1. PREVENTING CATHETER
ASSOCIATED BLOODSTREAM
INFECTIONS
BY TEAM A: Dorothy Alford, Linda Holmes, Rhuena
Luntok, Kim Russell & Alijandra ToKar
2. OBJECTIVES
– Identify and analyze the issue
– Accrediting and regulatory agencies
recommendations
• The Joint Commission (TJC)
• Center for Disease Control (CDC)
• Institute for Healthcare Improvement (IHI)
– Causes of the risk situation
– Solution
National Healthcare Quality Report (2007)
3. Identify and Analyze the Issue
•Improper care and
placement of central
venous catheters
(CVC)
•Risk for catheter
related blood stream
infection
CDC (2005)
4. Identify and Analyze the Issue
University Of Pennsylvania School Of Medicine (2009)
5. Accrediting & Regulatory Agencies
Recommendations
The Joint Commission (TJC, 2009)
– National Patient Safety Goal #7: Reduce the risk of health
care-associated infections
– Requires to comply with CDC hand hygiene guidelines
Centers for Disease Control and Prevention (CDC, 2002)
– Education and Training of health care providers
– Use of maximal sterile barrier precautions
– Use of 2% chlorhexidine preparation
– Avoid routine replacement of CVCs
– Use of antiseptic/antibiotic short term CVCs
6. Accrediting & Regulatory Agencies
Recommendations
Institute for Healthcare Improvement (IHI, 2009)
• Primary Driver
• Secondary Drivers
• Recommended Changes
1. Reliable hand hygiene,
2. Identify patients using Active Surveillance Testing (AST),
3. Use contact precautions for colonized or infected patients,
4. Use dedicated equipment as part of contact precautions for
colonized and infected patients,
5. Use appropriate room cleaning and disinfection,
6. Sustaining Improvement
7. Causes of the Risk Situation
• Economic and Social
– Healthcare workforce shortage
• Lack of healthcare education and training
– Certification process (Krein et al, 2007)
• Low level of support to evidenced based practice
– Use of maximal barrier protection
– Lack of standardized supplies (Snydman, 2006).
• Lack of surveillance system
– Tool to quantify adherence to accepted practices
– Hand hygiene
8. Causes of the Risk Situation
• Variables to CRBSI
– Type of CVC used
– Site selection
– Skin preparation
– Length of use
– Insertion technique
– Insertion site protection
– Dressing maintenance
Maki et al. (2006)
Harnage (2007)
9. Solution
Evidence based Central Line Bundles:
• Hand washing
• Full barrier precautions during insertion
• Cleaning skin with Chlorhexidine
• Optimal site selection avoiding femoral site
• Removing unnecessary lines
IHI, 2009
CDC, August
11. Conclusion
• Identify and Analyze the Issue
• Accrediting & Regulatory Agencies
Recommendations
• Causes of the Risk Situation
• Solution
12. References
Centers for Disease Control and Prevention (2005). Reduction in central
line - associated bloodstream infections among patients in the intensive
care units. Retrieved June 23, 2009, from http://www.cdc.gov.
Centers for Disease Control (CDC) (2002, August) Guidelines for the
prevention of catheter related blood stream infections. Morbidity and
Mortality Weekly Report 51(10) 1-32
Centers for Disease Control and Prevention. Guidelines for the Prevention
of Intravascular Catheter-Related Infections. MMWR 2002;51(No.
RR-10):[1].
Harnage, S. A. (2007). Achieving zero catheter related blood stream
infections: 15 month success in a community based medical center.
Journal of the American Vascular Association. 12(4), 218-225.
Institute for Healthcare Improvement (2009). Healthcare Associated
Infections. Retrieved on July 8, 2009 from http://www.ihi.org/IHI/Topics/
HealthcareAssociatedInfections/
13. Continue
Institute for Healthcare Improvement ( 2009). Community Change
Package. Retrieved on July 8, 2009 from
http://www.ihi.org/NR/rdonlyres/6B84549C-
BE1D-4835-922A-414D56A98352/0/IHIHAICommunityChangePackage
Dec08.doc
Krein, S. L., Hofer, T. P, Kowalski, C. P., Olmsted, R. N., Kauffman, C. A.,
Forman, J. H., Banaszak-Hall, J., and Saint, S. (2007, June). Use of
central venous catheter-related bloodstream infection prevention
practices by US hospitals. Mayo Clinic Proceedings, 82(6), 672-678.
Retrieved June 23, 2009, from http://www.mayoclinicproceedings.com
Maki, D. G., Kluger, D. M., and Crnich, C. J. (2006, September). The risk of
bloodstream infection in adult with different intravascular devices: A
systematic review of 200 published prospective studies. Mayo Clinic
Proceedings, 81(9), 1159-1171. Retrieved June 25, 2009, from http://
www.mayoclinicproceedings.com
MacCracken, L. (1998) Market driven strategy: An executive guide to
health Care’s integrated environment. Retrieved from UOP eResource
14. Continue
Syndman, D. R. (2006, September). Prevention of catheter and
intravascular device-related infections: A quality-of-care mandate fro
institutions and physicians. Mayo Clinic
The Joint Commission (2009). About Us. Retrieved on July 10, 2009 from
http://www.jointcommission.org/AboutUs/
The Joint Commission (2009). Patient Safety. Retrieved on July 10, 2009
from
http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoa
s/npsg_intro.htm
University of Pennsylvania School of Medicine; Penn medicine draws road
map for elimination of central line-associated bloodstream
infections. (2009). Biotech Business Week,1791. Retrieved July 9,
2009, from ProQuest Health and Medical Complete. (Document
ID: 1670871361).
