Implementing a Better Bundle in the Adult Population to Attain Zero Central Line Associated Blood...

Implementing a Better Bundle in the Adult Population to Attain

Zero Central Line Associated Blood Stream Infections:

A Prospective Surveillance

Timothy Royer, BSN, CRNI,Nurse Manager / IV Team – Retired 2009

VA Puget Sound Health Care System, Seattle, Washington

Timothy Royer, RN, BNS, CRNI

Financial Disclosures

• Nurse Consultant for:– Genentech – Cathflo Nurse Trainer– Medegen – Clinical Practice Consultant– Ethicon – Speaker’s Bureau

The studies presented herein were completed independently, without financial support, input, or influence from any manufacturer or commercial entity.


Objectives of this Presentation

• 1. Discuss 4 components of the central line bundle

• 2. Discuss strategies to implement the central line bundle


Topics Covered

• 1. National Patient Safety Goals (NPSG)s• 2. IHI Guidelines/Recommendations• 3. Components of the central line bundle• 4. Additional components to add to the central

line bundle• 5. Implementing the central line bundle• 6. Strategies for implementing the central line

bundle• 7. Measuring outcomes of the central line bundle


NPSG

• VII. Goal 7 – Reduce the risk of health care –associated infections.– A. Meeting Hand Hygiene Guidelines

(NPSG.07.01.01)– B. Not applicable to hospitals– C. Preventing Multidrug-Resistant Organism

Infections (NPSG.07.03.01)– D. Preventing Central Line–Associated Blood Stream

Infections (NPSG.07.04.01)– E. Preventing Surgical Site Infections

(NPSG.07.05.01)

http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/


IHI

• The central line bundle has five key components:– Hand hygiene– Maximal barrier precautions– Chlorhexidine skin antisepsis– Optimal catheter site selection, with

avoidance of using the femoral vein for central venous access in adult patients

– Daily review of line necessity, with prompt removal of unnecessary lines

http://www.ihi.org/nr/rdonlyres/0ad706aa-0e76-457b-a4b0-78c31a5172d8/0/centrallineinfectionshowtoguide.doc


Standards of Practice• Besides looking at the

NPSG, IHI, CDC Guidelines, and the Draft of the new CDC “Guidelines for the Prevention of Intravascular Catheter-Related Infections” we need to be guided in our practice with the “Infusion Nursing Standards of Practice”.

Your Standards of Practice should look well used too.

Infusion Nurses Society. Infusion Nursing Standards of Practice. J Infus Nurs. 2006;29(1S)


What Do We Do??• Protect the patient from the central venous catheter.

– Extraluminal causes for infection– Intraluminal causes for infection

• How do we get there?– Device selection– Care and Maintenance– Staff and patient education– Specialized Teams (IV Teams, Vascular Access Teams)

• What does it really boil down to?

Finding evidence and using critical thinking to make the right choices


Do we ever say, “That’s the way we have always

done it”?Just Asking


Where Evidence PointsAdditions with Overwhelming

EvidenceLogical Additions with Evidence

Still Being Gathered

Maximum sterile precautions Swabable connector surfaces

CHG Prep CHG bath in the ICUs

Special trained teams – IV Teams Sutureless manufactured securement devices

Hand Hygiene Standardized Catheter insertion cart with checklist

Scrubbing hub of catheter or connector Clear housing on needleless connectors

Education of nurses and physicians More PICCs in ICU

Prompt removal of unnecessary lines CHG eluting disk – near overwhelming evidence for routine use

Impregnated gel dressing – little evidence thus far

Saline flushing and locking; elimination of heparin

Decloting catheters


Maximum Barrier Precautions• For the operator placing the central line and for

those assisting in the procedure, maximal barrier precautions means strict compliance with hand hygiene and wearing a cap, mask, sterile gown, and sterile gloves.

• Include maximal barrier precautions as part of your checklist for central line placement.

