1. Catheter-Associated Bloodstream Infections & Nursing Intravenous Standards

2. MICU CVC-Associated BSI
This material was prepared for use by a UIHC Committee investigating ways to reduce morbidity & mortality

3. SICU Catheter-Associated Bloodstream Infection Rate
This material was prepared for use by a UIHC Committee investigating ways to reduce morbidity & mortality

4. 4JCE Catheter-Associated Bloodstream Infection Rate
This material was prepared for use by a UIHC Committee investigating ways to reduce morbidity & mortality

5. CVC-associated Bloodstream Infections
200,000 (80,000 ICU) CVC-associated BSI in the hospital per year.
10-20% attributable mortality w/ CVC infections in the ICU.
Costs of $3,700-$28,000 per line infection and total of $2.3 billion per year in US.

6. Median Catheter-associated BSI Rates by ICU Type in US
Am J Infect Control 2001; 29:

7. Central Venous Catheters
A CVC is an intravenous catheter whose tip ends in the central venous system
CVCs are commonly inserted through the jugular, subclavian, femoral, cephalic, & basilic veins
Indications for CVCs
Administer IV fluids, medications, blood products
Total parenteral nutrition (TPN)
Hemodynamic monitoring

8. Types of Central Venous Catheters
Long-term (>4-6 weeks): totally implantable port, tunneled catheters
Intermediate (>2 weeks, but <6 weeks): peripherally inserted central catheter (PICC)
Short-term (<2weeks): non-tunneled central catheter (e.g., triple lumen catheter)
Short-term, non-tunneled CVC Account for 90% of CA-BSI

9. Sources of Catheter-associated Bloodstream Infections
CONTAMINATION OF DEVICE PRIOR TO INSERTION
Extrinsic >>Manufacturer
SKIN ORGANISMS
Endogenous Flora
HCW hands
Contam Disinfectant
Invading Wound
CONTAMINATION OF
CATHETER HUB
Extrinsic (HCW)
Endogenous (Skin)
CONTAMINATED
INFUSATE
Fluid
Medication
Extrinsic
Manufacturer
Vein
HEMATOGENOUS
From Distant Local Infection
Fibrin Sheath,
Thrombus
Skin

10. Hand Hygiene
Perform hand hygiene with Avagard D before inserting peripheral or central venous catheters

11. CVC: Insertion
Person inserting central line must use maximum sterile barrier precautions
Sterile gloves and gown
Nonsterile masks and hats
Large sterile drapes that cover wide area
Prep site with 2% chlorhexidine gluconate (CHG)
Prep with side-to-side scrub for 30 seconds
Let dry for 30 seconds

12. Prevention of Central Venous Catheter-Related Infection by Using Maximal Sterile Barrier Precautions During Insertion
Control
MSB N
167
176
% Colonization
7.2%
2.3%*
Colonization per 1000 catheter days
1.0
0.3*
Sepsis per 1000 catheter days
0.5
0.08*
*p<0.05 vs. control
Raad et al, Infect Control Hosp Epidemiol 1994;15:

13. Reducing Risk of CVC Infections
Do not routinely replace CVC for purpose of preventing infection (NEJM 1992;327:1062-8)
Remove CVC as soon as possible
Strictly adhere to hand hygiene & aseptic technique during CVC insertion

14. A Controlled Trial of Scheduled Replacement of Central Venous and Pulmonary-Artery Catheters Cobb et al (NEJM 1992;327:1062-8)
Randomized pts. to one of four study Groups:
Routine CVC change Q 3 day by GWX
Routine CVC change Q 3 day to new site
CVC change by GWX only when CVC change indicated
CVC change to new site only when CVC change indicated.

15. A Controlled Trial of Scheduled Replacement of Central Venous and Pulmonary-Artery Catheters Cobb et al (NEJM 1992;327:1062-8)
No difference in infection rate in pts. undergoing scheduled change vs. those undergoing line change when indicated.
Higher rate CR-BSI in patients undergoing GWX (p=0.06).
High rate of mechanical complications in patients undergoing new stick (p=0.005).

16. Guidewire Exchange
Routine GWX of lines as prophylaxis against CVC infection not supported by literature.
Acceptable when line infection not suspected.
Do not use guidewire techniques to replace CVC for which there is strong suspicion of CVC-associated infection.
Tunneled CVC should never be changed over a guidewire.
Ok for line malfunction, new port for TPN, need to change type of line if no fever, elevated WBC or other clinical evidence of line infection
Potential indications for GWX when infection suspected
History of difficult line placement
No site for a new puncture (burns, venous thrombosis, etc.)
High or catastrophic risk of pneumothorax (e.g.. pneumonectomy patient on contralateral side from surgery)
Anticoagulation (guidewire exchange still not risk free)

17. Recommended Procedure for Guidewire Exchange of CVC
Wide skin prep as with all CVC placements.
Double glove and use MSB technique.
Once old line removed, remove outer gloves prior to handling new line.
Use new sterile caps on ports & new IV tubing.
When prepping, hold catheter with one hand, which is now contaminated (like Foley placement). Prep with other hand, starting with skin and then working up the line. Place prepped line either on to chest or on to a sterile barrier opened for this purpose, but not onto the bed (contaminating prep).
CAUTION: do not cut if patient is unstable or this is the only access!

