catheter-related bloodstream infection nov...

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Causes, Prevention andBest Practices

Nancy Moureau, BSN, CRNI, CPUI, VA-BC

Catheter-Related Bloodstream Infection

Disclosure

� Nancy Moureau has the following disclosures:� Consultant for PICC Excellence � Speakers Bureau for:

� 3M� Excelsior� Teleflex

Learning Objectives

At the end of this presentation the learner will be able to:

� Identify types and complications associated with central

venous catheters (CVC’s)

� Identify causes and pathogens of CR-BSI

� Describe best practice recommendations from various

organizations

� Discuss clinical application of best practice components

on prevention of CRBSI

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Classifications OfVascular Access Devices

Classes of Vascular Access Devices

� Peripheral Catheter� Central Venous Catheter� Arterial� Subcutaneous port� Dialysis Catheter� Umbilical Catheter

CVC Complications

� Catheter occlusion� Phlebitis� Catheter-related vessel

thrombosis� Catheter tip malposition� Catheter fracture� Air embolism� Infiltration and extravasation� CRBSI

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Where do Catheter Related Bloodstream Infections occur?

� What patient care units?

� What patient populations?

TABLE 2. Pooled means and key percentile of the distribution of central-line associated bloodstream in infection rates among hospitals participating in the in the National Healthcare Safety Network, CDC, 2006 –2007.

Percentile

Type of Intensive

care Unit

No.

Units

No.

CABSIs

Catheter-

days

Pooled mean Incidence/

1,000 catheter-days

10%

25%

50%

75%

90%

Burn 22 239 42452 5.6 0 1.5 3.8 8.2 13.5 Trauma 32 435 107620 4.0 0.3 1.5 4.0 5.7 7.7 Pediatric medical/surgical

71 404 140,848 2.9 0.0 0.0 2.1 3.8 6.0

Neurosurgical 39 173 68550 2.5 0 0 1.9 3.8 6.2 Medical 144 1073 454839 2.4 0 0.6 1.9 3.6 5.3 Surgical 128 881 383126 2.3 0 0.5 1.7 3.1 5.1 Coronary 121 373 181079 2.1 0 0 1.3 2.8 5.3 Medical/surgical Major teaching

104 692 342214 2.0 0 0.5 1.5 3.0 4.2

Inpatient medical ward

40 111 60257 1.8 0 0 0 2.2 3.4

Med/Surg All others

343 972 662489 1.5 0 0 0.6 2.0 3.6

Surgical cardiothoracic

97 397 275194 1.4 0 0 1.2 1.9 3.4

Inpatient medical/surgical ward

82 169 132133 1.3 0 0 0 1.6 4.0

Neurologic 15 31 25440 1.2 - - - - -

Edwards JR, Peterson KD, Andrus ML, Dudeck MA, Pollock DA and Horan TC. National Healthcare Safety Network (NHSN) Report, data summary for 2006 through 2007, issued November 2008. Am J Infect Control 2008;36:609-26

TABLE 3. Most common pathogens isolated from nosocomial bloodstream infections, SCOPE

Pathogen Total ICU Non-ICU

Coagulase-negative staphylococci 31.3 35.9 26.6

Staphylococcus aureus 20.2 16.8 23.7

Enterococcus spp 9.4 9.8 . 9.0

Candida spp. 9.0 10.1 7.9

Gram-negative rods

Escherichia coli

Klebsiella spp

Enterobacter spp.

Pseudomonas aeruginosa

Acinetobacter baumannii

Serratia spp.

5.6

4.8

4.3

3.9

1.7

1.3

3.7

4.0

4.7

4.7

2.1

1.6

7.6

5.5

3.8

3.1

1.3

0.9

Percentage of BSIs

1. Wisplinghoff H, Bischoff T, Tallent SM, Seifert H, Wenzel RP and Edmond MB. Nosocomial bloodstream infections in US hospitals: analysis of

24,179 cases from a prospective nationwide surveillance study. Clin Infect Dis 2004;39:309-17

2. Gaynes R, Edwards JR. Overview of nosocomial infections caused by gram-negative bacilli. Clin Infect Dis 2005;41:848-54

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CDC Criteria for CRBSI

� Positive semi quantitative (>15 colony-forming units

[CFU]/catheter segment) or quantitative (>103 CFU/catheter

segment) cultures whereby the same organism (species

and antibiogram) is isolated from the catheter segment and peripheral blood

� Simultaneous quantitative blood cultures with a ≥5:1 ratio CVC versus peripheral

