AAP Things That Work: Prevention of Catheter Related Bloodstream Infections

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AAP Things That WorkPrevention of Catheter
Related Bloodstream Infections

• Marlene R. Miller, M.D., M.Sc.
• Christopher T. McKee, DO
• Ivor Berkowitz, M.D.
• Claire Beers, R.N., M.S.N.
• Johns Hopkins Childrens Center
• Hospital Epidemiology and Infection Control
• Center for Innovations in Quality Patient Care

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Introduction

• Review Epidemiology
• Define Standard of Care
• Hand Hygiene
• Maximal Barrier Precautions
• Proper Antisepsis
• Insertion Sites of Choice
• Describe our intervention and results to date

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The Problem

• 250,000 cases of central venous catheter related
  bloodstream infections (CR-BSI) per year in US
• 80,000 cases per year in ICUs
• Attributable mortality 12-25
• Attributable cost 25,000 per episode

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Strategies For Prevention Adult Experience

• Hand Hygiene
• Use of Maximal Barrier Precautions
• Chlorhexidine for Skin Antisepsis
• Subclavian Site as First Choice
• Remove Unnecessary Lines

MMWR. 200251RR-10
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What Is Pediatric Best Practice?

• No studies published in pediatric literature
• Assume adult data holds for children
• Exception is optimal site of line insertion

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BSI Intervention

• Education on best practices
• Line cart
• Nursing check list for CL insertion
• Empowerment of nurses to stop procedures if best
  practices breached

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Hand Hygiene The Data

• Since 1977, 7 of 8 prospective studies have
  shown that improvement in hand hygiene
  significantly decreases infection rates

Clin Infect Dis 1999291287-94
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Alcohol-Based Hand Cleansers
Non-medicated soap used alcohol was mixture of
n-propanol and isopropanol hands contaminated
under clinical conditions Am J Infect
Control 1999 27258-61
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Hand Hygiene Be A Role Model

• HCWs in a room with a senior medical staff person
  or peer who did not wash their hands were
  significantly less likely to wash their own hands
  (OR 0.2, p
• Use of gloves does not obviate the need for hand
  hygiene

Emerg Infect Dis 2003 9217-23
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Hand Hygiene Best Practice

• Purell for routine hand cleaning
• Soap and water when hands are soiled and at start
  of day
• One of these types of cleanings should be done
  before inserting a central line

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Maximal Barrier Precautions
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Do I Really Need Maximal Barrier Precautions ?
Am J Med 199191(3B)197S-205S Infect Control
Hosp Epidemiol 199415231-8
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What Are Maximal Barrier Precautions?

• For You
• 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 patients head and body with a large
  sterile drape

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Who Needs To Be Dressed In MBP?

• The operator
• The assistant
• Anyone else who crosses the sterile field
• NOT people in the same room who are not involved
  with the procedure

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Skin Prep

• Chlorhexidine 2 is more effective than povidone
  iodine (Betadine) because it dries quickly and
  has longer residual action

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Skin Prep

• If you must use Betadine
• Allow Betadine to dry completely (at least 2
  minutes)
• Do not blow on, fan, or blot the site to make it
  dry faster!

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Dressing The Line

• Apply dressing immediately after placement when
  site is still sterile
• Use transparent dressing (Sorbaview) unless site
  is oozing or pt is allergic

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Maintaining The Line

• Change transparent dressing weekly, gauze
  dressing daily, and any dressing that is damp,
  bloody, or non-occlusive
• Do not use topical ointment or cream at insertion
  site
• Do not leave a line undressed
• Lines examined daily by medical staff

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What Site Is Best?

• No randomized trial satisfactorily has compared
  infection rates for catheters placed in jugular,
  subclavian, and femoral sites. MMWR, 8/9/02

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What Site Is Best?

• The Hopkins Experienceretrospective analysis of
  SICU IJ SC catheters that grew ? 15 cfu
• IJ position was the only predictive factor of ?
  15 cfu (OR 1.83, p

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What Site Is Best?

• RCT of femoral and SC lines in the ICU
• 145 pts femoral/144 pts SC
• Outcomes
• Similar rates of mechanical complication 17.3
  vs 18.8 (p NS)
• Higher rate of infectious complications
  (colonization and BSI combined) in femoral grp
  19.8 vs 4.5 (p
• Higher rate of thrombotic complications in
  femoral grp 21.5 vs. 1.9 (p
  thrombosis 6 vs 0

JAMA 2001,286700-7
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What Site Is Best?

• Based on these and other studies, the JHH VAD
  policy recommends that the preferred order of
  line placement is
• SC ?IJ ?F
• Other factors to consider in site choice
• Anatomic deformity
• Coagulopathy
• Operator experience

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What Site Is Best For Children?

• Traditionally femoral vein is site of first
  choice for all pediatric patients
• Operator experience is determining factor for
  placement of lines elsewhere
• Infectious data does not hold true in children
• Site of insertion does not correlate with
  infectious complications
• Same or fewer mechanical complications noted with
  femoral line placement
• No thrombotic risk with femoral line placement

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Summary of Best Practices

• Wash your hands or use waterless hand cleaners
• Use sterile technique and maximal barrier
  precautions when placing central lines
• Use chlorhexidine for line insertion and
  dressing changes
• Use femoral site if possible
• Dont put in lines that are not needed and take
  out lines that are not needed

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BSI Intervention

• Education on best practices
• Line cart
• Nursing check list for CL insertion
• Empowerment of nurses to stop procedures if best
  practices breeched

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BSI effort starts
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BSI Intervention

• Education on best practices
• Hand Hygiene
• Use of Maximal Barrier Precautions
• Chlorhexidine for Skin Antisepsis
• Femoral Site as First Choice
• Remove Unnecessary Lines
• Line cart
• Nursing check list for CL insertion
• Empowerment of nurses to stop procedures if best
  practices breeched

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Lessons Learned

• Actual and reported practices vary
• People may not know what you think they know
• Team work helps
• Maximized preparation helps (line cart)
• Need to be on alert for next best thing in new
  equipment