Recognising and Preventing Intravascular Catheter-related Infections Jan 2009 1

AIM To reduce the “risk” of infection caused by micro-organisms prior to commencing and during an I.V. therapy All Doctors and Nurses must be aware of how to minimise the risk of infection prior to the insertion of an I.V. cannula and during I.V. therapy Jan 2009 Jan 2009 2

Learning Outcomes:- The participants will: Be aware of how infection presents itself Identify how catheter colonisation occurs Be able to observe patient for signs of infection & to use the VIP score Identify potential sources of infection Understand how to incorporate the “Saving Lives – care bundles” to prevent infection and promote good practice Jan 2009 Jan 2009 3

3rd National HCAI Prevalence Survey Feb - May 2006 A total of 75,694 patients were surveyed 5743 of these had HCAIs, giving a prevalence of 7.59% (95% confidence) HCAI prevalence: England was 8.19% Wales 6.35%, Northern Ireland 5.43% Republic of Ireland 4.89%. Primary bloodstream (7.0%). Journal of Hospital Infection (2008) 69, 230 248 Jan 2009 Jan 2009 4

Are PVCs a risk for BSI? At any one time 61% of hospital patients were found to have a peripheral intravenous cannula or catheter in place1 1.9% of all hospital acquired infections in the UK are due to Peripheral Venous Catheters2 Catheters inserted in the emergency department had higher rates of infection despite shorter dwell time compared to those inserted on hospital wards3 Blood stream infections remain underestimated and potentially serious complications of peripheral vascular catheterisation3 1. 2006 HCAI prevalence survey 2 Emmerson et al, JHI, overview of Second National Prevalence survey of infections in hospitals (1996) 3 Pujol et al, Journal of Hospital Infection (2007) 67, 22-29 Jan 2009 5

Are CVCs a risk for BSI? >250,000 central venous catheters are used in the UK annually 30,000 are associated with infection Cost approx £10 million annually Mortality> 25% Particular problem in haematology and oncology Jan 2009 Jan 2009 6

Organisms 10% of HAB were caused by more than one organism The most commonly isolated organisms from all types of intravenous cannulae are coagulase -negative staphylococci (35%), with Staphylococcus aureus the second most common (25%)1 Meticillin resistant Staphylococcus aureus (MRSA) accounted for 40–45% of Staphylococcus aureus infections in a 2006 prevalence survey2 1 Managing bloodstream infection associated with intravascular catheters. Drug Therapy Bulletin 2001,39:75–80 2 Smyth ETM. Healthcare acquired infection prevalence survey 2006. Presented at 6th international conference of the Hospital Infection Society, Amsterdam 2006, Preliminary data available in Hospital Infection Society: The third prevalence survey of healthcare associated infections in acute hospitals, 2006 Jan 2009 Jan 2009 7 7

Associated factors Overall, almost 2/3 of bacteraemias of known source were associated with intravascular device or were device-related e.g. Catheter-associated urinary tract infection Ventilator associated respiratory tract infection Central IV catheters were the commonest source of hospital acquired bacteraemia Jan 2009 Jan 2009 8

Sources of hospital-acquired bacteraemia Nosocomial Infection National Surveillance Service. Surveillance of hospital-acquired bacteraemia in English hospitals 1997-2002. Jan 2009 Jan 2009 9

Blood-stream infection (BSI) Approx. 20% of BSIs are caused by haematogenous spread from another body site e.g. urinary tract, wound infection and respiratory tract (Wilson 1995) The majority of such infections originate from intravenous devices Blood-stream infection Although these account for only 6% of HAI’s, they are usually extremely serious and are associated with high mortality. Approximately 20% of blood-stream infections are caused by haematogenous spread from another body site (e.g. urinary tract, wound infection, respiratory tract) (Wilson, 1995) however the majority of such infections originate from intravenous devices. The prevention of infections associated with intravenous devices is discussed in lecture notes 5.20. Jan 2009 Jan 2009 10

Sources of Infection Intrinsic Sources of Infection/Contamination (Present prior to use) Extrinsic Sources of Infection/Contamination (Introduced in use) Drip Site Infection Jan 2009 Jan 2009 11

