1. The Central Line Bundle and YOU!
CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTION
The Central Line Bundle and YOU!
6/6/2013
Quality Assurance/Peer Review Report
Privileged Pursuant to O.R.C. Section , .251, .252
Central line associated blood stream infections are part of National Patient safety goal This safety goal requires medical centers to implement evidence based care of all central lines. In this presentation you will learn all components of the central line bundle.

2. NATIONAL PATIENT SAFETY GOAL 2009
2009 National Patient Safety Goal or (NPSG ) requires:
Implementation of best practice or evidence-based guidelines to prevent central line-associated bloodstream infections (CLABSIs) for short and long-term central venous catheters (CVCs) including PICCs
The deadly cost of CLABSIs:
~ 90 % of CLABSIs occur with CVCs
Estimate of 14,000 – 28,000 lives lost per year
Hospitalization prolonged a mean of 7 days
Hospitalization costs ↑~ $3,700 - $29,000
October 1, 2008 CMS (Medicare) no longer
reimbursing for CLABSIs acquired in the hospital
The cost of central line associated blood stream infections is very high. 90% of central line infections occur with central venous catheters . 14,000-28,000 lives are lost per year. Hospitalizations are prolonged an average of 7days, The hospital cost of a central line infection is increased $29,000 dollars. As of October 1, 2008 Medicare is no longer paying for nosocomial cath related blood stream infections.
4/15/2017
4/15/2017
University Hospitals
University Hospitals 2

3. How Can We IMPACT Central Line Associated Blood Stream Infections (CLABSIs)?
What is the Central Line Bundle?
Includes the following bundle of 5 care components:
1. Hand hygiene
2. Maximal barrier precautions
3. Chlorhexidine skin antisepsis
4. Optimal catheter site selection
5. Daily review for line necessity and assessment with prompt removal of unnecessary lines
The central line bundles are endorsed by the Institute of Hospital Improvement( IHI) and other agencies such as The University Consortium, SHEA ,American Hospitals Association, the joint commission and APIC.
The central line bundles includes 5 cares components that include Hand Hygiene, maximum barrier precautions, Chlorhexadine skin antisepsis, optimal catheter site selection and daily review for line necessity.
4/15/2017
University Hospitals

4. HAND HYGIENE – Just do it!
1. Perform hand hygiene before assisting with catheter insertion or manipulation.
2. Palpation of the insertion site should not be performed after antiseptic cleanse, unless aseptic technique is maintained.
3. Before and after inserting, replacing, accessing, repairing or dressing a central line.
Read slide
4/15/2017
University Hospitals

5. MAXIMAL BARRIER PRECAUTIONS
Use strict adherence as the inserter and all involved with the placement of a central line or guidewire exchange with the following:
Compliance with hand hygiene
Wear cap, mask, sterile gown and sterile gloves
Cap – covers all hair
Mask – covers nose and mouth tightly
Sterile drape – covers patient from head to toe with a small opening for line placement
Prior to inserting central line or performing a guidewire exhange all involved in the procedure should comply with hand hygiene, wear cap, mask, sterile gown and sterile gloves. Caps should cover all hair. A mask should cover the nose and mouth tightly. A sterile needs to be long enough to cover the patient head to toe with a small opening for line placement.
4/15/2017
University Hospitals

6. CHLORHEXIDINE SKIN PREP
Chlorhexidine (CHG) skin prep prior to placement and for dressing change.
PINCH wings on CHG applicator.
PRESS sponge against the skin allowing the solution to penetrate the pad.
PREP covering a large area using a back and forth, up and down, and diagonal friction scrub for at least 30 seconds. Allow to dry. Do not wipe, blot or fan.
Chlorhexadine 2% with 70% alcohol is recommended to be used prior to placement and for dressing changes. Alternative products such as betadine should only be used as an alternative for patietns with an allergy to CHG. In order to use chg skin prep pinch the wings on the chg applicator, [resee sponge pad against the skin allowing the solution to penetrate the pad. Cover a large area of skin using a back and forth and up and down and diagonal motion. Scrub for at lest 30 seconds. Allow to dry naturally do not wipe, blot or fan
4/15/2017
University Hospitals

7. OPTIMAL CATHETER SITE SELECTION
Subclavian vein is the preferred site for non-tunneled catheters and is associated with lower risk of CLABSIs rather than the jugular vein.
-Femoral site is associated with greater risk of infection and DVTs in adults.
University Hospitals preferred sites:
Subclavian and Internal jugular are preferred sites.
Femoral site would be an option for:
1. ECMO
2. Neuroprotective hypothermia-thermaguard 
Other insertion sites are not able to be accessed due to poor vascular upper extremities, etc.
4. A need for dialysis or other patient emergencies
Although a lot of discussion is taking place on the preference of subclavian vs. Internal jugular site preference, the subclavian vein is the preferred site for non-tunneled catheters and is associated with lower risk of central line associated blood stream infections. The femoral site is associated with greater risk of infection and DVTs in adults. At University Hospitals subclavian and internal juguar are the preferred sites. Femoral lines would be an option for patient on ECMO, neuroprotective hypotherimia – thermagard and dialysis or emergency situations where line access is needed such as a code. Femoral lines would be utilized if other insertion sites are not able to be accessed due to poor vascular in upper extremities or inability to obtain placement at preferred sites.
Consent should be obtained prior to insertion of all central lines unless it is an emergent situation.
4/15/2017
University Hospitals

