1. © 2009 Guidelines to Prevent Central Line Associated Blood Stream Infections

2. © 2009 Why do I Need to Complete this Orientation? Problem – Vascular access device (VAD) associated infections increase morbidity, mortality, hospital length of stay (LOS) and costs – Education of health care workers decreases health care associated infections Intervention – Mandatory course to achieve standardization of infection control practices during central vascular access device (C-VAD) insertion

3. © 2009 Why do I Need to Complete this Orientation? (Cont.) 1 Sheretz et al. Ann Intern Med. 2000;64:1-8 Outcome – Education in another center 1 achieved a 26% relative reduction in central line infections & saved 1.3 million dollars – Since implementation of this orientation, JHH central line related bloodstream infection (CLABSI) rates have decreased below the national average

4. © 2009 STATISTICS for CLABSIs 90% of all blood stream infections are associated with C-VADs 400,000 CLABSIs occur per year in U.S. CLABSIs are – 1) Associated with increased morbidity – 2) Associated with mortality rates of 10% to 20% – 3) Associated with prolonged hospitalization (mean of 7 days) and increase in medical costs > $28,000

5. © 2009 National Nosocomial Infection Surveillance (NNIS) Rates In 2003, NNIS (from the Centers for Disease Control & Prevention {CDC}) reported the number of CLABSIs per 1000 catheter days based on nationwide intensive care unit (ICU) surveillance Table 1 compares ICUs from one academic medical center to the national benchmark CLABSI rates

6. © 2009 Table 1: CLABSI Rate per 1000 Catheter Days NHSN 90th Percentile NHSN 50th Percentile Pre-VAD Training Post-VAD Training SICU 9.15.36.7 0.6 PICU 11.97.75.5 5.4 CVICU 4.92.87.6 2.7 MICU 9.86.17.8 3.3 CCU 7.94.65.0 1.2 NCCU 8.34.96.6 3.7 OncICU 9.34.7N/A 1.6

7. © 2009 Risk Factors for CLABSIs Site of insertion; subclavian vein poses less risk than internal jugular or femoral vein 2 Multiple lumen catheters- – increased tissue trauma predisposes to CLABSI – more manipulation and contamination of multiple ports/hubs TPN and/or lipids Low nurse to patient ratio 2 Merrer et al. JAMA. 2001;286:700-7

8. © 2009 Risk Factors for CLABSIs (Cont.) Infection elsewhere (remote, ie UTI or wound) – secondary source Colonization of catheter with organisms IV catheterization longer than 72 hours Inexperience of personnel inserting the C-VAD Use of stopcocks

9. © 2009 Process of Catheter Related Infections

10. © 2009 Evidence Based JHH 5 Steps to Preventing CLABSI Clean hands (waterless alcohol based hand sanitizer or wash hands with soap and water) Select best insertion site Use proper skin preparation (chlorhexidine) Use maximal barrier precautions Remove catheter as soon as possible

11. © 2009 Hand Hygiene: When and Where? Wash hands with soap & water or use a waterless hand sanitizer Before and after invasive procedures Between patients After removing gloves Before eating After using the bathroom If contamination is suspected

12. © 2009 Hand Hygiene Does Work! YearAuthorSetting Comparison Group Results 1982MakiICU (US)Crossover↓Nosocomial Infection 1984MassanariICU (US)Crossover↓Nosocomial Infection 2000Pittet Teaching Hospital, Switzerland Observational ↓Nosocomial Infection ↓MRSA Rates

13. © 2009 Infection Prevention Waterless Hand Hygiene Steps: Coat all surfaces of your hands thoroughly with waterless hand sanitizer, including your palms, in between fingers and under fingernails, backs of hands and around wrists. Rub your hands briskly until they feel comfortably dry. It takes about 15 seconds, and no water or towels are needed.

