This document summarizes a presentation about eliminating central line-associated bloodstream infections (CLABSIs) in patients with peripherally inserted central catheters (PICCs) at Coborn's Cancer Center. A survey of 13 PICC patients found that while PICC tray use had decreased, there were still 5 CLABSIs related to PICCs in the previous year. The survey also assessed patient knowledge of PICC care and found room for improvement in educating patients about signs of infection. The presentation recommends frequent re-education of patients and caregivers on PICC care best practices such as hand hygiene and hub disinfection to help further reduce CLABSI rates.

1. ELIMINATING
CENTRAL LINE
ASSOCIATED BLOOD
STREAM
INFECTIONS IN PICC
PATIENTS AT
COBORN’S CANCER
CENTER
Presented by:
Steve St. Marie, RN Student, SCSU

2. objectives
 Describe/explore survey results
 Review EBP

3. Definitions
 Peripherally-Inserted Central Catheter (PICC): catheter
inserted percutaneously into
a vein in the arm and
advanced to the distal
vena cava or proximal
right atrium; indicated
for treatments lasting
6 days to 1 yr
 Central Line Associated Blood-Stream Infection
(CLABSI): primary bloodstream infection, in a patient
with a central line in place within 48 hours before onset
of the bloodstream infection, that is not related to
infection at another site

4. Background
 As many as 170,000 non-ICU CLABSIs yearly in US
 Mortality rate estimated at 12-25%
 65-70% of CLABSIs preventable
 CDC estimate of CLABSI cost: best estimate $16550, but
range as high as $36441

5. PICC Utilization Rate and
PICC-Related CLABSI Instances
 Only 13 patients in survey
 PICC tray use down 35% from 2013 (400 trays) to
2014 (260 trays) during period of July through
October, compared to only 5% decrease for
Central Line trays during same period (2640 vs
2780)
 Despite decreasing trend in use, there were 5
CLABSIs related to PICCs at CCC during fiscal
year 2014 and 3 of those were in the last
reporting quarter (ending this past summer),
with no port infections in that same period

6. PICC Patient Survey, Purpose and
Methods
 To identify opportunities to improve overall PICC
care and reduce CLABSI incidence and severity,
PICC patients surveyed to assess:
• their perception of their care
within Coborn’s Cancer Center
• their own knowledge of PICC
home care and infection
S&S
o 10-question survey based on existing survey tool,
administered verbally and recorded manually

7. Demographics
 n = 13
 Age
 mean: approx. 58 yrs
 range: 26-80 yrs
 Gender
 7 male
 6 female
 Months since PICC was placed
 mean: 1.7
 median: 2
 range: 0 (as short as <1 week) to 5 (>4 months, <5)

8. QUESTIONS ABOUT CARE AT COBORN’S
CANCER CENTER
 Have you noticed any differences in how different
staff at CCC care for your PICC line? If yes,
what difference?
 Only 2 yes responses, neither including safety
concerns
 Consistent care across nursing staff
 Reinforces that no one person is responsible for
multiple PICC-related CLABSIs

9.  When staff use an alcohol wipe to clean the hub
(connection points) before connecting anything to
the line, do they scrub that connection point, or
wipe it off?
 2 responses that indicated “wiping” as opposed to
scrubbing
 Has anything about the way the staff here at
CCC cared for your PICC ever concerned you or
struck you as unusual? If so, what specifically?
 2 yes responses

10. Patient Knowledge and Home Practice
Questions
 How did you learn about how to care for your
PICC at home?
 12 responses that they learned by instruction from a
nurse
 2 responses that they also received written material
 2 responses included mention of also relying on a
caregiver for PICC care at home
 1 response that no instruction was received at all
 Suggests that written material should be offered to
take home

11.  If the dressing became loose or opened on one
side before a scheduled dressing change, what
would you do?
 8 responded that they would call CCC or another
specific hospital or clinic that was closer to them or
had to do with their PICC placement or care
 5 responded that they would (or would also) go to
CCC, another specific hospital or clinic that was
relevant to their PICC or would contact an RN
caregiver
 1 responded that they would use MyChart to contact
someone
 1 responded that they would tape it up themselves
 1 responded that whether they called CCC would
depend on how close they were to their dressing
change appointment

12.  What do you do when showering or bathing?
 12 responded that they cover it in saran wrap,
press’n’seal, an arm-length glove, or a plastic sleeve
 1 replied that they also typically take a bath and
when they do that they just hold their arm out of the
water
 1 responded that they only take a sponge bath