• Means covering the patient from head to toe with a sterile drape, with a small opening for the site of insertion.

• Using a checklist and empowering nurses to stop the procedure if sterile technique is broken.


Removal of Unnecessary Lines• Include daily review of line necessity as part of your

multidisciplinary rounds.• State the line day during rounds to remind all as to how long

the line has been in, e.g., “Today is line day 6.”• Include assessment for removal of central lines as part of

your daily goal sheets.• Record time and date of line placement for record-keeping

purposes and evaluation by staff to aid in decision making.• Define an appropriate timeframe for regular review of

necessity, such as weekly, when central lines are placed for long-term use (e.g., chemotherapy, extended antibiotic administration, etc.).

• Daily review was designed for the intensive care population and may not be appropriate when long-term use over weeks or months is planned.

No, it is not OK to say

“Just in Case…”


Evidence on Removal of Unnecessary Lines

• Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:2725-32

• Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med 2004;32:2014-20


Background for the Studies

• It is the goal of every infusion nurse and facility to have a zero Central Line Associated Blood Stream Infection (CLA-BSI) rate to prevent:– Morbidity– Mortality– Excess cost of care

• The central line bundle is a good start for insertion, we were looking for improvement and added additional items to come up with a Central Line Care and Maintenance Bundle (CLC&M Bundle)


Building a Better Care BundleWhat We Did

• June 2003 - Change to swabable positive displacement valve

• January 2005 – Maximal sterile barriers & CHG prep

• July 2006 - Chlorhexidine Gluconate (CHG) impregnated disk, increase use of PICCs in place of centrally inserted central catheters (CICVC), and a vigorous care and maintenance education program

• January 2007 – Started clear version of the same valve, as a cue, coupled with continuous Medical Center ”Scrub the Hub and Flushing with 20mls. of normal saline” campaign.


Infection Rate Run Chart

Medical Center Wide CLABSI rates

0.17

1.01

0.78

0.88

0.84

1.73

1.34

0.14

0.630.54

1.92

0.00

0.50

1.00

1.50

2.00

2.50

Jan -Jun2003

Jul -Dec2003

Jan -Jun2004

Jul -Dec2004

Jan -Jun2005

Jul -Dec2005

Jan -Jun2006

Jul -Dec2006

Jan -Jun2007

Jul -Dec2007

Jan -Jun2008

Feb -Apr2008

May -Jul

2008

Aug -Oct2008

Nov -Jan2009

Feb -Apr2009

May -Jun2009

6 Month Intervals

Infe

ctio

n R

ate

per

1000

cen

tral

line

day

s

CLABSI Rates

Started Clear Valves as a cue coupled with continued Medical Center "Scrub the Hub and flushing with 20mls. of NS" Campaign January 2007

Started Maximal Sterile Barriers April 2005

Changed to new Opaque Valve June 2003

**Centrally Inserted Central Venous Catheter*Peripherally Inserted Central Catheters

New Residents - Poor Compliance with Maximal Steriles Barrier, Nursing - Poor care and maintenance of catheter & hub

5 fold decrease in CLABSIs in the ICUs

Started CHG impregnated sponge along with increase use of *PICCs in place of **CICVCs & vigorous care education included. January 2006

Sustained ZeroCLABSI

17 months

3 Month Intervals


Rationale Behind the Additions to theCLC&M Bundle


Evidence & Logic for Additions• Evidence and critical thinking that was used

reduce Central line Associated Blood Stream Infections (CLABSI) (some newer references also cited):Specialized trained staff for central venous catheters

IV TeamsSwabable needleless connectors allow for a greater

reduction of bacteria colony counts on devicesClots form a tighter matrix when precipitates are

present in the lumen in the catheterCentral venous catheters with clots are at higher risk

for infectionPositive displacement valves prevent blood from

backing up the catheter on syringe removal


Prevention and/or early decloting of catheters reduces the risk of infection

Switching to saline locks from heparinUsing manufactured securement devices reduces

infection riskEducation on CVC care improves patient outcomes

including reducing CLA-BSIPeripherally Inserted Central Catheters (PICC) have a

lower infection riskChlorhexidine (CHG) eluting disk or dressings provide

an environment to keep colony counts low around insertion site

Clear housing for needleless connectors

Evidence & Logic for Additionscontinued


IV Teams / PICC Teams /Vascular Access Teams

• Not PICC Stick and Run teams or teams that perform venipunture well.

