Catheter-Associated Bloodstream Infections & Nursing Intravenous Standards

1. Catheter-Associated Bloodstream Infections &Nursing Intravenous Standards

2. MICU CVC-Associated BSI This material was prepared for use by a UIHC Committee investigating ways to reduce morbidity &mortality

3. SICU Catheter-Associated Bloodstream Infection Rate This material was prepared for use by a UIHC Committee investigating ways to reduce morbidity &mortality

4. 4JCE Catheter-Associated Bloodstream Infection Rate This material was prepared for use by a UIHC Committee investigating ways to reduce morbidity &mortality

5. CVC-associated Bloodstream Infections • 200,000 (80,000 ICU) CVC-associated BSI in the hospital per year. • 10-20% attributable mortality w/ CVC infections in the ICU. • Costs of $3,700-$28,000 per line infection and total of $2.3 billion per year in US.

6. Median Catheter-associated BSI Rates by ICU Type in US Am J Infect Control 2001; 29: 404-21

7. Central Venous Catheters • A CVC is an intravenous catheter whose tip ends in the central venous system • CVCs are commonly inserted through the jugular, subclavian, femoral, cephalic, & basilic veins • Indications for CVCs • Administer IV fluids, medications, blood products • Total parenteral nutrition (TPN) • Hemodynamic monitoring

8. Types of Central Venous Catheters • Long-term (>4-6 weeks): totally implantable port, tunneled catheters • Intermediate (>2 weeks, but <6 weeks): peripherally inserted central catheter (PICC) • Short-term (<2weeks): non-tunneled central catheter (e.g., triple lumen catheter) • Short-term, non-tunneled CVC Account for 90% of CA-BSI

9. CONTAMINATED INFUSATE Fluid Medication Extrinsic Manufacturer SKIN ORGANISMS Endogenous Flora HCW hands Contam Disinfectant Invading Wound CONTAMINATION OF CATHETER HUB Extrinsic (HCW) Endogenous (Skin) CONTAMINATION OF DEVICE PRIOR TO INSERTION Extrinsic >>Manufacturer Skin Vein Fibrin Sheath, Thrombus HEMATOGENOUS From Distant Local Infection Sources of Catheter-associated Bloodstream Infections

10. Hand Hygiene Perform hand hygiene with Avagard D before inserting peripheral or central venous catheters

11. CVC: Insertion • Person inserting central line must use maximum sterile barrier precautions • Sterile gloves and gown • Nonsterile masks and hats • Large sterile drapes that cover wide area • Prep site with 2% chlorhexidine gluconate (CHG) • Prep with side-to-side scrub for 30 seconds • Let dry for 30 seconds

12. Prevention of Central Venous Catheter-Related Infection by Using Maximal Sterile Barrier Precautions During Insertion *p<0.05 vs. control Raad et al, Infect Control Hosp Epidemiol 1994;15:231-238

13. Reducing Risk of CVC Infections • Do not routinely replace CVC for purpose of preventing infection (NEJM 1992;327:1062-8) • Remove CVC as soon as possible • Strictly adhere to hand hygiene & aseptic technique during CVC insertion

14. A Controlled Trial of Scheduled Replacement of Central Venous and Pulmonary-Artery CathetersCobb et al (NEJM 1992;327:1062-8) • Routine CVC change Q 3 day by GWX • Routine CVC change Q 3 day to new site • CVC change by GWX only when CVC change indicated • CVC change to new site only when CVC change indicated. Randomized pts. to one of four study Groups:

15. A Controlled Trial of Scheduled Replacement of Central Venous and Pulmonary-Artery CathetersCobb et al (NEJM 1992;327:1062-8) • No difference in infection rate in pts. undergoing scheduled change vs. those undergoing line change when indicated. • Higher rate CR-BSI in patients undergoing GWX (p=0.06). • High rate of mechanical complications in patients undergoing new stick (p=0.005).

16. Guidewire Exchange • Routine GWX of lines as prophylaxis against CVC infection not supported by literature. • Acceptable when line infection not suspected. • Do not use guidewire techniques to replace CVC for which there is strong suspicion of CVC-associated infection. • Tunneled CVC should never be changed over a guidewire.

17. Recommended Procedure for Guidewire Exchange of CVC • Wide skin prep as with all CVC placements. • Double glove and use MSB technique. • Once old line removed, remove outer gloves prior to handling new line. • Use new sterile caps on ports & new IV tubing.

