Strategies to Reduce the
Incidence of
Central Line-Associated
Bloodstream Infections
Wendy Kaler MPH, CIC
Manager of Infection Control
Saint Francis Memorial Hospital
San Francisco, CA

Saint Francis Memorial Hospital

Active daily interaction of IC as part of the ICU PI team
– Focus on NEED for indwelling central line
– D/C of femoral lines
– Catch early indications of infection

• Bundles
– IHI
– Provonost (NEJM Dec 28, 2006)
– Joint Commission NPSG#7
– CA SB 739
• Early use of PICC in neonates

Inserter: Complete BEFORE line insertion
Central Line Insertion Checklist
{Patient Label}
The components on this checklist are being used while inserting this central line
Education on central line-associated bloodstream infection prevention has been provided to the patient/family
Line : CVC PICC SVO2 Site : IJ SC Fem PICC
Date/time __________ Inserter Signature ______________________
 Hand hygiene is performed before and after assessing for catheter insertion sites as well as before and after inserting a catheter.
 Maximal barriers are utilized including sterile gloves, sterile gowns, masks, caps, and large sterile drapes.
 Disinfect clean skin with a Chlorhexidine/alcohol preparation and allow it to dry completely before inserting the line.
 Do not use topical antibiotic ointment or creams on insertion sites
(except when using dialysis catheters) because of their potential to promote fungal infections and antimicrobial resistance.
 Placement of catheters in the femoral vein should be avoided unless subclavian or jugular site is not an option due to patient circumstances.
Document reason for using femoral site in procedure note.
 Secure the catheter with sutures and/or securement devices (Statlock) whenever necessary to ensure that lines are not dislodged.
 Use sterile gauze and/or transparent, semi-permeable, dressing to cover the catheter site. If the site is oozing or the patient is diaphoretic a gauze dressing is preferable.
 Dressings on all new lines should be labeled with the date of insertion
***PLACE IN PATIENT CHART (behind MISC Tab)
(TO BE PART OF PERMANENT RECORD)

12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
Prevent Infection
Fact:
Catheters and other invasive devices are the # 1 exogenous cause of hospital-onset infections.
 Link to: NNIS Online at CDC

• During daily rounding
• Sticker in Physician Progress Notes
• EMR mandatory field

Maintenance Bundle for
Central Lines
• Most CL-BSI occur > 5 days after insertion
• Stabilized lines
• Timely dressing changes per policydressings dated
• Skin antisepsis at insertion site
• Dressings dry and intact
• Cleaning of port prior to accessing

Successful Disinfection of
Needleless Mechanical Valve
Access Ports: A Matter of Time and Friction
Kaler, W., Chinn, R. JAVA 12(3) Fall 2007
Rady Children’s Hospital
Sharp Memorial Hospital

We provide evidence that when access ports are subjected to the industry recommended disinfection time of 15 seconds with friction, alcohol alone or chlorhexidine/alcohol were equally effective in sterilizing MV ports inoculated with a 10 5 CFUs suspension of microorganisms, regardless of whether the MVs were constructed using positive, negative, or neutral displacement technologies.

IV Access Port Protection Caps
• Alcohol-impregnated caps-remain on the ports between use
Iveramed- Curos
Excelsior Medical

Port Protection Caps
• Decreases nursing time required to comply with
“port disinfection policy” (NPSG#7)
• Allows for monitoring of compliance with port disinfection policy (NPSG #7)
• Potential reduction of contaminated line-drawn blood cultures
– Appropriate antibiotic use
– Accurate CLABSI rates for PUBLIC REPORTING/CMS
Reporting

Nursing Attitude & Focus on Infection
Control Practices
• Barriers to following good infection control practices include:
– Not enough time
– Not enough resources
– Not enough information
– It is really not that important
– Not able to focus on task at hand due to many distractions

Nursing Attitude & Focus on Infection
Control Practices
• Possible solutions:
-
-
- Get staff level nurses involved in designing solutions
Make it personal
Provide evidence of effectiveness of methods
- Provide local data/risk
- Feedback of poor outcomes

Culture of a patient’s port surface

Staff EDUCATION
Re-usable Post-It® poster on each nursing unit… messages changed as needed

Making it Personal…
Our IV TEAM Lead posing as a patient

It’s an ATTITUDE …
Provide care as if it were YOU in that bed……

How do you know it’s a
CLA-BSI?

Public Reporting
 Antibiotic Resistance

LCBI
Surveillance Definitions
CRITERION 3
Patient <1 yr has at least one of the following signs or symptoms: fever, hypothermia, apnea, bradycardia
AND
Signs and symptoms and lab data not related to infection at another site
AND
A common skin contaminant cultured from 2 or more blood cultures drawn on separate occasions (within 2 days).

For QUANTITATIVE blood cultures
≤10 CFU not significant (Bradley, J. et al)
Ascher et al Diag Microbiol Infect Dis 1992 Aug 15(6) 499-503

Non-ambiguous
Blood Culture Results
• Peripheral vs line draw
• Line-draw technique
– DISCARD 1-3 ml
• Labeling of bottles
• Full info in lab report
• NO Catheter tip cultures

LCBI
Surveillance Definitions
CRITERION 1
• Patient has a recognized pathogen cultured from one or more blood cultures
AND
Organism cultured from blood is NOT related to an infection at another site

LCBI
Surveillance Definitions
CRITERION 3
Patient <1 yr has at least one of the following signs or symptoms: fever, hypothermia, apnea, bradycardia
AND
Signs and symptoms and lab data not related to infection at another site
AND
A common skin contaminant cultured from 2 or more blood cultures drawn on separate occasions (within 2 days).

ZERO