1. Central line Bundle Education National Patient Safety Goal 07.04.01 2009

2. Something you should know! Central line associated bloodstream infections can and do kill our patients They are preventable! Patients should not be harmed by the care that is intended to help them.

3. A Central line is defined As: An intravascular catheter that terminates at or close to the heart or in one of the great vessels and is used for…. *Infusion (TPN, Dialysis, Meds, Blood) *Withdrawal of blood *Hemodynamic monitoring

4. Line Contamination Leading to Bloodstream Infection Can occur at the time of insertion, during access of the line, or even at dressing changes. The cost to the health care system is huge and CLABSI is so preventable that reimbursement to treat it may be denied. And while the cost to healthcare is high the cost to the patient is IMMEASURABLE!

5. How to Prevent? One of the National Patient Safety Goals is to implement evidence-based practices known to reduce the risk of CLABSI To that end a grouping of best practices known as the “Central Line Bundle” has been created and is in fact now being widely used throughout the nation and locally.

6. Here are The KEY Components of the Bundle Optimal line and site selection What will the line be used for and how long will it be needed? PICC? IJ? Subclavian? Femoral sites should be avoided due to higher risk of infection and DVT

7. Hand Hygiene Wash or Alcohol foam Before and after palpating catheter insertion sites Immediately before donning sterile gown and gloves at insertion

8. Maximal Barrier Precautions A mask, cap, sterile gown and gloves must always be worn by the inserter. A mask and cap must always be worn by all healthcare persons in the room at the time of insertion. A full body drape must be used (head to toe) and a sterile field maintained

9. Skin Prep Chlorhexidine is the prep of choice, which means no more betadine! Apply the Chloraprep before draping, using back and forth gentle friction for 30 seconds MINIMUM over the immediate puncture site area ( check in with the clock please) and then work in the same manner outward for about 3” in all directions. DO NOT take the applicator back over the puncture site once you leave it. Allow to dry and do NOT wipe or blot After insertion - immediate sterile application of dressing

10. The Checklist Must be completed for EVERY line inserted. If all bundle components are not followed the checklist must reflect why. Nursing has the power to stop the procedure if sterility is compromised or if components are missed ie: hand hygiene not performed In a life threatening situation where the bundle may not be fully implemented a checklist must still be completed with patient sticker and reason not followed.

11. Central Line Insertion Checklist - sample Patient Sticker Date: __________ Location: _________ Inserter: ____________ Assistant: ____________ Safety Pause: ____ ID Patient ____ Emergent ____ Elective Site: ____ Subclavian ____ Internal Jugular ____ Groin ____ Upper Extremity Line Type: ____ Single Lumen ____ Double Lumen ____ Triple Lumen ____ Cordis ____ PICC * ____ Education sheet given to ____ Dialysis patient/family ____ Tunneled Insertion Bundle: Barriers: ____ Cap on Inserter ____ Cap on Assistant ____ Mask on Inserter ____ Mask on Assistant Hand Hygiene: ____ Pre Gowning (Inserter) (Foam or ____ Pre Gloving (Assistant) Wash) Prep: ____ Chloraprep ____ Minimum 30 seconds back and forth friction ____ Dry time (3 minutes) before insertion Insertion ____ Sterile Gown Barriers: ____ Sterile Gloves ____ Full Body Drape Dressing: ____ Applied immediately by inserter Please send completed checklist to Quality __

12. Get it Out! Daily review of line necessity and prompt removal when no longer needed. The longer the line is there the greater the risk.

13. Must Do’s for Line Accessing/Maintenance Firstly: You guessed it! Don’t touch that line until you’ve washed/foamed your hands Thoroughly scrub the tops AND threads of connectors with alcohol before you access them. Visual inspection or palpation requires STERILE gloves Pain may indicate start of problems

14. Do’s cont’d Anytime blood is drawn from the line each lumen must then be flushed with 20-30ml normal saline A lack of blood return through any lumen means an immediate need for declotting with altaplase.

15. Determination of a Central line Associated Bloodstream Infection Criterion #1 A recognized pathogen from one or more blood cultures and the organism is not related to an infection at another site OR..

16. Criterion 2 Patient has at least one of the following symptoms: Fever (>38ºC), chills, or hypotension and Symptoms are not related to infection at another site and Common skin contaminant (Corynebacterium spp., Bacillus (not B.anthracis), Propionibacterium spp., coagulase-negative staphylococci, viridans group streptococci, Aerococcus spp, Micrococcus spp) is cultured from two or more blood cultures drawn on separate occasions

17. Dressing Change The patient (unless intubated) and healthcare provider should be masked during the dressing change. Please thoroughly clean the site including the line segment that will be in the dressing and allow it to dry fully before applying the new dressing

18. Summary – key points Meticulous hand hygiene An insertion checklist followed every time Meticulous care of the line Get it out ASAP Document adherence to the bundle