41
CLABSI Prevention: Nursing Perspectives in Acute Care Hospitals April 4, 2019 Sean Lau, MBA, BSN, BS, RN, VA-BC Vascular Access Specialist
CLABSI Prevention:
Nursing Perspectives in Acute Care Hospitals
April 4, 2019
Sean Lau, MBA, BSN, BS, RN, VA-BC
Vascular Access Specialist
Objectives
Describe the etiology and patient risks of central line
associated bloodstream infections (CLABSI)
Explore common central line care and maintenance
practices observed in acute care hospitals
Discuss strategies that can be utilized moving forward to
focus on CLABSI prevention
Speaker Disclosure:
No presence of conflict of issue.
No Commercial Support
I will not discuss off label use and/or investigational use
CAUTION:
Much of this lecture has been developed from interactions with
many hospitals and vascular access health care professionals.
This material does not reflect any single institution
There are many photos or drawings of specific products. This
instructor does not intend to endorse any specific products, but
the drawings or photos are intended to illustrate the general
characteristics of vascular access products.
Each healthcare organization should evaluate their own vascular
access needs and choose appropriate devices and components
based on clinical evidence and efficacy, need, design to prevent
complications, compatibility, ease of use and cost effectiveness.
http://www.healthcarereportcard.illinois.gov/
files/pdf/CLABSI_pathogens_2010.pdf
What is a CLABSI?
➢ CLABSI is a Central Line Associated Bloodstream Infection
➢ CLABSI is a laboratory-confirmed bloodstream infection
(BSI) in a patient who had a central line within the 48
hour period before the development of the BSI, and that
is not related to an infection at another site.
Non-tunneled CVCs
Tunneled CVCs
Implantable Ports
Dialysis Catheters
Peripherally Inserted
Central Catheters (PICCs)
Catheter Related BSI Sources
Safdar N, Maki DG. The pathogenesis of catheter-related bloodstream infection with noncuffed short-term central venous catheters. Int Care Med. 2004;30:62-67.
HEMATOGENOUS
– Distant Source
via bloodstream
#4
SKINEndogenous
– Skin Flora
Exogenous –
HCW Hands
Catheter
#1
60%
HUBEndogenous
– Skin Flora
Exogenous –
HCW Hands
#2
12%
INFUSATEEndogenous
– Skin Flora
Exogenous –
HCW Hands
#3
1%
Costs of a Catheter-Related Bloodstream Infection
CLABSIs are commonly categorized as ‘never event’
30,000 CLABSI events occur in U.S. every year
Estimated cost /infection $70,696 with a range of $40,412 to
$100,980 (AHRQ: Eliminating CLABSIs: On the Cusp, 2012)
Added costs: increase length of stay, 25% increase in
attributed mortality
CLABSI Definition with Case Studies. CDC National Center for Emerging and Zoonotic Infectious Diseases.
https://www.cdc.gov/nhsn/pdfs/training/2018/clabsi-508.pdf
46% CLABSI Reduction!
CLABSI Definition with Case Studies. CDC National Center for Emerging and Zoonotic Infectious Diseases.
https://www.cdc.gov/nhsn/pdfs/training/2018/clabsi-508.pdf
CLABSI Data
National 2020 Target Goal – Reduce CLABSI by 50%
2,278 CLABSI reported in 2017
Additional 40% CLABSI reduction needed by 2020
Centers for Medicare and Medicaid Services (CMS) Value-Based Purchasing
Previous pay system rewarded ‘volume of care’
No longer pays hospitals for certain preventable errors
Reduce payments for hospitals ranking among the lowest-performing 25%
CLABSI Definition with Case Studies. CDC National Center for Emerging and Zoonotic Infectious Diseases.
https://www.cdc.gov/nhsn/pdfs/training/2018/clabsi-508.pdf
CDC CLABSI Prevention Measures
Proper Line Insertion Practices
Central Line Insertion Practices (CLIP)
Handle and Maintain Central Lines Appropriately
CDC CLABSI Prevention Measures
Proper Line Insertion Practices
Central Line Insertion Practices (CLIP)
Handle and Maintain Central Lines Appropriately
Hand hygiene compliance
Scrub access ports (or use antiseptic impregnated caps) prior to use
Only use sterile devices to access catheter
Central Line Dressings
Sterile, transparent, semipermeable, CHG impregnated
Change gauze dressings <2 days, semipermeable dressings <7 days, or
immediately when wet, soiled, or dislodged using aseptic technique with
clean or sterile gloves
Perform daily audits to determine whether each line is needed
Wash your hands, clean your catheter prior to using
sterile devices, change your dressing as needed or
within 2/7 days, and remove central lines promptly
WHAT IS THE PROBLEM?
