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Prevention of Infections Associated with Vascular Access Devices (VADs) Michigan Society of Infection Prevention & Control Fundamentals of Infection Prevention.

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Presentation on theme: "Prevention of Infections Associated with Vascular Access Devices (VADs) Michigan Society of Infection Prevention & Control Fundamentals of Infection Prevention."— Presentation transcript:

1 Prevention of Infections Associated with Vascular Access Devices (VADs) Michigan Society of Infection Prevention & Control Fundamentals of Infection Prevention & Control 2014 Karen Hoover, RN

2 AGENDA Epidemiology - Costs; Risks/Benefits Definitions Microbiology Rates, Risk Factors and Pathogenesis Prevention and Patient Care Practices Recommendations CDC guideline References 2011 Guidelines for the Prevention of Intravascular Catheter- Related Infections

3 Hand Hygiene and Aseptic Technique 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 catheters Sterile 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. 3 Perform hand hygiene procedures, either by washing hands with conventional soap and water or with alcohol-based hand rubs (ABHR ).

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 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. 5 Catheter Site Dressing Regimens

6 Classification of Healthcare Associated Bloodstream Infection Primary BSI: no apparent local site as cause of infection ◦40% associated with central line Secondary 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 BSI ◦ Central line meeting NHSN definition was present prior to onset of BSI Central Line-Related # [CR- BSI; clinical/research] ◦Positive semiquantitative (>15 CFU/catheter segment) or quantitative (>10 3 CFU/catheter segment catheter) culture ◦Same 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:

9 Central Line Definition Definition A vascular infusion device that terminates at or close to the heart or in one of the great vessels The 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 Clarifications anual/4psc_clabscurrent.pdf ◦Great 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, the umbilical 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 catheter An 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 catheter 10

11 Not considered central lines: Extracorporeal membrane oxygenation (ECMO) Femoral arterial catheters Intraaortic balloon pump (IABP) devices. Hemodialysis reliable outflow (HeRO) dialysis catheters 11

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 bradycardia And: 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. O rganisms 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 blood 4. Patient has purulent drainage at involved vascular site and blood culture not done or no organisms cultured from blood

14 V. Risk Factors Risk depends on catheter type & use; 2 or more controlled studies identified following Risk depends on catheter type & use; 2 or more controlled studies identified following :  prolonged hospitalization prior to catheter  prolonged duration of catheterization  heavy colonization of hub site  heavy colonization at insertion site  catheter insertion in internal jugular (IJ) vein  antibiotic usage during catheterization

15 A closer look at CLABSI: Home sweet Biofilm Donlon RM,Carr J. CDC PHIL # 7488

16 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 Comment Peripheral catheter: angiocatheter Plastic cath. arterial Hemodyn. midline Central catheter: Short term N ontunneled Short term, antim Chlor-Silver Pulm Artery Dialysis, long term cuff, tunnel PICC Outpatient Port

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 ICU 6 CLABSIs from PICC = 2.4% or 2.1/1,000 central line days Prior data from 13 studies: 0.2/100 PICCs; 0.4/1,000 central line days Increased frequency of use likely contributing to increased rate of BSI that is comparable to standard, central line in jugular or subclavian site PICCs HAVE Caught UP!!! ….2011

18 . 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 chemotherapychemotherapy Risk factors for infection Having a catheter for a long time Having a catheter that is not coated with a substance that kills bacteria Having a catheter inserted into a vein in the thigh Having a weakened immune system Being in the intensive care unit Having an infection elsewhere in the body or skin 18

19 . At Home Follow all instructions concerning your PICC line. Learn how to take care of your catheter. Follow these general guidelines: Follow specific instructions about showering and bathing Before touching the catheter, wash your hands or use a hand sanitizer. Wear gloves when touching the area. Change bandages as directed Wash 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. 19

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 education  Site of & technique of catheter insertion  Limit traffic in room during insertions  Type of catheter material  Hand hygiene and aseptic technique  Skin antisepsis …CHG  Catheter site dressing regimens..Biopatch  Catheter securement  Antimicrobial/antiseptic impregnated caths& cuffs  Chlorhexidine/Silver sulfadiazine; Minocycline/Rifampin  Systemic antibiotic prophylaxis; antibiotic antiseptic ointments  Scrub 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. 22

