1. The European Group for Blood and Marrow Transplantation How well are we doing with CVC’s in EBMT? London 5th October 2012 Arno Mank, Nurse Researcher, Past President, EBMT-NG Academic Medical Centre, Amsterdam The European Group for Blood and Marrow Transplantation

2. Overview Why? About CVC’s Guidelines/ Protocols Care aspects Collaborative survey/ EBMT guideline

3. The European Group for Blood and Marrow Transplantation Why Medication TPN Chemotherapy Blood sampling “Where are you infusing into? Patient diagnosis/medical condition Patient compliance to therapy “How long are infusing? Duration of therapy Length of therapy Number/frequency of infusions Alternative site infusion “What are you infusing? Drug (s) to be administered pH/ Osmolarity

4. The European Group for Blood and Marrow Transplantation Not like this!

5. The European Group for Blood and Marrow Transplantation Venous Access PI Midline Subclavian/ jugular PICC Tunnelled catheter Implanted port + 3 days 3 days to 4 weeks 1 week to 8 weeks 1 week to 4 month 3 weeks to 6 month > 6 weeks and intermitted

6. The European Group for Blood and Marrow Transplantation Subclavian/ jugularis catheter Long term / Short term (Non) tunnelled

7. The European Group for Blood and Marrow Transplantation Placement Vena Jugularis Vena Subclavia Vena Femoralis Vena Brachialis

8. The European Group for Blood and Marrow Transplantation Complications CVC Insertion: perforation bleeding pneumothorax arrhythmias During treatment: extravasations thrombosis catheter related infections

9. The European Group for Blood and Marrow Transplantation PICC line Upper arm/ Vena cava superior –Under ultra sound guidance inserted –Not invasive –No pneumothorax

10. The European Group for Blood and Marrow Transplantation Differences/ Discussion points Alternative peripheral IV, subclavia and jugular History/Development Length Suitable for infusion agents Can it be used for a medium till long period? For hospital and home infusion Single, double and triple lumen Thrombosis Cost saving Patient’s comfort Decreasing Infection rate

11. The European Group for Blood and Marrow Transplantation Guidelines and Protocols Documents which supports decisions and following actions.

12. The European Group for Blood and Marrow Transplantation Differences Protocol Specific Detailed Compulsory Acts: Who, What, How, Which Order Legal framework Guideline General Not/less detailed Advisory More informing/ evidence Supportive Guideline : what should be done Protocol: how certain transactions should be carried out

13. The European Group for Blood and Marrow Transplantation Diagnosis of acute fever for patient suspected short-term cvc infection Obtain samples for blood culture prior to the initiation of antibiotic therapy (A1 evidence) Mermel LA et.al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America.Clin Infect Dis. 2009;1;49(1):1-45.

14. The European Group for Blood and Marrow Transplantation Conclusion: there is room for improving European nurses’ knowledge of central venous catheter-related infections prevention guidelines. We recommend including supplementary support from current evidence-based guidelines in their educational curricula and continuing refresher programs. Labeau SO et.al. Centers for Disease Control and Prevention guidelines for preventing central venous catheter-related infection: results of a knowledge test among 3405 European intensive care nurses. Crit Care Med. 2009;37(1):320-323.

15. The European Group for Blood and Marrow Transplantation Educational intervention Warren DK et.al. A multicenter intervention to prevent catheter-associated bloodstream infections. Infect Control Hosp Epidemiol. 2006;27(7):662-9. An educational intervention that uses evidence-based practices can be successfully implemented in a diverse group of medical and surgical units and reduce catheter associated bloodstream infection rates

16. The European Group for Blood and Marrow Transplantation Summary of Recommendations Education, Training and Staffing Selection of Catheters and Sites Peripheral Catheters and Midline Catheters Central Venous Catheters. Hand Hygiene and Aseptic Technique Maximal Sterile Barrier Precautions Skin Preparation Catheter Site Dressing Regimens Patient Cleansing Catheter Securement Devices Antimicrobial/Antiseptic Impregnated Catheters and Cuffs Systemic Antibiotic Prophylaxis Antibiotic/Antiseptic Ointments Antibiotic Lock Prophylaxis, Antimicrobial Catheter Flush and Catheter Lock Prophylaxis Anticoagulants Replacement of Peripheral and Midline Catheters Replacement of CVCs, Including PICCs and Hemodialysis Catheters Umbilical Catheters Peripheral Arterial Catheters and Pressure Monitoring Devices for Adult and Pediatric Patients Replacement of Administration Sets Needleless Intravascular Catheter Systems Performance Improvement Indications for catheter insertion Choice of catheter Patient care prior to catheter insertion Antibiotic prophylaxis Catheter insertion Immediate patient care after catheter insertion Long-term catheter care Patient information Management of problem patients Prevention and management of catheter complications –Malfunction –Infection –Thrombosis catheter removal O'Grady et al.Clin Guidelines for the prevention of intravascular catheter-related infections. Infect Dis. 2011;52(9):e162-193 Bishop L, et.al. Guidelines on the insertion and management of central venous access devices in adults. Int J.Lab Hematol. 2007;29(4):261-78..

