Risk and Prevention of CRBSI Associated with Acute Hemodialysis Catheters Faisal Masud MD, FCCP, FCCM

Disclosures This event is sponsored by Teleflex Medical. Dr. Masud is a consultant for Teleflex Medical. Views and opinions expressed are those of Dr. Masud and do not necessarily represent the opinions and policies of Methodist Hospital and/or Methodist DeBakey Heart & Vascular Center. Dr. Masud did not disclose any conflicts of interest in relation to this presentation

Learning Objectives List the risks of bloodstream infections (BSI) associated with acute hemodialysis catheters. Describe evidence-based strategies to reduce BSI associated with hemodialysis catheters.

Continuing Education Credits (CE) At the end of this webinar you can obtain 1.0 contact hour by going to www.saxetesting.com/vh Complete the post-test and evaluation form Upon successful submission, you will be able to print out your certificate of completion Provider (Saxe Communications) is approved by the California Board of Registered Nursing Provider # 14477 No off-label use will be discussed in this presentation

Background Acute kidney injury (AKI): sudden, temporary, and sometimes fatal loss of kidney function Complications: Fluid imbalance High potassium levels Metabolic acidosis Damage to other organs Treatment: Supportive care CRRT (Continuous Renal Replacement Therapy) Hemodialysis

Background (cont’d) Patients with AKI need acute hemodialysis (HD) catheters. However, according to Maki: Acute HD catheters have the highest risk among CVC devices 8% or 4.8 per 1,000 catheter days From: The Risk of Bloodstream Infection in Adults With Different Intravascular Devices: A Systematic Review of 200 Published Prospective Studies. Maki DG, et al. Mayo Clin Proc. 2006;81(9):1159-71.

Acute Catheters: Indications for Use Rapid fluid administration Trauma (blood products, saline, volume expanders, etc.) Septic shock ( saline, vasopressors, volume expanders, etc.) Hemodialysis Extracorporeal removal of waste products from blood: creatinine, urea and free water Hemofiltration/Continuous Renal Replacement Therapy (CRRT) Similar to hemodialysis Used almost exclusively in ICU settings Done slowly over more extended time (12 – 24 hr) Apheresis Extracorporeal therapy Donor blood passed through an apparatus to separate one particular component; the rest is returned to circulation

Placement of Acute Catheters Internal jugular External jugular Subclavian Femoral ARTERY OR VEIN? SPECIFY IF IT’S EITHER OR BOTH. ALSO: Even if most of your audience knows that an acute catheter = a central line, it needs to be stated somewhere here.

Incidence of Infections with Central Lines In 2009, about 18,000 bloodstream infections occurred in ICU patients with central lines. About 23,000 more patients who were treated in other areas of the hospital also developed similar infections. About 37,000 bloodstream infections occurred in 2008 in hemodialysis patients with central lines. ADD CDC REF HERE

CDC Data In 2010, more than 380,000 U.S. patients relied on hemodialysis. 8 in 10 of those patients start treatment with a central line. A hemodialysis patient is 100x more likely to get a bloodstream infection from MRSA than other people. Rate of hospitalization in hemodialysis patients due to bloodstream infections has increased by 51% since 1993. United Press International. Using CDC advice, dialysis infections down 32 percent. [Press release]. May 19, 2013 .

Need Title Delete this and replace with a few bullet points regarding the goal of this report Dudeck MA, et al. National Healthcare Safety Network (NHSN) Report, Data Summary for 2011, Device-associated Module. Posted online April 1, 2013.

Lab-confirmed Central Line-associated BSI Rates and Central Line Utilization Ratios, 2011 Dudeck MA, et al. National Healthcare Safety Network (NHSN) Report, Data Summary for 2011, Device-associated Module. Posted online April 1, 2013. Do you have permission for chart — is it your redesign?

CREATE A TITLE THAT EXPLAINS WHAT THIS CHART SAYS Dudeck MA, et al. National Healthcare Safety Network (NHSN) Report, Data Summary for 2011, Device-associated Module. Posted online April 1, 2013. Do you have permission for chart — is it your redesign?

