How well are we doing
with CVC’s in EBMT?
London 5th October 2012
Arno Mank, Nurse Researcher,
Past President, EBMT-NG
Academic Medical Centre, Amsterdam
The
Marrow Transplantation
Transplantation
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for Blood
Blood and
and Marrow
Overview
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Why?
About CVC’s
Guidelines/ Protocols
Care aspects
Collaborative survey/ EBMT guideline
The European Group for Blood and Marrow Transplantation
Why
“Where are you infusing into?
• Patient diagnosis/medical
condition
• Patient compliance to
therapy
“What are you infusing?
• Drug (s) to be administered
• pH/ Osmolarity
“How long are infusing?
• Duration of therapy
• Length of therapy
• Number/frequency of infusions
• Alternative site infusion
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Medication
TPN
Chemotherapy
Blood sampling
The European Group for Blood and Marrow Transplantation
Not like this!
The European Group for Blood and Marrow Transplantation
Venous Access
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PI
Midline
Subclavian/ jugular
PICC
Tunnelled catheter
Implanted port
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+ 3 days
3 days to 4 weeks
1 week to 8 weeks
1 week to 4 month
3 weeks to 6 month
> 6 weeks and intermitted
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Subclavian/ jugularis catheter
• Long term / Short term
• (Non) tunnelled
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Placement
• Vena Jugularis
• Vena
Subclavia
• Vena
Femoralis
• Vena
Brachialis
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Complications CVC
• Insertion:
perforation
bleeding
pneumothorax
arrhythmias
• During treatment: extravasations
thrombosis
catheter related infections
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PICC line
Upper arm/ Vena cava superior
– Under ultra sound guidance inserted
– Not invasive
– No pneumothorax
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Differences/ Discussion points
Alternative peripheral IV, subclavia and jugular
• History/Development
• Length
• Suitable for infusion agents
• Can it be used for a medium till long period?
• For hospital and home infusion
• Single, double and triple lumen
• Thrombosis
• Cost saving
• Patient’s comfort
• Decreasing Infection rate
The European Group for Blood and Marrow Transplantation
Guidelines and Protocols
Documents which supports decisions and
following actions.
The European Group for Blood and Marrow Transplantation
Differences
Guideline
Protocol
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General
Not/less detailed
Advisory
More informing/ evidence
Supportive
Specific
Detailed
Compulsory
Acts: Who, What, How,
Which Order
• Legal framework
Guideline : what should be done
Protocol: how certain transactions should be carried out
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Diagnosis of acute fever for patient
suspected short-term cvc infection
Obtain samples for blood culture prior to
the initiation
of antibiotic therapy (A1 evidence)
Mermel LA et.al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related
infection: 2009 Update by the Infectious Diseases Society of America.Clin Infect Dis. 2009;1;49(1):1-45.
The European Group for Blood and Marrow Transplantation
Conclusion: there is room for improving European nurses’ knowledge
of central venous catheter-related infections prevention guidelines. We recommend
including supplementary support from current evidence-based guidelines
in their educational curricula and continuing refresher programs.
Labeau SO et.al. Centers for Disease Control and Prevention guidelines for preventing central venous
catheter-related infection: results of a knowledge test among 3405 European intensive care nurses.
Crit Care Med. 2009;37(1):320-323.
The European Group for Blood and Marrow Transplantation
Educational intervention
An educational intervention that uses evidence-based practices can be
successfully implemented in a diverse group of medical and surgical units and
reduce catheter associated bloodstream infection rates
Warren DK et.al. A multicenter intervention to prevent catheter-associated bloodstream infections.
Infect Control Hosp Epidemiol. 2006;27(7):662-9.
The European Group for Blood and Marrow Transplantation
Summary of Recommendations
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Education, Training and Staffing
Selection of Catheters and Sites
Peripheral Catheters and Midline Catheters
Central Venous Catheters.
Hand Hygiene and Aseptic Technique
Maximal Sterile Barrier Precautions
Skin Preparation
Catheter Site Dressing Regimens
Patient Cleansing
Catheter Securement Devices
Antimicrobial/Antiseptic Impregnated
Catheters and Cuffs
Systemic Antibiotic Prophylaxis
Antibiotic/Antiseptic Ointments
Antibiotic Lock Prophylaxis, Antimicrobial
Catheter Flush and Catheter Lock
Prophylaxis
Anticoagulants
Replacement of Peripheral and Midline
Catheters
Replacement of CVCs, Including PICCs and
Hemodialysis Catheters
Umbilical Catheters
Peripheral Arterial Catheters and Pressure
Monitoring Devices for Adult and Pediatric
Patients
Replacement of Administration Sets
Needleless Intravascular Catheter Systems
Performance Improvement
O'Grady et al.Clin Guidelines for the prevention of intravascular
catheter-related infections. Infect Dis. 2011;52(9):e162-193
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Indications for catheter insertion
Choice of catheter
Patient care prior to catheter insertion
Antibiotic prophylaxis
Catheter insertion
Immediate patient care after catheter insertion
Long-term catheter care
Patient information
Management of problem patients
Prevention and management of catheter
complications
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Malfunction
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Infection
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Thrombosis
catheter removal
Bishop L, et.al. Guidelines on the insertion and management of central
venous access devices in adults. Int J.Lab Hematol. 2007;29(4):261-78.