8. NEW CENTRAL LINE DRESSING AT UH: TEGADERM HCG
Studies have shown chlorhexidine gel pad effectively reduces skin flora
Gel pad easily conforms to body contours
Gel pad is transparent
Gel pad adsorbs fluids & blood
Remains effective & transparent over weeks time
No need to manipulate catheter placing gel pad
Tegaderm dressing eliminates Statlock need
University Hospitals Seidman Cancer Center 8

9. STEPS FOLLOWING INSERTION
Flush each lumen with 10ml normal saline solution via a 10cc syringe.
Apply sterile, occlusive dressing to site.
Attach male Luer-lock stopcock or Luer-lock IV tubing to each port and close clamps.
MD should order x-ray to confirm placement prior to infusion for subclavian and internal jugular lines. X-ray confirmation is not necessary for femoral lines.
MD should order CENTRAL LINE CARE/MAINTENANCE
Complete Procedure note-general in UHCare. Label as to type of line inserted.
Document daily assessment and need on progress note.
Assess for infiltration, phlebitis, infection, and any change from baseline appearance
Read slide
4/15/2017
University Hospitals 9 9

10. DAILY LINE ASSESSMENT AND REVIEW
The risk of CLABSIs increases over time.
Complete daily assessment of central line for infection.
Prompt removal of unnecessary lines.
The replacement of temporary catheters in the presence of bacteremia is not an acceptable replacement strategy. The source of infection is usually colonization of skin tract from the insertion site to the vein.
Roles in Daily Site Assessments:
Physicians should assess and document daily the criteria for the patient to maintain a central line.
For example: “R internal jugular CVC- clear, dry, intact, no erythema noted. Still necessary for IV access on pressors, etc.”
Should be discussed during daily attending rounds.
Daily line assessment and review. The risks of central line associated catheter infections increases over time. The central line should be assessed daily for signs of infection. Unnecessary lines should be removed promptly. The replacement of temporary catheters in the presence of bacteremia is not an acceptable replacement strategy. The source of infection usually colonizes into the skin tract from the insertion site to the vein.
Physicians should assess daily the criteria for the patient to maintain a central line. The doctor should document the need of the line daily in the patient progress note. Nurses should document the site of all central lines daily in the nursing assessment notes. A daily line assessment checklist should be developed and utilized at your facility.
4/15/2017
University Hospitals

11. CENTRAL LINE MAINTENANCE ORDER!
Central line maintenance includes:
Dressing, cap and tubing changes per protocol.
Scrubbing injection caps with alcohol for 15 seconds prior to accessing.
Daily review of line need.
Prompt removal of unnecessary lines.
HOW TO ORDER ON EMR?
CENTRAL LINE CARE/MAINTENANCE (order set)
Read slide
4/15/2017
University Hospitals

12. BE A PATIENT ADVOCATE! Be a bundler and protect your patients.
Educate others in the central line bundle.
Follow-up with management with other
ideas to support bundle compliance.
Evaluate the effectiveness of this strategy within your unit.
Read slide
4/15/2017
University Hospitals

13. Reducing Central Line Associated Bloodstream Infection (CLABSI) - National Patient Safety Goal #7.  
What is the Central Line Bundle? Includes the following 5 care components:
Hand hygiene
Maximal barrier precautions
Hat, mask, sterile gown, sterile gloves, sterile drape covering the entire patient
Cap and mask must be worn by all personnel entering the room.
STOP insertion if sterile technique is broken. If sterility is broken, a new kit and/or new drapes should be applied to patient and MD should start procedure over again.
Chlorhexidine skin antisepsis (if allergic use Betadine or alcohol)
Optimal catheter site selection
Subclavian most preferred site, then internal jugular vein, femoral vein (emergency)
MUST DOCUMENT DAILY CENTRAL LINE ASSESSMENT with 2 components:
Infection with prompt intervention when indicated
Necessity with prompt removal when no longer required
Should be part of the physical exam and assessment/plan
Remember the motto: “It does not count unless you document.”
Pre-procedure. Provide acceptable rational for line placement. Obtain informed consent and provide central line educational information. Perform time-out procedure using Universal Protocol (correct patient, correct side, correct site).
Post-procedure.
Obtain Chest X-ray if indicated.
Write PROCEDURE NOTE as soon as procedure has been performed. Must include the components above.
Place an order for central line maintenance.
HOW TO ORDER: On Orders tab, Type CENTRAL LINE CARE/MAINTENANCE
Along with your pager cards, you have the Central Line Bundle Reminder Card.