1850 Semmelweiss found increased rate of mortality with puerperal sepsis patients and advocated hand washing to stop spread of disease

Died in a mental institution, work never recognized as important

United States physicians insert > 5 million every year

Used for hemodynamic measurements, resuscitation, administration of medications and nutrition

15% of patients will have a complication

Mechanical complications 5-19%

Thrombotic complications 2-26%

Infectious complications 5-26%

N Engl J Med 2003;348:1123-33

In the U.S. 15 million CVC days 250,000 cases of CVC associated BSIs Mortality 12-25% Marginal cost is $25,000 per episode Lowball $6.25 billion

Average ICU rate of BSI 5.3/1000 catheter days

80,000 BSIs/ year in ICUs Studies show no increase in severity adjusted

mortality to 35% increase in mortality ? Attributable mortality

Cost per infection is $34,508-$56,000 Annual cost $296 million to $2.3 billion

Data January 1992-June 2001 Group of nearly 300 hospitals Med/surg rate major teaching 5.3% Med/surg rate all others 3.8% Rates influenced by severity, type of

illness, elective or urgent placement and type of catheter

Review current training for effectiveness, completeness

Define nurses’ role Mechanism for monitoring compliance

with training prior to ICU rotation Establish strategy for identifying and

training those we missed Communication plan to housestaff and

attendings Implement training requirements

Hand Hygiene Maximal barrier precautions Chlorhexidine skin antisepsis Optimal site selection, subclavian vein

preferred site Daily review of need for line with prompt

removal

Assess allergies Verify consent form completed and in

chart Assemble supplies with nursing staff Time out-right patient, right location,

assess site◦ Review appropriate landmarks with

attending◦ Subclavian preferred site if not

contraindicated

Remember to employ maximal barrier precautions Put on hat/mask for everyone in room Minimize number of people in room Close door prior to start of procedure Wash hands Sterile gown/gloves Chlorhexidine prep of site

◦ Pinch wings of applicator to break ampoule◦ Hold applicator down to saturate pad◦ With sponge against skin, apply chlorhexidine for at least 30

seconds using a back and forth scrub◦ Allow chlorhexidine to dry completely before beginning line

placement (~2 minutes)

Full body drape Perform procedure Transduce with pressure tubing to verify venous placement Apply needleless caps, flush ports with saline Suture catheter in place Apply Biopatch Apply Tegaderm Appropriate disposal of kit/drapes Order and check CXR for line placement Procedure note in chart Daily review of necessity of central line-advocate removal

ASAP

Development of Nursing checklist Nursing Ed for skills day/orientation CPC committee Update intranet with this information Utilize ICU nursing administration to keep at

the forefront of many QI projects

Inform patient/family of pending procedure

Assess allergies in chart Verify informed consent present Gather sterile supplies for maximum

barrier precautions i.e. gowns, gloves, drapes, masks, hats

Needleless caps Saline flush with syringes Biopatch Tegaderm

Minimize number of people in room Close door prior to start of procedure Everyone in room with hat/mask Everyone in room wash hands Time out Maximum barrier precautions Monitor sterile process and alert for breaks in procedure Clean site then apply Biopatch shiny or blue side up Sterile occlusive dressing application Obtain CXR for line placement Inform family of outcome of procedure

Review need for line on daily basis Advocate removal/PIC Monitor site q shift for signs/symptoms of

infection, irritation, redress if needed Alcohol ports prior to every access Tubing/needleless port change q 4 days

and more often as needed