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…..