Central Venous Lines and Central Venous Lines and Blood Stream InfectionsBlood Stream Infections

Breaking out the BundlesBreaking out the Bundles

Elizabeth Gilger, RN, CCRNElizabeth Gilger, RN, CCRNMedical University of South CarolinaMedical University of South Carolina

Infection ControlInfection Control

Did you know?Did you know?Approximately 90% of catheter related Approximately 90% of catheter related

blood stream infections (BSI) occur with blood stream infections (BSI) occur with central venous catheters (CVC)central venous catheters (CVC)

Between 500 and 4,000 patients die Between 500 and 4,000 patients die annually from BSIannually from BSI

Institute for Healthcare Improvement, 2007

Infection ControlInfection ControlDid you know?Did you know?

Mortality of ventilated patients who Mortality of ventilated patients who develop VAP is 46 %develop VAP is 46 %

$40,000 is the estimated cost $40,000 is the estimated cost accumulated due to VAP accumulated due to VAP

Institute for Healthcare Improvement, 2007

Blood Stream InfectionsBlood Stream Infections

Disruption of the integrity of the skin Disruption of the integrity of the skin creates an avenue for infectioncreates an avenue for infection

Infection spreads to the bloodstream Infection spreads to the bloodstream leading to Hemodynamic changes and leading to Hemodynamic changes and organ dysfunction and potentially may lead organ dysfunction and potentially may lead to death to death

Institute for Healthcare Institute for Healthcare Improvement (IHI)Improvement (IHI)

Developed in 1991 to improve health care Developed in 1991 to improve health care worldwide worldwide Developed improvement measures based on Developed improvement measures based on research. Many of these measures had been research. Many of these measures had been previously recommended by CDC in their previously recommended by CDC in their guidelines for the prevention of CVL related guidelines for the prevention of CVL related bloodstream infections.bloodstream infections.Incorporated bundles into the healthcare culture Incorporated bundles into the healthcare culture to ensure standardized practiceto ensure standardized practice

What is a bundle???What is a bundle???

Bundles are groupings of best Bundles are groupings of best practices with respect to a practices with respect to a disease process that disease process that individually improve care, but individually improve care, but when applied together result in when applied together result in substantially greater substantially greater improvement. improvement.

Institute for Healthcare Improvement, 2007

Central Line BundleCentral Line Bundle

Hand Hygiene Hand Hygiene Maximal Barrier Precautions Upon Maximal Barrier Precautions Upon Insertion Insertion Chlorhexidine Skin Antisepsis Chlorhexidine Skin Antisepsis Optimal Catheter Site Selection, with Optimal Catheter Site Selection, with Subclavian Vein as the Preferred Site for Subclavian Vein as the Preferred Site for NonNon--Tunneled Catheters Tunneled Catheters Daily Review of Line Necessity with Daily Review of Line Necessity with Prompt Removal of Unnecessary Lines Prompt Removal of Unnecessary Lines

Think Outside the BundleThink Outside the Bundle

CVL AssessmentCVL Assessment–– Each shift, assess for patency, site condition Each shift, assess for patency, site condition

and dressing patencyand dressing patency

–– If the CVL was placed in a true clinical If the CVL was placed in a true clinical emergency, the line is to be changed after 24 emergency, the line is to be changed after 24 hourshours

Think Outside the BundleThink Outside the Bundle

CVL CareCVL Care–– Change transparent dressings every 7 days, Change transparent dressings every 7 days,

those you cannot visualize the site i.e. gauze those you cannot visualize the site i.e. gauze dressing, change every 24 hoursdressing, change every 24 hours

–– Change tubing and caps every 72 hoursChange tubing and caps every 72 hours

–– Cleanse caps prior to tubing change, IVP Cleanse caps prior to tubing change, IVP medication or flushing with alcohol swab. Use medication or flushing with alcohol swab. Use friction!friction!

InsertionInsertionSite selectionSite selection--recommended site in adults is the recommended site in adults is the subclavian site. For pediatricssubclavian site. For pediatrics--no data. no data. Full barrier precautions should be usedFull barrier precautions should be used--MDs MDs should use gown, hat, gloves and mask. If you should use gown, hat, gloves and mask. If you are in and out of the room, wear a mask. If you are in and out of the room, wear a mask. If you stand there the entire time, you should use full stand there the entire time, you should use full barriers, too. barriers, too. Antibiotic impregnated catheters recommended Antibiotic impregnated catheters recommended for lines that are anticipated to remain 7 days or for lines that are anticipated to remain 7 days or more.more.

