The Peripheral Vascular Catheter PVC Bundle

1
The Peripheral Vascular Catheter (PVC) Bundle

• How to use it to reduce the risk
• of insertion site sepsis and blood stream
  infections in your ward

2
What do we know about PVCs from the HPS
prevalence survey?

• 1 in every 3 patients has a PVC!
• The majority of patients with PVCs are in the
  medical wards
• 11 of all HAIs identified were skin and soft
  tissue infections (many related to PVCs)
• So big a problem was identified that skin and
  soft tissue infections related to PVCs are
  considered a Priority Area.
• Source Scottish National Prevalence Survey 2007

3
What do we know from the scientific literature?

• There are many papers in the literature which
  confirm the importance of PVCs in causing skin
  and soft tissue infections and blood stream
  infections
• Some key papers are highlighted in the next slides

4
One study of Peripheral Vascular Catheters found
the following

• 52 Of patients had a PVC
• 33 Of PVCs were incorrectly dressed
• 52 Of PVCs were incorrectly positioned
• 46 Of PVCs were unused for 24 hours
• 23 Of PVCs had never been used
• 23 Of PVCs had no documented purpose
• 12 Of PVCs had visible phlebitis
• 6 Of PVCs had infiltration
• Thomas et al JHI 2006

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Extracts from a study into deaths following MRSA
infections
Six days post-operatively the patient was noted
to have pus coming from a cannula site. Case
study 6
After 8 days the PVC inserted on admission
showed signs of infection with a purulent
discharge. Case study 4
For almost half of the cases reviewed, The
source of the MRSA infection was an invasive
device, particularly PVC and CVC.
http//www.hpa.org.uk/publications/PublicationDisp
lay.asp?PublicationID107
6
Researchers in Spain found that blood stream
infections (BSIs) caused by PVCs were
statistically more likely to be caused by Staph.
aureus than BSIs from central vascular
catheters53 of PVC BSIs were S. aureus33 of
CVC BSIs were S. aureusP 0.01
Staph aureus bacteraemias includes MRSA and MSSAs
Pujol et al JHI 2007
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How do PVCs cause BSIs?
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The blood should be sterile free from microbes
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Healthcare interventions, like the use of
Peripheral Vascular Catheters make patients
vulnerable to infection as organisms can get
direct entry to the blood.
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Infections start locally at the catheter
insertion site,, but then
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If the catheter is not removed and the infection
is not treated effectively, the organisms can
infect the blood
12
Once the organisms are in the blood a Staph
aureus bacteraemia (SAB) has occurred
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The best way to prevent microbes from getting
into the blood is.
14
To Reduce Device Days Optimise Care
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But dont we always do our best?
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We are not as good as we think we are!
BREAKING NEWS
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These are Staphylococci sitting on a skin scale
that infect PVCs
18
As part of the SPSP, bundles have been devised to
help you make your care procedures more reliable.
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A bundle is

• A structured way of improving the processes of
  care and patient outcomes
• A small, straightforward set of practices -
  generally three to five - that, when performed
  collectively, reliably and continuously, have
  been proven to improve patient outcomes. 
• For more information see the IHI website at
  http//www.ihi.org/IHI/Topics/CriticalCare/Intensi
  veCare/ImprovementStories/WhatIsaBundle.htm

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What makes bundles effective at improving
practice?

• The bundles are based on the best available
  evidence
• All or nothing assessment
• Each bundle criteria is critical to achieving the
  bundle and improving care, so the bundle is
  scored only if all the criteria are achieved.
• The bundle is measured at the same time in the
  same place so that any changes in the results
  will reflect any changes in practice

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To identify all the possible bundle criteria that
could be used, a cause and effect chart was
produced from the evidence in the guidelines.
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A cause and effect chart describes all the
elements of a system under 4 main headings
People, Equipment, Environment, Methods the
next slide shows the cause and effect chart for
minimising skin and soft tissue infections
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The PVC Cause and Effect Chart
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The red writing on the cause and effect chart
indicates in the PVC bundle
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HPS has produced a bundle pack which may help you
to implement the PVC bundle

• A statement of commitment for the clinical team
  to sign
• A cause and effect chart describing the evidence
  for optimal practice
• A standard operating procedure for the bundle
  including the bundle criteria
• The data collection sheet

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The PVC bundle criteria are fixedBut how you use
the PVC bundle in your area is up to you and your
team.Using the PDSA methodology you will be
able to make the PVC bundle work in your area.
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Why have we picked these bundle criteria?
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These bundle criteria have been chosen because
the evidence identifies them as the most
important to reduce the risk of skin and soft
tissue infections and BSIs They will be
evaluated over time and may change.
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It is most important to emphasise that effective
infection prevention involves many other
practices, these must not be neglected whilst
concentrating on the bundle criteria See the
cause and effect chart.
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Does it work?
This is the first PVC bundle. But others have
found that using bundles reduces infection risks
by making processes more optimal. (Early
indications from Scotland have found this bundle
makes it safer for patients.) Apisarnthanarak et
al ICHE 2007
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Before you start a bundle

• You have to realise that quality improvement must
  be continuous.
• This is not a short term commitment quality
  improvement needs to be embedded into your
  systems to become part of what you do every day.

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The next few slides describe the 7 steps in
successful bundle implementation
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Step 1 - CommitmentThe first step is for the
team leader to get everyone to commit to doing
the bundle to improve patient safety.
Remember Patient safety is for life not just
for Christmas!
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Step 2 - Understand there will be consequences

• The team must consider that they will find out
  things they did not want to know, e.g. your team
  is not perfect!
• Consider how you will deal with this before you
  start
• Commit to feedback being for improvement and not
  judgement
• Acknowledge that where you are, is not where you
  want to be, and this process will help you
  improve
• Commit to not shooting the messenger, i.e. the
  one collecting the data!
• Commit to a no blame culture
• Remember you are doing this for optimal patient
  safety and to show the quality of your care not
  to damage your care team

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Step 3 - Work out the process that fits in with
your systems of working

• How often do you want to measure compliance (at
  least once a week)?
• Who will collect the data?
• When will they collect the data?
• Where will they put the completed sheets?
• Where will you display your results?
• What will you do with the results how will you
  act on them?
• Is everyone agreed on the process?

The data must be collected on the same day and at
the same time!
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Step 4 Start small

• Remember the PDSA methodology
• One patient, one nurse, one doctor one day
• The next time three patients,
• The next time five patients
• The next time all
• Dont expect to get it right first time

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Step - 5 When you are all agreed that it works on
five get ready to implement it ward wide

• Pick a start date
• Make sure everyone knows
• Have the bundle data collection forms ready
• BEGIN

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Step 6 Continuously assess progress
No skin and soft tissue infections due to PVC
There will be 100 compliance with the
bundle There will be no skin or soft tissue
infections due to PVCs
Dont use PVCs unless absolutely
necessary. Remove PVCs as soon as possible Dont
use a PVC just in case
The next slide has some considerations to help
improve processes
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Process Improvement
Any redundant steps
Can you stop it, e.g. remove catheter
Make it easier
Make it better
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Step 7 If its going well and you have improved
processes and reduce the risk of skin and soft
tissue infections try another bundle
If you find out anything that would help, share
others contact HPS HPSinfection
control_at_hps.scot.nhs.uk
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Well done for committing to improving patient
safety in your ward