1. Implementing a Better Bundle in the Adult Population to Attain Zero Central Line Associated Blood Stream Infections: A Prospective Surveillance
There are three things I want you to get out of this presentation on reducing your CLABSI rates:
1. Infections are prevented Extraluminally.
2. Infections are prevented Intraluminally.
3. Staff and patient education plays a large part in prevention.
Timothy Royer, BSN, CRNI,
Nurse Manager / IV Team – Retired 2009
VA Puget Sound Health Care System, Seattle, Washington

2. Financial Disclosures
Nurse Consultant for:
Genentech – Cathflo Nurse Trainer
Medegen – Clinical Practice Consultant
Ethicon – Speaker’s Bureau
The studies presented herein were completed independently, without financial support, input, or influence from any manufacturer or commercial entity.
Timothy Royer, RN, BNS, CRNI

3. Objectives of this Presentation
1. Discuss 4 components of the central line bundle
2. Discuss strategies to implement the central line bundle
Timothy Royer, RN, BNS, CRNI

4. Timothy Royer, RN, BNS, CRNI
Topics Covered
1. National Patient Safety Goals (NPSG)s
2. IHI Guidelines/Recommendations
3. Components of the central line bundle
4. Additional components to add to the central line bundle
5. Implementing the central line bundle
6. Strategies for implementing the central line bundle
7. Measuring outcomes of the central line bundle
Timothy Royer, RN, BNS, CRNI

5. Timothy Royer, RN, BNS, CRNI
NPSG
VII. Goal 7 – Reduce the risk of health care –associated infections.
A. Meeting Hand Hygiene Guidelines (NPSG )
B. Not applicable to hospitals
C. Preventing Multidrug-Resistant Organism Infections (NPSG )
D. Preventing Central Line–Associated Blood Stream Infections (NPSG )
E. Preventing Surgical Site Infections (NPSG )
Timothy Royer, RN, BNS, CRNI

6. Timothy Royer, RN, BNS, CRNI
IHI
The central line bundle has five key components:
Hand hygiene
Maximal barrier precautions
Chlorhexidine skin antisepsis
Optimal catheter site selection, with avoidance of using the femoral vein for central venous access in adult patients
Daily review of line necessity, with prompt removal of unnecessary lines
Timothy Royer, RN, BNS, CRNI

7. Your Standards of Practice should look well used too.
Besides looking at the NPSG, IHI, CDC Guidelines, and the Draft of the new CDC “Guidelines for the Prevention of Intravascular Catheter-Related Infections” we need to be guided in our practice with the “Infusion Nursing Standards of Practice”.
Your Standards of Practice should look well used too.
Infusion Nurses Society. Infusion Nursing Standards of Practice. J Infus Nurs. 2006;29(1S)
Timothy Royer, RN, BNS, CRNI

8. Finding evidence and using critical thinking to make the right choices
What Do We Do??
Protect the patient from the central venous catheter.
Extraluminal causes for infection
Intraluminal causes for infection
How do we get there?
Device selection
Care and Maintenance
Staff and patient education
Specialized Teams (IV Teams, Vascular Access Teams)
What does it really boil down to?
Finding evidence and using critical thinking to make the right choices
Timothy Royer, RN, BNS, CRNI

9. Do we ever say, “That’s the way we have always done it”?
Just Asking
Timothy Royer, RN, BNS, CRNI

10. Where Evidence Points Additions with Overwhelming Evidence
Logical Additions with Evidence Still Being Gathered
Maximum sterile precautions
Swabable connector surfaces
CHG Prep
CHG bath in the ICUs
Special trained teams – IV Teams
Sutureless manufactured securement devices
Hand Hygiene
Standardized Catheter insertion cart with checklist
Scrubbing hub of catheter or connector
Clear housing on needleless connectors
Education of nurses and physicians
More PICCs in ICU
Prompt removal of unnecessary lines
CHG eluting disk – near overwhelming evidence for routine use
Impregnated gel dressing – little evidence thus far
Saline flushing and locking; elimination of heparin
Decloting catheters
Timothy Royer, RN, BNS, CRNI