• Coordinate with Infectious Disease (Infection Preventionists) and Physician Directors of Departments.

• Very active participants in the Care and Maintenance of CVCs– Educate nurses on best practices– Using vigilance to ensure best nursing care and practices are

sustained– Provide additional training and education when new practices or

products are implemented• They should be active within committees

– Infectious Disease– Disposable Equipment Committee (DEC)– Nurse Practice Committee (NPC)– Facility Education Department– Equipment Committee– Pharmacy and Therapeutic Committee


• Bring in new vascular access products– The Steps

• Review new product• Self testing the devices

– Will it work?– Does it work like they say it does?– Where is the evidence?

» Manufacturer generated?» What level of research?

– Does it make sense?– Talk to your colleagues in different facilities– Talk with the manufacturers’ engineers– Talk with your own facility medical equipment engineers



• Clinical Evaluation– Involve all members of the Team

» Specialized Teams» Unit Managers and staff» Disposable Equipment Committee

• Make the right choice for the patient.• Present to the NPC and DEC

• Now the real hard work begins



Staff education Pre-educate the whole hospital on the new product

coming in. Be part of the education on the product. Competencies

Gathering Data with the CICs Initiating practice changeResearch – whether actual or reading and

implementing change.



Draft of CDC GuidelinesReferences for having “IV Teams”

• Nehme AE. Nutritional support of the hospitalized patient. The team concept. JAMA 1980;243:1906-8

• Soifer NE, Borzak S, Edlin BR and Weinstein RA. Prevention of peripheral venous catheter complications with an intravenous therapy team: a randomized controlled trial. Arch Intern Med 1998;158:473-7

• Tomford JW, Hershey CO, McLaren CE, Porter DK and Cohen DI. Intravenous therapy team and peripheral venous catheter-associated complications. A prospective controlled study. Arch Intern Med 1984;144:1191-4

• Scalley RD, Van CS and Cochran RS. The impact of an i.v. team on the occurrence of intravenous-related phlebitis. A 30-month study. J Intraven Nurs 1992;15:100-9

• Palefski SS, Stoddard GJ. The infusion nurse and patient complication rates of peripheral-short catheters. A prospective evaluation. J Intraven Nurs 2001;24:113-23

• Miller JM, Goetz AM, Squier C and Muder RR. Reduction in nosocomial intravenous device-related bacteremias after institution of an intravenous therapy team. J Intraven Nurs 1996;19:103-6

• Hunter MR. Development of a Vascular Access Team in an acute care setting. J Infus Nurs 2003;26:86-91

• Hawes ML. A proactive approach to combating venous depletion in the hospital setting. J Infus Nurs 2007;30:33-44

• Brunelle D. Impact of a dedicated infusion therapy team on the reduction of catheter-related nosocomial infections. J Infus Nurs 2003;26:362-6

• Bosma TL, Jewesson PJ. An infusion program resource nurse consult service: our experience in a major Canadian teaching hospital. J Infus Nurs 2002;25:310-5

• Pierce CA, Baker JJ. A nursing process model: quantifying infusion therapy resource consumption. J Infus Nurs 2004;27:232-44


Swabable Needleless Connectors

• Hadaway L, Richardson D. Needleless connectors? A primer on terminology. Journal of Infusion Nursing. 2010, Vol. 33:1– The configuration of the external

connection surface can have a direct impact on the outcome with the device.

