activity of a catheter containing chlorhexidine-
  silver sulfadiazine extends protection against catheter infections
  in vivo. Antimicrob Agents Chemother. 2001;45:1535–1538.
• Veenstra DL, Saint S, Sullivan SD. Cost-effectiveness of
  antiseptic-impregnated central venous catheters for the
  prevention of catheter related bloodstream infection. JAMA.
  1999;282:554–560.
• Eggimann P, Harbarth S, Constantin MN, et al. Impact of a
  prevention strategy targeted at vascular-access care on the
  incidence of infections acquired in intensive care. Lancet.
  2000;355:1864–1868.
• Sherertz RJ, Wesley E, Westbrook DM, et al. Education of
  physicians-in-training can decrease the risk for vascular
  catheter infection. Ann Intern Med. 2000;132:641–648.
• Anderson RN, Smith BL. Deaths: leading causes for 2002. Natl
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