Blood Stream Infection _ Prevent

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					100K Lives: Prevention Central
 Line Bloodstream Infections

        Nancy Knudsen, MD
    Historical Perspective
 1850 Semmelweiss found increased rate
  of mortality with puerperal sepsis
  patients and advocated hand washing
  to stop spread of disease
 Died in a mental institution, work never
  recognized as important
    Central venous catheters

 United States physicians insert > 5
  million every year
 Used for hemodynamic measurements,
  resuscitation, administration of
  medications and nutrition
 15% of patients will have a
       Complications of CVC

 Mechanical            complications 5-19%

 Thrombotic             complications 2-26%

 Infectious          complications 5-26%

   N Engl J Med 2003;348:1123-33
CVC Infectious Morbidity &
  Mortality in Hospitals

 In the U.S. 15 million CVC days
 250,000 cases of CVC associated BSIs
 Mortality 12-25%
 Marginal cost is $25,000 per episode
 Lowball $6.25 billion
    CVC Infectious Morbidity &
         Mortality in ICU
 Average ICU rate of BSI 5.3/1000 catheter
 80,000 BSIs/ year in ICUs
 Studies show no increase in severity
  adjusted mortality to 35% increase in
 ? Attributable mortality
CVC Infectious Cost in ICUs

 Cost per infection is $34,508-$56,000
 Annual cost $296 million to $2.3 billion
    National Nosocomial Infection
     Surveillance System: CDC
 Data January 1992-June 2001
 Group of nearly 300 hospitals
 Med/surg rate major teaching 5.3%
 Med/surg rate all others         3.8%
 Rates influenced by severity, type of
  illness, elective or urgent placement
  and type of catheter
          DUMC 2000

 5800 CVCs placed
 435 BSIs
 10,500 extra days
 Mortality 25%
 $17 million
           100K Lives

    The goal of this bold initiative is to prevent
     catheter-related blood stream infection (CR-
     BSI) and deaths from CR-BSI by implementing
     a set of interventions known as the “central
     line bundle” in all patients requiring a central
     line. ICUs that have implemented multifaceted
     interventions similar to the central line bundle
     have nearly eliminated CR-BSIs. Berenholtz
     SM, Pronovost PJ, Lipsett PA, etal. Eliminating
     catheter-related bloodstream infections in the
     intensive care unit. Crit Care Med.
100K Lives: Prevention of Central
  Line Bloodstream Infections
   Review current training for effectiveness,
   Define nurses’ role
   Mechanism for monitoring compliance with
    training prior to ICU rotation
   Establish strategy for identifying and training
    those we missed
   Communication plan to housestaff and
   Implement training requirements
100K Lives CR-BSI: Information

   Review/Update online course
    – 100,000 lives campaign information
    – Central line bundle
    – Requirements for housestaff
    – Duke data
    – Checklists for physicians/nurses
       Resident Education
   Three pronged approach utilizing Program
    directors of Med/Surg/Anes/ER and ICU
    Medical Directors to include
    – Yearly passing of on-line training course
    – Attendance at hands-on demonstration of proper
      sterile technique to all incoming residents
    – Observation in SICU/MICU by Knudsen/Govert
      with individual correction as needed
    On-line course location
 Click on Insertion of Central Line
  Catheters course
 Login in with Duke Unique ID
 Use generic password GMEquiz
     Central Line Bundle
   Hand Hygiene
   Maximal barrier precautions
   Chlorhexidine skin antisepsis
   Optimal site selection, subclavian vein
    preferred site
   Daily review of need for line with
    prompt removal
Physicians’ role: Preprocedure
    Assess allergies
    Verify consent form completed and in chart
    Assemble supplies with nursing staff
    Time out-right patient, right location, assess
     –   Review appropriate landmarks with attending
     –   Subclavian preferred site if not contraindicated
       Physicians’ role: Prep
   Remember to employ maximal barrier precautions
   Put on hat/mask for everyone in room
   Minimize number of people in room
   Close door prior to start of procedure
   Wash hands
   Sterile gown/gloves
   Chlorhexidine prep of site
    – Pinch wings of applicator to break ampoule
    – Hold applicator down to saturate pad
    – With sponge against skin, apply chlorhexidine for at least 30
      seconds using a back and forth scrub
    – Allow chlorhexidine to dry completely before beginning line
      placement (~2 minutes)
    Physicians’ role: Insertion
   Full body drape
   Perform procedure
   Transduce with pressure tubing to verify venous placement
   Apply needleless caps, flush ports with saline
   Suture catheter in place
   Apply Biopatch
   Apply Tegaderm
   Appropriate disposal of kit/drapes
   Order and check CXR for line placement
   Procedure note in chart
   Daily review of necessity of central line-advocate removal ASAP
Compliance/Tracking of On-line
   Collaboration with Kathy Andolsek in GME
   Monthly reminders to residents/program
    directors as to who still needs to take online
   Monthly reports to Infection Control to be
    compared with ICU schedules from
   Individuals who are not compliant to be
    followed up with by 100K team
Compliance/Tracking of Hands-on
    All ER residents inserviced and signed off in
     June 2005
    All Incoming Anesthesia residents inserviced
     July 2005, CA2s done at start of ICU rotation,
     entire residency done by June 2006
    All Surgery residents inserviced September
    Medicine residents inserviced in Spring prior
     to JAR rotations each year
Compliance/Tracking in ICU of
 appropriate sterile technique
 Consideration of form
 Observation by SICU/MICU attendings
  with individual instruction as needed
 On evaluations a sentence “___ clearly
  understands the importance of
  appropriate sterile technique in the
  prevention of bloodstream infections
  and demonstrated this adequately.”
   This initiative will be used to
    demonstrate part of the core
    competencies for the residents
    – Practice based learning
    – Systems based improvement
Future plans for June/July 2006
 Include as part of housestaff
  orientation, beepers/badges will not be
  given out until completion of on-line
  training and hands-on demonstration
 Identify incoming fellows from OSH who
  place lines i.e. Vas Rad/Pulm/Cardiac
  Anes/Nephrology/Cardiac and add to
  their orientation as well
      Nursing Education
 Development of Nursing checklist
 Nursing Ed for skills day/orientation
 CPC committee
 Update intranet with this information
 Utilize ICU nursing administration to
  keep at the forefront of many QI
    Nurses’ role: Preinsertion
   Inform patient/family of pending procedure
   Assess allergies in chart
   Verify informed consent present
   Gather sterile supplies for maximum barrier
    precautions i.e. gowns, gloves, drapes,
    masks, hats
   Needleless caps
   Saline flush with syringes
   Biopatch
   Tegaderm
    Nurses’ role Insertion
   Minimize number of people in room
   Close door prior to start of procedure
   Everyone in room with hat/mask
   Everyone in room wash hands
   Time out
   Maximum barrier precautions
   Monitor sterile process and alert for breaks in procedure
   Clean site then apply Biopatch shiny or blue side up
   Sterile occlusive dressing application
   Obtain CXR for line placement
   Inform family of outcome of procedure
    Nurses’ role Maintenance
   Review need for line on daily basis
   Advocate removal/PIC
   Monitor site q shift for
    signs/symptoms of infection, irritation,
    redress if needed
   Alcohol ports prior to every access
   Tubing/needleless port change q 4
    days and more often as needed
Before and After Patient Contact