Elimination of CentralLine Associated Bloodstream Infections: Application of the Evidence

1
Elimination of Central-Line Associated
Bloodstream Infections Application of the
Evidence
2
Central-Line Associated Bloodstream
Infections(CLA-BSIs)

• Estimated 250,000 cases occur annually
• Mortality rate of 12 to 25 for each infection
• Marginal cost to hospital can be as high as
  25,000 per episode

3
Surveillance for Hospital-Acquired Infections

• Surveillance is employed in healthcare facilities
  worldwide
• Comparison of hospital-acquired infections rates
  is made possible through various national
  surveillance networks that allow surveillance
  findings to be used for quality improvement and
  benchmarking efforts
• Largest database in US National Healthcare
  Safety Network

4
Risk Factors

• Four major risk factors are associated with
  increased catheter-related infection rates
• Cutaneous colonization of the insertion site
• Moisture under the dressing
• Prolonged catheter time
• Technique of care and placement of the central
  line

5
Evidence-Based Strategies Selected to Reduce
CLA-BSIs

• Central line-associated bloodstream infections
  bundle
• Hand hygiene
• Maximal sterile barriers
• Chlorhexidine for skin asepsis
• Avoid femoral lines
• Avoid/remove unnecessary lines

6
Hand Hygiene

• Cornerstone of any infection prevention program
• Many studies have shown that improvement in hand
  hygiene significantly decreases a variety of
  infectious complications
• Insufficient or ineffective hand hygiene
  contributes significantly to a greater bacterial
  burden and subsequent spread of microorganisms
  within the environment

7
Hand Hygiene

• Use of waterless alcohol-base hand rub
• Most effective and efficient method for hand
  antisepsis against bacterial pathogens
• When hands are visibly soiled, they should be
  washed with soap and water

8
Efficacy of Hand Hygiene Preparations in Killing
Bacteria
Best
Good
Better
Plain Soap
Antimicrobial soap
Alcohol-based handrub
9
Technological Advancements

• Electronic monitoring and voice-activated prompts
  to remind caregivers to perform hand hygiene
  resulted in improved compliance

Swoboda SM, Earsing K, Strauss K, et al.
Electronic monitoring and voice prompts improve
hand hygiene and decreased nosocomial infections
in an intermediate care unit. Crit Care Med.
200432358363.
10
Maximal Sterile Barriers

• Maximal sterile barriers improve sterile
  technique during catheter insertion
• The person inserting the central line wears a
  head cap, face mask, sterile body gown, and
  sterile gloves, and uses a full size drape to
  cover the patient from head to toe

11
Maximal Sterile Barriers

• One study found a 6-fold higher rate of
  catheter-related septicemia when minimal sterile
  barriers (sterile gloves and small drape) were
  used instead of maximal sterile barriers

Raad II, Hohn H, Gilbreath J, et al. Prevention
of central venous catheter-related infections by
using maximal sterile barrier precautions during
insertion. Infect Control Hosp Epidemiol.
199415231238.
12
Chlorhexidine for Skin Asepsis

• Studies have compared chlorhexidine gluconate
  (CHG) versus povidone iodine as a skin antiseptic
  for catheter insertion and routine insertion site
  care
• Recent meta-analysis, the use of CHG rather than
  povidone iodine was found to reduce the risk of
  CLA-BSIs by approximately 50 in hospitalized
  patients who required short term catheterization

Chaiyakunapruk N, Veenstra, DL, Lipsky BA, Saint
S. Chlorhexidine compared with povidone-iodine
solution for vascular catheter-site care a
meta-analysis. Ann Intern Med. 2002136792801.
13
Benefits of CHG

• 2 CHG in tincture of isopropyl alcohol has rapid
  bactericidal activity and is effective within 30
  seconds after application versus 2-minute period
  for povidone iodine
• CHG provides persistent bactericidal activity on
  the skin and maintains its activity in the
  presence of other organic material
• Minimal systemic absorption

14
How to Use CHG

• Back and forth, up and down motion
• Motion promotes penetration of the cleanser
  within multiple layers of the epidermis
• Clear solution
• Orange tinted solution now available

15
Site Selection Avoid Femoral Lines

• Insertion of CVCs can lead to serious and
  sometimes life-threatening complications, whether
  of mechanical, infectious, or thrombotic origin
• Higher rate of infectious complications in study
  comparing femoral lines versus subclavian lines
• 19.8 vs 4.5

16
Avoid and Remove Unnecessary Lines

• Once placed, there should be periodic, if not
  daily assessment, of its continued need, with
  emphasis on prompt removal

17
Empowerment of Nursing

• One of the most important steps in preventing
  CLA-BSIs is to empower the nursing staff to stop
  the central line insertion procedure if the
  guidelines were not followed

18
Line Care and Tubing Changes

• A transparent, semi permeable polyurethane
  dressing has many advantages over gauze but both
  have shown no difference in infection rates as
  long as they are used appropriately
• Benefits of a transparent dressing
• Ability to evaluate the insertion site while the
  dressing is in place
• Wicking of moisture away from the skin
• Less frequent dressing changes compared with
  standard gauze and tape dressings

19
Line Care

• CDC guidelines recommend routine changing of
  transparent dressing every 7 days and whenever
  either dressing is soiled or nonadherent
• Antibiotic ointment at the catheter insertion
  site should be avoided, as it promotes fungal
  infections and antibiotic resistance

20
Sorbaview

• Study at UVA in 2005 revealed that Sorbaview is
  more adherent, used less nursing time, and was
  better liked by patients than either tape and
  gauze

21
Tubing Changes

• Current CDC recommendation is to replace
  intravenous administration sets, including
  secondary sets and add-on devices, no more
  frequently than a 72 hour interval, unless
  catheter-related infectious is suspected or
  documented

22
Summary

• Prevention of infection is the foundation of any
  CLA-BSIs management program
• CLA-BSIs are one of the most prevalent
  healthcare-associated infections

23
References

• Centers for Disease Control and Prevention.
  Guidelines for the prevention of intravascular
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  Wkly Rep. 200251(RR- 10)336.
• Pittet D, Tarara D, Wenzel RP. Healthcare
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24
References

• National Nosocomial Infections Surveillance
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  1992June 2004, issued October 2004. Am J of
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• Mermel LA. Prevention of intravascular
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25
References

• Centers for Disease Control and Prevention.
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• Swoboda SM, Earsing K, Strauss K, et al.
  Electronic monitoring and voice prompts improve
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26
References

• Chaiyakunapruk N, Veenstra, DL, Lipsky BA, Saint
  S. Chlorhexidine compared with povidone-iodine
  solution for vascular catheter-site care a
  meta-analysis. Ann Intern Med. 2002136792801.
• Merrer J, DeJonghe B, Golliot F, et al.
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27
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