11. Maximum Barrier Precautions
For the operator placing the central line and for those assisting in the procedure, maximal barrier precautions means strict compliance with hand hygiene and wearing a cap, mask, sterile gown, and sterile gloves.
Include maximal barrier precautions as part of your checklist for central line placement.
Means covering the patient from head to toe with a sterile drape, with a small opening for the site of insertion.
Using a checklist and empowering nurses to stop the procedure if sterile technique is broken.
Timothy Royer, RN, BNS, CRNI

12. Removal of Unnecessary Lines
Include daily review of line necessity as part of your multidisciplinary rounds.
State the line day during rounds to remind all as to how long the line has been in, e.g., “Today is line day 6.”
Include assessment for removal of central lines as part of your daily goal sheets.
Record time and date of line placement for record-keeping purposes and evaluation by staff to aid in decision making.
Define an appropriate timeframe for regular review of necessity, such as weekly, when central lines are placed for long-term use (e.g., chemotherapy, extended antibiotic administration, etc.).
Daily review was designed for the intensive care population and may not be appropriate when long-term use over weeks or months is planned.
No, it is not OK to say
“Just in Case…”
Timothy Royer, RN, BNS, CRNI

13. Evidence on Removal of Unnecessary Lines
Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:
Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med 2004;32:
Timothy Royer, RN, BNS, CRNI

14. Background for the Studies
It is the goal of every infusion nurse and facility to have a zero Central Line Associated Blood Stream Infection (CLA-BSI) rate to prevent:
Morbidity
Mortality
Excess cost of care
The central line bundle is a good start for insertion, we were looking for improvement and added additional items to come up with a Central Line Care and Maintenance Bundle (CLC&M Bundle)
Timothy Royer, RN, BNS, CRNI

15. Building a Better Care Bundle What We Did
June Change to swabable positive displacement valve
January 2005 – Maximal sterile barriers & CHG prep
July Chlorhexidine Gluconate (CHG) impregnated disk, increase use of PICCs in place of centrally inserted central catheters (CICVC), and a vigorous care and maintenance education program
January 2007 – Started clear version of the same valve, as a cue, coupled with continuous Medical Center ”Scrub the Hub and Flushing with 20mls. of normal saline” campaign.
Timothy Royer, RN, BNS, CRNI

16. Infection Rate Run Chart
Timothy Royer, RN, BNS, CRNI

17. Rationale Behind the Additions to the CLC&M Bundle
Timothy Royer, RN, BNS, CRNI

18. Evidence & Logic for Additions
Evidence and critical thinking that was used reduce Central line Associated Blood Stream Infections (CLABSI) (some newer references also cited):
Specialized trained staff for central venous catheters IV Teams
Swabable needleless connectors allow for a greater reduction of bacteria colony counts on devices
Clots form a tighter matrix when precipitates are present in the lumen in the catheter
Central venous catheters with clots are at higher risk for infection
Positive displacement valves prevent blood from backing up the catheter on syringe removal
Timothy Royer, RN, BNS, CRNI

19. Evidence & Logic for Additions continued
Prevention and/or early decloting of catheters reduces the risk of infection
Switching to saline locks from heparin
Using manufactured securement devices reduces infection risk
Education on CVC care improves patient outcomes including reducing CLA-BSI
Peripherally Inserted Central Catheters (PICC) have a lower infection risk
Chlorhexidine (CHG) eluting disk or dressings provide an environment to keep colony counts low around insertion site
Clear housing for needleless connectors
Timothy Royer, RN, BNS, CRNI

