Presentation on theme: "Michigan Society of Infection Prevention & Control"— Presentation transcript:
1 Prevention of Infections Associated with Vascular Access Devices (VADs) Michigan Society of Infection Prevention & ControlFundamentals of Infection Prevention & ControlKaren Hoover, RN
2 AGENDA Epidemiology - Definitions Microbiology Costs; Risks/BenefitsDefinitionsMicrobiologyRates, Risk Factors and PathogenesisPrevention and Patient Care PracticesRecommendations CDC guidelineReferences2011 Guidelines for the Prevention of Intravascular Catheter-Related Infections
3 Hand Hygiene and Aseptic Technique Perform hand hygiene procedures, either by washing hands with conventional soap and water or with alcohol-based hand rubs (ABHR).Wear clean gloves, rather than sterile gloves, for the insertion of peripheral intravascular catheters, if the access site is not touched after the application of skin antiseptics.Maintain aseptic technique for the insertion and care of intravascular cathetersSterile gloves should be worn for the insertion of arterial, central, and midline catheters .Use new sterile gloves before handling the new catheter when guidewire exchanges are performed.Wear either clean or sterile gloves when changing the dressing on intravascular catheters.
4 Guidelines for the Prevention of Intravascular Catheter-Related Infections Prepare to clean skin with a greater than 0.5% chlorhexidine- based preparation before central venous catheter insertion and during dressing changes.Avoid using the femoral vein for central venous access in adult patients, Category 1A.And the second use a subclavian site rather than the jugular in adult patients to minimize infection risk for non-tunneled CVC placement, Category 1B.Minimize contamination risk by scrubbing the access port with an appropriate antiseptic chlorhexidine povidone-iodine IOTA 4 or 70% alcohol
5 Catheter Site Dressing Regimens Use either sterile gauze or sterile, transparent, sem-ipermeable dressing to cover the catheter site.If the patient is diaphoretic or if the site is bleeding or oozing, use a gauze dressing until this is resolved .Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled.Do not use topical antibiotic ointment or creams on insertion sites, except for dialysis catheters, because of their potential to promote fungal infections and antimicrobial resistance.Do not submerge the catheter or catheter site in water.
6 Classification of Healthcare Associated Bloodstream Infection Primary BSI: no apparent local site as cause of infection40% associated with central lineSecondary BSI: Another site of infection is source of BSI, e.g. UTI, SSI, Pneumonia
7 Comparison of Central Line Associated or Related BSI Definitions Central Line Associated BSI* [CLA-BSI; surveillance]LCBI-Laboratory- confirmed BSICentral line meeting NHSN definition was present prior to onset of BSICentral Line-Related #[CR- BSI; clinical/research]Positive semiquantitative (>15 CFU/catheter segment) or quantitative (>103 CFU/catheter segment catheter) cultureSame microorganism (species + antibiotic susceptibility profile) is isolated from the catheter segment AND peripheral blood; or simultaneous quantitative blood cultures with a >5:1 ratio CVC versus peripheral; or differential period of CVC culture versus peripheral blood culture positivity of >2 hours aka time to positivity
8 Pathogenesis of infection for percutaneous intravascular device; Clin Infect Dis 2002;34:1232-42
9 Central Line Definition A vascular infusion device that terminates at or close to the heart or in one of the great vesselsThe following are considered great vessels for the purpose of reporting central-line BSI and counting central-line days in the NHSN system:July 2013 CDC/NHSN Protocol Clarificationsanual/4psc_clabscurrent.pdfGreat Vessels:• Aorta• Pulmonary artery• Superior vena cava• Inferior vena cava• Brachiocephalic veins• Internal jugular veins• Subclavian veins• External iliac veins• Common iliac veins• Femoral veins• In neonates, theumbilical artery/vein.