Impact of Vascular Catheter-related BSI What is the rate of CRBSI at your institution? Especially dialysis patients Do you know how much CRBSI is costing your institution? Is that an acceptable rate? What is your goal? Have you done everything you can in your facility to achieve your target? How can you sustain your effort?

The Seven Deadly Sins Deviance Inattention Lack of ability Process inadequacy Task challenges Process complexity Uncertainty Hypothesis testing Exploratory testing

Consequences of The Seven Deadly Sins ADD REF

Pathogenesis of Medical device-related Infections Infectious Agent Infection Portal Of Entry Susceptible Host CHAIN OF INFECTION Colonization Meakins JL, Masterson BJ. Prevention of postoperative infection. ACS Surgery. 2003.

Pathogenesis / Technology-based Protocols! Infectious Agent Infection Treatment Prevention Portal Of Entry Susceptible Host CHAIN OF INFECTION Diagnosis Colonization Meakins JL, Masterson BJ. Prevention of postoperative infection. ACS Surgery. 2003.

Pathogenesis of Medical Device-related Infections Infectious Agent Infection Source Control Portal Of Entry Susceptible Host CHAIN OF INFECTION Colonization Meakins JL, Masterson BJ. Prevention of postoperative infection. ACS Surgery. 2003.

Model for Improvement Act Plan Study Do What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in an improvement? Act Plan Study Do More information is available in the How-to kit as well as on www.ihi.org. Source: The 5 Million Lives Campaign: Prevent Central Line Infections© Institute for Healthcare Improvement

Role of Leadership COMMIT: staff cannot improve without supportive leadership SET THE STANDARD: “This is how we will practice” FACILITATE RESOURCES: make time to work on testing SHARE DATA: to motivate staff for change Source: The 5 Million Lives Campaign: Prevent Central Line Infections© Institute for Healthcare Improvement

To Be Successful SET AN AIM: “Reduce the incidence of central line catheter-related bloodstream infections using the central line bundle.” SET A GOAL: “The rate of CRBSI will decrease by 50% in one year using the central line bundle.” PLAN WELL: Adopt a change methodology that accelerates improvement such as The Model for Improvement. Institute for Healthcare Improvement. The 5 Million Lives Campaign: Prevent Central Line Infections.

5 Sources of CLABSI Extraluminal Intraluminal 70%* 20-30%* *Estimated Objective: Discuss the 5 sources of CLABSI and the risk of Extraluminal and Intraluminal Supporting Tools: Have visuals to show the various surfaces that can be colonized and result in infections. Special attention should be paid to surfaces outside of clinical reach that antimicrobial catheters protect. Screen shots from our chloraguard animations should be considered. 20-30%* *Estimated CITE SOURCE(S) OF IMAGES AND PERMISSION 23

CDC 2011 GUIDELINES (Complete Title) Major areas of emphasis Provide education/training to clinicians who insert and manage lines. Perform periodic assessments of knowledge and adherence to established policies. Weigh risks/benefits of placing a central venous device at a recommended site to reduce infectious complications against the risk for mechanical complications. Avoid the subclavian site in hemodialysis patients and patients with advanced kidney disease to avoid risk of stenosis. Use ultrasound guidance to place central venous catheters to reduce number of cannulation attempts and mechanical complications. U/S guidance should only be used by those fully trained in its technique.

CDC GUIDELINES (cont’d) Use maximal sterile barrier precautions: a cap, mask, sterile gown, sterile gloves and a sterile full-body drape for the insertion of CVCs, PICCs, or guide wire exchanges. Prepare clean skin with a > 0.5% chlorhexidine preparation with alcohol before central venous catheter and peripheral arterial catheter insertion and during dressing changes. If there is a contraindication to chlorhexidine, use tincture of iodine, an iodophor, or 70% alcohol as alternatives. If previous successful implementation of CLABSI reduction strategy is not decreasing: Use a chlorhexidine/silver sulfadiazine or minocycline/rifampin impregnated CVC in patients whose catheter is expected to remain in place > 5 days. In patients older than 2 months, use a chlorhexidine-impregnated sponge dressing for temporary short-term catheters and appropriate use of Chlorhexidine for skin antisepsis and MSBs. ADD CDC REF HERE

Key Change: Central Line Checklist (Strategies & NPSG) Have identified staff member document compliance with insertion criteria at the time of insertion Serves as a reminder of steps vital to central line placement Establishes a clear understanding of when breaches should be stopped and effectively defines the reasons for an event report Serves as an investigation tool to help learn what factors may have contributed to a complication Create a culture of safety and prevention Empowers staff to stop line placement if improper techniques are used Instruct staff in use of critical communication strategies to facilitate important exchanges e.g., “The sterile field has been contaminated,” rather than, “You contaminated the catheter!” Institute for Healthcare Improvement. The 5 Million Lives Campaign: Prevent Central Line Infections.