20. IV Teams / PICC Teams / Vascular Access Teams
Not PICC Stick and Run teams or teams that perform venipunture well.
Coordinate with Infectious Disease (Infection Preventionists) and Physician Directors of Departments.
Very active participants in the Care and Maintenance of CVCs
Educate nurses on best practices
Using vigilance to ensure best nursing care and practices are sustained
Provide additional training and education when new practices or products are implemented
They should be active within committees
Infectious Disease
Disposable Equipment Committee (DEC)
Nurse Practice Committee (NPC)
Facility Education Department
Equipment Committee
Pharmacy and Therapeutic Committee
Timothy Royer, RN, BNS, CRNI

21. IV Teams / PICC Teams / Vascular Access Teams
Bring in new vascular access products
The Steps
Review new product
Self testing the devices
Will it work?
Does it work like they say it does?
Where is the evidence?
Manufacturer generated?
What level of research?
Does it make sense?
Talk to your colleagues in different facilities
Talk with the manufacturers’ engineers
Talk with your own facility medical equipment engineers
Timothy Royer, RN, BNS, CRNI

22. IV Teams / PICC Teams / Vascular Access Teams
Clinical Evaluation
Involve all members of the Team
Specialized Teams
Unit Managers and staff
Disposable Equipment Committee
Make the right choice for the patient.
Present to the NPC and DEC
Now the real hard work begins
Timothy Royer, RN, BNS, CRNI

23. IV Teams / PICC Teams / Vascular Access Teams
Staff education
Pre-educate the whole hospital on the new product coming in.
Be part of the education on the product.
Competencies
Gathering Data with the CICs
Initiating practice change
Research – whether actual or reading and implementing change.
Timothy Royer, RN, BNS, CRNI

24. Draft of CDC Guidelines References for having “IV Teams”
Nehme AE. Nutritional support of the hospitalized patient. The team concept. JAMA 1980;243:1906-8
Soifer NE, Borzak S, Edlin BR and Weinstein RA. Prevention of peripheral venous catheter complications with an intravenous therapy team: a randomized controlled trial. Arch Intern Med 1998;158:473-7
Tomford JW, Hershey CO, McLaren CE, Porter DK and Cohen DI. Intravenous therapy team and peripheral venous catheter-associated complications. A prospective controlled study. Arch Intern Med 1984;144:1191-4
Scalley RD, Van CS and Cochran RS. The impact of an i.v. team on the occurrence of intravenous-related phlebitis. A 30-month study. J Intraven Nurs 1992;15:100-9
Palefski SS, Stoddard GJ. The infusion nurse and patient complication rates of peripheral-short catheters. A prospective evaluation. J Intraven Nurs 2001;24:113-23
Miller JM, Goetz AM, Squier C and Muder RR. Reduction in nosocomial intravenous device-related bacteremias after institution of an intravenous therapy team. J Intraven Nurs 1996;19:103-6
Hunter MR. Development of a Vascular Access Team in an acute care setting. J Infus Nurs 2003;26:86-91
Hawes ML. A proactive approach to combating venous depletion in the hospital setting. J Infus Nurs 2007;30:33-44
Brunelle D. Impact of a dedicated infusion therapy team on the reduction of catheter-related nosocomial infections. J Infus Nurs 2003;26:362-6
Bosma TL, Jewesson PJ. An infusion program resource nurse consult service: our experience in a major Canadian teaching hospital. J Infus Nurs 2002;25:310-5
Pierce CA, Baker JJ. A nursing process model: quantifying infusion therapy resource consumption. J Infus Nurs 2004;27:232-44
Timothy Royer, RN, BNS, CRNI

25. Swabable Needleless Connectors
Hadaway L, Richardson D. Needleless connectors: A primer on terminology. Journal of Infusion Nursing , Vol. 33:1.
Hadaway L, Richardson D. Needleless connectors? A primer on terminology. Journal of Infusion Nursing , Vol. 33:1
The configuration of the external connection surface can have a direct impact on the outcome with the device.
The surface design is thought to be one factor in the controversy over the infection risk associated with each device.
Needleless connectors with smooth contours, no valleys, no crevices, and no hidden pockets have the easiest surfaces to disinfect.
When we made the switch in June 2003, little evidence was out there but it made good sense.
This applies to all vascular access device not just central
Timothy Royer, RN, BNS, CRNI