� Differential period of CVC culture versus peripheral blood culture positivity of >2 hours

CDC, 2011

Sources of CRBSI: Intraluminal

ContaminationContamination

Non-aseptic manipulations to hub and tubing Contaminated Infusate

Hub Contamination

Hub contamination infections� Seen in long-term catheters

(cuffed, surgically implanted or tunneled)

� Occur 2 or more weeks after insertion

10%Other

60% Skin

30% Hub

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Sources of CRBSI: Extraluminal

Contamination

Skin Contamination

Infections related to skin flora regrowth:

� Occur when organisms from the skin travel along the intercutaneous segment of the catheter

� Occur usually within first 2 weeks of insertion

� Are seen more often with short-term, non-tunneled, non-cuffed catheters

� Reduced with the use of maximum barrier precautions

60% Skin

10%Other

30% Hub

Biofilm

� When the catheter becomes contaminated, biofilm forms

� Biofilm-forming bacteria secrete a sticky carbohydrate coating to protect themselves from antibiotics and disinfectants

� Because of this coating, biofilm bacteria are unique from planktonic bacteria making biofilms notoriously difficult to kill

“The rule of thumb is that 1,000 times more of an antimicrobial agent is needed to kill a biofilm than a planktonic bacteria.” (William Costerton)

� A best practice is to prevent bacteria regrowth on the skin before biofilm can form

Candida albicans biofilm after 24

hours of development. Catheter wall

and intraluminal biofilm

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Microorganisms Commonly Associated with Biofilms on Central Venous Catheters

• Candida albicans

• Coagulase-negativeStaphylococcus

• Enterococcus species

• Klebsiella pneumoniae

• Pseudomonas aeruginosa

• Staphylococcus aureus

Ryder, M.A. Catheter-Related Infections: It's All About Biofilm. Topics in Advanced Practice Nursing eJournal.2005;5(3)

37%

14%13%

5%

5%

4%

3%

2%

17%Coag Neg Staph

Enterococcus

S aureus

Candida

Enterobacter

Pseudomonas

Klebsiella

E coli

Other

Most Common Pathogens Causing CRBSI

Impact of Skin Flora

� Location matters� Skin of the neck and thorax is oily and houses

approximately 1,000–10,000 CFUs per site

� Skin of the antecubital space is dry and cool and houses approximately 10 CFUs per site

� Even with stringent cleansing and prepping, up to 20% microbes remain on and within the skin after prepping – the skin can never be sterilized

What is Best Practice?

Best Practices are defined as:

Strategies, activities or approaches that have been shown through research and evaluation to be effective and/or efficient. Also known as evidence-based practice.

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Organizational Evidence for Best Practices

Examples:

� Centers for Disease Control 2011 Guidelines for Prevention of Catheter Related Infections– USA

� Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA ). 2008 Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals, 29(Supp 1):S22.

� Institute for Healthcare Improvement (IHI) www.IHI.org - USA

� Agency for Healthcare Research and Quality (AHRQ) - USA

� Registered Nurses Association of Ontario (RNAO) 2008 Best Practice Best Care – Canada; Infusion Nurses Society Standards of Practice (INS) - 2011,;Royal College of Nursing Standards of Practice 2010

� National Institute for Health and Clinical Excellence (NICE) – UK

� EPIC and EPIC2 2007 Guidelines for Preventing Hospital Acquired Infections –UK

� Infusion Nurses Society, Infusion Nursing Standards of Practice, www.ins1.org ,

� Association of Vascular Access (AVA) Position Statements, iSAVE THAT LINE Campaign

Best Practices

Vascular

Access

Education for

reducing

complications

and

infections

� Provide consistent and repeated education on management and prevention of complications with IV/CVADs.

� Education results in reduced infection and other complications.

� The principles and practice of infusion therapy should be included in the basic IV education curriculum, be available as continuing education, be provided in orientation to new employees and be made available through continuing professional development opportunities.

