1. ABSTRACT Patients on home parenteral nutrition are at high risk of acquiring catheter-related bloodstream infections (CRBSIs). A catheter maintenance protocol was instituted in one branch of a home infusion company over five quarters. Under this protocol, three anti- infective products, as well as related education and nursing care, were introduced: SwabCap®, the AMD antimicrobial foam disc, and AnchorDry. Over the course of the program, CRBSI rates decreased by 60%. INTRODUCTION Patients who receive parenteral nutrition (PN) are at high risk of acquiring a catheter- related bloodstream infection (CRBSI). This may be due to several factors:  Long catheter dwell times. These patients may require an indwelling catheter for a long period of time, and often have multi-lumen catheters, thus increasing the potential for bacterial ingress.  Underlying disease state. These patients may have a related disease, such as malnutrition or a compromised immune status.  Possible cross-contamination. These patients are at risk for cross-contamination related to the possible presence of ostomies, fistulas, drainage tubes, and diarrhea. Home PN (HPN) can be a life-saving therapy for these patients, and in many cases, it may be required for the remainder of the patient’s life. Maintaining vascular access is a key part of HPN, and therefore, consistent catheter maintenance practices are vital to protect these patients from CRBSIs. Preventing CRBSIs can help avoid hospital readmissions and help improve these patients’ quality of life. A previous retrospective review, which assessed national catheter infection rates by therapy over 21 months, identified that HPN patients had a CRBSI rate more than two times greater than their non-PN home infusion counterparts. This result prompted this home infusion provider to develop an HPN-specific catheter maintenance bundle and accompanying education program that would prevent or reduce possible causes of CRBSI. Recent literature has shown that HPN catheter infection rates can range from 1.01 to 8.8 per 1,000 catheter days. 1, 2 OBJECTIVE To prevent CRBSIs in patients receiving HPN with the implementation of a catheter maintenance bundle, as well as an expanded education program. The goal of the protocol is zero catheter infections. METHODOLOGY The catheter maintenance bundle and education program were implemented by a single branch of a home infusion company; the branch had more than 145 active HPN patients throughout the study period. The protocol was instituted at the beginning of the fourth quarter of 2012 and continued throughout 2013 for all branch patients on HPN, either as a single therapy or in conjunction with other home infusion therapies. The protocol included use of the following products:  SwabCap®, a 70% alcohol impregnated disinfection cap that covers the needleless connector between uses;  Kendall™ AMD Antimicrobial Foam Disc, a flat foam disc impregnated with polyhexamethylene biguanide hydrochloride (PHMB), an antiseptic from the same family as chlorhexidine gluconate;  AnchorDry, a moisture barrier that helps to protect the IV dressing during bathing; and  A work mat that included text describing common catheter complications and how to avoid them. This mat was used to provide initial and ongoing patient education. Prior to initiation of the bundle, a specialized educational offering was provided to all patients and relevant staff:  Company nurses and pharmacists were educated on use of the new products.  Patients and physicians received a letter informing them of the program. Within the letter, an educational document described each new product being used. Also, company nurses or pharmacists provided HPN patients with face-to-face education on use of the three new products.  Pharmacists and non-clinical staff involved in ordering supplies for the patient were educated on the program. During the two-year period of the study (including the three quarters prior to implementation of the protocol), we maintained ongoing records for all branch patients receiving HPN to assess for CRBSI rates. CRBSIs were identified using the method used by the Centers for Disease Control (CDC). (See Figure 1.) RESULTS For the 8,982 catheter days assessed before the catheter maintenance protocol began, 19 catheter infections occurred, for a rate of 2.12 per 1,000 catheter days. For the 14,826 catheter days assessed after the protocol was implemented, 13 infections occurred, for a rate of 0.88 per 1,000 catheter days. (See Figure 1.) Figure 1: Results, Pre- and Post-Protocol CONCLUSIONS The incidence of CRBSIs declined with increased education and use of the catheter maintenance bundle described above. The protocol was initiated on October 1, 2012 (Q4 2012), and decreased the rate of CRBSIs by 60% over the next five quarters. This infection reduction protocol has now been rolled out to all branches of the company. Number of CRBSIs* Catheter Days Catheter Infection Rate/1,000 Days Pre-Protocol Post-Protocol Figure 2: Results by Catheter Type, Pre- and Post-Protocol Combined PICC Imp Port Tunneled Catheter Catheter Type Number of Dwell Days 1 Leone M. Central vascular access device infection rates with parenteral nutrition. Support Line (a newsletter of Dietitians in Nutrition Support). 2010;32(6):10-13. 2 Zhao VM. Characterization of post-hospital infections in adults requiring home parenteral nutrition. Nutrition. 2013;29(1):52-59. 3 CDC/NHSN Surveillance Definitions for Specific Types of Infections. Centers for Disease Control and Prevention website. www.cdc.gov/nhsn/pdfs/pscmanual/17pscnosinfdef_current.pdf. January 2014. Accessed March 20, 2014. Catheter maintenance protocol started 10/1/12 *We characterize catheter infection as when any of the following are present: Fever over 100.4° not attributable to other health issues; Catheter exit site redness, drainage or cord; AND Blood/catheter culture or gram stain that confirms bacterial or fungal counts; OR The prescriber determines that the catheter is the most likely source of an infection (in which case, the prescriber removes the catheter or treats the patient/catheter with anti-infectives). 3 Number of CRBSIs PICC Imp Port Catheter Type CRBSIs/ 1,000 Catheter Days PICC Imp Port Catheter Type Catheter types included tunneled catheters, implanted ports, and peripherally inserted central catheters (PICCs). Of note, PICCs presented with the highest infection rate of the three catheter types, at almost four times the rate of implanted ports and more than twice that of tunneled catheters. (See Figure 2.) Tunneled Catheter Catheter Maintenance in the Home Parenteral Nutrition Patient = Reduced CRBSIs! Donna Maslak, RN,MBA, Deborah Rossettini, RN, BSN, Laura Trento, MS, RD, CNSC, Melissa Leone, RN, BSN Coram Specialty Infusion Services