26. Precipitates and Clots
Hardy
Suggests that a significant portion of clot occlusions seen in practice may be caused by many factors, including drug precipitates.
States a more tense fibrin matrix forms around the drug precipitates which leads to the formation of occlusions.
A clear needleless connector allows nurses to see if appropriate flushing was performed and if not, to continue flushing or change valve for improved outcomes
The photo illustrates an improperly flushed valve removed from a patient
Investigation on clear valves removed from patients
Hardy G, Ball P. Clogbusting: time for a concerted approach to catheter occlusions? Current Opinion in Clinical Nutrition and Metabolic Care. 2005, 8:277–283
Timothy Royer, RN, BNS, CRNI

27. Timothy Royer, RN, BNS, CRNI
Clots and Infection
We have known about the association of clots and infection for a long time:
Timsit J, Farkas J, et al. Central vein catheter-related thrombosis in intensive care patients: incidence, risks factors, and relationship with catheter-related sepsis. Chest 1998; 114;
Raad et al. The relationship between the thrombotic and infectious complications of CVC. JAMA 1994.
Stillman et al. Etiology of Catheter-associated sepsis: correlation with thrombogenicity. Arch Surg 1977
Timothy Royer, RN, BNS, CRNI

28. Saline Instead of Heparin
Evidence shows that heparin stimulates biofilm formation.
Shanks, Robert M. Q. et al Heparin Stimulates Staphylococcus aureus Biofilm Formation. Infection and Immunity. August 2005 p doe: /1AL
Costello JM, et. al. Systematic Intervention to Reduce Central Line–Associated Bloodstream Infection Rates in a Pediatric Cardiac Intensive Care Unit. Pediatrics. Vol. 121 No. 5 May 2008, pp
Timothy Royer, RN, BNS, CRNI

29. Saline Instead of Heparin
Research has demonstrated a correlation between catheter intraluminal biofilm formation and catheter-related bloodstream infection.
Andes D, et al. Development and Characterization of an In Vivo Central Venous Catheter Candida albicans Biofilm Model. Infection and Immunity, October 2004, p , Vol. 72, No. 10.
“Recent estimates suggest that the majority of hospital-acquired infections are biofilm associated.”
Donlan, R. M Biofilm formation: a clinically relevant microbiological process. Clin. Infect. Dis. 33:
Licking, E Getting a grip on bacterial slime. Business Week, 13 September 1999, p
Potera, C Forging a link between biofilms and disease. Science 283:
So, why are we using Heparin that stimulates Biofilm formation that is associated with Blood stream infections?
Just Asking
Studies before this were done when there was preservatives in the heparin. Was the heparin reducing infections?
For Heparin:
Randolf AG, Cook DJ, Gonzales CA, Andrew M. Benefit of heparin
in central venous and pulmonary artery catheters: a metaanalysis
of randomized controlled trials. Chest. 1998;113:165–
171.
This study is a very careful meta-analysis of 12 clinical trials of
prophylactic heparin. There was a trend for heparin to be beneficial
in preventing catheter thrombi or fibrin sleeves; however,
this finding did not reach statistical significance. In contrast,
heparin effectively reduced catheter-related venous thrombosis by
57%. Heparin also significantly decreased the bacterial colonization
of the catheter, and there was a strong reduction in catheterrelated
bacteremia. Cochrane Library Level: 1
Timothy Royer, RN, BNS, CRNI

30. Timothy Royer, RN, BNS, CRNI
Prevention of clots
Positive displacement valves decrease the risk of occlusion:
Jacobs BR, et al. Central venous catheter occlusions: A prospective, controlled trial examining the impact of a positive-pressure valve device. J. of Parenteral and Enteral Nutrition. 2004; 28:
Rummel M, Donnelly P, Fortenbaugh C. Clinical evaluation of a positive pressure device to prevent central venous catheter occlusion: Results of a pilot study. Clinical Journal of Oncology Nursing. 2001, 5, (6),
Feehery, Patricia A. RN, BS, CRNI, et al. Flushing 101, Journal of Vascular Devices, Summer 2003.
Timothy Royer, RN, BNS, CRNI