Identify how infection occurs INTRINSIC SOURCES (Present prior to use) 3 Stages in the life of infusion products during which contamination can occur :~ During Manufacture and Packaging Transport and Storage Usage The Devonport incident:- On 1st to 3rd March 1972 two surgeons noted a series of untoward reactions to their patients. They stopped all surgery and cease using IV fluids containing glucose (all pateints affected had received such fluids) 5 patients died. All had collapsed after receiving 5% Dextrose. Of the 17 unused bottles recovered 14 grew bacteria (not all the same type) in counts of 1 million/ml. Many bottles were cloudy. All came from the same sub-batch (failed to reach sterilising temperature due to retention of air (evidence of recording thermometer failed to indicate a rise in temperature. The incident served as a basis for the subsequent production of codes of good manufacturing practice. Jan 2009 Jan 2009 12

What errors can occur (1) 1990: Johannesburg Death of 15 babies Contaminated IV feeds 2000: India Death of 3 young mothers and 3 newborn babies Contaminated IV fluids 2002: Brazil 36 neonatal deaths in Brazil contaminated intravenous fluids. Endotoxin contaminated IV medication 2004: South Africa 6 premature babies died Enterobacter cloacae three containers one infusion set A pharmacist's dirty hands the main reason Jan 2009 13

What errors can occur (2) Evans Medical in Speke (not connected with present trading company) Tue 6th April 1971 5% Sterile Dextrose Solution - Lot D1192 29th Feb – 2nd Mar 1971 5 deaths at Devonport Hospital 6th Mar 1972 - Investigation begins 12th Jul 1972 - Clothier Report issued by Department of Health & Social Security The Devonport incident:- On 1st to 3rd March 1972 two surgeons noted a series of untoward reactions to their patients. They stopped all surgery and cease using IV fluids containing glucose (all patients affected had received such fluids) 5 patients died. All had collapsed after receiving 5% Dextrose. Of the 17 unused bottles recovered 14 grew bacteria (not all the same type) in counts of 1 million/ml. Many bottles were cloudy. All came from the same sub-batch (failed to reach sterilising temperature due to retention of air (evidence of recording thermometer failed to indicate a rise in temperature. The incident served as a basis for the subsequent production of codes of good manufacturing practice. Report of the Committee appointed to inquire into the circumstances, including the production, which led to the use of contaminated infusion fluids in the Devonport section of Plymouth General Hospital. (London: HMSO, 1972) Jan 2009 14

Prevention of infections INTRINSIC SOURCES Action Visual Inspection ~ a vital part Observe for leakage: ~ Pinhole leaks in PVC bags ~ Cracks in glass bottles Jan 2009 Jan 2009 15

EXTRINSIC SOURCES HOW DO THEY OCCUR? Jan 2009 Jan 2009 16

Identify how infection occurs EXTRINSIC SOURCES (Introduced in use) Bacterial migration from patient’s skin/infected sites/contaminated IV fluid Poor asepsis/staff’s hands/disinfectants IV drug incompatibility/additives Line/filter changes/insertion/manipulation of device Reflux of micro-organisms/retrograde contamination Intravenous devices are susceptible to infectious complications because bacteria can migrate into the bloodstream from the skin along the cannula, from the hub or side-port of the cannula and from contaminated IV fluid. Jan 2009 Jan 2009 17

Peripheral Intravenous Cannula Ongoing Care Observation & Record Jan 2009 Jan 2009 18 18

Sources of Infection/Contamination (Drip Site Infection) Hands of medical/nursing staff Patient’s own skin and flora Hub contamination Catheter contamination on insertion Other infected sites on patient’s own body Contaminated skin disinfectants/ infusate/cannula/admin set Sources of contamination Hands of medical/nursing staff – hands should be thoroughly washed and dried prior to any manipulation. In some cases an antiseptic solution should be used (e.g. insertion of central venous catheters). Patient’s own skin and flora – commensals (e.g. Staphylococcus epidermidis) are a potential source of contamination. Micro-organism counts should be reduced by thorough skin cleansing using alcohol-based povidone iodine or chlorhexidine antiseptics. Hub contamination – any manipulation of the device can contaminate the hub and lead to both intra- and extra-luminal contamination. Catheter contamination on insertion – the use of sterile equipment and competent insertion will reduce this potential risk. Haematogenous spread – micro-organisms present at other sites (e.g. wounds, pressure sores) can spread via the blood-stream and adhere to the lumen of the device acting as potential foci for infection. Contaminated infusate – all infusions should be checked for expiry date, intact packaging, colour and lack of foreign bodies. Jan 2009 Jan 2009 19