13.  Do you know what symptoms you might have if
your PICC line was infected? If so, what are
they?
 9 responses of redness at the site
 7 responses of pain or soreness at the site
 2 responses of drainage at the site
 3 responses of swelling or warmth at the sight
 5 responses of fever
 2 responses of malaise
 1 response of “No, I really don’t.”
 8 surveyed patients replied with 2 signs/symptoms or
less
 8 surveyed patients included only site-specific
signs/symptoms

14. Intraluminal vs Extraluminal,
Offending Organisms
 Extraluminal contamination associated with
migration of infection along outer surface of
catheter (originates at PICC site)
 Intraluminal contamination caused by
contamination of infusate or line, typically at
connection points and access hubs
 Intraluminal contamination is associated with
PICCs due to long placement time
 Most common intraluminal contamination
associated with connection points (by patient’s
normal flora or by hands of health care worker)

15.  Just 2 gram positive skin flora (coagulase-negative
staphylococci and Staphylococcus
aureus) account for 51% of healthcare-associated
blood infections in the US
 Organisms responsible for PICC infections in
fiscal year 2014 (normal skin flora in red):
 S. aureus (2)
 Pseudomonas aeruginosa
 Diptheroids
 Klebsiella pneumonia
 Suggests at least one intraluminal infection

16. Suggestions for Patient Teaching
 During EVERY dressing change, assess and
address:
 what to do when a dressing becomes loose
 whether the patient (and any caregivers) recognize
signs and symptoms of infection, both at the PICC
site and systemic, and what to do about it
 whether the patient would like or make use of
written material related to PICC care
Educate and re-educate
(and re-educate, ad nauseum!)

17. Important Points for Outpatient PICC Care
 Hand Hygiene
Washing is indicated before and after all patient care
and before and after glove applications
 Use of alcohol hand rub is typically acceptable, but
soap and water is indicated when hands are visibly
soiled or bloodied and after caring for a patient with
C. difficile infection or undiagnosed diarrhea
NAP TIME!
Close your eyes…

18.  Hub Disinfection
 Use appropriate antiseptic (chlorhexidine, povidone
iodine, an iodophor, or 70% alcohol)
 “Scrub the hub” for 10 seconds AND allow 20 seconds
to dry
 Patient Education (as per previous slide)
 Suggestion for future student project: collection
and/or creation of PICC home care information
packet

19. References
 Krook, J., Steinmann, K. (2014). Crashing Through the Barriers to
CLABSI Prevention [PowerPoint document].
www.mmicgroup.com/resources/webinars/upcoming/542-upcoming-crashing-
through-the-barriers+&
cd=3&hl=en&ct=clnk&gl=us&client=firefox-a
 Moureau, N., Dawson, R. (2010). Keeping needleless connectors clean,
part 1. Nursing: May 2010, 40(5), 18–19.
 doi: 10.1097/01.NURSE.0000371119.85145.99
 Tavianini, H., Deacon, V., Negrete, J., Salapka, S. (2014). Up for the
challenge: Eliminating peripherally inserted central catheter
infections in a complex patient population. Journal of the Association
for Vascular Access, 19(3), 159-164.
 Taylor, C., Lillis, C, LeMone, P., Lynn, P. (2011). Fundamentals of
nursing: the art and science of nursing care, 7th edition. Philadelphia,
PA: Lippincott, Williams & Wilkins.
 The Joint Commission. (May, 2012). Preventing central line–
associated bloodstream infections: A global challenge, a global
perspective. Oak Brook, IL: Joint Commission Resources.
http://www.PreventingCLABSIs.pdf

20.  United States Centers for Disease Control and Prevention, (2012).
Central venous catheter hub cleaning prior to accessing.
http://www.cdc.gov/dialysis/PDFs/collaborative/Protocol-Hub-
Cleaning-FINAL-3-12.pdf
 United States Center for Disease Control and Prevention, Rutala,
W., Weber, D, Healthcare Infection Control Practices Advisory
Committee (HICPAC). (2008) Guideline for disinfection and
sterilization in healthcare facilities.
http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.p
df
 Weingart, S., Hsieh, C., Lane, S., Cleary, A. (2013). Standardizing
central venous catheter care by using observations from patients
with cancer. Clinical Journal of Oncology Nursing, 18(3), 321-
326.
 Whited, A., Lowe, J. (February, 2013). Central line–associated
bloodstream infection: Not just an intensive care unit problem.
Clinical Journal of Oncology Nursing, 17(1), 21-24.