10 Other types of central catheters A tunneled catheter is surgically placed into a vein in the chest or neck and then passed under the skin. One end of the catheter comes out through the skin so medicines can be given right into the catheterAn implanted port is similar to a tunneled catheter, but an implanted port is placed entirely under the skin. Medicines are given by a needle placed through the skin into the catheterOther types of central catheters
11 Not considered central lines: Extracorporeal membrane oxygenation (ECMO)• Femoral arterial catheters• Intraaortic balloon pump (IABP) devices.• Hemodialysis reliable outflow (HeRO) dialysis cathetersNot considered central lines:
12 Clinical Sepsis (CSEP) Neonate/Infants - ONLY CSEP may be used only to report primary BSI in neonates and infants. It is not used to report BSI in adults and children.Clinical sepsis must meet the following criterion:Patient < 1 year of age has at least 1 of the following clinical signs or symptoms with no other recognized cause:fever (>38 C rectal),hypothermia (< 37 C rectal),apnea, or bradycardiaAnd:blood culture not done or no organisms detected in blood +no apparent infection at another site +physician institutes treatment for sepsis.
13 CVS-CARDIOVASCULAR SYSTEM INFECTION VASC-Arterial or venous infection 1. Organisms cultured from arteries or veins removed during a surgical operation and blood culture not done or no organisms.2. Evidence of arterial or venous infection seen during a surgical operation or histopathologic examination.3. At least 1 of the following signs or symptoms with no other recognized cause: fever; (>38 C), pain, erythema, or heat at involved vascular site and > than 15 colonies cultured from intravascular cannula tip using semiquant. method and blood culture not done or no organisms cultured from blood4. Patient has purulent drainage at involved vascular site and blood culture not done or no organisms cultured from blood
14 V. Risk Factors prolonged hospitalization prior to catheter Risk depends on catheter type & use; 2 or more controlled studies identified following:prolonged hospitalization prior to catheterprolonged duration of catheterizationheavy colonization of hub siteheavy colonization at insertion sitecatheter insertion in internal jugular (IJ) veinantibiotic usage during catheterization
15 A closer look at CLABSI: Home sweet BiofilmDonlon RM,Carr J. CDCPHIL #7488
16 Rates of BSI For Various Intravascular Devices (IVDs) [Maki DG, et al Rates of BSI For Various Intravascular Devices (IVDs) [Maki DG, et al. Mayo Clin Proc 2006; 81:Device No. of Studies Per 100 IVDs Per 1000 Device Days CommentPeripheral catheter:angiocatheter Plastic cath.arterial Hemodyn.midlineCentral catheter:Short term NontunneledShort term, antim Chlor-SilverPulm ArteryDialysis, long term cuff, tunnelPICC OutpatientPort
17 PICCs Are “Catching Up” [Safdar N. Chest 2005] Prospective Study of 251 PICCs in 151 hospitalized patients; 40% spent part of their stay in ICU6 CLABSIs from PICC = 2.4% or 2.1/1,000 central line daysPrior data from 13 studies: 0.2/100 PICCs; 0.4/1,000 central line daysIncreased frequency of use likely contributing to increased rate of BSI that is comparable to standard, central line in jugular or subclavian sitePICCs HAVE Caught UP!!! ….2011
18 . Having a catheter for a long time PICC is threaded through the arm vein until it reaches a larger vein close to the heart.It is used to deliver medicine, nutrition, IV fluids, and chemotherapyRisk factors for infectionHaving a catheter for a long timeHaving a catheter that is not coated witha substance that kills bacteriaHaving a catheter inserted into a vein inthe thighHaving a weakened immune systemBeing in the intensive care unitHaving an infection elsewhere in the bodyor skin.
19 . At Home Follow all instructions concerning your PICC line. Learn how to take care of your catheter. Followthese general guidelines:Follow specific instructions about showering and bathingBefore touching the catheter, wash your hands or use a hand sanitizer. Wear gloves when touching the area.Change bandages as directedWash the catheter caps with an antiseptic.Do not allow anyone to touch the catheter or the tube.Check the insertion site daily for signs of infection, such as redness or pain.Call your doctor if you think you have an infection..
20 National Healthcare Safety Network (NHSN) Data Report on CLABSI Edwards JR,et al. AJIC 2007;35:
21 Strategies for Prevention CLABSI QA and continuing educationSite of & technique of catheter insertionLimit traffic in room during insertionsType of catheter materialHand hygiene and aseptic techniqueSkin antisepsis …CHGCatheter site dressing regimens ..BiopatchCatheter securementAntimicrobial/antiseptic impregnated caths& cuffsChlorhexidine/Silver sulfadiazine; Minocycline/RifampinSystemic antibiotic prophylaxis; antibiotic antiseptic ointmentsScrub the hub
22 Ways patients can protect themselves from CLABSI: Research the hospital, if possible, to learn about its CLABSI rate.Speak up about any concerns so that healthcare personnel are reminded to follow the best infection prevention practices.Ask a healthcare provider if the central line is absolutely necessary. If so, ask them to help you understand the need for it and how long it will be in place.Pay attention to the bandage and the area around it. If the bandage comes off or if the bandage or area around it is wet or dirty, tell a healthcare worker right away.