CDC estimates that more than 2 million patients annually develop infections while hospitalized for other health problems and nearly 90, 000 dies as a result of these infections. Our presentation will focus on CRBSIs. Identifying and analyzing issues related to CRBSIs can be used for strategic planning and public health resources allocation. Accrediting an regulatory agencies ensure safe and efficient practice are being provided to all patients in healthcare industries, which is a positive effect in promoting better outcomes for patients and reducing the rate of infections. Many causes of the risk situations was found to be related to the intravascular devices (IVD), but we will propose solutions in this presentation, such as bundling groups of best practices measure to aid in reductions of CRBRI, that have significantly improved the situation.
There are many factors associated with CRBSI and these are: Economic and Social The decrease in healthcare professionals ultimately has impacted the delivery of quality care to the public. Decrease in staff results in lost productivity, decrease in patient satisfaction, and increased costs for healthcare for preventable nosocomial infections such as bloodstream infections from surgical inserted catheter. Lack of healthcare education and training Lack of healthcare education and training contributes to the problem, but the certification process for insertion of catheter and devices has significantly improved the situation. The certification of Infection Control Person (ICP) or hospital epidemiologist is also important as it promotes mastery and knowledge of current practices required for infection control and prevention (Krein et al, 2007). Low level of support to Evidence Based Practice Evidence based procedures recommended by the Centers for Disease Control (CDC) are used which have the greatest effect on the rate of CRBSI and the lowest barriers to implementation. The procedures recommended are hand washing, using full-barrier precautions during insertion of central venous catheters, cleaning the skin with chlorhexidine, avoiding the femoral site if possible, and removing unnecessary catheters (CDC, August). According to a study in Michigan, clinicians are educated about practices to control infection and harm resulting from catheter related bloodstream infections. They created a central-line cart with necessary supplies. Absence of standardized supplies prevents the person performing the procedures that adhere to accepted techniques (Snydman, 2006). Lack of surveillance system The other causes of CRBSI are lack of surveillance system that monitors vascular access condition and measures infection rate and poor implementation of tool to quantify adherence to accepted practices. A checklist should be used to ensure adherence to infection-control practices. Providers should be stopped (in nonemergency situations) if these practices are not followed. Finally, poor hand hygiene is the most common factor for catheter-related infections. Hand washing is the simplest and most effective form in preventing infection but it the one usually neglected.
The data analysis conducted by Maki et al. (2006) indicated that surgically implanted cuffed and tunneled all-purpose CVC (22.5%) has higher risk of infection than the use of temporary noncuffed but tunneled CVC (4.7%). Each intravascular device can pose a risk of infection depending on its use and degree of manipulation. Using a CVC impregnated with chlorhexidine or minocycline has significantly reduced the risk of infection. The site selection in placing a catheter also plays an important part in preventing infection. Femoral area is found to be the site where highest infection rate occurs. Keeping the catheter for an extended period of time also increases risk of infection. When risk is expressed as BSI per 1000 IVD-days, the highest rate of infection is seen when surgical cutdown is performed (9 per 1000 IVD-days. The rate was lowered with noncuffed nontunneled multilumen CVC (2.7), tunneled but noncuffed CVC (1.7), chlorhexidine-silver-sulfadiazine-impregnated CVC (1.6), and central venous ports (0.1) (Maki et al, 2006). Catheter related blood stream infection is a major cause of patient morbidity, mortality, and cost. The variables in catheter related blood stream infections include: vascular access device (VAD) selection, insertion site selection, skin prep, insertion technique, dressing maintenance, use of insertion site protection technology and clinician maintenance. These variables are critical to eliminating occlusion and extraluminal tract contamination (Harnage, 2007). Lowering CRBSI rates would decrease inpatient length of stay thereby decreasing cost.
Achieving decreased incidence of CRBSI requires a Continuous Quality Improvement (CQI) method to design or redesign the process of care. Solutions require use of research which developed Central Line Bundles that are evidence based interventions. The use of these interventions in practice for patients with intravascular central line catheters when implemented together result in better outcomes than when implemented individually (IHI, 2009). These evidence based Bundles demonstrate the greatest effect on the rate of CRBSI in the hospital. The components of the bundle include hand washing, using full-barrier precautions during insertion of central venous catheters, cleaning the skin with chlorhexidine, optimal catheter site selection with subclavian vein as preferred site and avoiding the femoral site if possible, and removing unnecessary catheters (CDC, August).
Successful outcomes depend upon the successful implementation of the Central Line Bundle. There must be an understanding of the importance of the implementation plan. Policy, protocols and procedures must be developed to guide staff as a basis in the process of care. Policy is a general description of the course of action. Protocols define the methods to be used and procedures describe the series of tasks to be performed in a certain order. Well-organized programs enable health-care providers to provide, monitor, evaluate care and educate which are critical to the success of reducing CRSBI. Successful implementation requires that staff have the necessary abilities and training to realize the new direction. Measures to minimize the risk for CRBSI should strike a balance between patient safety and cost effectiveness (MacCracken, 1998). Lastly communication is valuable through documentation, verbal report, and sharing success. Communication promotes continuity of care and improved quality. It is important to recognize and celebrate success with any improvement initiatives. Accomplishments validate the hard work involved in the change process and encourages strong networks, communication and collaboration.
These are the reference for located in the presentation
