ETMC July 2014

1. Central Line Associated Blood Stream Infection (CLABSI) and PreventionEducation for Medical Staff and their Allied Health Providers (AHP) ETMC July 2014

2. The information in this self-pace education presentation is intended to re fresh and / or bring new information to you regarding techniques to use to prevent Central Line Associated Blood Stream Infections (CLABSI). Some pertain to hospital staff while others pertain to anyone involved in the care of a patient.National Patient Safety Goal (NPSG) 07.04.01 - Implement evidence-based practices to prevent central line-associated bloodstream infections. Note: Involves short and long term central venous catheters and peripherally inserted central catheter (PICC) lines.

3. Statistics for CLABSI’s • 90% of all blood stream infections are associated with central vascular access devices. • 400,000 CLABSI’s occur per year in the US • CLABSI’s are: • Associated with increased morbidity • Associated with mortality rates of 10% - 20%. • Associated with prolonged hospitalization (mean of 7 days) and increase in medical costs $28,000 - $47,000. Joint Commission – CLABSI Fact Sheet

4. CLABSI Fact Sheet 1. CLABSIs result annually in*: • 84,551-203,916 preventable infections. • 10,426-25,145 preventable deaths. • $1.7-21.4 billion avoidable costs. 2. The following interventions decrease the risk for CLABSIs: • Appropriate hand hygiene, • Use of chlorhexidine for skin preparation, • Use of full-barrier precautions during central venous catheter insertion, • Avoid using the femoral vein for central venous catheters in adult patients, and • Removing unnecessary central venous catheters. • Umscheid, CA, et al. Estimating the proportion of reasonably preventable hospital-acquired infections and associated mortality and costs.

5. What is a Central Line? A central venous access device, also called a central line, is a long, thin, flexible tube used to give medicines, fluids, nutrients, or blood products over a long period of time, usually several weeks or more. A catheter is often inserted in the arm, neck or chest through the skin into a large vein. The catheter is threaded through this vein until it reaches a large vein near the heart. The following are some examples of central venous access devices used at ETMC. Multi-Lumen Catheter PICC Line Implanted Port Quinton Catheter Tunnel Catheter

6. Hand Hygiene Since 1977, at least 7 prospective studies have shown that improvement in hand hygiene significantly decreasesavariety of infectious complications. Proper hand-hygiene procedures can be achieved through the use of either a waterless, alcohol-based product or an antibacterial soap and water with adequate rinsing. Compared with peripheral venous catheters, CVCs carry a substantially greater risk for infection; therefore, the level of barrier precautions needed to prevent infection during insertion of CVCs should be more stringent than proper hand hygiene alone. Joint Commission – CLABSI Fact Sheet

7. Insertion Checklist • Use a catheter checklist to ensure adherence to infection prevention practices at the time of CVC insertion. • Maximal sterile barrier precautions (e.g., cap, mask, sterile gown, sterile gloves, and large sterile drape) during the insertion of CVCs substantially reduces the incidence of CLABSI compared with standard precautions (e.g., sterile gloves and small drapes). Joint Commission – CLABSI Fact Sheet

8. Time Out (Universal Protocol) • Patient ID x 2 • Announce the procedure to be performed • Mark/access the site • Patient is positioned correctly • All required equipment is in the room • Medications/syringes are labeled • All involved are present and agree that “TIME OUT” is correct

9. Catheter Insertion Kit • Use an all-inclusive catheter kit. • Use full maximal sterile barrier precautions during CVC Insertion. • A mask, cap, sterile gown, and sterile gloves are to be worn by all healthcare personnel involved in the catheter insertion procedure. • Kit contains protective wear for only one person. • Anyone else in the room must wear a mask and cap.

