CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTION

1. CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTION The Central Line Bundle and YOU! 6/6/2013 Quality Assurance/Peer Review Report Privileged Pursuant to O.R.C. Section 2305.24, .251, .252

2. NATIONAL PATIENT SAFETY GOAL 2009 2009 National Patient Safety Goal or (NPSG.07.04.01) requires: Implementation of best practice or evidence-based guidelines to prevent central line-associated bloodstream infections (CLABSIs) for short and long-term central venous catheters (CVCs) including PICCs The deadly cost of CLABSIs: ~ 90 % of CLABSIs occur with CVCs Estimate of 14,000 – 28,000 lives lost per year Hospitalization prolonged a mean of 7 days Hospitalization costs ↑~ $3,700 - $29,000 October 1, 2008 CMS (Medicare) no longer reimbursing for CLABSIs acquired in the hospital 9/10/2014 University Hospitals University Hospitals 2

3. How Can We IMPACT Central Line Associated Blood Stream Infections (CLABSIs)? • What is the Central Line Bundle? Includes the following bundle of 5 care components: 1. Hand hygiene 2. Maximal barrier precautions 3. Chlorhexidine skin antisepsis 4. Optimal catheter site selection 5. Daily review for line necessity and assessment with prompt removal of unnecessary lines University Hospitals

4. HAND HYGIENE – Just do it! 1. Perform hand hygiene before assisting with catheter insertion or manipulation. 2. Palpation of the insertion site should not be performed after antiseptic cleanse, unless aseptic technique is maintained. 3. Before and after inserting, replacing, accessing, repairing or dressing a central line. University Hospitals

5. MAXIMAL BARRIER PRECAUTIONS Use strict adherence as the inserter and all involved with the placement of a central line or guidewire exchange with the following: • Compliance with hand hygiene • Wear cap, mask, sterile gown and sterile gloves • Cap – covers all hair • Mask – covers nose and mouth tightly • Sterile drape – covers patient from head to toe with a small opening for line placement University Hospitals

6. CHLORHEXIDINE SKIN PREP • Chlorhexidine (CHG) skin prep prior to placement and for dressing change. • PINCH wings on CHG applicator. • PRESS sponge against the skin allowing the solution to penetrate the pad. • PREP covering a large area using a back and forth, up and down, and diagonal friction scrub for at least 30 seconds. Allow to dry. Do not wipe, blot or fan. University Hospitals

7. OPTIMAL CATHETER SITE SELECTION Subclavian vein is the preferred site for non-tunneled catheters and is associated with lower risk of CLABSIs rather than the jugular vein. -Femoral site is associated with greater risk of infection and DVTs in adults. University Hospitals preferred sites: • Subclavian and Internal jugular are preferred sites. • Femoral site would be an option for: 1. ECMO 2. Neuroprotective hypothermia-thermaguard  • Other insertion sites are not able to be accessed due to poor vascular upper extremities, etc. 4. A need for dialysis or other patient emergencies University Hospitals

8. NEW CENTRAL LINE DRESSING AT UH: TEGADERM HCG Studies have shown chlorhexidine gel pad effectively reduces skin flora Gel pad easily conforms to body contours Gel pad is transparent Gel pad adsorbs fluids & blood Remains effective & transparent over weeks time No need to manipulate catheter placing gel pad Tegaderm dressing eliminates Statlock need University Hospitals Seidman Cancer Center 8

9. STEPS FOLLOWING INSERTION Flush each lumen with 10ml normal saline solution via a 10cc syringe. Apply sterile, occlusive dressing to site. Attach male Luer-lock stopcock or Luer-lock IV tubing to each port and close clamps. MD should order x-ray to confirm placement prior to infusion for subclavian and internal jugular lines. X-ray confirmation is not necessary for femoral lines. MD should order CENTRAL LINE CARE/MAINTENANCE Complete Procedure note-general in UHCare. Label as to type of line inserted. Document daily assessment and need on progress note. Assess for infiltration, phlebitis, infection, and any change from baseline appearance 9/10/2014 University Hospitals 9

10. DAILY LINE ASSESSMENT AND REVIEW • The risk of CLABSIs increases over time. • Complete daily assessment of central line for infection. • Prompt removal of unnecessary lines. • The replacement of temporary catheters in the presence of bacteremia is not an acceptable replacement strategy. The source of infection is usually colonization of skin tract from the insertion site to the vein. Roles in Daily Site Assessments: • Physicians should assess and document daily the criteria for the patient to maintain a central line. • For example: “R internal jugular CVC- clear, dry, intact, no erythema noted. Still necessary for IV access on pressors, etc.” • Should be discussed during daily attending rounds. University Hospitals

11. CENTRAL LINE MAINTENANCE ORDER! Central line maintenance includes: • Dressing, cap and tubing changes per protocol. • Scrubbing injection caps with alcohol for 15 seconds prior to accessing. • Daily review of line need. • Prompt removal of unnecessary lines. HOW TO ORDER ON EMR? • CENTRAL LINE CARE/MAINTENANCE (order set) University Hospitals

12. BE A PATIENT ADVOCATE! • Be a bundler and protect your patients. • Educate others in the central line bundle. • Follow-up with management with other ideas to support bundle compliance. • Evaluate the effectiveness of this strategy within your unit. University Hospitals

13. Reducing Central Line Associated Bloodstream Infection (CLABSI) - National Patient Safety Goal #7. • What is the Central Line Bundle? Includes the following 5 care components: • Hand hygiene • Maximal barrier precautions • Hat, mask, sterile gown, sterile gloves, sterile drape covering the entire patient • Cap and mask must be worn by all personnel entering the room. • STOP insertion if sterile technique is broken. If sterility is broken, a new kit and/or new drapes should be applied to patient and MD should start procedure over again. • Chlorhexidine skin antisepsis (if allergic use Betadine or alcohol) • Optimal catheter site selection • Subclavian most preferred site, then internal jugular vein, femoral vein (emergency) • MUST DOCUMENT DAILY CENTRAL LINE ASSESSMENT with 2 components: • Infection with prompt intervention when indicated • Necessity with prompt removal when no longer required • Should be part of the physical exam and assessment/plan • Remember the motto: “It does not count unless you document.” • Pre-procedure. Provide acceptable rational for line placement. Obtain informed consent and provide central line educational information. Perform time-out procedure using Universal Protocol (correct patient, correct side, correct site). • Post-procedure. • Obtain Chest X-ray if indicated. • Write PROCEDURE NOTE as soon as procedure has been performed.Must include the components above. • Place an order for central line maintenance. • HOW TO ORDER: On Orders tab, Type CENTRAL LINE CARE/MAINTENANCE