Catheter related infections in ICU

Catheter Related Infections
Mansoor Masjedi MD , FCCM
Shiraz University of Medical sciences
3rd
international congress of critical care medicine
Teh., Iran ; 20-22th Jan. 2016

AgendaAgenda
What are the Devices.
Epidemiology.
Pathogenesis.
Diagnosis.
Treatment.
Prevention.

Downloaded from: Infectious Diseases (on 16 November 2007 12:04 PM)
© 2007 Elsevier

8
Three ways stop cock
(open connector)
Single use vials, used
multiple times
Peripheral catheter with no
sterile catheter dressing
Central line with no sterile
dressing
Multiple use vials with
inserted needles
CL insertion without
maximal barriers

PercentageofHAIsPercentageofHAIs
Country Type of Study/Unit HAI Rate (%) Year
Albania Adult ICUs 31.6 2008
Albania Surgical ICUs 22.0 2008
Argentina (INICC Study) Multicenter adult ICU 27.0 2003
Bangladesh Adult ICUs 30 2011
Brazil Multicenter newborn ICU 28.1 2004
Brazil Newborn ICU 50.7 2002
Brazil(INICC Study) Multicenter adult ICU 29.6 2006
Bulgaria Newborn ICU 1.9 2011
Chile Hospitalwide 14.0 2001
China Hospitalwide 3.04 2005
China Newborn ICU 11.6 2007
Colombia Newborn ICU 5.3 2005
Colombia (INICC Study) Multicenter adult ICU 12.2 2006
Costa Rica (INICC Study) Adult ICU 4.8 2009
Croatia (INICC Study) Adult ICU 7.0 2006
Cuba (INICC Study) Multicenter adult ICU 22.4 2011
Egypt Pediatrie ICU 23.0 2005
Egypt (INICC study) Adult ICU 32.8 2012
Egypt (INICC study) Pediatric ICU 24.5 2012
India Pediatric ICU 19.3 2011
India (INICC Study) Multicenter adult ICU 12.3 2005
Kosovo Adult ICU 64.3 2008
Kosovo Adult and New Born 17.4 2006
Kuwait Adult MS ICU 10.6 2008
Lebanon (INICC study) Adult ICU 9.8 2012
Macedonia (INICC study) Adult ICU 2.1 2010

PercentageofHAIsPercentageofHAIs
Country Type of Study/Unit HAI Rate (%) Year
Mexico Hospitalwide 21.0 2002
Mexico Multicenter adult ICU 23.2 2000
Mexico (INICC Study) Multicenter adult ICU 24.4 2006
Morocco (INICC Study) Adult medical ICU 19.3 2005
Pakistan Adult ICUs 39.7 2007
Peru (INICC Study) Multicenter adult ICU 11.2 2005
Philippines (INICC Study) Adult ICU 19.1 2006
Poland (INICC study) Adult ICU 24.3 2012
Saudi Arabia Multicenter hospitalwide 2.8 2004
Saudi Arabia Hospitalwide maternity 4.0 2002
Saudi Arabia Hospitalwide 8.5 2002
Saudi Arabia Adult ICU 19.8 2002
Saudi Arabia Newborn ICU 35.8 2002
Serbia Adult ICUs 40.8 2006
Tanzania Multicenter hospitalwide 14.8 2003
Tanzania Adult medical ICU 40.0 2003
Tunisia (INICC study) Newborn and Pediatric 4.1 2010
Turkey Adult ICU 12.5 2000
Turkey Multicenter adult ICU 48.7 2004
Turkey Neurology ICU 88.9 2005
Turkey General pediatric wards 3.02 2012
Turkey Intensive care unit 25.6 2011
Turkey Intensive care unit 20.1 2011
Turkey Newborn ICU 29.7 2010
Turkey (INICC Study) Multicenter adult ICU 20.5 2005
INICC 8 countries Multicenter adult ICU 14.7 2005
Range: 2% to 88%