– The surface design is thought to be one factor in the controversy over the infection risk associated with each device.

• Needleless connectors with smooth contours, no valleys, no crevices, and no hidden pockets have the easiest surfaces to disinfect.

• When we made the switch in June 2003, little evidence was out there but it made good sense.

Hadaway L, Richardson D. Needleless connectors: A primer on terminology. Journal of Infusion Nursing. 2010, Vol. 33:1.

This applies to all vascular access device not just

central


Precipitates and Clots• Hardy

– Suggests that a significant portion of clot occlusions seen in practice may be caused by many factors, including drug precipitates.

– States a more tense fibrin matrix forms around the drug precipitates which leads to the formation of occlusions.

• A clear needleless connector allows nurses to see if appropriate flushing was performed and if not, to continue flushing or change valve for improved outcomes

• The photo illustrates an improperly flushed valve removed from a patient

Investigation on clear valves

removed from patients

Hardy G, Ball P. Clogbusting: time for a concerted approach to catheter occlusions? Current Opinion in Clinical Nutrition and Metabolic Care. 2005, 8:277–283


Clots and Infection

• We have known about the association of clots and infection for a long time:– Timsit J, Farkas J, et al. Central vein catheter-related

thrombosis in intensive care patients: incidence, risks factors, and relationship with catheter-related sepsis. Chest 1998; 114;207-213.

– Raad et al. The relationship between the thrombotic and infectious complications of CVC. JAMA 1994.

– Stillman et al. Etiology of Catheter-associated sepsis: correlation with thrombogenicity. Arch Surg 1977


Saline Instead of Heparin

• Evidence shows that heparin stimulates biofilm formation.– Shanks, Robert M. Q. et al Heparin Stimulates

Staphylococcus aureus Biofilm Formation. Infection and Immunity. August 2005 p. 4596-4606 doe: 10.1128/1AL.73.8.4596-4606.2005

– Costello JM, et. al. Systematic Intervention to Reduce Central Line–Associated Bloodstream Infection Rates in a Pediatric Cardiac Intensive Care Unit. Pediatrics. Vol. 121 No. 5 May 2008, pp. 915-923.


Just Asking

• Research has demonstrated a correlation between catheter intraluminal biofilm formation and catheter-related bloodstream infection.– Andes D, et al. Development and Characterization of an In Vivo

Central Venous Catheter Candida albicans Biofilm Model. Infection and Immunity, October 2004, p. 6023-6031, Vol. 72, No. 10.

• “Recent estimates suggest that the majority of hospital-acquired infections are biofilm associated.”

– Donlan, R. M. 2001. Biofilm formation: a clinically relevant microbiological process. Clin. Infect. Dis. 33:1387-1392.

– Licking, E. 1999. Getting a grip on bacterial slime. Business Week, 13 September 1999, p. 98-100.

– Potera, C. 1999. Forging a link between biofilms and disease. Science 283:1837-1838.

• So, why are we using Heparin that stimulates Biofilm formation that is associated with Blood stream infections?

Saline Instead of Heparin


Prevention of clots

• Positive displacement valves decrease the risk of occlusion:

– Jacobs BR, et al. Central venous catheter occlusions: A prospective, controlled trial examining the impact of a positive-pressure valve device. J. of Parenteral and Enteral Nutrition. 2004; 28:2 113-118.

– Rummel M, Donnelly P, Fortenbaugh C. Clinical evaluation of a positive pressure device to prevent central venous catheter occlusion: Results of a pilot study. Clinical Journal of Oncology Nursing. 2001, 5, (6), 261-265.

– Feehery, Patricia A. RN, BS, CRNI, et al. Flushing 101, Journal of Vascular Devices, Summer 2003.


Proactive Approach to Occlusion• Because Evidence shows that clots are

associated with infection:– Prevent clotting of catheters

• Proper flushing– Draft of the Guidelines for the Prevention of Intravascular

Catheter-Related Infections: Exterior Housing of needleless connectors “inadequate flushing of the device due to poor visualization of the fluid flow pathway in opaque devices”.

