The document provides information on catheter-related bloodstream infections (CR-BSIs) including what they are, where they come from, why proper central venous catheter (CVC) care and maintenance is crucial to prevent them, and recommendations from the CDC on prevention. CR-BSIs are associated with high morbidity, mortality, and costs. Adherence to best practices like aseptic technique during insertion and dressing changes, appropriate hand hygiene, and following policies on injection caps, flushing and medication administration can help reduce the risk of these infections.

1. CVC Care & Maintenance to prevent CR-BSIs INTRODUCTION -What is a CR-BSI? -Where do CR-BSIs come from? Why is CVC care and maintenance so crucial? -What is our role? -What are our resources?

2. What is a CR-BSI? A Catheter-Related Bloodstream Infections (CR-BSIs) Clinical manifestations Fever, chills, hypotension At least one positive blood culture from a peripheral vein No other apparent source Line in during 48 hours prior to BSI References: [1] Appendix A, CDC Guideline MMWR. Aug. 9 2002;51(RR10):27-28.

3. CR-BSIs Where do they come from?

4. Bloodstream Infections (BSIs) and Device Use 87% of BSIs are associated with device use 1 Common devices: Central venous catheters (CVCs) Arterial catheters Peripherally inserted central catheters (PICCs) Dialysis catheters and ports Peritoneal dialysis catheters Epidural catheters External fixator pins 1 . Richards M, Edwards J, Culver D, Gaynes R. Nosocomial infections in medical intensive care units in the United States. National Nosocomial Infections Surveillance System. Critical Care Medicine . 1999;27:853-854. Evidence-based Choice for Catheter-related Bloodstream Infection (CR-BSI) Prevention- William R. Jarvis, M.D.

5. Biofilm Biofilm is a complex, highly organized community of microorganisms enclosed in a self-produced exopolysaccharide matrix attached to tissue or inanimate surfaces. All medical-device-related infections originate as biofilm infections. Bacteria in a biofilm are chemically and physically protected by the biofilm structure and are also slow growing and are difficult to kill with antimicrobial therapies 1 . Ryder, MA. Catheter-Related Infections: It's All About Biofilm. Topics in Advanced Practice Nursing eJournal . 2005;5(3) ©2005 Medscape Posted 08/18/2005 . http://www.medscape.com/viewarticle/508109

6. Sources of Contamination 1. 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. 1 Skin Organisms Endogenous- Skin flora Extrinsic-HCW hands 2 Contaminated Catheter Hub Endogenous-Skin flora Extrinsic-HCW hands 3 Contaminated Infusate Extrinsic-Fluid Medication Intrinsic-Manufacturer

7. Why is CVC care and maintenance so crucial ? I- Antibiotic resistance trends are likely to continue placing upward pressure on infection rates. 1 II- Accrediting agencies are now holding hospitals and their executives accountable for infection control. 2 III- CR-BSIs (Catheter Related-Blood Stream Infections) are a significant cause of hospital morbidity and mortality. 3 IV- CMS (Centers for Medicare & Medicaid Services) will no longer reimburse for CR-BSIs due to recent changes. V- Most importantly our patients expect and deserve the best health care we can provide. 1. Wenzel, RP. The impact of hospital-acquired bloodstream infections. Emerging Inf Dis . 2001; 7(2):174-177. 2. Centers for Disease Control and Prevention. Guidelines for the prevention of intravascular catheter-related infections. Morbidity Mortality Weekly Report . 2002;51:1-29. 3.JCAHO, Hospital Program Infection Control Standards: Surveillance, prevention, and control of infection. 2005. 1-10.

8. Why is CVC care and maintenance so crucial ? I-Antibiotic Resistance Another growing concern of CRBSI (and infections in general) is the alarming rates of bacterial antibiotic resistance. The three most common pathogens causing CRBSI are coagulase negative staphylococcus, Enterococcus, and Staphylococcus aureus, all of which are commonly resistant to multiple antibiotics and therefore are more difficult to treat.

9. Why is CVC care and maintenance so crucial ? II- Accountability In 2009, TJC- National Patient Safety Goal #7 had prevention of BSI added as a new part of the goal to start Jan. 1, 2010.

10. Why is CVC care and maintenance so crucial ? III- Morbidity & Mortality CR-BSIs are a significant cause of hospital morbidity & mortality Each year, approximately 350,000 patients will acquire a CR-BSI 1 12%–25% of CR-BSIs will result in infection-attributable death. 2 1. Wenzel, RP. The impact of hospital-acquired bloodstream infections. Emerging Inf is . 2001; 7(2):174-177. 2. Centers for Disease Control and Prevention. Guidelines for the prevention of intravascular catheter-related infections. Morbidity Mortality Weekly Report . 2002;51:1-29. 4.Evidence-based Choice for Catheter-related Bloodstream Infection (CR-BSI) Prevention- William R. Jarvis, M.D.