14. © 2009 1. Wet hands 2. Obtain soap 3. Lather for 10-15 seconds 4. Rinse hands 5. Turn off faucet handles with paper towel Infection Prevention Handwashing Steps:

15. © 2009 C-VAD Site Selection Use the SUBCLAVIAN site unless medically contraindicated (e.g. patient has an anatomic deformity, coagulopathy, or has renal disease that may require dialysis)

16. © 2009 C-VAD Site Selection: Special Considerations For patients on hemodialysis, National Kidney Foundation 2000 Guidelines recommended against the use of the subclavian vein for any VAD unless use of the IJ vein is absolutely contraindicated. This is due to the risk of subclavian vein stenosis If the IJ vein is chosen, use the right side to reduce risk of non-infectious complications

17. © 2009 C-VAD Line Selection Use a single lumen C-VAD, unless multiple lumens are absolutely necessary Consider a tunneled or implanted C-VAD for patients requiring long-term access (> 30 days), or a PICC or cuffed C-VAD for patients requiring therapy for >1 week Evaluate daily the need for C-VAD and remove when not needed or change to a single lumen C-VAD when possible

18. © 2009 Aseptic Technique: Goals Remove transient organisms and soil from the skin Reduce number of resident microbial flora and inhibit their rebound growth Create a sterile working surface that acts as a barrier between the insertion site and any possible source of contamination

19. © 2009 Aseptic Technique Prepare skin with antiseptic/detergent Chlorhexidine 2% in 70% isopropyl alcohol Pinch wings on the “Chloraprep” applicator to pop the ampule. Hold the applicator down to allow the solution to saturate the pad. Press sponge against skin, apply chlorhexidine solution using a back and forth friction scrub for at least 30 seconds. Do not wipe or blot Allow antiseptic solution time to dry completely before puncturing the site (may take 2 minutes).

20. © 2009 Evidence supporting use of Chlorhexidine: Skin Prep−Meta Analysis Pooled RR for BSI Ann Intern Med. 2002;136:792-801

21. © 2009 Maximal Barriers Required for C-VAD Insertion Use face mask, cap and sterile gloves Wear a sterile gown with neck snaps and wrap-around ties properly secured Instruct anyone assisting you to wear the same barriers Drape the patient with a LARGE sterile drape that covers the entire patient

22. © 2009 Maximal Barrier Precautions (MBR) Decrease CLABSI Infections OR=odds ratio MBR= inserter washes hands and wears mask, sterile gown, sterile gloves and patient’s head & body are covered with a large, sterile drape AuthorDesignCatheter TypeOR for Infection without MBR Mermel / 1990 Prospective Swan-Ganz 2.2 Cross-Sectional(p<0.03) Raad / 1994 Prospective Central 6.3 Randomized(p<0.03)

23. © 2009 Caveats: Catheter Insertion IV antimicrobial prophylaxis does not reduce CLABSI 1 Insertion of C-VADs through open techniques/cutdown increases the risk of CLABSI Ensure adequate room to perform the procedure without risk of contamination 1 Ranson. J Hosp Infect. 1990;15(1):95-102.

24. © 2009 Post Insertion: C-VAD Care Antimicrobial ointments do not reduce the incidence of CLABSI Apply a sterile dressing to the insertion site before the sterile barriers are removed Transparent dressings are preferred to allow visualization of the site If the insertion site is oozing, apply a gauze dressing instead of a transparent dressing Replace C-VAD dressings when the dressing becomes damp, loosened, soiled or after lifting the dressing to inspect the site

25. © 2009 Replacing CVADs Remove the line as soon as possible Routine C-VAD guidewire exchange or site rotation is not recommended 1 Guidewire exchange is acceptable for replacing a malfunctioning catheter or downsizing a PA catheter to a CVC Patients who clearly have a CLABSI should not undergo guidewire exchange Selected patients with suspected BSI and limited venous access may have their catheter exchanged over a guidewire and the catheter tip should be cultured Switch to a new set of sterile gloves before handling the new catheter 1 Eyer et al. Crit Care Med. 1990;18(10):1073-9.