Country Setting HAI per 1000 bed
days
Year
Argentina (INICC Study) Multicenter adult ICU 90.0 2003
Brazil Multicenter adult ICU 30.6 2006
Brazil Multicenter newborn ICU 24.9 2004
Brazil Newborn ICU 62.0 2002
China Newborn ICU 14.9 2007
Colombia (INICC Study) Newborn ICU 6.2 2005
Colombia (INICC Study) Multicenter adult ICU 18.2 2006
Costa Rica (INICC Study) Adult ICU 13.9 2009
Croatia (INICC Study) Adult ICU 25.6 2006
Cuba (INICC Study) Multicenter adult ICU 30.6 2011
Egypt Pediatric ICU 40.0 2005
Egypt Pediatric ICU 8.6 2011
Egypt Multicenter ICUs 20.5 2012
Egypt (INICC Study) Adult ICU 52.9 2012
Egypt (INICC Study) Pediatric ICU 22.8 2012
India Hospitalwide 36.2 2004
India Pediatric ICU 21 2011
India (INICC Study) Multicenter adult ICU 21.4 2005
INICC (INICC Study) Multicenter adult ICU 22.5 2005
Kuwait Adult MS ICU 20.6 2008
Lebanon (INICC study) Adult ICU 11.85 2012
Lithuania 5 Pediatric ICUs 24.5 2009
Macedonia (INICC study) Adult ICU 4.5 2010
Mexico (INICC Study) Multicenter adult ICU 39.0 2006
Morocco (INICC Study) Adult medical ICU 20.4 2005
Peru (INICC Study) Multicenter adult ICU 25.3 2005
Philippines (INICC Study) Adult ICU 27.5 2006
Poland (INICC Study) Adult ICU 21.9 2012
Serbia Adult ICUs 65.6 2006
Tunisia (INICC Study) Pediatric and Newborn 6.88 2010
Turkey Burn ICU 18.2 2009
Turkey General Pediatric wards 3.17 2012
Turkey ICU 21.6 2011
Turkey Newborn ICU 17.3 2010
Turkey (INICC Study) Multicenter adult ICU 48.4 2005
Turkey (INICC Study) Neurology ICU 84.2 2005
HAIsper1000BedDaysHAIsper1000BedDays
Range: 11 to 90 HAIs per 1000 Bed days

CLABSIper1000CLdaysCLABSIper1000CLdays
Country ICU Type CLABSI per 1000 CL
days
Year
Argentina Adult 11.4 2002
Argentina (INICC Study) Adult 30.3 2004
Brazil NICU 17.3 2010
Brazil PICU 10.2 2003
Brazil (INICC Study) Adult 9.1 2008
Brazil (INICC Study) Adult, PICU 34.0 2003
Brazil (INICC Study) NICU 3.1 2007
China NICU 18 2007
China (INICC Study) Adult 3.1 2011
Colombia (INICC Study) Adult 11.3 2006
Costa Rica (INICC Study) Adult 4.65 2009
Croatia (INICC Study) Adult 8.3 2006
Cuba (INICC Study) Adult 2.0 2011
Egypt (INICC Study) Adult 22.5 2011
Egypt (INICC Study) PICU 18.8 2011
El Salvador (INICC Study) PICU 10.1 2011
El Salvador (INICC Study) NICU 16.1 2011
India Adult, PICU, NICU 0.48 2010
India NICU 27.0 2011
India (INICC Study) Adult 7.9 2007
Iran Adult 147.3 2004

Country ICU Type CLABSI per 1000 CL
days
Year
Kuwait Adult 5.5 2008
Lebanon (INICC Study) Adult 5.2 2011
Lithuania PICU 7.7 2009
Macedonia (INICC Study) Adult 1.47 2010
Mexico (INICC Study) Adult 23.1 2006
Morocco (INICC Study) Adult 15.7 2009
Peru PICU 18.1 2010
Peru (INICC Study) Adult 7.7 2008
Philippines (INICC Study) Adult 4.6 2011
Philippines (INICC Study) PICU 8.23 2011
Philippines (INICC Study) NICU 20.8 2011
Poland (INICC Study) Adult 4.01 2011
Saudi Arabia NICU 8.2 2009
Tunisia Adult 15.3 2006
Tunisia (INICC Study) PICU, NICU 8.65 2010
Turkey Adult 11.8 2010
Turkey NICU 3.8 2012
Turkey (INICC Study) Adult 17.6 2007
INICC 15 countries NICU 13.7 2011
INICC 18 countries Adult, PICU, 9.2 2008
INICC 8 countries Adult, PICU, NICU 18.5 2006
CLABSIper1000CLdaysCLABSIper1000CLdays
Range: 2 to 147 CLABs per 1000 CL days

