Preventing Central Line
Associated Bloodstream
Infections (CLABSIs)
What Clinical Staff Should Know
Prepared by
Ann Bailey RNC-NIC, BSN, MBA, CIC
Joanne Dixon MN, RN, CIC
Gwen Irwin, RN, CRNI
Judy Smith, RN, BSN, CRNI
December 18, 2009
Objectives
Upon completion of this module, the learner will be
able to:
• Summarize the Joint Commission 2010
National Patient Safety Goal 07.04.01
related to Central Line Associated
Bloodstream Infections (CLABSIs),
effective 01/01/10
• Includes using “Bundle” with respect to
preventing CLABSIs
• Define “Bundle”
• Name 2 ways patients get CLABSIs
• List 4 evidence-based practices that
have been shown to help prevent
CLABSIs
The Joint Commission
2010 National Patient Safety Goal
(NPSG)
• NPSG 07.04.01 focuses on the prevention of
CLABSIs.
• All those who manage central lines MUST have education
about the importance of preventing CLABSIs.
• Includes staff, doctors, APNs or other licensed providers
• Patients and families MUST be educated about CLABSI
prevention before any central line insertion.
• CLABSI surveillance will be hospital wide, not targeted to
ICUs.
• For adults, NO femoral catheters, unless other sites aren’t
available.
Patient and Family Education
Before Central Line Insertion
• FAQ Catheter Associated
Bloodstream Infections from
Joint Commission covers:
• Providers doing hand hygiene
• Steps for maximum barrier CVL
insertion
• Clean hands before using CVL
• Clean connectors with antiseptic
solution before using CVL
• Decide every day if CVL is
needed.
• Ask providers to clean hands if
patient doesn’t see them.
• Tell nurse if dressing comes off or
wet or dirty.
• And more
The Joint Commission
2010 National Patient Safety Goal
(NPSG)
• NPSG 07.04.01 focuses on the prevention of
CLABSIs.
• Also includes the CVL insertion bundle.
• We have had in place for almost 5 years.
• Also includes part of the CVL maintenance
bundle.
• We have had in place for about 2 years.
What is a Bundle?
• A grouping of evidence-based best practices
that individually improve care, but when applied
together result in substantially greater
improvement.
• Science behind the bundle elements is well
established – the standard of care.
• Bundle element compliance can be measured
as “ yes/no.”
• “All or none” approach.
The CVL Insertion Bundle
1.
2.
3.
4.
Hand hygiene immediately prior to insertion
-wash hands or
-use alcohol-based hand gel/foam
Maximal barrier precautions
-full body sterile drape
-clinician and assistant wear cap, mask, sterile gown, gloves
-persons within 6 feet wear hat and mask
Skin antisepsis with chlorhexidine 2% / 70% isopropyl alcohol.
Subclavian site considered 1st choice; avoid IJ & femoral.
Exceptions: Should be rare for adults
- Hemodialysis catheters
- When high risk for pneumothorax
- When high risk for noncompressible hematoma
The CVL Maintenance Bundle
1. Perform good hand hygiene, prior to handling
line
-Hand washing or
-Use alcohol-based hand gel/foam
2. Assess dressing/site with routine assessment
3. Scrub connector vigorously with alcohol x 15
seconds
-Allow to dry before accessing
4. Assess line patency for brisk return and easy
flushing
5. Assess to determine if patient meets criteria for
line necessity
Why Prevent CLABSIs?
• Nationally and annually:
• 80,000 central line associated bloodstream infections occur in
ICUs
• 250,000 hospital-wide, including ICUs
• Seton Family of Hospitals
• The majority of CLABSIs occur outside of the critical care units
• Check your unit’s CLABSIs with your infection preventionist, if you
are interested in more information
• Increases the patient’s risk of death significantly
• CLABSIs lead to longer length of stay (LOS)
• National estimates show the cost of a BSI can be as high as
$25,000 per episode
(MMWR, August 9, 2002 Vol. 51, No. RR-10)
How do CLABSIs happen?
• Introduction of pathogens into the
bloodstream from the skin around
insertion site
• Introduction of pathogens into the
bloodstream from the hub or
connector of the catheter.
• Most frequent cause nationally
• Also true at Seton
Factors That Increase Risk of BSIs
• CVLs in areas that have increased colonization
of organisms
• such as the internal jugular or femoral sites
• Multiple lumens: More manipulation and
contamination.
(MMWR, August 9, 2002 Vol. 51, No. RR-10)
• Use of stopcocks
(MMWR, August 9, 2002 Vol. 51, No. RR-10)
• Contamination of IV tubing or connectors (caps)
• Longer dwell time of CVC
Factors That Lower Risk of BSIs
• Select subclavian site over internal jugular or
femoral sites, if PICC not used
• Perform hand hygiene
• Use maximum barrier precautions
• Skin prep with chlorhexidine rather than
povidone-iodine
• Skin prep on clean skin
• Maintain patency of all lumens
• Free of sluggishness or occlusion; brisk blood return
• Remove line when no longer necessary
CVL Insertion Bundle Component:
CVL Site Choices
Femoral Vein
Last choice
Subclavian Vein
First Choice
Internal Jugular
Second choice
Hand Hygiene – The Most Important Way to
Prevent Any Infection
Alcohol-based hand gel/foam - apply
product to palm of one hand and rub
hands together, covering all surfaces
of hands and fingers until hands are
dry
Handwashing - 10-15 seconds of
soap and friction, rinse, dry and
turn off faucet with clean paper
towel
CVL Insertion Bundle Component:
Maximum Sterile Barrier Precautions
Sterile gown
Hat and mask
Sterile gloves
Persons within 6 feet also
wear hat and mask
CVL Insertion Bundle Component:
Chloraprep®
• Gross debris or dirt should be
removed
• with an alcohol pad, prior to
using the skin prep.