CDC CLABSI Prevention Measures
1. Wash your hands
2. Clean your catheter prior to using sterile devices
3. Change your dressing as needed or within 7 days
4. Remove unneeded central lines
CDC CLABSI Prevention Measures
Hand hygiene compliance
When are the 5 moments in Hand Hygiene?
What are the 6 steps in Hand Hygiene?
What are the commonly missed areas?
Measure #1: Hand Hygiene
https://www.who.int/infection-prevention/campaigns/clean-hands/5moments/en/
Hand hygiene compliance
What are the 3 types of hand hygiene?
Soap, Antimicrobial Soap, or Alcohol-based Gel?H
Effectiveness in Killing Bacteria? daily
Measure #1: Hand Hygiene
https://www.who.int/infection-prevention/campaigns/clean-hands/5moments/en/
Good Better Best
Plain Soap Antimicrobial soap Alcohol-based hand rub
When hands are visibly dirty, contaminated,
or soiled, wash with non-antimicrobial or
antimicrobial soap and water.
If hands are not visibly soiled, use an
alcohol-based hand rub for routinely
decontaminating hands.
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16. WHO Hand Hygiene Guidelines 2009
Measure #1: Hand Hygiene
1. Wash your hands
2. Clean your catheter prior to using sterile devices
3. Change your dressing as needed or within 7 days
4. Remove unneeded central lines
CDC CLABSI Prevention Measures
Measure #2: Accessing Central Line
Clean your catheter prior to using sterile devices
Needleless Connectors
Hubs #2 Source of CR-BSI
Clear to observe if any soil or debris?
Design does matter
Surface/Transparency
Simmons S, Bryson C, Porter S. “Scrub the Hub”: Cleaning duration and reduction in bacterial load on central venous catheters.
Crit care Nursing Quart 2011;34:31-35.
Measure #2: Accessing Central Line
Clean your catheter prior to using sterile devices
Scrub the hub / Alcohol impregnated caps
How long to scrub?
Alcohol cap: Limitations? Reuse? Ok in showers?
Which cap to use? How long before effective?
Measure #2: Accessing Central Line
Clean your catheter prior to using sterile devices
Multiple IV Therapy Administration
Tubing Care
How often to clean the hub?
Is this STERILE?
Measure #2: Accessing Central Line
Clean your catheter prior to using sterile devices
Blood Cultures
APIC Implementation Guide to Prevent CLABIs and INS SOP
Every effort should be made to draw peripheral cultures
• False positive cultures → unnecessary treatment
Use of a central line for BCs should be done only in the absence
of peripheral venipuncture sites or to diagnosis CR-BSI
If cultures are from an indwelling catheter, the sample should
be drawn straight from the hub of the catheter or via the new
needleless connector (remove old needleless connector)
Boyce, J., et al. (2013) Infection Control & Hospital Epidemiology
APIC Implementation Guide (2015) Guide for preventing CLABSIs.
Infusion Nursing Society. (2016) Infusion Therapy Standards of Practice. JIN.
1. Wash your hands
2. Clean your catheter prior to using sterile devices
3. Change your dressing as needed or within 7 days
4. Remove unneeded central lines
CDC CLABSI Prevention Measures
Central Line Dressings
Dressing Care
When to use
Semi-permeable
vs Gauze?
Allergies?
Measure #3: Dressings
Central Line Dressings
Dressing Change
How to disinfect the skin?
How long to use?
Measure #3: Dressings
Central Line Dressings
Dressing Change
How to prep/clean/protect skin?
Adhesive/Adhesive Remover/Skin Protectant?
Allergies?
Measure #3: Dressings
Central Line Dressings
Dressing Care
Antimicrobial agent? Dry?
Measure #3: Dressings
Central Line Dressings
Dressing Change
PICC external length?
Tip Location?
Measure #3: Dressings
Central Line Dressings
Dressing Care
Securement device?
Measure #3: Dressings
Central Line Dressings
Dressing Care
Intact?