VAPper1000MVdaysVAPper1000MVdays
Country ICU Type VAP per 1000 MV
days
Year
Albania Adult, PICU, NICU 40.0 2008
Brazil NICU 3.2 2010
Brazil (INICC Study) Adult, PICU 26.0 2003
Brazil (INICC Study) NICU 4.3 2007
China NICU 63.3 2007
Costa Rica (INICC Study) Adult 29.9 2009
Egypt (INICC Study) PICU 31.8 2011
El Salvador (INICC Study) NICU 9.9 2011
Iran Adult 275 2004

Country ICU Type VAP per 1000 MV days Year
Peru PICU 7.9 2010
Philippines (INICC Study) NICU 0.44 2011
Turkey NICU 13.76 2012
VAPper1000MVdaysVAPper1000MVdays
Range: 3 to 275 VAP per 1000 MV days

CAUTIper1000UCdaysCAUTIper1000UCdays
Country ICU Type CAUTI per 1000 UC
days
Year
Albania Adult, PICU, NICU 41.0 2008
Iran Adult 137.5 2004

Country ICU Type CAUTI per 1000 UC
days
Year
Peru PICU 5.1 2010
CAUTIper1000UCdaysCAUTIper1000UCdays
Range: 0.1 to 137 CAUTI per 1000 UC days

CLAB Rates Stratified Socio-Economic LevelCLAB Rates Stratified Socio-Economic Level
95%CI 18.06-20.1 6.5-7.5 7.3-7.8
Rosenthal VD, et al. Pediatric Critical Care 2012. Infection 2012.

CLAB Rates Stratified By Hospital TypeCLAB Rates Stratified By Hospital Type
95%CI 9.6-10.3 8.6-9.9 5.4-6.3

VAP Rates Stratified By Hospital TypeVAP Rates Stratified By Hospital Type
95%CI 13.3-14.2 19.8-21.0 6.4-7.7

21
PHILIPPINESPHILIPPINES
MACEDONIAMACEDONIA
PAKISTANPAKISTAN
EGYPTEGYPT
CUBACUBAEl SALVADOREl SALVADOR
KOSOVOKOSOVO
NIGERIANIGERIA
DOMINICANDOMINICAN
GUATEMALAGUATEMALA
LEBANONLEBANON
CHINACHINA
THAILANDTHAILAND
JAPANJAPAN
URUGUAYURUGUAY
MALAYSIAMALAYSIA
PANAMAPANAMA
1000 Hospitals of 200 CITIES of 54 COUNTRIES of 4 CONTINENTS
COSTA RICACOSTA RICA
CHILECHILE
SAUDISAUDI
ARABIAARABIA
UKRAINEUKRAINE
VENEZUELAVENEZUELA
CROATIACROATIA
VIETNAMVIETNAM
POLANDPOLAND
SUDANSUDAN

Papers published by INICC byPapers published by INICC by
specific Country of Europe, Asiaspecific Country of Europe, Asia
and Africaand Africa

Five INICC International ReportsFive INICC International Reports
(One every second year, from 2006 to 2014)(One every second year, from 2006 to 2014)
Publication year 2006
Number of
Countries
8
Peer Review
Journal
Annals of
Internal
Medicine
23
2008
18
American
Journal of
Infection
Control
2010
25
American
Journal of
Infection
Control
2012
36
American Journal of
Infection Control
2014
43
American Journal of
Infection Control
Submitted