SHEA/IDSA 2008 HAI Prevention Compendium

Sherertz R, et al. 2000 Ann Inter Med

Coopersmith C, et al. 2002 Crit Care Med

Warren D, et al. 2003 Crit Care Med

O’Grady N, et al. 2011 CDC Guidelines

Best Practices

Establish

Teams for

IV/PICC/

CVAD

placement

� A specialized team of individuals educated on insertion and care of devices will result in fewer complications

� Team management of CVAD selection, placement, dressing changes and monitoring has the greatest effect

Hawes M. 2007 JIN

INS Standards of Practice 2011

Robinson M, et al. 2005 JPEN

Hornsby s, et al. 2005 JIN

Soifer N, et al. 1998 Arch Intern Med

Alexander M, et al 2002 Nursing Spectrum


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Best Practices

Preferred

antisepsis

2%

Chlorhexidine

with 70%

Alcohol

� Chlorhexidine used for prepping prior to CVC placement through the skin reduces skin flora and maintains a residual effect up to 48 hours

� Chlorhexidine with Alcohol has faster killing action and shorter dry time. Use back and forth frictional scrub for 30 seconds, allow to dry up to 3 minutes

� Consistent use of Chlorhexidine has a cumulative effect to prevent skin flora regrowth

Chaiyakunapruk N, et al. 2003 Clin Infect Dis


Maki D, et al. 1991 Lancet

Daily

Bathing

� For critically ill patients with a CVC,

consider daily bathing with

chlorhexidine gluconate/alcohol

combination washcloths to reduce

colonization and CRBSI (IB)

� Excludes head, mucous membranes,

and non-intact skin

� In a 6 month study of adult ICU

patients: reduction of MRSA by 25%,

VRE by 45%

Climo et al.,2009

Best Practices

© Sage Products, Inc.

Best Practices

Chlorhexidine

Impregnated

Dressings

� Studies show reduction of CRBSI with CHG impregnated dressing.

� Impregnated dressings show effective reduction of skin flora up to and beyond 7 days.

� Catheter –skin junction site should be visualized daily.

Bhende S, Rothenburger S. 2007 JAVA

INS Standards of Practice 2011.

Chambers 2005 Journ Hospital Infec

Safdar N, Maki D. 2004 Intens Care Med


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Best Practices

Antimicrobial

Catheters� Use of antimicrobial catheters reduces

CRBSI by as much as 40%� Minocycline/Rifampin� Chlorhexidine and Silver Sulfadiazine� Use for high risk patients or when

infection rate exceeds goals despite implementation of bundle.

Alonso-Echanove J, et al. 2003 Inf Contr Hosp Epid


Marik P, et al. 1999 Crit Care Med

Darouiche R, et al. 1999. NEJM

Raad I, et al. 1997 Ann Inter Med

Maki D, et al. 1997 Ann Inter Med

What is the Central Line Bundle?� …is a group of interventions related to patients with

intravascular central catheters that, when implemented together, result in better outcomes than when implemented individually

� The science behind the bundle is so well established that it should be considered standard of care

� The key components of the IHI Central Line Bundle are:1. Hand Hygiene 2. Maximal Barrier Precautions Upon Insertion 3. Chlorhexidine Skin Antisepsis 4. Optimal Catheter Site Selection, with Avoidance of the

Femoral Vein for Central Venous Access in Adult Patients

5. Daily Review of Line Necessity with Prompt Removal of Unnecessary Lines

Best Practices

Intentional

Catheter

Selection

� Assess the patient for appropriateness of catheter, size and lumens.

� Use single lumen catheter unless multi-lumen device is essential for therapy

� Consideration for the condition of the patient, need, duration and treatment help to guide selection

� Certain access areas on the body carry less risk with insertion related to skin flora. Use device and area with least risk.

EPIC 2007

Grinspun D. 2008 RNAO Guidelines

Barton A, et al, 1998 Jour Nurs Care Qual


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Best Practices

Maximum

Sterile

Barriers

� Use of strict sterile procedure with maximum barriers reduces infection

� Incorporation of full body drapes improves sterile procedure when ultrasound is used for CVC insertion

� Personal protective equipment is standard with mask, head cover, sterile gown and sterile gloves

� Incorporation of a Central Line Checklist will aid compliance with sterile technique and best practices


Pratt R, et al. 2007 EPIC2

Pronovost P, et al. 2006 NEJM

Saver C. 2006 Nurs Man www.IHI.org

Maki D. 1994 Inf Contr Hosp Epid

Raad I, et al. 1994 Infect Contr Hosp Epid

DAILY CHECKLIST FOR CVC CARE AND MAINTENANCE

Date:

Every day, evaluate the following:

Need for continued use of CVC

Can current IV medications be given orally?