The European Group for Blood and Marrow Transplantation
Care aspects CVC
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Indication/Choice Catheter/Lumen
Insertion
Hand washing
Sterile or Non touch method/ Gloves
Manipulation
Change Administration sets
Dressing change
Removal
Registration
– General
– Infection
• Quality and Education
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Indication/Choice Catheter
• For how long
• Not necessarily, then remove
• Replace not routinely
• Each lumen increases the risk of infection
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Insertion
• Sterile barrier
• Surgery or department
• Chlorhexidine or iodine
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Hands Washing/ Disinfection
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Cleaning: Washing and Drying
Infection Prevention: Alcohol
Willingness?
Training and checking
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Gloves - No touch method
• Use either clean or sterile gloves when
changing
• Use the ‘no touch’ method for dressing
change and flushing protocol
• Security?
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Manipulation
• Opening the catheter
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Medication
Blood sampling
Patient preference
Combination
• How often changing the administration
sets
– 24/72/96 hours?
– Different between fluids/ blood products
The European Group for Blood and Marrow Transplantation
Dressing change
• Daily inspection (external contamination)
– Dry: Transparent dressing every 5-7 days?
– Wet: Gauze dressing should every 2 days?
• Well-healed tunnelled CVAD maybe no dressing
• Chlorhexidine impregnated dressing (Biopatch ®)
The European Group for Blood and Marrow Transplantation
Flushing/ Needleless connector
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Saline, Heparin, other?
Disconnecting/ blood sampling
Lock solution
Volume at least 2 times volume of the lumen
Normal saline between incompatible drugs
Frequency
Use of correct needless connector
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Administration/Registration:
General and infection
electronic patient record
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Quality/ Qualification/ Education
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Registration by the law
Knowledgeable and skilled
Train the trainer
IV/CVC team
– specialisation
– surveillance
How well are we doing with CVC’s in EBMT?
The European Group for Blood and Marrow Transplantation
Collaboration IDWP with EBMT-NG
• The Infection Disease Working Party aims to
promote and conduct educational activities
and clinical investigations on all the topics
concerning the diagnosis, the prophylaxis and
the management of infectious complications
following HSCT.
•The Nurses Group also!
•Focus on Central Line Associated Blood Stream
Infections (CLABSI)
The European Group for Blood and Marrow Transplantation
Study design
Aims of the study
To evaluate self-reported adherence to CLABSI prevention guidelines in EBMT centres and possible
association with HSCT outcome.
Analysis endpoints:
Primary: Assessment of current practice of CLABSI prevention in HSCT setting in Europe.
Secondary: Assessment of possible association between self-reported adherence to bundle of
recommendations in the guidelines for CLABSI prevention and observed outcome of HSCT in
terms of 100 day mortality and graft versus host disease.
Study Design
cross sectional study, questionnaire for collection of data on guidelines used and self-reported
adherence to international guidelines for prevention of central line associated bloodstream
infections.
Inclusion Criteria
All centres in the EBMT database.
Timeline
Preparation of the online questionnaire – June 2012
Invitation to the study - October 2012
Filling the data by centres – December 2012
Analysis of the data – January 2013
Abstract preparation – February 2013
Publication preparation until March 2013
Presentation at the EBMT 2013
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Questionnaire
A study specific questionnaire has been constructed based on recommendations from international guidelines. two
parts:
- written guidelines used at the centre. SOP
- different aspects of central venous line practice. Current practice
Key areas
- Education of healthcare professionals on prevention of CLABSI
- The organization of CVC insertions in the department
- Type of catheter preferred by centre
- Adherence to full barrier precautions during the insertion
- Central venous catheter management
- Diagnostics of infection
pre tested for content validity by nurses and physicians from selected EBMT centres who will assess the content
and relevance of each item for measuring the adherence to the guideline.
Feasibility
The data collected in this study should give answer to two questions:
To what extent are guidelines of CLABSI prevention in HSCT implemented in Europe.
The possible connection with 100 day mortality and GvHD and self-reported practice of CLABSI prevention bundle
as judged from questionnaires
The European Group for Blood and Marrow Transplantation
Involved people
Infectious Diseases Working Party/EBMT-Nurses Group
Investigators
• Emilian Snarski Medical University of Warsaw POLAND
• Eva Johansson Associate Professor, Senior Lecturer Division
of Nursing | Karolinska Institute Stockholm SWEDEN
• Arno Mank, nurse researcher past president EBMT Nurses
Group Academic Medical Centre Amsterdam The Netherlands
Statistician
• Simona Iacobelli
Study coordinator
• Jennifer Hoek
Study Coordinator European Group for Blood and Marrow
Transplantation idwp.ebmt@lumc.nl
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QUESTIONS?
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