10. Chlorhexidine • In a study from 1991, preparation of central venous and arterial sites with a 2% aqueous chlorhexidine gluconate lowered BSI rates compared with site preparation with 10% povidone-iodine or 70% alcohol. Since that time, there has been growing evidence that chlorhexidine-containing skin preparation is superior to other options. A meta-analysis from 2002 that pooled results of these studies demonstrated use of a chlorhexidine-containing preparation decreased central catheter related infections by 49% relative to povidone-iodine preparations. Because a smaller effect of chlorhexidine was seen in studies using a 0.5% concentration of chlorhexidine, preparations with greater concentrations are recommended. Joint Commission – CLABSI Fact Sheet

11. Aseptic Technique • Healthcare personnel should be empowered to stop the procedure if a breach in aseptic technique are observed • Preventing infections is our #1 Goal

12. Subclavian Vein • The site at which a catheter is placed influences the subsequent risk for catheter-related infection and noninfectious complications. For adults, lower extremity insertion sites are associated with a higher risk for infection than are upper extremity sites. As a result, authorities recommend that the femoral vein be avoided. Place CVCs in an alternative site to reduce the risk for infection. The risk of noninfectious complications should be assessed on an individual basis when determining which site to place the CVC. Joint Commission – CLABSI Fact Sheet

13. Securement Device • Securement devices prevent the catheter from sliding in and out from the insertion site. This plays an important role in infection prevention and catheter daily placement. • Multi-lumen catheters are secured with sutures. Make sure not to insert the central line past the double line. This space is needed to place the antimicrobial disc. A StatLock can be used if the sutures are loose or the physician orders it. • PICC lines are secured with a StatLock and must be replaced weekly with the dressing change. Some of these lines are also sutured into place per physician order. • Quinton catheters have a larger bore and requires a different antimicrobial patch that has a larger round hole center. These lines are also sutured in place

14. Hub/Clave • Before accessing catheter hubs/claves or injection ports, clean them with an chlorhexidine preparation or a 70% alcohol prep pad to reduce contamination • Chlorhexidine containing sponge dressing for CVC’s in patients older than 2 months of age

15. Care of Central Lines • All central line dressings will have the clear plastic film dressing. • All central line dressings will be changed every Friday and prn when the dressing is compromised. • All central line blue claves will be changed every Friday and tubing will be changed every Monday and Friday. • All central lines will be flushed q 8 hours with prefilled saline syringe. • All central lines will be flushed before and after medication administration and lab draws with prefilled saline syringe. • All central line blue claves will be scrubbed with an alcohol prep pad each and every time the line is accessed. • All central lines will have an antimicrobial disc to prevent infections. If the disc is saturated with blood or fluid the dressing must be changed. Tell the nurse or place an order to change the dressing. • All central line dressings will be dated when it was last changed.

16. CVC Daily Rounds • One of the most effective strategies for preventing a CLABSI is to eliminate, or at least reduce, exposure to central venous catheters. The decision regarding the need for a catheter however is complex and therefore difficult to standardize into a practice guideline. Nonetheless, to reduce exposure to central venous catheters, the multidisciplinary team should adopt a strategy to systematically evaluate daily whether any catheters or tubes can be removed. Joint Commission – CLABSI Fact Sheet

17. Intrinsic and Extrinsic Risk Factors for CLABSI Joint Commission – CLABSI Fact Sheet

18. CLABSI Criteria Surveillance Definition (different from clinical) • Must have a central line in place for two calendar days. • Must have a recorded symptom like chills or hypotension and/or a temperature greater than 100.4 the day before, day of or the day after. • Must have one positive blood culture from a central line or venipuncture or 2 common commensals drawn from 2 or more blood cultures on separate occasions, no more than 1 day between. • Unable to link the pathogen to another site such as sputum, wound or urine.

19. Documentation • Documenting a link between a central line and an bloodstream infection will automatically code the entry as a CLABSI (Central Line Associated Blood Stream Infection) even if the criteria does not meet the surveillance definition and criteria. • Document and interpret the organism found in the blood stream as either bactremia, septicemia, sepsis/SIR, or severe sepsis, contaminate, or colonization. These terms will drive the specifics of the coding.

20. East Texas Medical Center - Tyler Completion Verification for Central Line Associated Blood Stream Infection (CLABSI) and PreventionEducation for Medical Staff and their Allie Health Providers (AHP) I _____________________________________ certify that I have reviewed the power point presentation titled "Central Line Associated Blood Stream Infection (CLABSI) and Prevention Education for Medical Staff and their Allie Health Providers (AHP)" for CY 2014.  Signature and Title: ____________________________ Date_______________