• by washing with soap and water,
prior to using the skin prep.
• Clean with friction for minimum
of 30 seconds.
• Allow Chloraprep® to completely
dry, before procedure for best
results.
• DO NOT REMOVE Chloraprep®
after the procedure is completed.
Exception: neonates <2 months.
CVL Maintenance Bundle Component:
Assess line patency for brisk return
and easy flushing
Research studies indicate a direct correlation with
occlusions, fibrin sheaths, and risk of CLABSIs
No blood return? Flushes easily?
• Probable fibrin sheath or fibrin
tail
• Treat as soon as possible
• Treat with Alteplase per
declotting protocol
Infusing
around sheath
Fibrin
sheath
Catheter
Attempting to
withdraw blood
CVL Maintenance Bundle Component:
Daily Review for Line Necessity
Remove when No Longer Indicated
Indications for a CVL
• Hemodynamic monitoring
• Administration of certain medications that require central
administration, e.g. vasopressors, chemotherapy, TPN
• Long term IV therapy, e.g. antibiotics or inotropes
• Plasmapheresis, apheresis, hemodialysis, or continuous renal
replacement therapy
• Poor peripheral venous access, when IV treatment is still needed
CVL Maintenance Bundle Component:
Scrub the Hub with Alcohol for 15 seconds,
prior to accessing
•
Vigorous scrubbing is
necessary to remove
pathogens
Research shows that 5
seconds is not enough.
•
•
•
67% of pathogens are still
transferred.
Research shows that 15
seconds with friction is 100%
effective in disinfection.
If this step is skipped,
the patient is inoculated
with the organisms of his
surroundings.
CVL Maintenance Bundle Component:
Assess dressing/site with routine assessment
Keep dressing clean dry and intact
• Loose and wet
dressings are sites of
potential infection.
• CHANGE THEM!
• Cover the site
dressing and the
connectors during
showers.
Aquaguard is available:
7”x7” Lawson number 080204
Potential ways of contamination
• The top of the
medication vial is not
sterile.
• The top is a “dust
cover.”
• Clean vigorously
with alcohol before
accessing the vial
with the blunt fill
needle.
Disconnecting tubing
Sterile end cap in place
Not recommended by
manufacturer. Off-label use.
How do you know if the tubing
tip is still sterile?
Indicates tip sterility maintained
Some Prefilled Saline Syringes
Are for Flushing ONLY
• The saline flush syringes in the clear cellophane
package is ONLY for flushing
• According to the manufacturer, DO NOT use
for medication dilution.
• The inside of the barrel & the fluid pathway is all
that is sterile on these syringes.
• When you push out saline, the outer side of the
plunger contaminates the inside of the barrel.
• Then, when you draw back into the syringe, you are
pulling the plunger over areas that were just
contaminated.
• If you do this, you could be pushing pathogens into
the patients’ bloodstreams.
• The saline flush syringes in the sterile peel pack
may be used for medication dilution.
Your Role
• Follow the bundle components specific to your role in the
patient’s care
• Provide appropriate/indicated patient teaching regarding
these bundle component and other recommended
practices
• Document patient education related to the goal of CLABSI
prevention
• Patient education materials related to CLABSI prevention
can be found on the Intranet:
•
•
•
•
http://intranet.seton.org/polandproc/infectcontrol/docs/clabsi.pdf
http://intranet.seton.org/polandproc/infectcontrol/docs/clabsi_largertext.pdf
http://intranet.seton.org/polandproc/infectcontrol/docs/clabsi_spanish.pdf
http://intranet.seton.org/polandproc/infectcontrol/docs/clabsi_span_lg_txt.pdf
• Remind peers of the importance of following the bundle
components and other recommended practices if they are
observed to be non-compliant
Policies
Central line insertion and dressing policies:
Caring for Central Venous Catheters (CVC), (adult
patients)
Caring for Central Venous Catheters (CVC), e.g.
Broviac, Hickman, Groshong, Hohn, Peripherally
Inserted Central Catheter (PICC) (pediatric patients)
Caring for Peripherally Inserted Central Catheter
(PICC) in Neonatal Patients
Caring for Temporary and Permanent Hemodialysis
Catheters, e.g. Quinton or Perm Cath
Declotting Central Venous Catheters with Alteplase,
Partial or Total Occlusion
References
http://www.cdc.gov/ncidod/dhqp/gl_intravascular.html
http://www.ihi.org/ihi/search/searchresults.aspx?searchterm=clabsi&searchtype=basic
http://www.jointcommission.org/NR/rdonlyres/868C9E07-037F-433D-88580D5FAA4322F2/0/RevisedChapter_HAP_NPSG_20090924.pdf
Pronovost, MD PhD, Peter, Needham, MD, PhD., Dale….An Intervention to Decrease Catheter-Related
Bloodstream Infections in the ICU (Michigan Keystone Project), New England Journal of Medicine
December 28, 2006; Vol. 355, #26.
Maki DG, Mermel L, Genthner D, Hua S, Chiacchierini RP. An evaluation of BIOPATCH Antimicrobial
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Ngo A. A Theory-based Intervention to Improve Nurses’ Knowledge, Self-efficacy, and Skills to Reduce
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