31. Proactive Approach to Occlusion
Because Evidence shows that clots are associated with infection:
Prevent clotting of catheters
Proper flushing
Draft of the Guidelines for the Prevention of Intravascular Catheter-Related Infections: Exterior Housing of needleless connectors “inadequate flushing of the device due to poor visualization of the fluid flow pathway in opaque devices”.
INS Standard 35: INS Standard 35: Injection and Access Caps: “If the integrity of the injection or access cap is compromised or if residual blood remains within the cap, it should be replaced immediately and consideration should be given to changing the catheter and administration set.”
Care and maintenance and proper tip placement
CVC with tips in a proximal position were 16 times more likely to have thrombosis than those in a distal position.
Cadman et al. To clot or not to clot? That is the question in central venous catheters. Clinical Radiology, 59;4: April 2004
Timothy Royer, RN, BNS, CRNI

32. Proactive Approach to Occlusion
Quick resolution of occluded catheter
*Declot early with any signs of sluggish or non-aspirating CVCs
No tying or taping off of occluded lines
We are not taping off lumens with occlusions, are we?
Just Asking
*Deitcher SR, Fesen MR, Kiproff PM, et al, for the Cardiovascular Thrombolytic to Open Occluded Lines-2 Investigators. Safety and efficacy of alteplase for restoring function in occluded central venous catheters: results of the Cardiovascular Thrombolytic to Open Occluded Lines trial. J Clin Oncol. 2002;20:
Blaney M, Shen V, Kerner JA, for the CAPS Investigators. Alteplase for the treatment of central venous catheter occlusion in children: results of a prospective, open-label, single-arm study (the Cathflo Activase Pediatric Study). J Vasc Interv Radiol. 2006;17:
Timothy Royer, RN, BNS, CRNI

33. Non-suture CVC Securement
Citation used in the draft of the new CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections - Catheter securement devices.
Lines
“Sutureless securement devices avoid disruption around the catheter entry site and may decrease the degree of bacterial colonization.”
Yamamoto AJ, Solomon JA, Soulen MC, et al. Sutureless securement device reduces complications of peripherally inserted central venous catheters. J Vasc Interv Radiol 2002;13:77-81
INS Standards of Practice: Standard 43. Catheter Stabilization.
“Whenever feasible using a manufactured catheter stabilization device is preferred.”
Infusion Nurses Society. Infusion Nursing Standards of Practice. J Infus Nurs. 2006;29(1S): S44.
Timothy Royer, RN, BNS, CRNI

34. Staff Education on CVC Care
Reducing CLA-BSIs with staff education
Costello study (2008)
Interventions involving staff education, increased awareness, and practice changes led to decreased rates
Garcia study (2007)
An extensive education program led to better adherence to proper infection control practices
Safdar study (2008)
“The implementation of educational interventions may reduce HCAI considerably”
Costello JM, et. al. Systematic Intervention to Reduce Central Line–Associated Bloodstream Infection Rates in a Pediatric Cardiac Intensive Care Unit. Pediatrics, Vol. 121 No. 5 May 2008, pp
Garcia R, Jendresky L. A study of the effects on bacteremia and sharps injury rates after introduction of an advanced luer activated device (LAD) for intravascular access in a large hospital setting. American Journal of Infection Control, June 2007, Vol 35, Issue 5 E75.
Safdar N, Abad C. Educational interventions for prevention of healthcare-associated infection: a systematic review. Crit Care Med (3):
Timothy Royer, RN, BNS, CRNI

