CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTION

The Central Line Bundle and YOU!

6/6/2013

Quality Assurance/Peer Review Report

Privileged Pursuant to O.R.C. Section 2305.24, .251, .252

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NATIONAL PATIENT SAFETY GOAL 2009

2009 National Patient Safety Goal or (NPSG.07.04.01) requires:

• Implementation of best practice or evidence-based guidelines to prevent central line-associated bloodstream infections (CLABSIs) for short and long-term central venous catheters (CVCs) including PICCs

The deadly cost of CLABSIs:• ~ 90 % of CLABSIs occur with CVCs• Estimate of 14,000 – 28,000 lives lost per year• Hospitalization prolonged a mean of 7 days• Hospitalization costs ↑~ $3,700 - $29,000 • October 1, 2008 CMS (Medicare) no longer

reimbursing for CLABSIs acquired in the hospital

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How Can We IMPACT Central Line Associated Blood Stream Infections

(CLABSIs)?

• What is the Central Line Bundle? Includes the following bundle of 5 care components:1. Hand hygiene2. Maximal barrier precautions3. Chlorhexidine skin antisepsis4. Optimal catheter site selection5. Daily review for line necessity and assessment with prompt removal of unnecessary lines

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HAND HYGIENE – Just do it!

1. Perform hand hygiene before assisting with catheter insertion or manipulation.

2. Palpation of the insertion site should not be performed after antiseptic cleanse, unless aseptic technique is maintained.

3. Before and after inserting, replacing, accessing, repairing or dressing a central line.

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MAXIMAL BARRIER PRECAUTIONS

Use strict adherence as the inserter and all involved with the placement of a central line or guidewire exchange with the following:

• Compliance with hand hygiene• Wear cap, mask, sterile gown and sterile gloves• Cap – covers all hair• Mask – covers nose and mouth tightly• Sterile drape – covers patient from head to toe with

a small opening for line placement

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CHLORHEXIDINE SKIN PREP

• Chlorhexidine (CHG) skin prep prior to placement and for dressing change.

• PINCH wings on CHG applicator.• PRESS sponge against the skin allowing the solution to

penetrate the pad.• PREP covering a large area using a back and forth, up and

down, and diagonal friction scrub for at least 30 seconds. Allow to dry. Do not wipe, blot or fan.

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OPTIMAL CATHETER SITE SELECTION

Subclavian vein is the preferred site for non-tunneled catheters and is associated with lower risk of CLABSIs rather than the jugular vein.

-Femoral site is associated with greater risk of infection and DVTs in adults.

University Hospitals preferred sites:• Subclavian and Internal jugular are preferred sites.• Femoral site would be an option for:

1. ECMO

2. Neuroprotective hypothermia-thermaguard 

3. Other insertion sites are not able to be accessed due to poor vascular upper extremities, etc.

4. A need for dialysis or other patient emergencies

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NEW CENTRAL LINE DRESSING AT UH: TEGADERM HCG

• Studies have shown chlorhexidine gel pad effectively reduces skin flora

• Gel pad easily conforms to body contours • Gel pad is transparent • Gel pad adsorbs fluids & blood • Remains effective & transparent over weeks time• No need to manipulate catheter placing gel pad• Tegaderm dressing eliminates Statlock need

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STEPS FOLLOWING INSERTION• Flush each lumen with 10ml normal saline solution via a 10cc

syringe.

• Apply sterile, occlusive dressing to site.

• Attach male Luer-lock stopcock or Luer-lock IV tubing to each port and close clamps.

• MD should order x-ray to confirm placement prior to infusion for subclavian and internal jugular lines. X-ray confirmation is not necessary for femoral lines.

• MD should order CENTRAL LINE CARE/MAINTENANCE

• Complete Procedure note-general in UHCare. Label as to type of line inserted.

• Document daily assessment and need on progress note.

– Assess for infiltration, phlebitis, infection, and any change from baseline appearance

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DAILY LINE ASSESSMENT AND REVIEW

• The risk of CLABSIs increases over time.• Complete daily assessment of central line for infection.• Prompt removal of unnecessary lines.• The replacement of temporary catheters in the presence

of bacteremia is not an acceptable replacement strategy. The source of infection is usually colonization of skin tract from the insertion site to the vein.

Roles in Daily Site Assessments:• Physicians should assess and document daily the

criteria for the patient to maintain a central line.– For example: “R internal jugular CVC- clear, dry, intact, no

erythema noted. Still necessary for IV access on pressors, etc.”

• Should be discussed during daily attending rounds.

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CENTRAL LINE MAINTENANCE ORDER!

Central line maintenance includes:• Dressing, cap and tubing changes per protocol.• Scrubbing injection caps with alcohol for 15

seconds prior to accessing.• Daily review of line need.• Prompt removal of unnecessary lines.

HOW TO ORDER ON EMR?• CENTRAL LINE CARE/MAINTENANCE (order

set)

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BE A PATIENT ADVOCATE!

• Be a bundler and protect your patients.• Educate others in the central line bundle.• Follow-up with management with other

ideas to support bundle compliance.• Evaluate the effectiveness of this strategy

within your unit.

Reducing Central Line Associated Bloodstream Infection (CLABSI) - National Patient Safety Goal #7.

  What is the Central Line Bundle? Includes the following 5 care components:1. Hand hygiene2. Maximal barrier precautions

– Hat, mask, sterile gown, sterile gloves, sterile drape covering the entire patient– Cap and mask must be worn by all personnel entering the room.– STOP insertion if sterile technique is broken. If sterility is broken, a new kit and/or new drapes should be

applied to patient and MD should start procedure over again.3. Chlorhexidine skin antisepsis (if allergic use Betadine or alcohol)4. Optimal catheter site selection

– Subclavian most preferred site, then internal jugular vein, femoral vein (emergency)5. MUST DOCUMENT DAILY CENTRAL LINE ASSESSMENT with 2 components:

– Infection with prompt intervention when indicated– Necessity with prompt removal when no longer required– Should be part of the physical exam and assessment/plan– Remember the motto: “It does not count unless you document.”

Pre-procedure. Provide acceptable rational for line placement. Obtain informed consent and provide central line educational information. Perform time-out procedure using Universal Protocol (correct patient, correct side, correct site).

Post-procedure.1. Obtain Chest X-ray if indicated.2. Write PROCEDURE NOTE as soon as procedure has been performed. Must include the components

above.3. Place an order for central line maintenance.

– HOW TO ORDER: On Orders tab, Type CENTRAL LINE CARE/MAINTENANCE