11. Why is CVC care and maintenance so crucial ? IV- Cost Incremental cost per episode of CR-BSI ranges from $25,000 to $56,000 1 . Hospitals absorb the majority of these costs U.S. hospitals incur as much as $2.3 billion per year as a result of CR-BSI CMS will no longer reimburse for CR-BSIs due to recent changes. 1.Centers for Disease Control and Prevention. Guidelines for the prevention of intravascular catheter-related infections. Morbidity Mortality Weekly Report . 2002;51:1-29.

12. Why is CVC care and maintenance so crucial ? V- Our patients **We have an obligation to our patients to provide excellence in health care**

13. CR-BSIs Let’s look at what we can do to prevent CR-BSIs?

14. CDC Recommendations Provider Training - Only personnel who have been trained and exhibit competency in the insertion of catheters should perform catheter insertion. The same applies to care and maintenance. Hand Hygiene - Proper hand hygiene is paramount before and after catheter care. Aseptic Technique Sterile aseptic technique including use of cap, mask, sterile gown, sterile gloves, and head to toe sterile sheet for CVC insertion. Sterile aseptic technique including use of mask and sterile gloves for dressing changes. Clean aseptic technique when accessing CVC for medication administration, blood sampling, or flushing.

15. CDC Recommendations cont Catheter Entry Site - Catheter site choice should be based on risk of infection vs. risk of mechanical injury. Skin Antisepsis - Disinfect skin before catheter insertion and during dressing changes with 2% CHG (chlorhexidine). Catheter Dressing -Sterile gauze or transparent dressing should be used to cover the catheter entry site. Dressing Change – Change gauze dressing after 24 hours. Transparent dressing may be changed every 7 days if CHG disk is used or more frequent if dressing is damp, loose, or soiled. *** Catheter Discontinuation – Catheter necessity should be reviewed daily with prompt removal of unnecessary lines.

16. What can we do to prevent CR-BSIs? Site Checks Every Shift. Good Shift to Shift Communication. Hand Washing and Antiseptic Foam use. Follow UTSW Policy on Injection Caps, Medication Administration, & Flushing. Dressing Changes Proper Venous Access Selection

17. What we can do to prevent CR-BSIs? I- Site checks every shift Visual inspection of the CVC insertion site CVC dressing, and the CVC itself at the start of each shift can help prevent future complications. WHAT TO LOOK FOR: 1- Is the dressing clean, dry, intact, & dated? 2- Is the dressing due to be changed? 3-How does the skin integrity under & around the dressing look? 4-Is the catheter in the same position as documented at time of insertion? 5-Are all ports of the CVC in working order? Do they flush easily and draw briskly?

18. What we can do to prevent CR-BSIs? II. Good shift to shift communication. Communicate: 1- Your site check observations. 2- Dressing, tubing, or cap changes you may have performed. 3- Any patient complaints, questions, or concerns. 4- Any tests or procedures that may utilized the patient’s CVC. 5- Any interventions you may have performed, such as a CXR or line declot.

19. What we can do to prevent CR-BSIs? III. Hand Washing and use of Antiseptic Foam. ***Hand washing*** T he most important thing we can do!* Before & after patient care. Before accessing a CVC. *Remember to wear gloves when accessing a CVC*

20. What we can do to prevent CR-BSIs? IV. Follow UTSW Policy on: a- Injection Caps b- Medication Administration c- Flushing.

21. a- Injection Caps ***ALWAYS WASH HANDS FIRST*** Change all central line caps: 1- On admission If patient was admitted with a CVC 2-Every Tuesday & Friday Regardless of when caps were last changed 3-Every 24hrs If used for blood, blood products, or lipid emulsions 4-PRN

22. b- Medication Administration ***ALWAYS WASH HANDS FIRST*** 1- Using aseptic technique, draw up medication to be given or spike IVF/IV ABX 2- Don clean exam gloves. 3- Open an alcohol pad. 4- Clean the injection cap with an alcohol pad for 15 seconds with a twisting motion like juicing an orange. Allow to air dry for 15 seconds. Do not fan or blow on the cap.

23. b- Medication Administration cont 5- While holding the cap so that it does not touch anything twist the needle and cap off the syringe or remove protective cap from IV tubing then push and twist clockwise onto the injection cap. 6- Unclamp the catheter and administer medication. **If you are unable to flush the catheter, do not force the fluid through the cap. Instead, ensure there are no other clamps or kinks in the line. You may even try changing injection caps. If still unable to flush, contact the physician and refer to policy # 4-4032 on catheter occlusion.** 7- When medication complete, close the clamp, then twist counter-clockwise to remove. 8- Flush line per VAD protocol.

24. c- Flushing ***ALWAYS WASH HANDS FIRST*** 1- Using aseptic technique, draw up 10ml 0.9% saline (20ml if flushing after blood/blood products) 2- Don clean exam gloves. 3- Open an alcohol pad. 4- Clean the injection cap with an alcohol pad for 15 seconds with a twisting motion like juicing an orange. Allow to air dry for 15 seconds. Do not fan or blow on the cap. 5- While holding the cap so that it does not touch anything twist the needle and cap off the syringe & then push and twist the syringe clockwise onto the cap.