35. PICCs in ICUs have a Lower Infection Rate
As noted in this facility’s Run Chart.
Timothy Royer, RN, BNS, CRNI

36. Other Hospital (Med/Surg ICU) Data
*Poster Presentation “Early Use of PICCs is Associated with Decreased Catheter-Related Blood Stream Infections”
*Study from the Mayo Clinic Poster Presented at the 32nd Critical Care Congress of the Society of Critical Care Medicine as a Poster Abstract. Patel, B: 2003
Timothy Royer, RN, BNS, CRNI

37. Chlorhexidine (CHG eluting disk)
Why are we worried about extraluminally?
Most noncuffed CVCs BSIs were extraluminally acquired and derived from cutaneous microflora.
Safdar N, Maki DG. The pathogenesis of catheter-related bloodstream infection with noncuffed short-term central venous catheters. Intensive Care Med Jan;30(1):62-72.
More evidence that supports:
Levy I, et al. Chlorhexidine-impregnated dressing for prevention of colonization of central venous catheters in infants and children: a randomized controlled study. Pediatr Infect Dis J Aug:24(8);676-9.
Timothy Royer, RN, BNS, CRNI

38. More Evidence on CHG disk
Chambers ST, et al. Reduction of exit-site infections of tunneled intravascular catheters among neutropenic patients by sustained-release chlorhexidine dressings: results from a prospective randomized controlled rial. Hosp. Infect :53-61.
Garland JS, e al. Local reactions to a chlorhexidine gluconate-impregnated antimicrobial dressing in very low birth weight infants. Pediarics. Jun;107(6):
Roberts B, Cheung D. Biopatch-a new concept in antimicrobial dressings for invasive device. Aust Crit Care Mar;11(1):16-19.
Fauerbach LL, et al. Continuing evolution of multidisciplinary approach to prevention of central line-associated bacteremias. AJIC. May 2004;(32)3.
Maki DG, et al. Prospective, randomized, investigator-masked trial of a novel chlorhexidine-impregnated disk on central venous and arterial catheters. Infect Cont Hosp Epidemiol Feb;21(2):96.
Timothy Royer, RN, BNS, CRNI

39. Recently Published CHG Impregnated Sponges Clinical Evidence
Timsit, J, Schwebel C, Bouadma L, et al. Chlorhexidine-Impregnated Sponges and Less Frequent Dressing Changes for Prevention of Catheter-Related Infections in Critically Ill Adults: A Randomized Controlled Trial. JAMA. 2009; 301(12): (doi: /jama
Conclusions:
In this study use of Chlorhexidine-Impregnated Sponges decreased the rates of catheter-related blood stream infection by 76 %.
Timothy Royer, RN, BNS, CRNI

40. Dressings with CHG Gel Pads
Evidence is very limited right now.
Below are Posters presented at the Association for Vascular Access Conference 2009 in Las Vegas, NV.
Effect of Tegaderm Chlorhexidine Gluconate (CHG) Gel Dressing on Adult Central Venous Line Related Primary Bloodstream infections. Mary E. Reilly, RN, BSN. Decreased CLABSI from 2.1 to 0.7.
Chlorhexidine Gluconate (CHG) at Central Line Insertion Sites: Disc vs. Gel Pad Tegaderm. Pat Catudal, RN and Susanne Meninger, RN. Rates stayed the same, but “ease of use” was factor in selecting this product.
USE OF AN ANTIMICROBIAL IV DRESSING WITH A MAINTENANCE BUNDLE. Sally Valdez, RN, BSN and Barbara Calabrese, RN. Rates reduced from 1.4 to zero with switching to the gel pad dressing and more diligent adherence to their maintenance bundle.
Timothy Royer, RN, BNS, CRNI