– INS Standard 35: INS Standard 35: Injection and Access Caps: “If the integrity of the injection or access cap is compromised or if residual blood remains within the cap, it should be replaced immediately and consideration should be given to changing the catheter and administration set.”

• Care and maintenance and proper tip placement– CVC with tips in a proximal position were 16 times more likely

to have thrombosis than those in a distal position.– Cadman et al. To clot or not to clot? That is the question in

central venous catheters. Clinical Radiology, 59;4:349-355. April 2004


– Quick resolution of occluded catheter• *Declot early with any signs of sluggish or non-

aspirating CVCs

– No tying or taping off of occluded lines

Proactive Approach to Occlusion

*Deitcher SR, Fesen MR, Kiproff PM, et al, for the Cardiovascular Thrombolytic to Open Occluded Lines-2 Investigators. Safety and efficacy of alteplase for restoring function in occluded central venous catheters: results of the Cardiovascular Thrombolytic to Open Occluded Lines trial. J Clin Oncol. 2002;20:317-324.

Blaney M, Shen V, Kerner JA, for the CAPS Investigators. Alteplase for the treatment of central venous catheter occlusion in children: results of a prospective, open-label, single-arm study (the Cathflo Activase Pediatric Study). J Vasc Interv Radiol. 2006;17:1745-1751.

We are not taping off lumens with occlusions, are we?Just Asking


Non-suture CVC Securement

• Citation used in the draft of the new CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections - Catheter securement devices.Lines 555-556– “Sutureless securement devices avoid disruption around the

catheter entry site and may decrease the degree of bacterial colonization.”

• Yamamoto AJ, Solomon JA, Soulen MC, et al. Sutureless securement device reduces complications of peripherally inserted central venous catheters. J Vasc Interv Radiol 2002;13:77-81

• INS Standards of Practice: Standard 43. Catheter Stabilization. – “Whenever feasible using a manufactured catheter stabilization

device is preferred.”• Infusion Nurses Society. Infusion Nursing Standards of Practice. J

Infus Nurs. 2006;29(1S): S44.


Staff Education on CVC Care• Reducing CLA-BSIs with staff education

– Costello study (2008)• Interventions involving staff education, increased awareness,

and practice changes led to decreased rates– Garcia study (2007)

• An extensive education program led to better adherence to proper infection control practices

– Safdar study (2008)• “The implementation of educational interventions may reduce

HCAI considerably”

Costello JM, et. al. Systematic Intervention to Reduce Central Line–Associated Bloodstream Infection Rates in a Pediatric Cardiac Intensive Care Unit. Pediatrics, Vol. 121 No. 5 May 2008, pp. 915-923.

Garcia R, Jendresky L. A study of the effects on bacteremia and sharps injury rates after introduction of an advanced luer activated device (LAD) for intravascular access in a large hospital setting. American Journal of Infection Control, June 2007, Vol 35, Issue 5 E75.

Safdar N, Abad C. Educational interventions for prevention of healthcare-associated infection: a systematic review. Crit Care Med. 2008 36(3): 933-940.


PICCs in ICUs have a Lower Infection Rate

• As noted in this facility’s Run Chart.


Other Hospital (Med/Surg ICU) Data• *Poster Presentation “Early Use of PICCs is

Associated with Decreased Catheter-Related Blood Stream Infections”

*Study from the Mayo Clinic Poster Presented at the 32nd Critical Care Congress of the Society of Critical Care Medicine as a Poster Abstract. Patel, B: 2003

Variable Before After Percent

Total Patients 1156 1286 + 11%

Total lines inserted 516 614 + 19%

CICC Line Days 2618 1755 - 33%

PICC Line Days 2253 3757 + 67%

CR BSI /1000 line days 3.2 1.9 - 41%


Chlorhexidine (CHG eluting disk)• Why are we worried about extraluminally?