23 Don’t get the central line or the central line insertion site wet. Tell a healthcare worker if the area around the catheter is sore or red or if the patient has a fever or chills.Do not let any visitors touch the catheter or tubing.The patient should avoid touching the tubing as much as possible.In addition, everyone visiting the patient must wash their hands—before and after they visit.
24 Efficacy of Maximal Sterile Barrier Precautions Minimal Maximum* Local inf. 7.2% 2.3% CLA-BSI 3.6% 0.6% *cap, mask, sterile gloves, sterile gown, head/body of patient covered with large sterile drape Vs. sterile gloves, small sterile drape
25 Other Aspects of BSI prevention IV access devices:Temporal association:newer needleless access devices & increased rate of CLABSI:Rupp ME, CID 2007Salgado CD, ICHE 2007Field K, ICHE 2007Maragakis LL, ICHE 2006Flushing techniqueCatheter dressing, IV system care & maintenance
26 Patient Safety Using Hygiene 1 yr. cross over study in two MICUs, Stroger hospital, Chicago ILIntervention: daily cleansing of patients with disposable cloth containing chlorhexidine gluconate (CHG)Control group: daily cleansing with soap and waterResults:Intervention group:4.1 primary BSIs / 1,000 pt. days6.4 / 1,000 central line daysControl group:10.4/ 1,000 pt. Days16.8 / 1,000 central line daysConclusion: Incidence of BSI in CHG-cloth group was 61% lower than control (soap and water) group. Reduction of concentration of bacteria on skin lessens risk of BSI.Bleasdale SC,et al. Arch Intern Med 2007;167:2073-9
27 Using Surveillance to Prevent CVC-BSI, PHRI, 2001-05 Pittsburgh. Reg. Hth. Initiative- CDC66 ICUs; 32 hospitalsEvidence-based care interventionsEducationEquipmentProcess/outcome68% drop in CVC- BSI [4.31 to 1.36/1000 CVC daysMMWR (Oct.14);54:
28 An estimated 41,000 central line-associated bloodstream infections (CLABSI) occur in U.S. hospitals each year.* ↑ LOS* ↑ hospital cost* ↑ risk for mortalityNHSN Requirements: Surveillance for HAI CLABSI:1/ Adult, Pediatric, and Neonatal ICUs10/2012 Adult & Pediatric LTAC ICUs & Wards1/2015 Adult & Pediatric Medical, Surgical, & Medical/Surgical Wards
29 Present on Admission (POA): Infections that are POA, as defined in Chapter 2, are not considered HAIs and therefore are never reported to NHSN.Healthcare-associated infections (HAI): All NHSN site specific infections must first meet the HAI definition as defined in Chapter 2 before a site specific infection (e.g., CLABSI) can be reported to NHSN..