Measure #3: Dressings
Dressing Disruption (Timsit et al, 2012)
Measure #3: Dressings
1. Wash your hands
2. Clean your catheter prior to using sterile devices
3. Change your dressing as needed or within 7 days
4. Remove unneeded central lines
CDC CLABSI Prevention Measures
Practice #4: Central Line De-Escalation
Promptly remove unnecessary central lines
High resistance to central line removal
Designate specialist to round on patients with central lines
Antibiotics, parental nutrition, vasopressors, inotropes,
chemotherapy are typically justified
Blood sampling, narcotics, antiemetics, IVF generally do not justify
continued central line access
Antimicrobial stewardship – providers re-evaluation
Shift to oral equivalent meds when clinically appropriate
Avoid central lines for empiric anti-infective agents
Use PIVs / midlines until central access is clearly warranted
Wash your hands, clean your catheter prior to using
sterile devices, change your dressing as needed or
within 7 days, and audit your lines
THIS IS THE PROBLEM!
CDC CLABSI Prevention Measures
MO
BIL
ITY
PSYCH
OSO
CIA
L
EDUCATION ADMISSION/DISCHARGES
MEDICATIONS CHARTING
Wash your hands, clean your catheter prior to using
sterile devices, change your dressing as needed or
within 7 days, and audit your lines
What’s the problem?
CDC CLABSI Prevention Measures
Diaphoretic (neuro or medicine) → Dry and Intact Dressing?
Non-compliant/Disoriented (EtOH Withdrawal) → Aseptic Dressing Change
Bleeding / 3rd Spacing (Liver failure or medication) → Dressing Dry
Skin allergies / Contact Dermatitis → CHG, Adhesives, Alcohol, Iodine
Patients: Burns, Stroke, Oncology, Renal, Dietary
Ineffective CLABSI Prevention Solutions
Scenario 1: Auditing central line patient care
Management Driven
Expensive/Labor intensive
Big Brother / Cheerleader micromanagement
Scenario 2: Silver Bullet Solutions (Product/Procedural Change)
Expensive/Labor intensive
Adding one more thing to RN busy workload → Resistance
Scenario 3: Central Line Care Skills Days
Expensive/Labor intensive
Education + Hands on Training ≠ Competence
Effective CLABSI Prevention Solutions
Quality can be FREE with main costs: ingenuity and creativity
Change daily practice standards to integrate essential central line care
Scenario 1: Auditing central line patient care
Nurse Driven
Frequency: Change of shift, Medication Admin, Patient Rounds
10 secs - from IV Medication to Vascular Access Device
IV Medication label → Alcohol Caps → Needleless Connectors (clean)
→ Dressing labeled and intact→ Catheter secured → Dry Insertion Site
Effective CLABSI Prevention Solutions
Quality can be FREE, only costing ingenuity and creativity
Change daily practice standards to integrate essential central line care
Scenario 2: Silver Bullet Solutions (Product/Procedural Change)
Should be a result to address measured gaps in practice
New additional changes are used in collaboration with units
Example: Dressing Dwell needs additional adhesive or different dressing
Blood Cultures taken only by phlebotomists via peripheral stick
Effective CLABSI Prevention Solutions
Quality can be FREE, only costing ingenuity and creativity
Change daily practice standards to integrate essential CVAD care
Scenario 3: Central Line Skills Days
Should be a result to address measured gaps in practice
Education + Hands on Training ≠ Competence
Enlist clinical specialists for on-going training
Should be unit specific to address deficit knowledge or practice gaps
Dressing change skills day make no sense for units with little/no
patients who have central lines
CLABSI Prevention Topics not covered…
Additional Topics:
Biofilms – what are they and how do we overcome them
Thrombosis – Flushing regimen and declotting protocols
VAD Selection – Catheter to vein ratio, vein preservation
Nurse Management Role in CLABSI Prevention
Catheter Locks (i.e. Saline, Heparin, EtOH)
Hemostasis / 3rd Spacing
Finally…
What is your role in vascular access care?
Patients with central lines are at the mercy of every healthcare
professional who touches their catheter!
You are on the front line between our patients and physicians.
Overworked and overwhelmed
When you have a functional central line – your job just got easier
Take vascular access care as a priority (not THE)
If you don’t have the resources you need to be successful,
advocate for your patient and go get them
MORE QUESTIONS OR FEEDBACK? [email protected]