– Most noncuffed CVCs BSIs were extraluminally acquired and derived from cutaneous microflora.

• Safdar N, Maki DG. The pathogenesis of catheter-related bloodstream infection with noncuffed short-term central venous catheters. Intensive Care Med. 2004 Jan;30(1):62-72.

• More evidence that supports:– Safdar N, Maki DG. The pathogenesis of catheter-related

bloodstream infection with noncuffed short-term central venous catheters. Intensive Care Med. 2004 Jan;30(1):62-72.

– Levy I, et al. Chlorhexidine-impregnated dressing for prevention of colonization of central venous catheters in infants and children: a randomized controlled study. Pediatr Infect Dis J. 2005 Aug:24(8);676-9.


More Evidence on CHG disk– Chambers ST, et al. Reduction of exit-site infections of tunneled

intravascular catheters among neutropenic patients by sustained-release chlorhexidine dressings: results from a prospective randomized controlled rial. Hosp. Infect. 2005. 61:53-61.

– Garland JS, e al. Local reactions to a chlorhexidine gluconate-impregnated antimicrobial dressing in very low birth weight infants. Pediarics. Jun;107(6):1431-6.

– Roberts B, Cheung D. Biopatch-a new concept in antimicrobial dressings for invasive device. Aust Crit Care. 1998 Mar;11(1):16-19.

– Fauerbach LL, et al. Continuing evolution of multidisciplinary approach to prevention of central line-associated bacteremias. AJIC. May 2004;(32)3.

– Maki DG, et al. Prospective, randomized, investigator-masked trial of a novel chlorhexidine-impregnated disk on central venous and arterial catheters. Infect Cont Hosp Epidemiol. 2000 Feb;21(2):96.


Recently Published CHG Impregnated Sponges

Clinical EvidenceTimsit, J, Schwebel C, Bouadma L, et al. Chlorhexidine-Impregnated Sponges and Less Frequent Dressing Changes for Prevention of Catheter-Related Infections in Critically Ill Adults: A Randomized Controlled Trial. JAMA. 2009; 301(12):1231-1241 (doi: 10.1001/jama.2009.376

Conclusions: In this study use of Chlorhexidine-Impregnated Sponges decreased the rates of catheter-related blood stream infection by 76 %.


Dressings with CHG Gel Pads

• Evidence is very limited right now.• Below are Posters presented at the Association for

Vascular Access Conference 2009 in Las Vegas, NV.– Effect of Tegaderm Chlorhexidine Gluconate (CHG) Gel

Dressing on Adult Central Venous Line Related Primary Bloodstream infections. Mary E. Reilly, RN, BSN. Decreased CLABSI from 2.1 to 0.7.

– Chlorhexidine Gluconate (CHG) at Central Line Insertion Sites: Disc vs. Gel Pad Tegaderm. Pat Catudal, RN and Susanne Meninger, RN. Rates stayed the same, but “ease of use” was factor in selecting this product.

– USE OF AN ANTIMICROBIAL IV DRESSING WITH A MAINTENANCE BUNDLE. Sally Valdez, RN, BSN and Barbara Calabrese, RN. Rates reduced from 1.4 to zero with switching to the gel pad dressing and more diligent adherence to their maintenance bundle.


Needleless Connectors with

Clear Housings


Connectors with Clear Housing• *INS Standard 35: INS Standard 35: Injection

and Access Caps: “If the integrity of the injection or access cap is compromised or if residual blood remains within the cap, it should be replaced immediately and consideration should be given to changing the catheter and administration set.”

• **Using this Standard; a needleless connector with opaque housing does not allow the nurse to see if appropriate flushing was performed and if not to continue flushing or change the valve.