30 CMS Reporting Requirements January 2011 – CLABSIs in adult, pediatric & neonatal ICUsOutpatient Dialysis Facilities:January 2012I.V. antimicrobial startsPositive blood culturesSigns of vascular access infectionLong Term Acute Care (LTAC)Facilities:October 2012CLABSIs in adult and pediatric ICUs and wards
31 II Surveillance for BSI Recommendations for Placement of Intravascular Catheters in Adults & ChildrenI Education HCWEducate on indications for use of IV catheters IAAssess competence for insertion and maintenance IAEnsure appropriate ICU nursing staff-to-patient ratiosII Surveillance for BSIMonitor sites visually and/or palpationsEncourage patients to report changesRecord operator, date and time of CR insertion in std mannerDo not routinely culture catheter tips IAIII Hand HygieneProper hand hygiene with soap/water; alcohol based gels IAUse of gloves still requires hand hygiene IAIV Aseptic technique during insertion and care IAWear clean or sterile gloves; clean for insertion of PIV; sterile for insertion of arterial lines or CVCsWear clean or sterile gloves when changing dressings
32 Recommendations for Placement of Intravascular Catheters in Adults & Children V Catheter InsertionCutdown procedures should not be considered routine IAVI Catheter Site careCutaneous antisepsis: Preferred antiseptic = 2% CHG; also tincture of iodine, iodophor or 70% alcohol IAAllow to dry (iodophor should dry 2 min)Do not apply organic solvent like acetone prior to insertion IAVII Catheter site dressing regimentsSterile gauze or transparent semi-permeable dressings IAWell healed tunneled CVC site may not need dressingReplace dressing if damp, loose or soiledChange dressings regularly, at least weeklyNo topical antibiotic ointment on insertion sites IA(exception dialysis)
33 Recommendations for Placement of Intravascular Catheters in Adults & Children VIII Selection and replacementSelect catheter with lowest risk of complication IARemove catheter when no longer essential IADo not remove/replace routinely just to reduce infection riskAdults -Replace PIV every72-96 hrs to prevent phlebitis;Peds-leave in place until therapy completed unless complicationReplace all catheter place under ER conditions within 48 hrsUse clinical judgment to determine when to replace a catheter that could be source of infectionReplace any short term CVC if purulence observed at siteReplace all CVCs is patient hemodynamically unstable and CR-BSI suspectedDo not use guide wire technique to replace catheters when CR-BSI suspected
34 IX Replacement of administration sets Recommendations for Placement of Intravascular Catheters in Adults & ChildrenIX Replacement of administration setsReplace sets no more frequently than 72 hours unless inf IAReplace tubing for blood, lipid emulsions within 24 hours.Replace tubing used for propofol every 6-12 hrs IANeedleless systems: change components as often as set; change caps no more frequently than 72 hrs;wipe access port with appropriate antiseptic and access only with sterile devicesParenteral fluids: Complete infusion of lipid-containing within 24 hrs of hanging; lipid emulsion: 12 hrs; blood within 4 hours; no recommendation for other parenteral fluidsX IV Injection portsClean ports with 70% alcohol or iodophor IACap stopcocks when not in use.
35 Recommendations for Placement of Intravascular Catheters in Adults & Children XI Prep and QC of IV admixturesAdmix in LAF hood using aseptic techniqueDo not use containers with cracks, leaks etcUse single dose vials whenever possible; do not combine left over content for later use IAIf multidose used, follow manufacturer recommendationsXII In line filtersDo not use routinely for IC purposes IAXIII IV therapy personnelDesignate trained personnel for insertion and maintenance of IV catheters IAXIV Prophylactic antibioticsDo not use prophylactic antibiotic routinely before insertion of IC catheters to prevent infection IA
36 PIV including Mid-line catheters: CVC: Selected recommendations Recommendations for Placement of Intravascular Catheters in Adults & ChildrenPIV including Mid-line catheters:Selection of catheter, site and catheter site careCVC: Selected recommendationsSurveillance: Determine CR-BSI rates & monitor; express as BSI/1000 catheter-days; investigate unexpected eventsUse CVC with minimum # ports/lumens neededUse antimicrobial/antiseptic-impregnated CVC in adult if expected in place for >5 days if after implementing strategy to reduce, rate remains.KEY STRATEGY: Education; use of maximal sterile barrier precautions and 2% CHG prep during CVC insertion.
37 Recommendations for Placement of Intravascular Catheters in Adults & Children CVC Selected issuesNo recommendation: impregnated cath in childrenDesignate competent personnel to supervise trainees for catheter insertion 1AMaximal barriers for insertion means: cap, mask, sterile gown, gloves, large sterile sheet for catheter, including PICCS and guidewire exchange 1AGuidewire: exchange only for malfunction (not infection); use new set sterile gloves for new cathCatheter care: Designate one port for hyperalAntibiotic locks: Do not use routinely to prevent CR-BSIDressings: Replace when loose, wet, soiled. Short term CVC every 2 days gauze; 7 days transparent (adults)Tunneled or implanted CVC: no more than 1/wk
38 Recommendations for Placement of Intravascular Catheters in Adults & Children Arterial and Pressure Monitoring Devices(Selected recommendations)Use disposable transducer assemblies if possible; sterilize transducer domes if reusable requiredReplace at 96 hr intervalsKeep all solutions sterileDo not administer dextrose-container/TPN through pressure monitoring circuitNew tubing/catheters planned to avoid attaching wrong solution.