Can frequency of ordered labs be decreased?

Is there evidence of catheter or site complications?

Can CVC be flushed without resistance and brisk blood return upon aspiration?

Ensure all stopcocks, ports are cleared of blood

Is dressing occlusive and without drainage, blood, or moisture?

Perform dressing change or port access every __ days

Perform needleless connector change every __ days

Perform infusion tubing change every ___ days

Performance measures:

Hand hygiene performed before and after care

Use of clean gloves for all CVC access

CVC maintenance supplies readily available

Disinfection of needleless connectors prior to accessing

For muli-lumen CVC, dedicated lumen for TPN

Daily bathing with CHG

Considerations for continued use of CVC:

• Patient receiving the following therapies: hyperosmolar therapies e.g. TPN, chemotherapy, vesicants, irritants, vasopressive drips, CVP monitoring, and frequent blood sampling

• Patient conditions: hemodynamically unstable, rapid infusion of large volumes of fluid/blood, critical airway, poor access, and need for frequent or long-term access

Type of CVC: ___________________ Location of CVC: ______________

Date of insertion: ________________ CVC tip placement: ____________

Presented at the Association of Vascular Access (AVA) Conference, September, 2009

P Catudal, D Doellmanwww.avainfo.org

Best Practices

Daily

Assessment

of Site

Necessity

�Perform daily assessment of insertion

site with palpation and visualization.

Monitor for complications.

� Institute a systematic process to assess

each central venous catheter for

necessity with prompt discontinuation.

�No delays in discontinuation of devices

when therapy is complete

Pronovost P, et al. 2006 NEJM


Saver C. 2006 Nurs Man www.IHI.org

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Maintenance Bundle

� Maintenance Best Practices � Disinfect before access� Remove nonessential catheters� Change dressings weekly and when loose using

CHG skin antisepsis� New tubing for new catheter or every 96 hours,

exceptions apply� Keep piggyback intermittent sets connected to

maintain closed system and reduce contamination� Consider disinfecting caps for tubing and CVC

access points� Perform surveillance for infection and compliance

Halton et al., 2009; Parencevich & Pittet, 2009, ESPEN 2009

Risk Factors for BSI During the Process of CVC Care Maintenance

� Provider knowledge of risk factors� Minimize CVC manipulation� Consolidate blood draws� Daily site inspection (visual & palpation)� Dressing change protocol� Hand hygiene prior to accessing hubs� Hub antisepsis prior to accessing� Tubing replaced after blood product infusions� Hubs replaced after any opening� Nurse-to-patient ratio� Specialized line teams� Protocol for CVC removal

Use of Needless

Connectors

� Utilize a needleless connector at CVC hubs and stopcocks (1A)

� Minimize the use of stopcocks If a stopcock is used, cap port(s) with a needleless connector and disinfect prior to use

� Educate clinicians on appropriate use of needleless connectors per manufacturer’s guidelines

� Consider use of a closed system for infusion, medication administration, and blood sampling

Casey et al., 2003; Yebenes, et al., 2004

Best Practices

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Needleless

Connector

/Hub

Antisepsis

and change

� Vigorously scrub needleless connector (diaphragm and sides) prior to entry with seconds (or manufacturer’s guidelines) and allow to dry (1A)

� Organizational CVC policies to address consistent practice for antisepsis of needleless connectors

� Alcohol or chlorhexidine gluconate /alcohol combination using friction for a minimum of 15 seconds.

� Needleless connectors to be changed at least as frequently as the administration set

� For CVCs that are locked, change no more

frequently than every 96 hours

Kaler & Chinn, 2007

Best Practices

Process

Improvement Plan

� Perform surveillance or processes:

-Hand hygiene

-Sterile or aseptic technique-Proper skin disinfectant andapplication-Catheter access technique-Infusion tubing change technique-Dressing change technique-Complication rates

-Collect data onCRBSI rates

-Identify trends,and potential lapses with infection controlpractices

Best Practices

Putting it all together

� Provide the very best and most effective care for our patients as evidenced by a zero intravenous catheter infection rate and few catheter related complications, by using best practices that have been shown through research and evaluation to be effective and/or efficient

� Is there any reason we cannot apply ALL the best practices?

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Thank you for your attention

Nancy Moureau

[email protected]

QUESTIONS?

catheter-related bloodstream infection nov...

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