INICC
2002-2005
(Annals 2006)
INICC
2002-2007
(AJIC 2008)
INICC
2003-2008
(AJIC 2010)
INICC
2004-2009
(AJIC 2012)
INICC
2007-2012
(AJIC 2014)
Number of
Countries
8 18 25 36 43
Participating
Countries
Argentina, Brazil,
Colombia, India,
Mexico, Morocco,
Peru, and Turkey
Argentina, Brazil,
Chile, Colombia,
Costa Rica, Cuba,
India, Kosovo,
Lebanon, Macedonia,
Mexico, Morocco,
Nigeria, Peru,
Philippines, El
Salvador, Turkey,
Uruguay
Argentina, Brazil,
China, Colombia,
Costa Rica, Cuba,
Greece, India, Jordan,
Kosovo, Lebanon,
Lithuania,
Macedonia, Mexico,
Morocco, Pakistan,
Panama, Peru,
Philippines, El
Salvador, Thailand,
Tunisia, Turkey,
Venezuela, Uruguay
Argentina, Brazil,
Bulgaria, China,
Colombia, Costa
Rica, Cuba,
Dominican Republic,
Ecuador, Egypt,
Greece, India, Jordan,
Kosovo, Lebanon,
Lithuania,
Macedonia, Malaysia,
Mexico, Morocco,
Pakistan, Panama,
Peru, Philippines,
Puerto Rico, El
Salvador, Saudi
Arabia, Singapore, Sri
Lanka, Sudan,
Thailand, Tunisia,
Turkey, Venezuela,
Vietnam, Uruguay
Argentina,
Bolivia, Brazil,
Bulgaria, China,
Colombia, Costa
Rica, Cuba,
Dominican Republic,
Ecuador, Egypt,
Greece, India, Iran,
Jordan, Kosovo,
Lebanon, Lithuania,
Macedonia, Malaysia,
Mexico, Morocco,
Pakistan, Panama,
Peru, Philippines,
Poland, Puerto Rico,
Romania, El
Salvador, Saudi
Arabia, Serbia,
Singapore,
Slovakia, Sri Lanka,
Sudan, Thailand,
Tunisia, Turkey,
United Arab
Emirates, Uruguay,
Venezuela, Vietnam
Number of
ICUs
55 98 173 422 503

INICC
2002-2005
(Annals 2006)
INICC
2002-2007
(AJIC 2008)
INICC
2003-2008
(AJIC 2010)
INICC
2004-2009
(AJIC 2012)
INICC
2007-2012
(AJIC 2014)
Medical Cardiac ICU
CLABSI - 9.9 (8.7 – 11.3) 8.5 (7.5 – 9.7) 6.2 (5.6 – 6.9) 3.5 (3.1 – 3.9)
CAUTI - 6.4 (5.3 – 7.7) 4.4 (3.5 – 5.3) 3.7 (3.2 – 4.3) 5.9 (5.4 – 6.4)
VAP - 20.2
(17.0 – 23.9)
14.9
(12.4 – 17.9)
10.8
(9.5 – 12.3)
11.5
(10.5 – 12.5)

Medical-surgical ICU
CLABSI - 8.9 (8.4 – 9.4) 7.4 (7.2 – 7.7) 6.8 (6.6 – 7.1) 4.9 (4.8 – 5.1)
CAUTI - 6.6 (6.2 – 7.0) 6.1 (5.9 – 6.4) 7.1 (6.9 – 7.4) 5.3 (5.2 – 5.8)
VAP - 19.8
(14.2 – 27.1)
14.7
(14.2 – 15.2)
18.4
(17.9 – 18.8)
16.5
(16.1 – 16.8)

Pediatric ICU
CLABSI - 6.9 (5.6 – 8.3) 7.8 (7.1 – 8.5) 4.6 (3.7 – 5.6) 6.1 (5.7 – 6.5)
CAUTI - 4.0 (2.4 – 6.2) 4.4 (3.6 – 5.4) 4.7 (4.1 – 5.5) 5.6 (5.1 – 6.1)
VAP - 7.9 (6.0 – 10.1) 5.5 (4.9 – 6.0) 6.5 (5.9 – 7.1) 7.9 (7.4 – 8.4)

Newborn ICU (1501-
2500 g)

CLABSI - 15.2
(10.3 – 21.5)
13.9
(12.4 – 15.6)
11.9
(10.2 – 13.9)
4.8
(3.7 – 6.1)
VAP - 6.68 (3.0 – 12.7) 9.50 (7.9 – 11.3) 10.1 (7.9 – 12.8) 10.7 (8.4 – 13.4)