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. 23

24 Efficacy of Maximal Sterile Barrier Precautions MinimalMaximum * Local inf.7.2%2.3% CLA-BSI3.6%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 2007 ◦ Salgado CD, ICHE 2007 ◦ Field K, ICHE 2007 ◦ Maragakis LL, ICHE 2006  Flushing technique Catheter dressing, IV system care & maintenance

26 Patient Safety Using Hygiene 1 yr. cross over study in two MICUs, Stroger hospital, Chicago IL ◦Intervention: daily cleansing of patients with disposable cloth containing chlorhexidine gluconate (CHG) ◦Control group: daily cleansing with soap and water Results: ◦Intervention group:  4.1 primary BSIs / 1,000 pt. days  6.4 / 1,000 central line days ◦Control group:  10.4/ 1,000 pt. Days  16.8 / 1,000 central line days Conclusion: 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, Pittsburgh. Reg. Hth. Initiative- CDC ◦66 ICUs; 32 hospitals  Evidence-based care interventions  Education  Equipment  Process/outcome ◦68% drop in CVC- BSI [4.31 to 1.36/1000 CVC days ◦MMWR 2005 (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 mortality NHSN Requirements: Surveillance for HAI CLABSI: 1/2011 Adult, Pediatric, and Neonatal ICUs 10/2012 Adult & Pediatric LTAC ICUs & Wards 1/2015 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. 29

30 CMS Reporting Requirements January 2011 – CLABSIs in adult, pediatric & neonatal ICUs Outpatient Dialysis Facilities: January 2012 I.V. antimicrobial starts Positive blood cultures Signs of vascular access infection Long Term Acute Care (LTAC)Facilities: October 2012 CLABSIs in adult and pediatric ICUs and wards 30

31 Recommendations for Placement of Intravascular Catheters in Adults & Children IEducation HCW ◦ Educate on indications for use of IV catheters IA ◦ Assess competence for insertion and maintenance IA ◦ Ensure appropriate ICU nursing staff-to-patient ratios II Surveillance for BSI ◦ Monitor sites visually and/or palpations ◦ Encourage patients to report changes ◦ Record operator, date and time of CR insertion in std manner ◦ Do not routinely culture catheter tips IA III Hand Hygiene ◦ Proper hand hygiene with soap/water; alcohol based gels IA ◦ Use of gloves still requires hand hygiene IA IV Aseptic technique during insertion and care IA ◦ Wear clean or sterile gloves; clean for insertion of PIV; sterile for insertion of arterial lines or CVCs ◦ Wear clean or sterile gloves when changing dressings

32 Recommendations for Placement of Intravascular Catheters in Adults & Children Recommendations for Placement of Intravascular Catheters in Adults & Children V Catheter Insertion ◦ Cutdown procedures should not be considered routine IA VI Catheter Site care ◦ Cutaneous antisepsis: Preferred antiseptic = 2% CHG; also tincture of iodine, iodophor or 70% alcohol IA ◦ Allow to dry (iodophor should dry 2 min) ◦ Do not apply organic solvent like acetone prior to insertion IA VII Catheter site dressing regiments ◦ Sterile gauze or transparent semi-permeable dressings IA ◦ Well healed tunneled CVC site may not need dressing ◦ Replace dressing if damp, loose or soiled ◦ Change dressings regularly, at least weekly ◦ No topical antibiotic ointment on insertion sites IA (exception dialysis)

33 Recommendations for Placement of Intravascular Catheters in Adults & Children VIII Selection and replacement ◦ Select catheter with lowest risk of complication IA ◦ Remove catheter when no longer essential IA ◦ Do not remove/replace routinely just to reduce infection risk ◦ Adults -Replace PIV every72-96 hrs to prevent phlebitis; ◦ Peds-leave in place until therapy completed unless complication ◦ Replace all catheter place under ER conditions within 48 hrs ◦ Use clinical judgment to determine when to replace a catheter that could be source of infection ◦ Replace any short term CVC if purulence observed at site ◦ Replace all CVCs is patient hemodynamically unstable and CR-BSI suspected ◦ Do not use guide wire technique to replace catheters when CR-BSI suspected

34 Recommendations for Placement of Intravascular Catheters in Adults & Children IX Replacement of administration sets ◦ Replace sets no more frequently than 72 hours unless inf IA ◦ Replace tubing for blood, lipid emulsions within 24 hours. ◦ Replace tubing used for propofol every 6-12 hrs IA ◦ Needleless 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 devices ◦ Parenteral fluids: Complete infusion of lipid-containing within 24 hrs of hanging; lipid emulsion: 12 hrs; blood within 4 hours; no recommendation for other parenteral fluids X IV Injection ports ◦ Clean ports with 70% alcohol or iodophor IA ◦ Cap stopcocks when not in use.