41. Needleless Connectors with Clear Housings
Timothy Royer, RN, BNS, CRNI

42. Connectors with Clear Housing
*INS Standard 35: INS Standard 35: Injection and Access Caps: “If the integrity of the injection or access cap is compromised or if residual blood remains within the cap, it should be replaced immediately and consideration should be given to changing the catheter and administration set.”
**Using this Standard; a needleless connector with opaque housing does not allow the nurse to see if appropriate flushing was performed and if not to continue flushing or change the valve.
Why are we using opague housings?
Just Asking
*Infusion Nurses Society. Infusion Nursing Standards of Practice.
J Infus Nurs. 2006;29(1S): S35.
** Hadaway L, Richardson D. Needleless connectors? A primer on terminology. Journal of Infusion Nursing , Vol. 33:1.
Timothy Royer, RN, BNS, CRNI

43. Draft CDC Guidelines Exterior Housing
Potential explanations for outbreaks associated with these devices include difficulty encountered in adequate disinfection of the surface of the connector due to physical characteristics of the plastic housing diaphragm interface, fluid flow properties (laminar vs. turbulent), internal surface area, potential fluid dead space, inadequate flushing of the device due to poor visualization of the fluid flow pathway in opaque devices, and the presence of internal corrugations that could harbor organisms, particularly if the catheters are used to access blood
Timothy Royer, RN, BNS, CRNI

44. Clearly Beyond the Central Line Bundle
A Five-Fold Decrease of Intravascular Central Line Associated Bloodstream Infections (CLABSI) in the six months.
Reduction to zero CLABSI and sustained since. (July 2009)

45. Research presented at the 2007 VHA MRSA Prevention Forum
Showing the impact of clear needleless connectors in the first six months. One CLABSI in January 2007 in MICU
Timothy Royer, RN, BNS, CRNI

46. Timothy Royer, RN, BNS, CRNI
Objective
Intravascular needleless connectors can be a potential source of bloodstream contamination and infection
To reduce contamination and bloodstream infections in the MICU and CCU:
Conduct staff education regarding potential sources of bloodstream infection
Implement clear valves which can be visually inspected to ensure proper flushing was performed and if residual remains, replace.
Timothy Royer, RN, BNS, CRNI

47. Timothy Royer, RN, BNS, CRNI
Significant Results
Central Line Associated Bloodstream Infections decreased five-fold from 7.4/1000 line days to 1.5/1000 line days (p<0.05)
Blood Culture Contamination decreased 60% from 4.39/1000 line days to 1.77/1000 line days
Cost savings avoidance of over $241,000
Savings of $116,000 attributed to decrease in CLABSI
Savings of $125,000 attributed to decrease in contaminated blood cultures
Timothy Royer, RN, BNS, CRNI

48. Timothy Royer, RN, BNS, CRNI
Summary
After blood draws, blood residue not flushed from the valve may serve as a growth media for microbes
Most valves are opaque and blood residue cannot be visualized
Changing to a clear valve shows residue
Efficacious flushing techniques and replacing valves if visible residue remains resulted in a five-fold decrease in Intravascular Catheter Associated Bloodstream Infections
Timothy Royer, RN, BNS, CRNI

49. Changes Implemented to Reach Goal of Zero
Replace standard opaque valves with clear valves that can be flushed clear
Educate staff on the importance of disinfecting valves before every access, otherwise contamination on the access port may be infused into the patient
Educate staff on the reason for practicing proper flushing techniques and for changing valves if visible residue remains, to remove growth media for microbes
Timothy Royer, RN, BNS, CRNI

50. CLEAR VALVES provide macroscopic inspection of residue.
Valves may become contaminated with infusion residue or transient blood.
CLEAR VALVES provide macroscopic inspection of residue.
At our facility we reduced residue with
20-ml of flush solution.
Timothy Royer, RN, BNS, CRNI

51. Risky residue should be revealed,
Clear valves can be visually inspected to ensure proper flushing techniques are practiced
Risky residue should be revealed,
not hidden!
Timothy Royer, RN, BNS, CRNI

52. Goals for the 6 year Prospective Study
Decrease Contaminated Blood Cultures
Decrease CLABSI Rates
Decrease Patient Care Costs
Measures
Defined Blood Culture Contamination rates per 1000 line days
Defined CLABSI rates per 1000 line days using standard surveillance
Calculated cost savings/avoidance
Timothy Royer, RN, BNS, CRNI