18. CVC: Dressing Change Change dressing when wet, soiled or bloody
Change transparent dressing q 7 days
If transparent dressing is contraindicated and a gauze dressing is used, change gauze dressing q 48 hours

19. CVC: Dressing Change Perform hand hygiene with Avagard D
Assemble supplies
Put on clean gloves and remove old dressing down to the exit site
Pull the dressing toward the exit site of the catheter (this helps prevent pulling out the line)
Remove the remainder of the dressing by pulling off the dressing toward the exit site

20. CVC: Dressing Change
Observe exit site for redness, drainage, or other signs of infection
If there is any redness observed or drainage at the site/dressing, remove gloves and perform hand hygiene
Put on sterile gloves & palpate the area for tenderness, swelling, or drainage
If there is drainage, obtain swab culture and physician/LIP order for culture

21. CVC: Dressing Change
Clean area around site with CHG using side-to-side strokes
Clean under catheter and around exit site
Allow CHG to dry for 30 seconds.
Do not fan or blow on the site
ChloraPrep 3 ml applicator available in Processed Stores MHO8980

22. CVC: Dressing Change
Apply transparent dressing Note: No longer necessary to use 2x2 gauze dressing under transparent dressing
Do not use topical antibiotic ointment or creams at exit site
Securely anchor catheter to skin
Record date, time and initials on tape or dressing

23. CVC: Maintenance
Cleanse outside of hubs with alcohol before each use – allow to air dry
Administer TPN through a dedicated port
If using central line for pressure monitoring, change transducers, stopcocks, flush devices, and flush solutions q 96 hours

24. Tubing and Solution Changes
Change maintenance IV solutions at least q 96 hours, or sooner if medications added to solution expire
Change IV tubing q 96 hours, except
Blood tubing q 24 hours
Lipid tubing q 24 hours
Tubing used for lipid-based meds (such as Propofol) every 12 hours
Change tubing and solution for intermittent IV every 24 hours

25. Peripheral IV: Insertion
Prep insertion site for 30 seconds with 2% CHG
Use mechanical friction in a side-to-side application
Allow site to dry for 30 seconds
ChloraPrep 1.5 ml applicator available in Processed Stores MHO8979

26. Peripheral IV: Insertion
Note: If peripheral IV is to be placed for < 6 hours (such as in clinics), an alcohol prep may be used
If an alcohol prep is used and the peripheral IV is needed for more than 6 hours, it is recommended that the site be changed

27. Peripheral IV: Insertion and Maintenance
Change peripheral IV site every 96 hours
Do not place tape directly over the insertion site
Use a transparent dressing over insertion site
Do not use topical antibiotic ointment or creams on insertion site

28. Peripheral IV: Flush
Cleanse diaphragm of saline vial with 70% alcohol before withdrawing saline
Replace the cap on the IV line each time it is removed
Discard saline vial at the manufacturer’s expiration date

29. Arterial Line: Maintenance
Replace flush solution, tubing, and transducer (down to stopcock closest to the patient) every 96 hours
Replace dressing every 96 hours
Change dressing when wet, soiled or bloody
Cleanse exit site with 2% CHG using side-to-side scrub
Allow to dry for 30 seconds before applying new dressing

30. Blood Culture Collection
When an order for a blood culture is written, interpret the order to mean the following:
Collect 2 blood culture sets sequentially from two different sites
Whenever possible, collect a 3rd blood culture set 4-6 hours later

31. Blood Culture Collection
Blood cultures obtained from a peripheral site are preferred
For patients with poor venous access, blood may be drawn from an intravascular catheter
One of the first two blood culture sets should be drawn from a peripheral site

32. Blood Culture Collection
For a blood culture set, obtain 1 aerobic and 1 anaerobic bottle
Disinfect the top of each bottle with 70% alcohol swab
Allow the top to dry for 1 minute
Inoculate each bottle with 10 ml of blood

33. Blood Culture Collection: Peripheral
Obtain Blood Culture Prep Kit II
Perform hand hygiene
Select the vein to be used
Use “Isopropyl Alcohol Frepp” to scrub site vigorously for 30 seconds
Allow to dry
Cepti-Seal Blood culture Prep Kit II is available in Processed Stores MHO7577

34. Blood Culture Collection: Peripheral
Use “Iodine Tincture Sepp” to apply iodine tincture to venipuncture site, starting at center and moving outward in concentric circles to periphery
Allow the iodine to dry for at least 30 seconds
Do not touch site after prep (unless wearing sterile gloves)

35. Blood Culture Collection: Peripheral
Put on sterile gloves
Perform venipuncture and obtain 20 ml of blood
Cleanse the venipuncture site with 70% alcohol after the sample is obtained

36. Blood Culture Collection: Central Line
Perform hand hygiene
Clean catheter junction with alcohol swab and allow to dry
Aspirate 10 ml aliquot of fluid from catheter and discard
Aspirate 20 ml of blood from catheter