How infection presents itself Local site infection Inflammation of the vein (phlebitis) Bacteraemia and Septicaemia Catheter colonisation Jan 2009 Jan 2009 20

Patient’s signs of Infection Deteriorating patient condition Pyrexia Rigors Tachycardia Tachypnoea Cyanosis Hypertension Confusion/agitation No Clinical symptoms Jan 2009 Jan 2009 21

Meditech IV Intervention Jan 2009 Jan 2009 22

Document intervention Jan 2009 Jan 2009 23

How does catheter colonisation occur? The IV device becomes covered by a film of protein such as albumin, fibrinogen and immunoglobulin mixed with micro-organisms and known collectively as a “BIOFILM” A catheter-related infection The incidence of septicaemia as a measure (Weightman et al 1988 & Ricard et al 1985) The occurrence of phlebitis (Tager et al 1983) The colonisation of the catheter (Maki et Ringer 1987) Catheter colonisation is frequently used as a measure of IV device infection and is strongly associated with bacteraemia (Graham et al 1991, Mermel et al 1991) How does catheter colonisation occur? Microorganisms adhere to the surface of the catheter and can be detected by culturing the tip of the device when it is removed Jan 2009 Jan 2009 24

Biofilm Formation Attachment At insertion Skin bacteria polyurethane/silicon catheter Attachment A biofilm is an assemblage of microbial cells that is irreversibly associated (not removed by gentle rinsing) with a surface and enclosed in a matrix of primarily polysaccharide material. Noncellular materials such as mineral crystals, corrosion particles, clay or silt particles, or blood components, depending on the environment in which the biofilm has developed, may also be found in the biofilm matrix. Biofilm-associated organisms also differ from their planktonic (freely suspended) counterparts with respect to the genes that are transcribed. Biofilms may form on a wide variety of surfaces, including living tissues, indwelling medical devices, industrial or potable water system piping, or natural aquatic systems. The solid surface may have several characteristics that are important in the attachment process. Characklis et al.[6] noted that the extent of microbial colonization appears to increase as the surface roughness increases. This is because shear forces are diminished, and surface area is higher on rougher surfaces. The physicochemical properties of the surface may also exert a strong influence on the rate and extent of attachment. Most investigators have found that microorganisms attach more rapidly to hydrophobic, nonpolar surfaces such as Teflon and other plastics than to hydrophilic materials such as glass or metals. Biofilm cells may be dispersed either by shedding of daughter cells from actively growing cells, detachment as a result of nutrient levels or quorum sensing, or shearing of biofilm aggregates (continuous removal of small portions of the biofilm) because of flow effects. Jeske C, et al. Anaesth Analg 97:240. 2003 Livesly M, et al. Eur J Clin Micro Infect Dis 17:108.1998 Elliott T, et al. Eur J Clin Micro Infect Dis 16:210.1997 Jan 2009 25

Biofilm Formation Attachment & Adhesion Seconds/Minutes Protein/Platelets/White Blood Cells Attachment & Adhesion A biofilm is an assemblage of microbial cells that is irreversibly associated (not removed by gentle rinsing) with a surface and enclosed in a matrix of primarily polysaccharide material. Noncellular materials such as mineral crystals, corrosion particles, clay or silt particles, or blood components, depending on the environment in which the biofilm has developed, may also be found in the biofilm matrix. Biofilm-associated organisms also differ from their planktonic (freely suspended) counterparts with respect to the genes that are transcribed. Biofilms may form on a wide variety of surfaces, including living tissues, indwelling medical devices, industrial or potable water system piping, or natural aquatic systems. The solid surface may have several characteristics that are important in the attachment process. Characklis et al.[6] noted that the extent of microbial colonization appears to increase as the surface roughness increases. This is because shear forces are diminished, and surface area is higher on rougher surfaces. The physicochemical properties of the surface may also exert a strong influence on the rate and extent of attachment. Most investigators have found that microorganisms attach more rapidly to hydrophobic, nonpolar surfaces such as Teflon and other plastics than to hydrophilic materials such as glass or metals. Biofilm cells may be dispersed either by shedding of daughter cells from actively growing cells, detachment as a result of nutrient levels or quorum sensing, or shearing of biofilm aggregates (continuous removal of small portions of the biofilm) because of flow effects. Jeske C, et al. Anaesth Analg 97:240. 2003 Livesly M, et al. Eur J Clin Micro Infect Dis 17:108.1998 Elliott T, et al. Eur J Clin Micro Infect Dis 16:210.1997 Jan 2009 26