53. Timothy Royer, RN, BNS, CRNI
Method
Prospective surveillance and enhanced central line care in the whole medical center through a dedicated IV/PICC Team for the past 6 years.
Prospective BSI surveillance and case finding were the responsibility of the IV Team and the infection control team.
Infection rates tracked every 6 months using the NNIS and now the NHSN definitions.
Data were tracked from January 2003 through July 2009
Timothy Royer, RN, BNS, CRNI

54. Part of the Care and Maintenance Education Program
Timothy Royer, RN, BNS, CRNI

55. Clear Valve Enhancement January 2007
With the switch to clear version of the same valve.
Realized a thorough flush involved 20mls. of Normal Saline (NS)
To clear precipitates
To clear blood
Better yet if valve has visible signs – Change the valve
Clear valve serves as a visual cue reminding nurses to complete best practices – priming, swabbing, and flushing
Timothy Royer, RN, BNS, CRNI

56. Clear Valve Education Enhancement
Timothy Royer, RN, BNS, CRNI

57. Timothy Royer, RN, BNS, CRNI
Results
Over 13,000 of in-patient central line days per year
Includes CICVCs and PICCs
Rates were calculated for the whole Medical Center including
Intensive Care Units (ICUs)
Medical Surgical Units
Spinal Cord Injury Unit
Transitional Care Unit
Using CHG disk along with a continuous vigorous education on the care of central lines produced a CLA-BSI rate from 1.92 to 0.63
Increasing the use of PICCs in place of CICVCs, especially in the ICUs, decreased infection rates.
Impressive continued drop to zero CLA-BSI rate was noted with the implementation of the use of clear positive displacement valves as a cue to clean, flush, or change the valve. P value <0.05
As of July, 2009 – 536 days with zero CLA-BSIs
Cost savings of over $241,000 in the first six months for a five-fold decrease in CLA-BSI in the ICUs alone and 60% reduction in contaminated blood cultures (savings of $125,000 in contaminated cultures and $116,000 in bloodstream infections) as calculated, July 2007, VA Puget Sound Health Care System
Timothy Royer, RN, BNS, CRNI

58. Infection Rate Run Chart
Timothy Royer, RN, BNS, CRNI

59. Timothy Royer, RN, BNS, CRNI
Conclusions
Decreases in CLA-BSI occurred with the use of:
Maximal Sterile Barriers & CHG prep
Increased use of PICCs in the ICU
CHG impregnated disk
Education program on catheter and hub/valve care
Dedicated IV/PICC Team
Swabable, positive displacement valve
Timothy Royer, RN, BNS, CRNI

60. Timothy Royer, RN, BNS, CRNI
Conclusions
All the reductions in CLA-BSIs are significant clinically
However
A clinically and statistically significant drop in CLA-BSIs occurred and were sustained P>0.05 with:
With clear positive displacement valves and a campaign reinforced with the clear valve visual cue to scrub the hub and flush the catheter or change the valve.
CHG eluting disk.
Timothy Royer, RN, BNS, CRNI

61. Implications for Practice in the Adult Population
Protecting extraluminally with long acting CHG
Blood and debris are growth media for bacteria
Care of catheters that include:
Flush with 20mls of NS to clear the catheter
Flush or change the valve if blood, precipitate or debris is visible, a clear valve makes this practice possible
Coupled with a vigorous cued staff education program
Are associated with
reduced infections rates
Timothy Royer, RN, BNS, CRNI

62. Are you Using Evidence and Critical Thinking?
Just Asking
Timothy Royer, RN, BNS, CRNI

63. Timothy Royer, RN, BNS, CRNI
Thank you.
Questions?
Timothy Royer, RN, BNS, CRNI

64. Remember not to lose Focus on the Whole Patient.
Timothy Royer, RN, BNS, CRNI