1. © 2009 On the CUSP: STOP BSI Evidence for Best Practices for Placement and Maintenance of Central Lines

2. © 2009 Learning Objectives Review evidence for the 5 key best practices for CLABSI prevention – Remove unnecessary lines – Hand hygiene – Use of maximal barrier precautions – Chlorhexidine for skin antisepsis – Avoid femoral lines Review approaches for central line site care MMWR. 2002;51:RR-10

3. © 2009 Hand Hygiene: The Evidence Clin Infect Dis 1999;29:1287-94 Lancet 2000;356:1307-1312 Since 1977, 7 prospective studies have shown that improvement in hand hygiene significantly decreases a variety of infectious complications

4. © 2009 What are Maximal Barrier Precautions? For Provider: – Hand hygiene – Non-sterile cap and mask All hair should be under cap Mask should cover nose and mouth tightly – Sterile gown and gloves For the Patient – Cover patient’s head and body with a large sterile drape

5. © 2009 Maximal Barrier Precautions

6. © 2009 Maximal Barrier Precautions: The Evidence Author & Year Study Design Type of Catheter OR for Infection without MBP Mermel 1991 Prospective Non-randomized Swan-Ganz2.2 (p=0.03) Raad 1994 Prospective Randomized Central3.3 (p=0.03) Lee 2008 Prospective Non-randomized Central5.2 (p=0.02) Am J Med 1991;91(3B):197S-205S Infect Control Hosp Epidemiol 1994;15:231-8 Infect Control Hosp Epidemiol 2008; 29:947-950

7. © 2009 Skin Prep: Chlorhexidine Ann Intern Med. 2002;136:792-801

8. © 2009 What Site is Best? RCT of femoral (N = 145) and subclavian (N = 144) lines in the ICU Outcomes – Higher rate of infectious complications in femoral group: 19.8% vs. 4.5% (p <.001) – Higher rate of thrombotic complications in femoral group: 21.5% vs. 1.9% (p <.001); complete thrombosis 6% vs 0% – Similar rates of mechanical complications: 17.3% vs 18.8% (p = NS) JAMA 2001;286:700-7

9. © 2009 Strategies for Prevention: 5 Key “Best Practices” Remove unnecessary lines Hand hygiene Use of maximal barrier precautions Chlorhexidine for skin antisepsis Avoid femoral lines MMWR. 2002;51:RR-10

10. © 2009 Catheter Site and Hub Care Clean catheter hubs & injection ports with 70% alcohol or chlorhexidine/alcohol before accessing Change transparent dressings and perform site care with chlorhexidine – Routinely every 5-7 days – If the dressing is loose, soiled or damp Replace administration sets not used for blood products or lipids at least every 96 hours Infect Control Hosp Epidemiol 2008;29:S22-30

11. © 2009 Action Items Assess compliance with best practices for catheter insertion Assess compliance with best practices for catheter site care Address solutions for barriers to best practice

12. © 2009References Guidelines for the Prevention of Intravascular Catheter-Related Infections; August 2002. – www.journals.uchicago.edu/doi/abs/10.1086/344188 Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals; October 2008. – www.journals.uchicago.edu/doi/pdf/10.1086/591059