25. c- Flushing cont 6- Unclamp the catheter and flush with 10ml of 0.9% saline. **If you are unable to flush the catheter, do not force the fluid through the cap. Instead, ensure there are no other clamps or kinks in the line. You may even try changing injection caps. If still unable to flush, contact the physician and refer to policy # 4-4032 on catheter occlusion.** 7- Close the clamp, then twist the syringe counter-clockwise to remove. 8- Discard needle and uncapped syringe into a sharps container. 9- Follow same procedure for Heparin flush as indicated buy VAD protocol.

26. What we can do to prevent CR-BSIs? V. Dressing changes: a- Scheduled & PRN. b- Sterile Aseptic Technique. c- Removal of old dressing with site inspection. d- Thorough cleaning with antiseptic skin prep. e- Proper application of new securement device (PICC Lines), CHG disk, & transparent dressing. f- Date, time , & initials.

27. V. Dressing changes a-Scheduled & PRN. Dressing changes are done every 7 days when using the CHG disk as long as the dressing is C/D/I (Clean, Dry, and Intact). PRN dressing changes should be performed prior to the 7 th day if the dressing becomes: loose, wet, soiled, or the CHG disk is noted to be engorged with blood or body fluid.

28. V. Dressing changes b- Sterile Aseptic Technique. Sterile aseptic technique Including use of mask and sterile gloves for all dressing changes……no exceptions! Remember All aseptic technique begins and ends with good hand washing!

29. V. Dressing changes c- Removal of old dressing with site inspection . Removing the old dressing should be done with great care so not to dislodge or displace the CVC from it’s original position. Remember to wear your mask and clean gloves during this phase. Visually inspect for: skin color & integrity, the amount of catheter that is out of the skin, and any blood or fluid.

30. V. Dressing changes d- Thorough cleaning with antiseptic skin prep. Clean & disinfect the skin with Antiseptic prep composed of Chlorhexidine gluconate 2% and Isopropyl alcohol 70% . Use repeated back-and-forth strokes of the applicator for approximately 30 seconds . Completely wet the treatment area with antiseptic. Allow the area to air dry for approximately 30 seconds . Do not blot or wipe away.

31. V. Dressing changes e- Securing Your PICC After Cleaning. (Skip this section if CVC is sutured.) 1. After allowing 30 seconds for CHG prep to dry apply skin prep to area where securement device is to be placed. Allow 10-15 seconds to air dry. 2. Next, place catheter in securement device before placing pad on skin. 3. With one hand, slide the securement anchor pad under the catheter wing. Making sure the notched side of the securement device is facing the insertion site, slide one of the catheter wing into one side of the securement device, then do the same with the other side. 4. Put the anchor pad over the skin site, making sure the catheter is in place. Peel away the paper backing one side at a time. Press on to skin. 5. Apply dressing over the securement device with center of dressing over the insertion site and CHG disk.

32. V. Dressing changes e- Proper CHG disk application 1- Soft foam side to the skin “Foam To The Bone” 2- Foam side has the CHG 3- ”If you see white, the disk is not right”. 1- BLUE Side Up 2- BLUE to the Sky 3- BLUE side does NOT release CHG 1- Adequate distance between catheter hub & insertion site. 2- 360 o coverage around insertion site. 3- Slit at the 11 o’clock or 1 o’clock position (shown here).

33. Several Examples of Properly Placed CHG Disk Note: 1- All have adequate room between catheter hub and insertion site for proper CHG disk application. 2- CHG disk has 360 o coverage with slit @ the 11 o'clock or 1 o'clock position. 3- Blue side up.

34. V. Dressing changes e- Application of new dressing. 1. Remove sterile dressing from CVC dressing change kit. 2. Peel the liner from the dressing, exposing the adhesive surface. 3. Position the transparent portion of the dressing so that it is centered over the insertion site, while holding the notched portion off the skin. The reinforced tabs of the dressing will help to secure the cannula. The tabs can be overlapped slightly to provide additional stabilization and cushioning under the catheter hub. 4. Overlap the tabs under the catheter to form a tight seal around the catheter or lumens. 5. Slowly remove the frame while smoothing down the dressing edges. Seal the edges of the notch and smooth the dressing from the center toward edges using firm pressure to enhance adhesion. 6. Record date, time, & initials on the documentation label, then place the label on the dressing. 7. The sterile tape strips can be used: • Under the catheter wings or hub — to protect the skin • Over the catheter wings or hub — to enhance catheter stability • To secure IV tubing or to stabilize catheter lumens

35. Several Examples of proper application of transparent dressing .

36. VI- Proper Venous Access Selection Based on best practice guidelines, not a coin toss. 1- Follow the Vascular Access Planning Decision Tree when deciding what type of access is best for your patient’s needs. 2- Not all patient need central venous access. 3- Difficulty starting a PIV is not a reason to place a central line, and a PICC, is a central line. 4- If your are unable to obtain peripheral access you may request a Sono-guided PIV be placed by the Super User in your unit. 5- If a CVC is chosen, catheter necessity must be reviewed daily , with prompt removal of unnecessary lines.