Biofilm Formation Adhesion & Maturation 1-2 Hours Fibrin Sheath A biofilm is an assemblage of microbial cells that is irreversibly associated (not removed by gentle rinsing) with a surface and enclosed in a matrix of primarily polysaccharide material. Noncellular materials such as mineral crystals, corrosion particles, clay or silt particles, or blood components, depending on the environment in which the biofilm has developed, may also be found in the biofilm matrix. Biofilm-associated organisms also differ from their planktonic (freely suspended) counterparts with respect to the genes that are transcribed. Biofilms may form on a wide variety of surfaces, including living tissues, indwelling medical devices, industrial or potable water system piping, or natural aquatic systems. The solid surface may have several characteristics that are important in the attachment process. Characklis et al.[6] noted that the extent of microbial colonization appears to increase as the surface roughness increases. This is because shear forces are diminished, and surface area is higher on rougher surfaces. The physicochemical properties of the surface may also exert a strong influence on the rate and extent of attachment. Most investigators have found that microorganisms attach more rapidly to hydrophobic, nonpolar surfaces such as Teflon and other plastics than to hydrophilic materials such as glass or metals. Biofilm cells may be dispersed either by shedding of daughter cells from actively growing cells, detachment as a result of nutrient levels or quorum sensing, or shearing of biofilm aggregates (continuous removal of small portions of the biofilm) because of flow effects. Jeske C, et al. Anaesth Analg 97:240. 2003 Livesly M, et al. Eur J Clin Micro Infect Dis 17:108.1998 Elliott T, et al. Eur J Clin Micro Infect Dis 16:210.1997 Jan 2009 27

Biofilm Formation Detachment 2-3 Days Thrombus Formation A biofilm is an assemblage of microbial cells that is irreversibly associated (not removed by gentle rinsing) with a surface and enclosed in a matrix of primarily polysaccharide material. Noncellular materials such as mineral crystals, corrosion particles, clay or silt particles, or blood components, depending on the environment in which the biofilm has developed, may also be found in the biofilm matrix. Biofilm-associated organisms also differ from their planktonic (freely suspended) counterparts with respect to the genes that are transcribed. Biofilms may form on a wide variety of surfaces, including living tissues, indwelling medical devices, industrial or potable water system piping, or natural aquatic systems. The solid surface may have several characteristics that are important in the attachment process. Characklis et al.[6] noted that the extent of microbial colonization appears to increase as the surface roughness increases. This is because shear forces are diminished, and surface area is higher on rougher surfaces. The physicochemical properties of the surface may also exert a strong influence on the rate and extent of attachment. Most investigators have found that microorganisms attach more rapidly to hydrophobic, nonpolar surfaces such as Teflon and other plastics than to hydrophilic materials such as glass or metals. Biofilm cells may be dispersed either by shedding of daughter cells from actively growing cells, detachment as a result of nutrient levels or quorum sensing, or shearing of biofilm aggregates (continuous removal of small portions of the biofilm) because of flow effects. Jeske C, et al. Anaesth Analg 97:240. 2003 Livesly M, et al. Eur J Clin Micro Infect Dis 17:108.1998 Elliott T, et al. Eur J Clin Micro Infect Dis 16:210.1997 Jan 2009 28

BIOFILM Biofilm helps bacteria adhere to the catheter and resist anti-microbial agents circulating in the blood It can be difficult to treat catheter-related infections without removing the device Jan 2009 Jan 2009 29

Normal flora Numbers of bacteria that colonize different parts of the body Hair follicles Sebaceous/Sweat glands Temperature Numbers per square centimeter of skin surface Jan 2009 30

Insertion site colonisation is a major risk factor for CR-BSI 80% of resident and transient skin flora reside in the first 5 cell layers of the epidermis* Does current application methodology ensure that the solution reaches into the cracks and fissures of the epidermal layer? *Hendley JO, Ashe KM. Antimicrob Agents Chemother 1991;35:627-31 Jan 2009 31