18. CVC: Dressing Change • Change dressing when wet, soiled or bloody • Change transparent dressing q 7 days • If transparent dressing is contraindicated and a gauze dressing is used, change gauze dressing q 48 hours

19. CVC: Dressing Change • Perform hand hygiene with Avagard D • Assemble supplies • Put on clean gloves and remove old dressing down to the exit site • Pull the dressing toward the exit site of the catheter (this helps prevent pulling out the line) • Remove the remainder of the dressing by pulling off the dressing toward the exit site

20. CVC: Dressing Change • Observe exit site for redness, drainage, or other signs of infection • If there is any redness observed or drainage at the site/dressing, remove gloves and perform hand hygiene • Put on sterile gloves & palpate the area for tenderness, swelling, or drainage • If there is drainage, obtain swab culture and physician/LIP order for culture

21. CVC: Dressing Change • Clean area around site with CHG using side-to-side strokes • Clean under catheter and around exit site • Allow CHG to dry for 30 seconds. • Do not fan or blow on the site

22. CVC: Dressing Change • Apply transparent dressing Note: No longer necessary to use 2x2 gauze dressing under transparent dressing • Do not use topical antibiotic ointment or creams at exit site • Securely anchor catheter to skin • Record date, time and initials on tape or dressing

23. CVC: Maintenance • Cleanse outside of hubs with alcohol before each use – allow to air dry • Administer TPN through a dedicated port • If using central line for pressure monitoring, change transducers, stopcocks, flush devices, and flush solutions q 96 hours

24. Tubing and Solution Changes • Change maintenance IV solutions at least q 96 hours, or sooner if medications added to solution expire • Change IV tubing q 96 hours, except • Blood tubing q 24 hours • Lipid tubing q 24 hours • Tubing used for lipid-based meds (such as Propofol) every 12 hours • Change tubing and solution for intermittent IV every 24 hours

25. Peripheral IV: Insertion • Prep insertion site for 30 seconds with 2% CHG • Use mechanical friction in a side-to-side application • Allow site to dry for 30 seconds

26. Peripheral IV: Insertion • Note: If peripheral IV is to be placed for < 6 hours (such as in clinics), an alcohol prep may be used • If an alcohol prep is used and the peripheral IV is needed for more than 6 hours, it is recommended that the site be changed

27. Peripheral IV: Insertion and Maintenance • Change peripheral IV site every 96 hours • Do not place tape directly over the insertion site • Use a transparent dressing over insertion site • Do not use topical antibiotic ointment or creams on insertion site

28. Peripheral IV: Flush • Cleanse diaphragm of saline vial with 70% alcohol before withdrawing saline • Replace the cap on the IV line each time it is removed • Discard saline vial at the manufacturer’s expiration date

29. Arterial Line: Maintenance • Replace flush solution, tubing, and transducer (down to stopcock closest to the patient) every 96 hours • Replace dressing every 96 hours • Change dressing when wet, soiled or bloody • Cleanse exit site with 2% CHG using side-to-side scrub • Allow to dry for 30 seconds before applying new dressing

30. Blood Culture Collection • When an order for a blood culture is written, interpret the order to mean the following: • Collect 2 blood culture sets sequentially from two different sites • Whenever possible, collect a 3rd blood culture set 4-6 hours later

31. Blood Culture Collection • Blood cultures obtained from a peripheral site are preferred • For patients with poor venous access, blood may be drawn from an intravascular catheter • One of the first two blood culture sets should be drawn from a peripheral site

32. Blood Culture Collection • For a blood culture set, obtain 1 aerobic and 1 anaerobic bottle • Disinfect the top of each bottle with 70% alcohol swab • Allow the top to dry for 1 minute • Inoculate each bottle with 10 ml of blood

33. Blood Culture Collection: Peripheral • Obtain Blood Culture Prep Kit II • Perform hand hygiene • Select the vein to be used • Use “Isopropyl Alcohol Frepp” to scrub site vigorously for 30 seconds • Allow to dry

34. Blood Culture Collection: Peripheral • Use “Iodine Tincture Sepp” to apply iodine tincture to venipuncture site, starting at center and moving outward in concentric circles to periphery • Allow the iodine to dry for at least 30 seconds • Do not touch site after prep (unless wearing sterile gloves)

35. Blood Culture Collection: Peripheral • Put on sterile gloves • Perform venipuncture and obtain 20 ml of blood • Cleanse the venipuncture site with 70% alcohol after the sample is obtained

36. Blood Culture Collection: Central Line • Perform hand hygiene • Clean catheter junction with alcohol swab and allow to dry • Aspirate 10 ml aliquot of fluid from catheter and discard • Aspirate 20 ml of blood from catheter