1. Preventing Central Line Associated Bloodstream Infections (CLABSIs)
What Clinical Staff Should Know
Prepared by
Ann Bailey RNC-NIC, BSN, MBA, CIC
Joanne Dixon MN, RN, CIC
Gwen Irwin, RN, CRNI
Judy Smith, RN, BSN, CRNI
December 18, 2009

2. Name 2 ways patients get CLABSIs
Objectives Upon completion of this module, the learner will be able to:
Summarize the Joint Commission 2010 National Patient Safety Goal related to Central Line Associated Bloodstream Infections (CLABSIs), effective 01/01/10
Includes using “Bundle” with respect to preventing CLABSIs
Define “Bundle”
Name 2 ways patients get CLABSIs
List 4 evidence-based practices that have been shown to help prevent CLABSIs

3. The Joint Commission 2010 National Patient Safety Goal (NPSG)
NPSG focuses on the prevention of CLABSIs.
All those who manage central lines MUST have education about the importance of preventing CLABSIs.
Includes staff, doctors, APNs or other licensed providers
Patients and families MUST be educated about CLABSI prevention before any central line insertion.
CLABSI surveillance will be hospital wide, not targeted to ICUs.
For adults, NO femoral catheters, unless other sites aren’t available.

4. Patient and Family Education Before Central Line Insertion
FAQ Catheter Associated Bloodstream Infections from Joint Commission covers:
Providers doing hand hygiene
Steps for maximum barrier CVL insertion
Clean hands before using CVL
Clean connectors with antiseptic solution before using CVL
Decide every day if CVL is needed.
Ask providers to clean hands if patient doesn’t see them.
Tell nurse if dressing comes off or wet or dirty.
And more

5. The Joint Commission 2010 National Patient Safety Goal (NPSG)
NPSG focuses on the prevention of CLABSIs.
Also includes the CVL insertion bundle.
We have had in place for almost 5 years.
Also includes part of the CVL maintenance bundle.
We have had in place for about 2 years.

6. What is a Bundle?
A grouping of evidence-based best practices that individually improve care, but when applied together result in substantially greater improvement.
Science behind the bundle elements is well established – the standard of care.
Bundle element compliance can be measured as “ yes/no.”
“All or none” approach.

7. The CVL Insertion Bundle
Hand hygiene immediately prior to insertion
-wash hands or
-use alcohol-based hand gel/foam
Maximal barrier precautions
-full body sterile drape
-clinician and assistant wear cap, mask, sterile gown, gloves
-persons within 6 feet wear hat and mask
Skin antisepsis with chlorhexidine 2% / 70% isopropyl alcohol.
Subclavian site considered 1st choice; avoid IJ & femoral.
Exceptions: Should be rare for adults
- Hemodialysis catheters
- When high risk for pneumothorax
- When high risk for noncompressible hematoma

8. The CVL Maintenance Bundle
Perform good hand hygiene, prior to handling line
-Hand washing or
-Use alcohol-based hand gel/foam
Assess dressing/site with routine assessment
Scrub connector vigorously with alcohol x 15 seconds
-Allow to dry before accessing
Assess line patency for brisk return and easy flushing
Assess to determine if patient meets criteria for line necessity

9. Why Prevent CLABSIs? Nationally and annually:
80,000 central line associated bloodstream infections occur in ICUs
250,000 hospital-wide, including ICUs
Seton Family of Hospitals
The majority of CLABSIs occur outside of the critical care units
Check your unit’s CLABSIs with your infection preventionist, if you are interested in more information
Increases the patient’s risk of death significantly
CLABSIs lead to longer length of stay (LOS)
National estimates show the cost of a BSI can be as high as $25,000 per episode
(MMWR, August 9, 2002 Vol. 51, No. RR-10)

10. How do CLABSIs happen?
Introduction of pathogens into the bloodstream from the skin around insertion site
Introduction of pathogens into the bloodstream from the hub or connector of the catheter.
Most frequent cause nationally
Also true at Seton

11. Factors That Increase Risk of BSIs
CVLs in areas that have increased colonization of organisms
such as the internal jugular or femoral sites
Multiple lumens: More manipulation and contamination. (MMWR, August 9, 2002 Vol. 51, No. RR-10)
Use of stopcocks (MMWR, August 9, 2002 Vol. 51, No. RR-10)
Contamination of IV tubing or connectors (caps)
Longer dwell time of CVC
The risk of infection depends on the site of placement, colonization of organisms at insertion site and prolonged use of the central catheter

12. Factors That Lower Risk of BSIs
Select subclavian site over internal jugular or femoral sites, if PICC not used
Perform hand hygiene
Use maximum barrier precautions
Skin prep with chlorhexidine rather than povidone-iodine
Skin prep on clean skin
Maintain patency of all lumens
Free of sluggishness or occlusion; brisk blood return
Remove line when no longer necessary
The risk of infection is reduced by adhering to maximal barrier precautions when placing the central line and using chlorhexidine for disinfection prior to insertion.

13. CVL Insertion Bundle Component: CVL Site Choices
Femoral Vein Last choice
Subclavian Vein First Choice
Internal Jugular Second choice

14. Hand Hygiene – The Most Important Way to Prevent Any Infection
Alcohol-based hand gel/foam - apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers until hands are dry
Handwashing seconds of soap and friction, rinse, dry and turn off faucet with clean paper towel

15. Immediately before accessing the central line

16. CVL Insertion Bundle Component: Maximum Sterile Barrier Precautions
Sterile gown
Hat and mask
Sterile gloves
Persons within 6 feet also wear hat and mask

17. CVL Insertion Bundle Component: Chloraprep®
Gross debris or dirt should be removed
with an alcohol pad, prior to using the skin prep.
by washing with soap and water, prior to using the skin prep.
Clean with friction for minimum of 30 seconds.
Allow Chloraprep® to completely dry, before procedure for best results.
DO NOT REMOVE Chloraprep® after the procedure is completed. Exception: neonates <2 months.