Care of intravenous devices Operator’s microflora Hub/Port colonization Patient’s skin microflora Local infection Contaminated fluid Care of intravenous devices Intravenous (IV) devices are used for the administration of fluids, blood products, nutritional support and blood monitoring. Infections associated with these devices can be life-threatening, particularly in susceptible patients. However, infection can largely be avoided by good infection control practices. Sources of contamination Hands of medical/nursing staff – hands should be thoroughly washed and dried prior to any manipulation. In some cases an antiseptic solution should be used (e.g. insertion of central venous catheters). Patient’s own skin and flora – commensals (e.g. Staphylococcus epidermidis) are a potential source of contamination. Micro-organism counts should be reduced by thorough skin cleansing using alcohol-based povidone iodine or chlorhexidine antiseptics. Hub contamination – any manipulation of the device can contaminate the hub and lead to both intra- and extra-luminal contamination. Catheter contamination on insertion – the use of sterile equipment and competent insertion will reduce this potential risk. Haematogenous spread – micro-organisms present at other sites (e.g. wounds, pressure sores) can spread via the blood-stream and adhere to the lumen of the device acting as potential foci for infection. Contaminated infusate – all infusions should be checked for expiry date, intact packaging, colour and lack of foreign bodies. Insertion and care of the IV device: aseptic technique should be used at all times wear appropriate barrier protection according to the type of IV device being inserted wash hands thoroughly before insertion and any manipulation if not visibly clean, the skin site should be washed with soap and water apply an antiseptic to the insertion site (e.g. povidone iodine/chlorhexidine) and allow to dry before proceeding if the device is not sutured, secure the IV device using sterile tape use sterile transparent semi-permeable film dressings to cover the insertion site change dressings when no longer intact, when moisture collects and at least every seven days. Hands should be washed thoroughly before changing dressings inspect the site at least daily for signs of infection (i.e. inflammation, pus and pain) minimise manipulations of the device. Maintain a closed system when-ever possible. Bacteria Haematogenous spread Contaminated on insertion Jan 2009 Jan 2009 32

For Hubs/ Ports Not for skin cleansing Use Povidone-iodine for sensitivity

Care Bundles can be used to improve the quality of process and outcomes Jan 2009

Care Bundles can be used to improve the quality of process and outcomes Jan 2009

Jan 2009

Saving Lives through Care Bundles Saving Lives Implementation Programme: CVC Care Bundle Peripheral IV Care Bundle Preventing Surgical Site Infection Taking Blood Culture (Best Practice) Care Bundles can be used to improve the quality of process and outcomes Jan 2009

Peripheral Intravenous Cannula Care Bundle High Impact Intervention(HII) - Elements of the care process: Jan 2009 Jan 2009 38

Peripheral Intravenous Cannula Care Bundle High Impact Intervention(HII) - Elements of Care process Jan 2009 Jan 2009 39

Central Venous Cannula Care Bundle High Impact Intervention(HII) - Elements of the care process Jan 2009 Jan 2009 40

Central Venous Cannula Care Bundle High Impact Intervention(HII) - Elements of the care process Jan 2009 Jan 2009 41

Central Venous Cannula Care Bundle High Impact Intervention(HII) - Elements of the care process Jan 2009 Jan 2009 42

Summary Infection Prevention Guidelines Handwashing/ANTT IV Infusion/catheter site prep/care Selection of :~ Catheter Type, Catheter Insertion Site, Sterile transparent semi-permeable film dressing/tape Change administration set (12 or 24 or 72 hrs) Rotate peripheral IV cannulae (72hrs) Care of intravenous devices Intravenous (IV) devices are used for the administration of fluids, blood products, nutritional support and blood monitoring. Infections associated with these devices can be life-threatening, particularly in susceptible patients. However, infection can largely be avoided by good infection control practices. Sources of contamination Hands of medical/nursing staff – hands should be thoroughly washed and dried prior to any manipulation. In some cases an antiseptic solution should be used (e.g. insertion of central venous catheters). Patient’s own skin and flora – commensals (e.g. Staphylococcus epidermidis) are a potential source of contamination. Micro-organism counts should be reduced by thorough skin cleansing using alcohol-based povidone iodine or chlorhexidine antiseptics. Hub contamination – any manipulation of the device can contaminate the hub and lead to both intra- and extra-luminal contamination. Catheter contamination on insertion – the use of sterile equipment and competent insertion will reduce this potential risk. Haematogenous spread – micro-organisms present at other sites (e.g. wounds, pressure sores) can spread via the blood-stream and adhere to the lumen of the device acting as potential foci for infection. Contaminated infusate – all infusions should be checked for expiry date, intact packaging, colour and lack of foreign bodies. Insertion and care of the IV device: aseptic technique should be used at all times wear appropriate barrier protection according to the type of IV device being inserted wash hands thoroughly before insertion and any manipulation if not visibly clean, the skin site should be washed with soap and water apply an antiseptic to the insertion site (e.g. povidone iodine/chlorhexidine) and allow to dry before proceeding if the device is not sutured, secure the IV device using sterile tape use sterile transparent semi-permeable film dressings to cover the insertion site change dressings when no longer intact, when moisture collects and at least every seven days. Hands should be washed thoroughly before changing dressings inspect the site at least daily for signs of infection (i.e. inflammation, pus and pain) minimise manipulations of the device. Maintain a closed system when-ever possible. Jan 2009 Jan 2009 43