Policy 75Policy 75--A A Prior to placement of the line, someone, usually the RN, Prior to placement of the line, someone, usually the RN, is designated to monitor the sterile field and practice. is designated to monitor the sterile field and practice. This designee This designee must stop the proceduremust stop the procedure if the if the appropriate steps are not followed. appropriate steps are not followed. If the patient is conscious, the designee will stop the If the patient is conscious, the designee will stop the procedure by saying procedure by saying ““Break ScrubBreak Scrub””: indicating to the : indicating to the clinician that the bundle has not been followed and the clinician that the bundle has not been followed and the procedure must be stopped. procedure must be stopped. If the clinician does not stop the procedure, the RN is to If the clinician does not stop the procedure, the RN is to notify the nurse manager. notify the nurse manager. Find this checklist on the ClinicianFind this checklist on the Clinician’’s Order site at s Order site at http://http://www.musc.edu/cce/ORDFRMSwww.musc.edu/cce/ORDFRMS//

CVL Insertion Carts and SuppliesCVL Insertion Carts and Supplies

To facilitate adherence to the bundle, carts To facilitate adherence to the bundle, carts are being purchased for nursing unitsare being purchased for nursing unitsThese carts will hold necessary suppliesThese carts will hold necessary suppliesPhysicians have participated in the Physicians have participated in the selection of drapes for the adult and selection of drapes for the adult and pediatric populations. pediatric populations. A variety of drapes are available in A variety of drapes are available in different styles and sizes.different styles and sizes.

3 rolls of tape3 rolls of tape2 boats 4 x 4s2 boats 4 x 4s

6 OpSites6 OpSites4 Biopatch4 Biopatch

6 Chlorapreps6 Chlorapreps

6 10 ml syringes6 10 ml syringes2 transducer covers2 transducer covers

4 packs KY4 packs KY4 vials 30 ml saline4 vials 30 ml saline

4 vial adaptors4 vial adaptors6 injection ports6 injection ports

3 sterile gowns3 sterile gowns

Sterile Gloves: 2 of Sterile Gloves: 2 of each 6.5, 7, each 6.5, 7, 7.5 and 87.5 and 8

Box of hatsBox of hats Box of masksBox of masks

2 Proxima Drapes2 Proxima Drapes 2 Arrow Drapes2 Arrow Drapes

2 triple lumens2 triple lumens2 quad lumens2 quad lumens

1 Long Quinton1 Long Quinton1 Short Quinton 1 Short Quinton

2 Cordis2 Cordis

1. After use, clean cart thoroughly with Cavicide. 2. For isolated patients, avoid taking cart inside the room.3. Restock after each use from the Pyxis, charging supplies to the

patient.4. Check daily to make sure lock is secure.

CVL Cart

http://www.learnovation.com/johnwise_samples.htm

You can’t betoo clean!!!

And wash your hands!!!!!!!!And wash your hands!!!!!!!!

Question 1Question 1

1. Which of the following personal 1. Which of the following personal protective equipment are required to be protective equipment are required to be worn by the physician for central venous worn by the physician for central venous line insertion?line insertion?

a)a) Gloves and gownGloves and gownb)b) Gloves, gown and maskGloves, gown and maskc)c) Gloves, gown, mask, and hatGloves, gown, mask, and hatd)d) None of the aboveNone of the above

Question 2 Question 2

2. The preferred site for central venous line 2. The preferred site for central venous line placement in adults is placement in adults is

a)a) Jugular veinJugular veinb)b) Femoral veinFemoral veinc)c) Subclavian veinSubclavian veind)d) All of the above are acceptableAll of the above are acceptable

Question 3Question 3

3. The Central Line Bundle includes all of 3. The Central Line Bundle includes all of the following except:the following except:

a)a) Hand hygieneHand hygieneb)b) Daily review of line necessityDaily review of line necessityc)c) Ensuring optimal site selectionEnsuring optimal site selectiond)d) Chlorhexidine skin Chlorhexidine skin antipsesisantipsesise)e) Keeping the HOB elevated 30 degreesKeeping the HOB elevated 30 degrees

Question 4Question 4

4. The RN or designee in the CVL 4. The RN or designee in the CVL placement procedure has the authority to placement procedure has the authority to stop the procedure if sterile technique is stop the procedure if sterile technique is broken by saying:broken by saying:

a)a) ““Time OutTime Out””b)b) ““Break ScrubBreak Scrub””c)c) ““STOP!STOP!””d)d) The RN or designee cannot stop the The RN or designee cannot stop the

procedure procedure

CONSISTENCY IS BEST PRACTICECONSISTENCY IS BEST PRACTICE