*Infusion Nurses Society. Infusion Nursing Standards of Practice.J Infus Nurs. 2006;29(1S): S35.** Hadaway L, Richardson D. Needleless connectors? A primer on terminology. Journal of Infusion Nursing. 2010, Vol. 33:1.

Just Asking

Why are we using opague housings?


Draft CDC GuidelinesExterior Housing

Potential explanations for outbreaks associated with these devices include difficulty encountered in adequate disinfection of the surface of the connector due to physical characteristics of the plastic housing diaphragm interface, fluid flow properties (laminar vs. turbulent), internal surface area, potential fluid dead space, inadequate flushing of the device due to poor visualization of the fluid flow pathway in opaque devices, and the presence of internal corrugations that could harbor organisms, particularly if the catheters are used to access blood

Clearly Beyond the Central Line Bundle

A Five-Fold Decrease of Intravascular A Five-Fold Decrease of Intravascular Central Line Associated Bloodstream Central Line Associated Bloodstream Infections (CLABSI) in the six months.Infections (CLABSI) in the six months.

Reduction to zero CLABSI and Reduction to zero CLABSI and sustained since. (July 2009)sustained since. (July 2009)


Research presented at the 2007 VHA MRSA Prevention Forum

Showing the impact of clear needleless connectors in the first six months. One CLABSI in January 2007 in MICU


Objective

• Intravascular needleless connectors can be a potential source of bloodstream contamination and infection

• To reduce contamination and bloodstream infections in the MICU and CCU:– Conduct staff education regarding potential

sources of bloodstream infection

– Implement clear valves which can be visually inspected to ensure proper flushing was performed and if residual remains, replace.


Significant Results• Central Line Associated Bloodstream Infections

decreased five-fold from 7.4/1000 line days to 1.5/1000 line days (p<0.05)

• Blood Culture Contamination decreased 60% from 4.39/1000 line days to 1.77/1000 line days

• Cost savings avoidance of over $241,000– Savings of $116,000 attributed to decrease in

CLABSI– Savings of $125,000 attributed to decrease in

contaminated blood cultures


Summary

• After blood draws, blood residue not flushed from the valve may serve as a growth media for microbes

• Most valves are opaque and blood residue cannot be visualized

• Changing to a clear valve shows residue • Efficacious flushing techniques and replacing

valves if visible residue remains resulted in a five-fold decrease in Intravascular Catheter Associated Bloodstream Infections


Changes Implemented to Reach Goal of Zero

• Replace standard opaque valves with clear valves that can be flushed clear

• Educate staff on the importance of disinfecting valves before every access, otherwise contamination on the access port may be infused into the patient

• Educate staff on the reason for practicing proper flushing techniques and for changing valves if visible residue remains, to remove growth media for microbes


• Valves may become contaminated with

infusion residue or transient blood.

• CLEAR VALVES provide macroscopic

inspection of residue.

• At our facility we reduced residue with

20-ml of flush solution.


Risky residue should be revealed,not hidden!

Clear valves can be visually inspected to ensure proper

flushing techniques are practiced


Goals for the 6 year Prospective Study

• Decrease Contaminated Blood Cultures

• Decrease CLABSI Rates

• Decrease Patient Care Costs

Measures• Defined Blood Culture Contamination rates

per 1000 line days• Defined CLABSI rates per 1000 line days

using standard surveillance• Calculated cost savings/avoidance


Method

• Prospective surveillance and enhanced central line care in the whole medical center through a dedicated IV/PICC Team for the past 6 years.

• Prospective BSI surveillance and case finding were the responsibility of the IV Team and the infection control team.

• Infection rates tracked every 6 months using the NNIS and now the NHSN definitions.