18. CVL Maintenance Bundle Component: Assess line patency for brisk return and easy flushing
Research studies indicate a direct correlation with occlusions, fibrin sheaths, and risk of CLABSIs

19. No blood return? Flushes easily?
Probable fibrin sheath or fibrin tail
Treat as soon as possible
Treat with Alteplase per declotting protocol
Infusing
around sheath
Fibrin
sheath
Attempting to
withdraw blood
Catheter

20. CVL Maintenance Bundle Component: Daily Review for Line Necessity
Remove when No Longer Indicated
Indications for a CVL
Hemodynamic monitoring
Administration of certain medications that require central administration, e.g. vasopressors, chemotherapy, TPN
Long term IV therapy, e.g. antibiotics or inotropes
Plasmapheresis, apheresis, hemodialysis, or continuous renal replacement therapy
Poor peripheral venous access, when IV treatment is still needed

21. CVL Maintenance Bundle Component: Scrub the Hub with Alcohol for 15 seconds, prior to accessing
Vigorous scrubbing is necessary to remove pathogens
Research shows that 5 seconds is not enough.
67% of pathogens are still transferred.
Research shows that 15 seconds with friction is 100% effective in disinfection.
If this step is skipped, the patient is inoculated with the organisms of his surroundings.

22. CVL Maintenance Bundle Component: Assess dressing/site with routine assessment

23. Keep dressing clean dry and intact
Loose and wet dressings are sites of potential infection.
CHANGE THEM!
Cover the site dressing and the connectors during showers.
Aquaguard is available:
7”x7” Lawson number

24. Potential ways of contamination
The top of the medication vial is not sterile.
The top is a “dust cover.”
Clean vigorously with alcohol before accessing the vial with the blunt fill needle.

25. Disconnecting tubing Sterile end cap in place
Not recommended by manufacturer. Off-label use.
How do you know if the tubing tip is still sterile?
Indicates tip sterility maintained

26. Some Prefilled Saline Syringes Are for Flushing ONLY
The saline flush syringes in the clear cellophane package is ONLY for flushing
According to the manufacturer, DO NOT use for medication dilution.
The inside of the barrel & the fluid pathway is all that is sterile on these syringes.
When you push out saline, the outer side of the plunger contaminates the inside of the barrel.
Then, when you draw back into the syringe, you are pulling the plunger over areas that were just contaminated.
If you do this, you could be pushing pathogens into the patients’ bloodstreams.
The saline flush syringes in the sterile peel pack may be used for medication dilution.

27. Your Role
Follow the bundle components specific to your role in the patient’s care
Provide appropriate/indicated patient teaching regarding these bundle component and other recommended practices
Document patient education related to the goal of CLABSI prevention
Patient education materials related to CLABSI prevention can be found on the Intranet:
Remind peers of the importance of following the bundle components and other recommended practices if they are observed to be non-compliant

28. Policies
Central line insertion and dressing policies:
Caring for Central Venous Catheters (CVC), (adult patients)
Caring for Central Venous Catheters (CVC), e.g. Broviac, Hickman, Groshong, Hohn, Peripherally Inserted Central Catheter (PICC) (pediatric patients)
Caring for Peripherally Inserted Central Catheter (PICC) in Neonatal Patients
Caring for Temporary and Permanent Hemodialysis Catheters, e.g. Quinton or Perm Cath
Declotting Central Venous Catheters with Alteplase, Partial or Total Occlusion

29. References http://www.cdc.gov/ncidod/dhqp/gl_intravascular.html
Pronovost, MD PhD, Peter, Needham, MD, PhD., Dale….An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU (Michigan Keystone Project), New England Journal of Medicine December 28, 2006; Vol. 355, #26.
Maki DG, Mermel L, Genthner D, Hua S, Chiacchierini RP. An evaluation of BIOPATCH Antimicrobial Dressing compared to routine standard of care in the prevention of catheter-related bloodstream infection. Johnson & Johnson Wound Management, a division of ETHICON, INC., Data on file.
Menyhay SZ, Maki DG. Disinfection of needleless catheter connectors and access ports with alcohol may not prevent microbial entry: the promise of a novel antiseptic-barrier cap. Infect Control Hosp Epidemiol. 2006;27:23-27.
Ngo A. A Theory-based Intervention to Improve Nurses’ Knowledge, Self-efficacy, and Skills to Reduce PICC Occlusion. Journal of Infusion Nursing; Vol. 28, No. 3: pp
Oncu S et al. Central Venous Catheter-Related Infections: An Overview with Special Emphasis on Diagnosis, Prevention, and Management: The Internet Journal of Anesthesiology ;Vol. 7, No. 1.
Pyrek K. Battling Biofilm: Surface Science, Antimicrobials Help Combat Medical Device-Related Infections. Infection Control Today; Sept
Ryder M. Catheter-Related Infections: It’s All About Biofilm. Topics in Advanced Practice Nursing eJournal. August 2005.
Ryder M. The Role of Biofilm in Vascular Catheter-Related Infections. New Developments in Vascular Diseases: pp15-25.
Timsit, J. Central vein catheter-related thrombosis in intensive care patients: incidence, risk factors, and relationships with catheter-related sepsis. Chest; July 1998.
“To Err is Human: Building a Safer Health System.” Institute of Medicine. Quality of Health Care in America Project