Evidence-based Best Practices (Strategies & NPSG) Hand Hygiene 101 Wash hands if they are obviously soiled Wash hands or use an alcohol-based waterless hand cleaner Before and after invasive procedures Between patients After removing gloves Before eating After using the bathroom If contamination is suspected CDC guidelines available at: http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf Image provided by author Centers for Disease Control and Prevention. MMWR. 2002;51(No. RR-16):1-34. Institute for Healthcare Improvement. The 5 Million Lives Campaign: Prevent Central Line Infections.

Evidence-based Best Practices (Strategies & NPSG) Prepping Cleanse area prior to prep CDC and nine other organizations prefer a 2% chlorhexidine-based preparation Use back-and-forth strokes for a minimum of 30 seconds Completely wet treatment area Allow to air-dry for approximately 30 seconds Do not blot or wipe dry Proper drying promotes maximum activity of the prep as well as best adherence of dressings

What are Maximal Barrier Precautions? Evidence-based Best Practices (Strategies & NPSG) What are Maximal Barrier Precautions? Improper Proper For Provider: Hand hygiene Non-sterile cap and mask All hair under cap Mask covers nose and mouth tightly Sterile gown/gloves Image provided by author Institute for Healthcare Improvement. The 5 Million Lives Campaign: Prevent Central Line Infections.

What are Maximal Barrier Precautions? Evidence-based Best Practices What are Maximal Barrier Precautions? For the Patient: Cover patient’s head and body with a large sterile drape Image provided by author Institute for Healthcare Improvement. The 5 Million Lives Campaign: Prevent Central Line Infections.

At Insertion ( strategies recommendation & NPSG) Use an all-inclusive catheter cart or kit (B-II).   A catheter cart or kit that contains all necessary components for aseptic catheter insertion is to be available and easily accessible in all units where CVCs are inserted.

The ErgoPack System: Taking the Safest Approach to Catheter Insertion Image provided by author

Maximum Barrier ErgoPack System Complies with CDC, SHEA/IDSA, IHI, INS, JCAHO, NHSN, OSHA Guidelines: Latex-free components Include: 21-Step insertion checklist for clinical record Procedural stop sign Alcohol hand gel Hi-lite orange Chloraprep Biopatch Tegaderm dressing Exclusive: 54″ x 96″ head-to-toe drape w/ 18″ x 18″ clear window with a 4″ fenestration Cap, gown, mask Sharps safety features (Safety Glide needles, SharpsAway II Locking Disposal Cup, Safety Scalpel) HemoHopper ARROWg+ard Blue® Catheter (chlorhexidine/silver sulfadiazine catheter)

Impact of Catheter ( strategies/recommendations) Use antiseptic- or antimicrobial-impregnated CVCs for adult patients (A-I). The risk of CLABSI is reduced with some currently marketed catheters impregnated with antiseptics (e.g., chlorhexidine-silver sulfadiazine) or antimicrobials (e.g., minocycline-rifampin). Consider the use of such catheters in these circumstances:  Hospital units or patient populations have a CLABSI rate higher than the institutional goal, despite compliance with basic CLABSI prevention practices.  Patients have limited venous access and a history of recurrent CLABSI.  Patients are at heightened risk for severe sequelae from a CLABSI (e.g., patients with recently implanted intravascular devices, such as a prosthetic heart valve or aortic graft). ADD REF(S)

Most Common Pathogens of CLABSIs CDC: the most commonly reported causative pathogens are Coagulase-negative staphylococci (S. aureus) Enterococci Candida spp. Gram-negative bacilli accounted for 19% and 21% of CLABSIs reported to CDC. Migration of skin organisms at the insertion site into the cutaneous catheter tract and along the surface of the catheter with colonization of the catheter tip is the most common route of infection for short-term catheters . ADD REF(S)

