Disclosures  

•  Teleflex  Ultrasound-­‐guided  central  venous  &  arterial  access:  compliance  within  prac=ce  –  Faculty  Member  

What  we  already  know  

•  Currently,  nurses  provide  majority  of  care  to  VADs  

•  >  ~95%  hospital  admissions  will  have  some  form  of  VAD  within  24hr  of  admission  

•  OSen  first  line  of  management  during  any  given  hospital  admission  -­‐  ER  

•  Vascular  access  procedures  are  the  most  commonly  performed  invasive  procedure  in  the  world  today.  

What  we  already  know  

• With  that  knowledge,  clinicians  need  to  be  aware  of  the  types  of  CVCs  available,  the  advantages  and  disadvantages  of  each  type,  and  how  catheter  selec=on  and  implementa=on  of  recommended  preven=ve  strategies  can  impact  the  CRBSI  rate.    

•  These  devices  and  strategies  work  together  as  a  collabora=ve  approach  but  cannot  individually  provide  the  significant  impact  needed  to  affect  CRBSIs.    

Typical  ICU  trauma  pa=ent;  

~  mul=-­‐infusion  therapy  

~  mul=ple  wounds  

Portals  for  cross-­‐infec=on?  

Early  Assessment  

•  Selec=on  of  device(s)  based  on  a  needs  assessment  

• Minimises  the  need  for  inappropriate  devices  

•  Ongoing  monitoring  is  essen=al  

•  Products/device  review  and  analysis  •  Defining  terminology  and  repor=ng  outcome  measures  

The  powers  of  observa=on..  

Shoe  leather  surveillance  is  the  best  form  of  monitoring  

Interven=on  

•  Preven=on  of  infec=on  • Maintaining  a  closed  IV  system  

• Maintaining  a  patent  device  

•  Preven=ng  damage  to  the  device  (Malleb  and  Bailey  1996)  

•  Surveillance,  management,  and  leadership  following  project  implementa=ons  

CRBSI  or  CLABSI?  Confused  yet?  

CDC  says  what..  

•  CRBSI  criteria  require  one  of  the  following:  –  A  posi=ve  semi  quan=ta=ve  (>15  colony-­‐forming  units  [CFU]/catheter  segment)  or  quan=ta=ve  (>103CFU/catheter  segment)  cultures  whereby  the  same  organism  (species  and  an=biogram)  is  isolated  from  the  catheter  segment  and  peripheral  blood  

–  Simultaneous  quan=ta=ve  blood  cultures  with  a  ≥5:1  ra=o  CVC  versus  peripheral  

–  Differen=al  period  of  CVC  culture  versus  peripheral  blood  culture  posi=vity  of  >2  hours  

•  A  CLABSI  as  defined  by  CDC,  is  a  primary  (i.e,  no  apparent  infec=on  at  another  site)  BSI  in  a  pa=ent  that  had  a  central  line  within  the  48-­‐hour  period  before  the  development  of  the  BSI.  BSI  is  defined  using  either  laboratory  confirmed  bloodstream  infec=on  (LCBI)  or  clinical  sepsis  (CSEP)  defini=ons    

•  In  the  CDC/NHSN  defini=on  of  CLABSI,  there  is  no  minimum  period  of  /me  that  the  central  line  must  be  in  place  in  order  for  the  BSI  to  be  considered  central  line–associated.    

•  The  culture  of  the  catheter  -p  is  not  a  criterion  for  CLABSI!  

Involving  people..  

• While  most  facili=es  have  tradi=onally  disseminated  infec=on  data  to  hospital-­‐wide  commibees  and  administra=on,  it  is  essen=al  to  also  share  this  informa=on  with  the  people  who  can  actually  make  a  difference—the  direct  care  providers.  Involving  proceduralists  who  place  the  central  venous  catheters  provides  valuable  feedback  on  poten=al  technique  issues.  

Maximal  barrier..  

Products  

•  Analysis  of  specific  types  of  products,  (e.g.  catheters,  valves,  site  dressings,  fluid  bags,  accessory  products),  con=nues  to  have  benefit.    

•  But  the  true  value  of  a  specific  product  is  best  recognized  in  rela=on  to  all  products  that  make  up  the  pa=ent’s  IV  system.    

Educa=on  and  training  

•  Mul=ple  studies  have  demonstrated  improvement  with  educa=on  and  training  

•  Physicians  have  currently  no  creden=aled/standardized  method  for  learning  catheter  inser=on  

•  Many  nurses  have  very  lible  exposure  to  principles  and  prac=ces  of  catheter  management  

•  See  one,  do  one,  teach  one  method  is  NOT  an  adequate  educa=onal  tool!  

•  Mul=disciplinary  group  to  create  educa=onal  plan    

Preven=ons  matched  with  source  of  organisms  

Skin  •  Hand  hygiene  

•  Skin  an=sepsis  •  Inser=on  site  •  Maximal  barriers  

•  Catheter  stabiliza=on  •  Dressings  •  An=microbial  catheters  

Preven=ons  matched  with  source  of  organisms  

Infusate  •  Single  use  flushing  system  

•  Laminar  air  flow  work  bench  •  Strict  adherence  to  asep=c  technique  when    

Preven=ons  matched  with  source  of  organisms  

Catheter  hub  manipula=on  •  Hand  hygiene  

•  Number  of  catheter  lumens  •  Hub  an=sepsis  •  Tubing  and  cap  changes  

•  Flushing  procedures  •  An=microbial  catheters  •  Needleless  injec=on  devices  

Who’s  who  in  the  zoo!  

•  Reducing  CRBSI  is  EVERYONES  business,  not  just  one  clinician  specialty  

•  Nurses,  physicians,  respiratory  therapists,  technicians,  as  well  as  pa=ents  themselves,  take  the  responsibility  to  prevent  infec=ous  complica=ons  through  constant  vigilance  in  monitoring  the  device  Its  not  your  -tle,  but  it’s  the  difference  you  

make  at  the  bedside  that  counts  

Tim.Spencer@sswahs.nsw.gov.au  

• Webcast  was  to  share  knowledge  and  best  prac=ces  on  IV  therapy  management  including  CLABSI  preven=on  and  beyon  

hbp://vioca.st/Andrew_Jackson_Infec=on_Preven=on_IV_Management_Educa=onal_Webcast