Overall -
CLABSI 12.5
(11.7 – 13.3)
9.2
(8.8 – 9.7)
7.6
(7.4 – 7.9)
6.8
(6.7 – 7.0)
4.8
(4.7 – 4.9)
CAUTI 8.9
(8.3 – 9.5)
6.5
(6.1 – 6.9)
6.3
(6.0 – 6.5)
6.3
(6.2 – 6.5)
5.3
(5.2 – 5.4)
VAP 24.1
(22.8 – 25.5)
19.5
(18.7 – 20.3)
13.6
(13.3 – 14.0)
15.8
(15.5 – 16.1)
14.7
(14.5 – 14.9)

International Nosocomial Infection Control
Consortium (INICC) report, data summary for
2007- 2012, Device-associated module
AJIC published in 2014
Víctor Daniel Rosenthal 1; Dennis George Maki 2; Yatin Mehta 3; Hakan Leblebicioglu 4; Ziad
Ahmed Memish 5; Haifaa Hassan Al-Mousa 6; Hu Bijie 7; Carlos Alvarez-Moreno 8; Eduardo A
Servolo-Medeiros 9; Anucha Apisarnthanarak 10; Lul Raka 11; Luis E Cuellar 12; Altaf Ahmed 13;
Josephine Anne Navoa-Ng 14; Amani Ali El-Kholy 15; Souha Sami Kanj 16; Ider Bat-Erdene 17;
Wieslawa Duszynska 18; Nguyen Van Truong 19; Maria Marcela Bovera 20; Lucy Chai See-Lum 21;
Rosalia Fernandez-Hidalgo 22; Gabriela Di-Silvestre 23; Farid Zand 24; Sona Hlinkova 25; Vladislav
Belskiy 26; Hussain Al-Rahma 27; Marco Tulio Luque-Torres 28; Nesil Bayraktar 29; Zan Mitrev 30;
Vaidotas Gurskis 31; Dale Fisher 32; ilham Bulos Abu-Khader 33; Kamal Berechid 34; Arnaldo
Rodríguez-Sánchez 35; Florin Horhat 36; Osiel Requejo-Pino 37; Nassya Hadjieva 38; Nejla Ben-
Jaballah 39; Elías García-Mayorca 40; Luis Kushner-Dávalos 41; Srdjan Pasic 42; Luis E. Pedrozo-
Ortiz 43; Eleni Apostolopoulou 44; Nepomuceno Mejía 45; May Osman Gamar-Elanbya 46; Kushlani
Jayatilleke 47; Miriam de Lourdes-Dueñas 48; Guadalupe Aguirre-Avalos 49.
Rosenthal, V. D., et alRosenthal, V. D., et al. International Nosocomial Infection Control
Consortium (INICC) report, data summary for 2007- 2012, Device-
associated module" American journal of infection control" American journal of infection control

INICC report – 43 countries- “2007 to 2012”.INICC report – 43 countries- “2007 to 2012”.
Countries included: Argentina, Bolivia, Brazil, Bulgaria, China, Colombia, Costa Rica,
Cuba, Dominican Republic, Ecuador, Egypt, Greece, India, Iran, Jordan, Kosovo,
Lebanon, Lithuania, Macedonia, Malaysia, Mexico, Morocco, Pakistan, Panama, Peru,
Philippines, Poland, Puerto Rico, Romania, El Salvador, Saudi Arabia, Serbia,
Singapore, Slovakia, Sri Lanka, Sudan, Thailand, Tunisia, Turkey, United Arab Emirates,
Uruguay, Venezuela, Vietnam
ICUs: 503
Patients: 605,310
Bed days: 3,338,396
Central Line days: 1,650,901
Ventilator days: 1,197,681
Urinary catheter days: 1,947,650
BSI (n): 7887
VAP (n): 17,605
CAUTI (n): 10,322
Total IAD: 35,814
Rosenthal, V. D., et alRosenthal, V. D., et al. International Nosocomial Infection Control
Consortium (INICC) report, data summary for 2007- 2012, Device-
associated module" American journal of infection control" American journal of infection control