ARROWg+ard Blue AGB Chlorhexidine/silversulfadiazine fights infection by inhibiting microorganisms from migrating along the exterior surface of the catheter > 30 studies and reviews since 1992 demonstrate that it protects against CLASBIs Reduces bacterial colonization by 60% Reduces catheter-related bacteremia by 80%

Target Zero: Support Evidence-based Practices David Redo Pittet D, et al. JAMA. 1994;271(20):1598-1601. .

The Catheter’s Role in Interrupting Pathogenesis Maximal sterile barrier with effective prepping Correct catheter size and tip Aseptic care Assess and dress Barrier precautions include cap, mask, gown, gloves, drape, and CHG/IPA. The catheter size should correlate with the lumen of the selected vein. The terminal tip should be distal to the SVC. Staff education should include hand hygiene, catheter selection, and site swabbing techniques. Assess and dress includes inspecting CHG dressings, performing dressing changes, administering flush solutions, and assessing catheter function daily. CITE SOURCE OF IMAGE ADD REF

Additional Layer of Protection in Preventing Pathogenesis Barrier precautions Correct catheter size and tip Aseptic care Assess and dress Antimicrobial catheter Additional prevention technologies provide the added benefits of an additional layer of risk reduction, technology that complements other bundle layers, and a last line of defense in preventing infection. This last line of defense partially compensates for lapses in technique, fatigue that could lead to noncompliance, and failures to implement evidence-based practices. Antimicrobial catheters are proven to reduce infection and are designed to protect areas other bundle layers can’t touch, including the subcutaneous tract, the internal lumen, and hematogenous seeding. CITE SOURCE OF IMAGE AND ACKNOWLEDGE THAT YOU HAVE PERMISSION TO USE IT ADD REF

Our Goal CITE SOURCE OF IMAGE AND PERMISSION

After Insertion ( strategies recommendation and NPSG) Disinfect catheter hubs, needleless connectors, and injection ports before accessing the catheter (B-II). NOTE: Before accessing catheter hubs or injection ports, clean them with an alcoholic chlorhexidine preparation or 70% alcohol to reduce contamination.

Important Points re. Dressing Allow prep to dry completely Maximizes activity of prep Allows dressing to stick to skin Follow sterile technique Do not use antibiotic ointment or creams on insertions sites, except for dialysis catheters Chlorhexidine-impregnated dressings: Biopatch, Tegaderm, etc. Transparent occlusive dressing; leave in place up to 7 days if clean and dry

Performance Measures (strategies/recommendation) Compliance with CVC insertion guidelines as documented on an insertion checklist Compliance with documentation of daily assessment regarding the need for continuing CVC access Compliance with cleaning of catheter hubs and injection ports before they are accessed Compliance with avoiding the femoral vein site for CVC insertion in adult patients

Good Guys Do Win A recent study shows that, following CDC recommendations, there Vascular Access-related BSI in hemodialysis patients was reduced by 54%. That represented $23,000 in cost savings. Data show that 58% fewer bloodstream infections occurred in hospital ICU patients with central lines in 2009 than in 2001. Overall, the decrease in infections saved up to 27,000 lives and is associated with $1.8B in excess medical costs. In 2009 alone, reducing infections saved about 3,000-6,000 lives and about $414 million in extra medical costs compared with 2001. http://www.upi.com/Health_News/2013/05/19/Using-CDC-advice-dialysis-infections-down-32-percent/UPI-22911369015802/#ixzz2U7blPkbe ADD REFS

Summary Key Points Prevention is the goal Right Care, Right Now (for the) Right Patient Save Lives, Save Money Make business case an issue for hospital administrators Make patient care an issue for physicians Quality care for both Persevere―Change is hard

Continuing Education Credits (CE) At the end of this webinar you can obtain 1.0 contact hour by going to www.saxetesting.com/vh Complete the post-test and evaluation form Upon successful submission, you will be able to print out your certificate of completion Provider (Saxe Communications) is approved by the California Board of Registered Nursing Provider # 14477

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