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

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

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

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

Timothy Royer, RN, BNS, CRNI NPSG VII. Goal 7 – Reduce the risk of health care –associated infections. A. Meeting Hand Hygiene Guidelines (NPSG.07.01.01) B. Not applicable to hospitals C. Preventing Multidrug-Resistant Organism Infections (NPSG.07.03.01) D. Preventing Central Line–Associated Blood Stream Infections (NPSG.07.04.01) E. Preventing Surgical Site Infections (NPSG.07.05.01) http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/ Timothy Royer, RN, BNS, CRNI

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 http://www.ihi.org/nr/rdonlyres/0ad706aa-0e76-457b-a4b0-78c31a5172d8/0/centrallineinfectionshowtoguide.doc Timothy Royer, RN, BNS, CRNI

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

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

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

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

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

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

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;355:2725-32 Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med 2004;32:2014-20 Timothy Royer, RN, BNS, CRNI

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

Building a Better Care Bundle What We Did June 2003 - Change to swabable positive displacement valve January 2005 – Maximal sterile barriers & CHG prep July 2006 - 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

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

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

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

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

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

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

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

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

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

Swabable Needleless Connectors Hadaway L, Richardson D. Needleless connectors: A primer on terminology. Journal of Infusion Nursing. 2010, Vol. 33:1. Hadaway L, Richardson D. Needleless connectors? A primer on terminology. Journal of Infusion Nursing. 2010, 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

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

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;207-213. 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

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. 4596-4606 doe: 10.1128/1AL.73.8.4596-4606.2005 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. 915-923. Timothy Royer, RN, BNS, CRNI

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. 6023-6031, Vol. 72, No. 10. “Recent estimates suggest that the majority of hospital-acquired infections are biofilm associated.” Donlan, R. M. 2001. Biofilm formation: a clinically relevant microbiological process. Clin. Infect. Dis. 33:1387-1392. Licking, E. 1999. Getting a grip on bacterial slime. Business Week, 13 September 1999, p. 98-100. Potera, C. 1999. Forging a link between biofilms and disease. Science 283:1837-1838. 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

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; 28:2 113-118. 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), 261-265. Feehery, Patricia A. RN, BS, CRNI, et al. Flushing 101, Journal of Vascular Devices, Summer 2003. Timothy Royer, RN, BNS, CRNI

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;4:349-355. April 2004 Timothy Royer, RN, BNS, CRNI

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;20:317-324. 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;17:1745-1751. Timothy Royer, RN, BNS, CRNI

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 555-556 “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

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. 915-923. 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. 2008 36(3): 933-940. Timothy Royer, RN, BNS, CRNI

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

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

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. 2004 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. 2005 Aug:24(8);676-9. Timothy Royer, RN, BNS, CRNI

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. 2005. 61:53-61. Garland JS, e al. Local reactions to a chlorhexidine gluconate-impregnated antimicrobial dressing in very low birth weight infants. Pediarics. Jun;107(6):1431-6. Roberts B, Cheung D. Biopatch-a new concept in antimicrobial dressings for invasive device. Aust Crit Care. 1998 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. 2000 Feb;21(2):96. Timothy Royer, RN, BNS, CRNI

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):1231-1241 (doi: 10.1001/jama.2009.376 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

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

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

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. 2010, Vol. 33:1. Timothy Royer, RN, BNS, CRNI

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

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)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Timothy Royer, RN, BNS, CRNI Thank you. Questions? We2frogs@oz.net Timothy Royer, RN, BNS, CRNI

Remember not to lose Focus on the Whole Patient. We2frogs@oz.net Timothy Royer, RN, BNS, CRNI