HAI rates INICC vs CDC-NHSN (USA)HAI rates INICC vs CDC-NHSN (USA)
INICC
2007–2012
Pooled Mean (95% CI)
U.S. NHSN
2012
Pooled Mean (95% CI)
Medical Cardiac ICU
CLABSI 3.5 (3.1 – 3.9) 1.1 (1.0 – 1.1)
CAUTI 5.9 (5.4 – 6.4) 2.2 (2.0 – 2.3)
VAP 11.5 (10.5 – 12.5) 1.0 (0.8 – 1.1)

Medical-surgical ICU
CLABSI 4.9 (4.8 – 5.1) 0.9 (0.9 – 1.0)
CAUTI 5.3 (5.2 – 5.8) 1.2 (1.2 – 1.3)
VAP 16.5 (16.1 – 16.8) 1.1 (1.0 – 1.2)

Pediatric ICU
CLABSI 6.1 (5.7 – 6.5) 1.4 (1.3 – 1.6)
CAUTI 5.6 (5.1 – 6.1) 2.7 (2.5 – 3.0)
VAP 7.9 (7.4 – 8.4) 0.8 (0.6 – 0.9)

Newborn ICU (1501-2500 g)
CLABSI 4.8 (3.7 – 6.1) 0.6 (0.5 – 0.8)
VAP 10.7 (8.4 – 13.4) 0.2 (0.1 – 0.5)
Rosenthal, V. D., et alRosenthal, V. D., et al. International Nosocomial Infection Control Consortium (INICC) report, data
summary for 2007- 2012, Device-associated module" American journal of infection control" American journal of infection control

EngageEngage
Partner with Infection
Control, ID experts
Increase awareness
about morbidity and
mortality associated
with CLABSI
Make harm visible
Tell stories
Post # infections
Estimates of opportunity
to improve

TEAMFORMATION
ICU DirectorICU Nurse Manager
Infection Control
Practitioners
Chief Hospital
Epidemiologist
Attendings &
Residents
Nursing Staff
(ICU)
QA/Quality Staff
QI experts
Frontline
Staff
Infectious
Disease experts
Leaders
National Quality
Scholars

Form the Dream Team
• Heterogeneous in make up;
homogeneous in mind set
• All stakeholders must be
included
• All RN teams fail because MDs
insert lines
• Find a high profile champion
• Get a process owner
Vanderbilt Infection Control & Prevention

Thank You Notes to NICU Staff
Thank You FromThank You From
Baby Boy JonesBaby Boy Jones
I have gone 136 days without a
bloodstream infection. Keep up the
good work! My Mom left some
“kisses” for you! XOXOX

EducateEducate
Educate staff and senior leaders
about CDC guidelines
Develop a resource notebook
Develop policies and procedures
CDC guidelines and Fact Sheet
Power point slides for In-services
Consider a quiz to evaluate provider
knowledge
Can use on-line training

EvaluateEvaluate
Outcome measure: CLABSI rate
Rate, # infections, weeks/months since
last infection
Process measures
% checklists completed
% violations noted
# lines removed
Celebrate success

Share the DataShare the Data
CLA-BSI in Trauma
0
1
2
3
4
5
6
7
8
9
2005 2006 2007
Infsper100devicedays
Trauma
CDC Benchmark
BSI Bundle