35 Recommendations for Placement of Intravascular Catheters in Adults & Children XI Prep and QC of IV admixtures ◦ Admix in LAF hood using aseptic technique ◦ Do not use containers with cracks, leaks etc ◦ Use single dose vials whenever possible; do not combine left over content for later use IA ◦ If multidose used, follow manufacturer recommendations XII In line filters ◦ Do not use routinely for IC purposes IA XIII IV therapy personnel ◦ Designate trained personnel for insertion and maintenance of IV catheters IA XIV Prophylactic antibiotics ◦ Do not use prophylactic antibiotic routinely before insertion of IC catheters to prevent infection IA

36 Recommendations for Placement of Intravascular Catheters in Adults & Children PIV including Mid-line catheters: ◦ Selection of catheter, site and catheter site care CVC: Selected recommendations ◦ Surveillance: Determine CR-BSI rates & monitor; express as BSI/1000 catheter-days; investigate unexpected events ◦ Use CVC with minimum # ports/lumens needed ◦ Use 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 issues ◦ No recommendation: impregnated cath in children ◦ Designate competent personnel to supervise trainees for catheter insertion 1A ◦ Maximal barriers for insertion means: cap, mask, sterile gown, gloves, large sterile sheet for catheter, including PICCS and guidewire exchange 1A ◦ Guidewire: exchange only for malfunction (not infection); use new set sterile gloves for new cath ◦ Catheter care: Designate one port for hyperal ◦ Antibiotic locks: Do not use routinely to prevent CR-BSI ◦ Dressings: 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 required ◦ Replace at 96 hr intervals ◦ Keep all solutions sterile ◦ Do not administer dextrose-container/TPN through pressure monitoring circuit New tubing/catheters planned to avoid attaching wrong solution.

39 Recommendations for Placement of Intravascular Catheters in Adults & Children Umbilical Catheters Selected recommendations ◦ Arterial or Venous: Remove and do not replace if any sign of CR-BSI, vascular insufficiency or thrombosis ◦ Cleanse with antiseptic- avoid tincture of iodine ◦ Do not use topical antibiotic ointment/creams ◦ Remove as soon as possible; venous catheters can be used up to 14 days if managed aseptically

40 App. B Duration of Catheterization App. B Duration of Catheterization

41 Appendix B

42 References abscurrent.pdf July abscurrent.pdf guidelines-2011.pdf Infusion Nurses Society. Infusion Nursing Standards of Practice. J Infus Nurs 2006; 29 (Jan./Feb): S1 – S92.

43 Definitions 43 “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 organism “ recognized pathogen ” A 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

44 Comments on blood cults 44 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 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. Blood cultures drawn through central lines can have a higher rate of contamination than blood cultures collected through peripheral venipuncture

45 Primary Bloodstream Infection 45 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, and a 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 46 Patient has a recognized pathogen cultured from one or more blood cultures, and organism 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 and Signs and symptoms and positive laboratory results are not related to an infection at another site, and Common commensal is cultured from two or more blood cultures drawn on separate occasions.

47 Laboratory-Confirmed Bloodstream Infection Criteria 47 Patient ≤ 1 year of age has at least one of the following signs or symptoms: fever (>38oC core), hypothermia (<36oC core), apnea, or bradycardia and positive laboratory results are not related to an infection at another site And the same common commensal

48 Transfer Rule 48 If 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 . 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 or symptoms of localized infection at a vascular access site, but no other infection can be found, the infection is considered a primary BSI. Purulent phlebitis confirmed with a positive semiquantitative culture of a catheter tip, but with either negative or no blood culture is considered a CVS-VASC, not a BSI or a SST-SKIN or a ST infection. Occasionally a patient with both peripheral and central IV lines develops a primary bloodstream infection (LCBI) that can clearly be attributed to the peripheral line (e.g., pus at the insertion site and/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. 50


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