Presentation on theme: "Preventing Central Line Associated Bloodstream Infections (CLABSIs)"— Presentation transcript:
1Preventing Central Line Associated Bloodstream Infections (CLABSIs) What Clinical Staff Should KnowPrepared byAnn Bailey RNC-NIC, BSN, MBA, CICJoanne Dixon MN, RN, CICGwen Irwin, RN, CRNIJudy Smith, RN, BSN, CRNIDecember 18, 2009
2Name 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 01/01/10Includes using “Bundle” with respect to preventing CLABSIsDefine “Bundle”Name 2 ways patients get CLABSIsList 4 evidence-based practices that have been shown to help prevent CLABSIs
3The 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 providersPatients 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.
4Patient and Family Education Before Central Line Insertion FAQ Catheter Associated Bloodstream Infections from Joint Commission covers:Providers doing hand hygieneSteps for maximum barrier CVL insertionClean hands before using CVLClean connectors with antiseptic solution before using CVLDecide 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
5The 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.
6What 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.
7The CVL Insertion Bundle Hand hygiene immediately prior to insertion-wash hands or-use alcohol-based hand gel/foamMaximal barrier precautions-full body sterile drape-clinician and assistant wear cap, mask, sterile gown, gloves-persons within 6 feet wear hat and maskSkin 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
8The CVL Maintenance Bundle Perform good hand hygiene, prior to handling line-Hand washing or-Use alcohol-based hand gel/foamAssess dressing/site with routine assessmentScrub connector vigorously with alcohol x 15 seconds-Allow to dry before accessingAssess line patency for brisk return and easy flushingAssess to determine if patient meets criteria for line necessity
9Why Prevent CLABSIs? Nationally and annually: 80,000 central line associated bloodstream infections occur in ICUs250,000 hospital-wide, including ICUsSeton Family of HospitalsThe majority of CLABSIs occur outside of the critical care unitsCheck your unit’s CLABSIs with your infection preventionist, if you are interested in more informationIncreases the patient’s risk of death significantlyCLABSIs 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)
10How do CLABSIs happen?Introduction of pathogens into the bloodstream from the skin around insertion siteIntroduction of pathogens into the bloodstream from the hub or connector of the catheter.Most frequent cause nationallyAlso true at Seton
11Factors That Increase Risk of BSIs CVLs in areas that have increased colonization of organismssuch as the internal jugular or femoral sitesMultiple 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 CVCThe risk of infection depends on the site of placement, colonization of organisms at insertion site and prolonged use of the central catheter
12Factors That Lower Risk of BSIs Select subclavian site over internal jugular or femoral sites, if PICC not usedPerform hand hygieneUse maximum barrier precautionsSkin prep with chlorhexidine rather than povidone-iodineSkin prep on clean skinMaintain patency of all lumensFree of sluggishness or occlusion; brisk blood returnRemove line when no longer necessaryThe risk of infection is reduced by adhering to maximal barrier precautions when placing the central line and using chlorhexidine for disinfection prior to insertion.
13CVL Insertion Bundle Component: CVL Site Choices Femoral Vein Last choiceSubclavian Vein First ChoiceInternal Jugular Second choice
14Hand 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 dryHandwashing seconds of soap and friction, rinse, dry and turn off faucet with clean paper towel
16CVL Insertion Bundle Component: Maximum Sterile Barrier Precautions Sterile gownHat and maskSterile glovesPersons within 6 feet also wear hat and mask
17CVL Insertion Bundle Component: Chloraprep® Gross debris or dirt should be removedwith 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.
18CVL 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
19No blood return? Flushes easily? Probable fibrin sheath or fibrin tailTreat as soon as possibleTreat with Alteplase per declotting protocolInfusingaround sheathFibrinsheathAttempting towithdraw bloodCatheter
20CVL Maintenance Bundle Component: Daily Review for Line Necessity Remove when No Longer IndicatedIndications for a CVLHemodynamic monitoringAdministration of certain medications that require central administration, e.g. vasopressors, chemotherapy, TPNLong term IV therapy, e.g. antibiotics or inotropesPlasmapheresis, apheresis, hemodialysis, or continuous renal replacement therapyPoor peripheral venous access, when IV treatment is still needed
21CVL Maintenance Bundle Component: Scrub the Hub with Alcohol for 15 seconds, prior to accessing Vigorous scrubbing is necessary to remove pathogensResearch 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.
22CVL Maintenance Bundle Component: Assess dressing/site with routine assessment
23Keep 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
24Potential 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.
25Disconnecting 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
26Some Prefilled Saline Syringes Are for Flushing ONLY The saline flush syringes in the clear cellophane package is ONLY for flushingAccording 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.
27Your RoleFollow the bundle components specific to your role in the patient’s careProvide appropriate/indicated patient teaching regarding these bundle component and other recommended practicesDocument patient education related to the goal of CLABSI preventionPatient 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
28PoliciesCentral 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 PatientsCaring for Temporary and Permanent Hemodialysis Catheters, e.g. Quinton or Perm CathDeclotting Central Venous Catheters with Alteplase, Partial or Total Occlusion
29References 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: ppOncu 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; SeptRyder 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