The Check ListThe Check List
Adapt to your own
institution
Must be filled out for each
line insertion
Include 5 BSI bundle
elements
Simpler is better
Can always add
elements as you become
better at capturing data
LF
Time end
(catheter secured):
MR #:
Check if:
Femoral
Internal Jugular
//Date:
Type of catheter:
Triple lumen
Introducer
Swan-Ganz
Insertion Site:
Subclavian
Other (specify):
Pt/Family teaching done
Consent obtained
Pre-insertion skin prep (check any used):
Alcohol Betadine (povidone-iodine) Chlorhexidine Other (specify):
Describe the circumstances under which this line was placed:
Non-emergent Emergent (life-threatening or code situation)
Please file page 2 in patients chart and return top form to the designated location in the ICU.
List all sites where insertion was attempted.
Other (specify):
:Time start
(1st needle stick): :
How many different needle sticks did the patient receive (number of skin breaks)?
1 Unknown
The provider inserting this line:
* If “No”, was this procedure supervised by someone with least five (5) central lines experience?
Yes No Didn’t ask
Yes No
Please use military time
(i.e. 1:00 pm is 13:00)
a. Handed-off his/her pager before the procedure?
Yes Nob. Washed hands immediately prior to procedure?
Yes No *
Didn’t ask
Didn’t ask
Didn’t askc. Has previously placed at least five (5) central lines?
Describe the level of training of the person who actually inserted the line?
Medical Student Intern (PGY-1) Resident (PGY-2+) Fellow Attending
Barrier precautions (check any used):
Sterile gloves Sterile gown Mask Sterile towels Full body drape
Side:
Right
Left
2 3 4 5 6+
Follow-up CXR: Ordered Not ordered (specify reason):
CXR findings (check all that apply):
No pneumothorax Pneumothorax (describe action taken):
Catheter in good position Catheter position adjusted (describe):
Type of dressing: Bio-occlusive Gauze Other (specify):
Patient tolerated the procedure well? Yes No
Was the sterile field maintained throughout the entire procedure? Yes No
Complications? None Other (describe):
Dressing applied by: Nurse Proceduralist Other (specify):
Nursing Checklist:
Central Venous Catheter Insertion
Vanderbilt University Medical Center
RIJ LIJ RSC LSC RF
Guidewire exchange
Placement unsuccessful
MC 2705 (Rev. 06/04)
NOTE: Please use either black or blue ink to complete this form.
Comments:
Vascath
Signature: ______________________________________________ Date: _________________
Indications for use:
Pressors
Hemodynamic monit.
Fluids/blood products
Frequent lab draws
Pre-existing infection
Nurse Practitioner
Double lumen
atVanderbilt
Monroe Carell Jr.
OR
CCU MICU SICU
BICU PCCU NICU
NSICUTICU
Other

ExecuteExecute
Hand Hygiene
Remove Unnecessary Lines
Use of Maximal Barrier Precautions
Chlorhexidine for Skin Antisepsis
Avoid femoral lines

Hand HygieneHand Hygiene
Empower nursing to enforce use of a central line checklist
to be sure all processes related to central line placement,
including hand hygiene, are executed for each line
placement.
Include hand hygiene as part of your checklist for central
line placement.
Keep soap/alcohol-based hand hygiene dispensers
prominently placed and make universal precautions
equipment, such as gloves, only available near hand
sanitation equipment.
Post signs at the entry and exits to the patient room as
reminders.
Initiate a campaign using posters including photos of
celebrated hospital doctors/employees recommending
hand hygiene.
Create an environment where reminding each other about
hand hygiene is encouraged.

Start SmallStart Small
Select the team and the venue. It is often best to start in
one ICU. Many hospitals will have only one ICU, making
the choice easier.
Assess where you stand presently. What precautions are
taken presently when placing lines? Is there a process in
place? If so, work with staff to begin preparing for
changes.
Contact your Infection Control Department. Learn about
your catheter-related bloodstream infection rate and how
frequently the hospital reports it to regulatory agencies.
Organize an educational program. Teaching the core
principles to the ICU staff will open many people’s minds
to the process of change.
Introduce the central line bundle to the staff.

One ICU…then the RestOne ICU…then the Rest
Once the bundle has been applied
to one patient and subsequent
shifts, increase utilization to the
remainder of the ICU.
Engage in additional PDSA cycles
to refine the process and make it
more reliable.
After achieving reduction in CR-BSI
in the pilot ICU, spread the changes
to other ICUs, and eventually to
other places in the hospital where
central lines are inserted
…So Use Data

Potential BarriersPotential Barriers
Fear of change
Use knowledge
Use optimism
Communication breakdown
Involve all stakeholders
on the front end
MD and staff partial “buy-in”
Supply continuous data to
all groups
Changes in rates convert
the non-believers

Do remember theDo remember the
Reasons for InfectionsReasons for Infections
are Many but solutionsare Many but solutions
are few …are few …
47

Catheter related infections in ICU

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