39 Recommendations for Placement of Intravascular Catheters in Adults & Children Umbilical Catheters Selected recommendationsArterial or Venous: Remove and do not replace if any sign of CR-BSI, vascular insufficiency or thrombosisCleanse with antiseptic- avoid tincture of iodineDo not use topical antibiotic ointment/creamsRemove as soon as possible; venous catheters can be used up to 14 days if managed aseptically
42 Referencesabscurrent.pdf July 2013guidelines-2011.pdfInfusion Nurses Society. Infusion Nursing Standards of Practice. J Infus Nurs 2006; 29 (Jan./Feb): S1 – S92.
43 Definitions“one or more blood cultures” means that at least one bottle from a blood draw is reported by the laboratory as having grown at least one organismA few of the recognized pathogens are S. aureus, Enterococcus spp., E. coli, Pseudomonas spp., Klebsiella spp., Candida spp.“two or more blood cultures drawn on separate occasions” means 1) that blood from at least two blood draws were collected within two calendar days of each other“recognized pathogen”
44 Comments on blood cults Blood cultures drawn from different sites (e.g., different venipunctures or different lumens of the same central line) should undergo separate decontaminations and are therefore considered drawn on “separate occasions”.Blood cultures drawn through central lines can have a higher rate of contamination than blood cultures collected through peripheral venipunctureBlood culture may consist of a single bottle for a pediatric blood draw due to volume constraints. Each bottle from two or more draws would have to be culture-positive for the same commensal.
45 Primary Bloodstream Infection Primary bloodstream infections (BSI) are laboratory-confirmed bloodstream infections (LCBI)that are not secondary to a community- acquired infection or an HAI meeting CDC/NHSN criteria at another body site .Central line-associated BSI (CLABSI): A laboratory-confirmed bloodstream infection (LCBI) where central line (CL) or umbilical catheter (UC) was in place for >2 calendar days on the date of event, with day of device placement being Day 1, anda CL or UC was in place on the date of event or the day before. If a CL or UC was in place for >2 calendar days and then removed, the LCBI criteria must be fully met on the day of discontinuation or the next day. If the patient is admitted or transferred into a facility with a central line in place (e.g., tunneled or implanted central line), day of first access is considered Day1.
46 Laboratory-Confirmed Bloodstream Infection Criteria Patient has a recognized pathogen cultured from one or more blood cultures, andorganism cultured from blood is not related to an infection at another site.Patient has at least one of the following signs or symptoms: fever (>38 C), chills, or hypotension andSigns and symptoms and positive laboratory results are not related to an infection at another site, andCommon commensal is cultured from two or more blood cultures drawn on separate occasions.
47 Laboratory-Confirmed Bloodstream Infection Criteria Patient ≤ 1 year of age has at least one of the following signs or symptoms: fever (>38oC core), hypothermia (<36oC core), apnea, or bradycardiaandpositive laboratory results are not related to an infection at another siteAnd the same common commensal
48 Transfer RuleIf all elements of a CLABSI are present within 2 calendar days of transfer from one inpatient location to another in the same facility or a new facility (i.e., on the day of transfer or the next day), the infection is attributed to the transferring location or facility. Receiving facilities should share information about such HAIs with the transferring facility to enable reporting.
49 . *Catheter tip cultures are not used to determine whether a patient has a primary BSI.* When there is a positive blood culture and clinical signs orsymptoms of localized infection at a vascular access site, but noother infection can be found, the infection is considered aprimary BSI.Purulent phlebitis confirmed with a positive semiquantitativeculture of a catheter tip, but with either negative or no bloodculture is considered a CVS-VASC, not a BSI or a SST-SKIN ora ST infection.Occasionally a patient with both peripheral and central IV linesdevelops a primary bloodstream infection (LCBI) that can clearlybe attributed to the peripheral line (e.g., pus at the insertion siteand/or matching pathogen from pus and blood).
50 Patient has a central line inserted on June 1. On June 3, the central line is removed and on June 4 the patient has a positive blood culture with S. aureus.This is a CLABSI because the central line was in place for >2 calendar days (June 1, 2, and 3), and was in place the day before the date of event..