• Data were tracked from January 2003 through July 2009


Part of the Care and Maintenance Education Program


Clear Valve EnhancementJanuary 2007

• With the switch to clear version of the same valve.– Realized a thorough flush

involved 20mls. of Normal Saline (NS)

• To clear precipitates• To clear blood

– Better yet if valve has visible signs – Change the valve

– Clear valve serves as a visual cue reminding nurses to complete best practices – priming, swabbing, and flushing


Clear Valve Education Enhancement


Results• Over 13,000 of in-patient central line days per year

– Includes CICVCs and PICCs– Rates were calculated for the whole Medical Center including

• Intensive Care Units (ICUs)• Medical Surgical Units• Spinal Cord Injury Unit• Transitional Care Unit

• Using CHG disk along with a continuous vigorous education on the care of central lines produced a CLA-BSI rate from 1.92 to 0.63

• Increasing the use of PICCs in place of CICVCs, especially in the ICUs, decreased infection rates.

• Impressive continued drop to zerozero CLA-BSI rate was noted with the implementation of the use of clear positive displacement valves as a cue to clean, flush, or change the valve. P value <0.05

• As of July, 2009 – 536 days with zero CLA-BSIs• Cost savings of over $241,000 in the first six months for a five-fold

decrease in CLA-BSI in the ICUs alone and 60% reduction in contaminated blood cultures (savings of $125,000 in contaminated cultures and $116,000 in bloodstream infections) as calculated, July 2007, VA Puget Sound Health Care System


Infection Rate Run Chart

Medical Center Wide CLABSI rates

0.17

1.01

0.78

0.88

0.84

1.73

1.34

0.14

0.630.54

1.92

0.00

0.50

1.00

1.50

2.00

2.50

Jan -Jun2003

Jul -Dec2003

Jan -Jun2004

Jul -Dec2004

Jan -Jun2005

Jul -Dec2005

Jan -Jun2006

Jul -Dec2006

Jan -Jun2007

Jul -Dec2007

Jan -Jun2008

Feb -Apr2008

May -Jul

2008

Aug -Oct2008

Nov -Jan2009

Feb -Apr2009

May -Jun2009

6 Month Intervals

Infe

ctio

n R

ate

per

1000

cen

tral

line

day

s

CLABSI Rates

Started Clear Valves as a cue coupled with continued Medical Center "Scrub the Hub and flushing with 20mls. of NS" Campaign January 2007

Started Maximal Sterile Barriers April 2005

Changed to new Opaque Valve June 2003

**Centrally Inserted Central Venous Catheter*Peripherally Inserted Central Catheters

New Residents - Poor Compliance with Maximal Steriles Barrier, Nursing - Poor care and maintenance of catheter & hub

5 fold decrease in CLABSIs in the ICUs

Started CHG impregnated sponge along with increase use of *PICCs in place of **CICVCs & vigorous care education included. January 2006

Sustained ZeroCLABSI

17 months

3 Month Intervals


Conclusions

• Decreases in CLA-BSI occurred with the use of:– Maximal Sterile Barriers & CHG prep– Increased use of PICCs in the ICU– CHG impregnated disk– Education program on catheter and hub/valve

care– Dedicated IV/PICC Team– Swabable, positive displacement valve


Conclusions

• All the reductions in CLA-BSIs are significant clinically

• However– A clinically and statistically significant

drop in CLA-BSIs occurred and were sustained P>0.05 with:

• With clear positive displacement valves and a campaign reinforced with the clear valve visual cue to scrub the hub and flush the catheter or change the valve.

• CHG eluting disk.


Implications for Practice in the Adult Population

• Protecting extraluminally with long acting CHG• Blood and debris are growth media for bacteria

– Care of catheters that include:• Flush with 20mls of NS to clear the catheter• Flush or change the valve if blood, precipitate or

debris is visible, a clear valve makes this practice possible

• Coupled with a vigorous cued staff education program

Are associated withAre associated withreduced infections ratesreduced infections rates


Are you UsingEvidence

andCritical Thinking?

Just Asking


Thank you.

Questions?Questions?

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Remember not to lose Focus on the Whole Patient.

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Implementing a Better Bundle in the Adult Population to Attain Zero Central Line Associated Blood...

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