Summary Infection Prevention Guidelines Record date of insertion & removal of the device Keep number of lines, lumens & stopcocks to minimum Maintenance and inspection of I.V. line/site Quality control of infusion/additives Cleanliness of equipment Care of intravenous devices Intravenous (IV) devices are used for the administration of fluids, blood products, nutritional support and blood monitoring. Infections associated with these devices can be life-threatening, particularly in susceptible patients. However, infection can largely be avoided by good infection control practices. Sources of contamination Hands of medical/nursing staff – hands should be thoroughly washed and dried prior to any manipulation. In some cases an antiseptic solution should be used (e.g. insertion of central venous catheters). Patient’s own skin and flora – commensals (e.g. Staphylococcus epidermidis) are a potential source of contamination. Micro-organism counts should be reduced by thorough skin cleansing using alcohol-based povidone iodine or chlorhexidine antiseptics. Hub contamination – any manipulation of the device can contaminate the hub and lead to both intra- and extra-luminal contamination. Catheter contamination on insertion – the use of sterile equipment and competent insertion will reduce this potential risk. Haematogenous spread – micro-organisms present at other sites (e.g. wounds, pressure sores) can spread via the blood-stream and adhere to the lumen of the device acting as potential foci for infection. Contaminated infusate – all infusions should be checked for expiry date, intact packaging, colour and lack of foreign bodies. Insertion and care of the IV device: aseptic technique should be used at all times wear appropriate barrier protection according to the type of IV device being inserted wash hands thoroughly before insertion and any manipulation if not visibly clean, the skin site should be washed with soap and water apply an antiseptic to the insertion site (e.g. povidone iodine/chlorhexidine) and allow to dry before proceeding if the device is not sutured, secure the IV device using sterile tape use sterile transparent semi-permeable film dressings to cover the insertion site change dressings when no longer intact, when moisture collects and at least every seven days. Hands should be washed thoroughly before changing dressings inspect the site at least daily for signs of infection (i.e. inflammation, pus and pain) minimise manipulations of the device. Maintain a closed system when-ever possible. Jan 2009 Jan 2009 44

References Department of Health (2003) “Winning Ways” Working together to reduce Healthcare Associated Infection in England (Report from CMO) Emmerson, A.M. et al. The second national prevalence survey of infection in hospital: overview of results. Journal of Hospital Infection (1996) 32: 3, 175-190. HCA Control of Infection Manual www.infectioncontrolservices.co.uk Maki, D.G. and Ringer, M. (1987) Evaluation of dressings regimens for prevention of infection with peripheral venous catheters. J. Am. Med. Ass., 285, 2396-403 Weightman N.C et al (1988) Bacteraemia related to indwelling central venous catheters: prevention diagnosis and treatment. Eur. J. of Clin. Microbiol. and Inf. Dis., 7, 125-129 Little et al. Gloves to fit the bill. Nursing Times (1999) Vol 95 No20, 57-58 Pratt et al. epic 2: National Evidence-Based Guidelines for Preventing Healthcare-Associated infections in NHS Hospitals in England. Journal of Hospital Infection (2007) 65(Supplement 1): February 2007 Am J Infect Control 2005;33:83e87 Lobo R, Levin A, Gomes L, et al. Impact of an educational program and policy changes on decreasing catheter associated bloodstream infections in a medical intensive care unit in Brazil. Department of Health. The Health and Social Care Act 2008: Code of Practice for health and social care on the prevention and control of infections and related guidance. Department of Health. London. 2009. Available http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_110288 Jan 2009 Jan 2009 45 45

Aseptic Non Touch Technique (ANTT) Principles DVD Jan 2009 Jan 2009 46