26. © 2009 Suspected C-VAD Infections Remove the C-VAD in a patient with proven CLABSI (i.e., blood culture positive for a recognized pathogen with no identified secondary source) If a BSI is only suspected, or the C-VAD is not known to be the source, or the C-VAD cannot be removed, clinical judgment is necessary. Extensive, evidence- based guidelines exist for the diagnosis and treatment of catheter-related infections 1 1 Mermel et al. Clin Infect Dis. 2001;32(9):1249-72.

27. © 2009 Draw two sets of blood cultures from a patient with new episode of suspected C-VAD infection, preferably both sets peripherally It is not always necessary to remove the CVAD in a mildly ill patient with unexplained fever If the catheter is the suspected source of the infection, it can be changed over a wire and cultured. If the catheter culture grows  15 colony forming units of organisms, remove it and place at a different site Tailor antimicrobial therapy to the individual patient, based on severity of illness, suspected pathogen, and presence of complicating factors Suspected C-VAD Infections (Cont.)

28. © 2009 C-VAD Line Cultures: Indications The utility of catheter cultures is controversial Nonetheless, proper technique is imperative to evaluate the data. The catheter tip may be submitted for semi- quantitative culture if there is clinical suspicion of CLABSI Routinely removed catheters should NOT be sent for culture

29. © 2009 C-VAD Line Cultures: Method Remove all dressings and cap off all hubs/ports, then paint the site with antiseptic solution, and include within the sterile field Remove C-VAD en-bloc. Under no circumstance should catheters be cut prior to removal Remove the catheter aseptically, avoiding contact with the patient’s skin and catheter tray Use sterile scissors (not the scalpel used to cut the CVAD sutures) to cut a 5cm segment, including the tip and place it into a culture container

30. © 2009 A catheter culture yield of  15 CFU, accompanied by signs and/or symptoms of infection is consistent with a catheter-related infection Do not give antibiotics based on a positive catheter culture only, evaluate the clinical picture C-VAD Line Cultures: Interpretation

31. © 2009 Blood Cultures Patients with a new episode of suspected catheter- related infection should have two sets of peripheral blood samples drawn for culture. In rare instances where access for peripheral blood draws is limited, one set may be drawn from the line and one percutaneously

32. © 2009 Peripheral Blood Cultures: Method Don sterile gloves and observe Standard Precautions Apply chlorhexidine 2% in 70% isopropyl alcohol (Chloraprep Frepp) using a back and forth friction rub for at least 30 seconds over a 5 cm area Allow solution time to dry completely before puncturing the skin Do not touch the venipuncture site after skin prep except with sterile gloves Insert needle into vein and withdraw 20cc of blood (adults) Distribute the blood evenly between 2 culture bottles (10 cc per bottle), taking care not to inject air into the anaerobic bottle Always send a second set of blood cultures from a separate venipuncture site

33. © 2009 Arterial Line: Site Selection Radial artery is the preferred site Dorsalis pedis is an alternative Femoral sites have higher infection rates and risk of thrombosis Brachial/maxillary sites are a last resort, due to lack of collateral circulation

34. © 2009 Arterial Lines: Aseptic Technique As with C-VADs, always: – Clean your hands with soap & water or waterless hand cleaner – Maintain Standard Precautions – Perform a thorough skin preparation – Use barrier protection

35. © 2009 Arterial Lines: Barriers For radial or dorsalis pedis sites, create a generous sterile working surface using sterile drapes; wear sterile gloves and a mask with face shield Femoral or axillary arterial catheters may increase the risk of infection and require maximum barriers as with C- VADs, including mask, sterile gloves, sterile gown and large sterile drape

36. © 2009 With Special Thanks to All the Contributors to this Effort: Sean Berenholtz, M.D. Roy Brower, M.D. Raphe Consunji, M.D. Sara Cosgrove, M.D. Pamela Lipsett, M.D. Trish Perl, M.D. Peter Pronovost, M.D. Lisa Cooper, R.N.