Strategies to Reduce the Strategies to Reduce the Incidence ofIncidence of
Central Line-Associated Central Line-Associated Bloodstream InfectionsBloodstream Infections
Wendy Kaler MPH, CICWendy Kaler MPH, CICManager of Infection ControlManager of Infection Control
Saint Francis Memorial HospitalSaint Francis Memorial Hospital
San Francisco, CA San Francisco, CA
Saint Francis Memorial Hospital
Team involvement…..
ICU RoundingICU Rounding
•Active daily interaction of IC as Active daily interaction of IC as part of the ICU PI teampart of the ICU PI team
– Focus on NEED for indwelling central Focus on NEED for indwelling central lineline
– D/C of femoral linesD/C of femoral lines– Catch early indications of infection Catch early indications of infection
ICU Rounding Photo hereICU Rounding Photo here
Celebrate milestones
Process Improvements…….
Insertion of Central Lines
•Bundles– IHI– Provonost (NEJM Dec 28, 2006)– Joint Commission NPSG#7– CA SB 739
•Early use of PICC in neonates
Inserter: Complete BEFORE line insertion {Patient Label}
Central Line Insertion Checklist
The components on this checklist are being used while inserting this central line
Education on central line-associated bloodstream infection prevention has been provided to the patient/ family Line: CVC PICC SVO2 Site: IJ SC Fem PICC Date/time__________ Inserter Signature ______________________
Hand hygiene is performed before and after assessing for catheter insertion sites as well as before and after inserting a catheter.
Maximal barriers are utilized including sterile gloves, sterile gowns,
masks, caps, and large sterile drapes. Disinfect clean skin with a Chlorhexidine/alcohol preparation and allow
it to dry completely before inserting the line. Do not use topical antibiotic ointment or creams on insertion sites
(except when using dialysis catheters) because of their potential to promote fungal infections and antimicrobial resistance.
Placement of catheters in the femoral vein should be avoided unless
subclavian or jugular site is not an option due to patient circumstances. Document reason for using femoral site in procedure note. Secure the catheter with sutures and/or securement devices (Statlock)
whenever necessary to ensure that lines are not dislodged. Use sterile gauze and/or transparent, semi-permeable, dressing to
cover the catheter site. If the site is oozing or the patient is diaphoretic a gauze dressing is preferable.
Dressings on all new lines should be labeled with the date of insertion
***PLACE IN PATIENT CHART (behind MISC Tab) (TO BE PART OF PERMANENT RECORD)
Link to: NNIS Online at CDC
Fact:
Catheters and other invasive devices are the # 1 exogenous cause of hospital-onset infections.
Prevent InfectionStep 2: Get the catheters out
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
Central Line Needs Central Line Needs AssessmentAssessment
• During daily rounding During daily rounding
• Sticker in Physician Progress NotesSticker in Physician Progress Notes
• EMR mandatory fieldEMR mandatory field
Maintenance Bundle Maintenance Bundle forfor
Central Lines Central Lines• Most CL-BSI occur > 5 days after Most CL-BSI occur > 5 days after
insertioninsertion
• Stabilized linesStabilized lines
• Timely dressing changes per policy- Timely dressing changes per policy- dressings dateddressings dated
• Skin antisepsis at insertion siteSkin antisepsis at insertion site
• Dressings dry and intactDressings dry and intact
• Cleaning of port prior to accessingCleaning of port prior to accessing
Successful Disinfection of Successful Disinfection of Needleless Mechanical Valve Needleless Mechanical Valve
Access Ports: A Matter of Access Ports: A Matter of Time and FrictionTime and Friction
Kaler, W., Chinn, R. Kaler, W., Chinn, R. JAVA 12(3) Fall JAVA 12(3) Fall
20072007 Rady Children’s HospitalRady Children’s Hospital
Sharp Memorial HospitalSharp Memorial Hospital
ConclusionConclusion We provide evidence that when We provide evidence that when
access ports are subjected to the access ports are subjected to the industry recommended industry recommended disinfection time of 15 secondsdisinfection time of 15 seconds with friction, alcohol alone or with friction, alcohol alone or chlorhexidine/alcohol were chlorhexidine/alcohol were equally effective in sterilizing MV equally effective in sterilizing MV ports inoculated with a 10ports inoculated with a 105 5 CFUs CFUs suspension of microorganisms, suspension of microorganisms, regardless of whether the MVs regardless of whether the MVs were constructed using positive, were constructed using positive, negative, or neutral displacement negative, or neutral displacement technologies.technologies.
IV Access Port Protection Caps
•Alcohol-impregnated caps-remain on the ports between use
Iveramed- Curos
Excelsior Medical
Port Protection CapsAdvantages
• Decreases nursing time required to comply with “port disinfection policy” (NPSG#7)
• Allows for monitoring of compliance with port disinfection policy (NPSG #7)
• Potential reduction of contaminated line-drawn blood cultures – Appropriate antibiotic use– Accurate CLABSI rates for PUBLIC
REPORTING/CMS Reporting
Nursing Attitude & Focus on Infection Control Practices
•Barriers to following good infection control practices include:– Not enough time– Not enough resources– Not enough information– It is really not that important– Not able to focus on task at hand due to
many distractions
Nursing Attitude & Focus on Infection Control Practices
• Possible solutions: - Get staff level nurses involved in
designing solutions - Make it personal - Provide evidence of effectiveness
of methods - Provide local data/risk
- Feedback of poor outcomes
Culture of a patient’s port surface
Staff EDUCATION
Re-usable Post-It® poster on each nursing unit…
messages changed as needed
Making it Personal…
Our IV TEAM Lead posing as a patient
Infection ControlIt’s an ATTITUDE…
Provide care as if it were YOU in that bed……
How do you know it’s a CLA-BSI?
Are you involved in the RCAs?
Specimen Collection
•Garbage in = Garbage out
Public Reporting Antibiotic Resistance
LCBI Surveillance Definitions
CRITERION 3
Patient <1 yr has at least one of the following signs or symptoms: fever, hypothermia, apnea, bradycardia
ANDSigns and symptoms and lab data not related to
infection at another siteANDA common skin contaminant cultured from 2 or more
blood cultures drawn on separate occasions (within 2 days).
For QUANTITATIVE blood cultures
Ascher et al Diag Microbiol Infect Dis 1992 Aug 15(6) 499-503
≤10 CFU not significant (Bradley, J. et al)
Non-ambiguous Blood Culture Results
•Peripheral vs line draw
•Line-draw technique– DISCARD 1-3 ml
•Labeling of bottles
•Full info in lab report
•NO Catheter tip cultures
LCBI Surveillance Definitions
CRITERION 1
•Patient has a recognized pathogen cultured from one or more blood cultures
ANDOrganism cultured from blood is NOT
related to an infection at another site
LCBI Surveillance Definitions
CRITERION 3
Patient <1 yr has at least one of the following signs or symptoms: fever, hypothermia, apnea, bradycardia
ANDSigns and symptoms and lab data not related to
infection at another siteANDA common skin contaminant cultured from 2 or more
blood cultures drawn on separate occasions (within 2 days).
ZERO is the goal…..
Process and
teamwork (good relationships)
get you there…..