17. The European Group for Blood and Marrow Transplantation Care aspects CVC Indication/Choice Catheter/Lumen Insertion Hand washing Sterile or Non touch method/ Gloves Manipulation Change Administration sets Dressing change Removal Registration –General –Infection Quality and Education

18. The European Group for Blood and Marrow Transplantation Indication/Choice Catheter For how long Not necessarily, then remove Replace not routinely Each lumen increases the risk of infection

19. The European Group for Blood and Marrow Transplantation Insertion Sterile barrier Surgery or department Chlorhexidine or iodine

20. The European Group for Blood and Marrow Transplantation Hands Washing/ Disinfection Cleaning: Washing and Drying Infection Prevention: Alcohol Willingness? Training and checking

21. The European Group for Blood and Marrow Transplantation Gloves - No touch method Use either clean or sterile gloves when changing Use the ‘no touch’ method for dressing change and flushing protocol Security?

22. The European Group for Blood and Marrow Transplantation Manipulation Opening the catheter –Medication –Blood sampling –Patient preference –Combination How often changing the administration sets –24/72/96 hours? –Different between fluids/ blood products

23. The European Group for Blood and Marrow Transplantation Dressing change Daily inspection (external contamination) –Dry: Transparent dressing every 5-7 days? –Wet: Gauze dressing should every 2 days? Well-healed tunnelled CVAD maybe no dressing Chlorhexidine impregnated dressing (Biopatch ®)

24. The European Group for Blood and Marrow Transplantation Flushing/ Needleless connector Saline, Heparin, other? Disconnecting/ blood sampling Lock solution Volume at least 2 times volume of the lumen Normal saline between incompatible drugs Frequency Use of correct needless connector

25. The European Group for Blood and Marrow Transplantation Administration/Registration: General and infection electronic patient record

26. The European Group for Blood and Marrow Transplantation Quality/ Qualification/ Education Registration by the law Knowledgeable and skilled Train the trainer IV/CVC team –specialisation –surveillance How well are we doing with CVC’s in EBMT?

27. The European Group for Blood and Marrow Transplantation Collaboration IDWP with EBMT-NG The Infection Disease Working Party aims to promote and conduct educational activities and clinical investigations on all the topics concerning the diagnosis, the prophylaxis and the management of infectious complications following HSCT. The Nurses Group also! Focus on Central Line Associated Blood Stream Infections (CLABSI)

28. The European Group for Blood and Marrow Transplantation Study design Aims of the study To evaluate self-reported adherence to CLABSI prevention guidelines in EBMT centres and possible association with HSCT outcome. Analysis endpoints: Primary: Assessment of current practice of CLABSI prevention in HSCT setting in Europe. Secondary: Assessment of possible association between self-reported adherence to bundle of recommendations in the guidelines for CLABSI prevention and observed outcome of HSCT in terms of 100 day mortality and graft versus host disease. Study Design cross sectional study, questionnaire for collection of data on guidelines used and self-reported adherence to international guidelines for prevention of central line associated bloodstream infections. Inclusion Criteria All centres in the EBMT database. Timeline Preparation of the online questionnaire – June 2012 Invitation to the study - October 2012 Filling the data by centres – December 2012 Analysis of the data – January 2013 Abstract preparation – February 2013 Publication preparation until March 2013 Presentation at the EBMT 2013

29. The European Group for Blood and Marrow Transplantation Questionnaire A study specific questionnaire has been constructed based on recommendations from international guidelines. two parts: - written guidelines used at the centre. SOP - different aspects of central venous line practice. Current practice Key areas - Education of healthcare professionals on prevention of CLABSI - The organization of CVC insertions in the department - Type of catheter preferred by centre - Adherence to full barrier precautions during the insertion - Central venous catheter management - Diagnostics of infection pre tested for content validity by nurses and physicians from selected EBMT centres who will assess the content and relevance of each item for measuring the adherence to the guideline. Feasibility The data collected in this study should give answer to two questions: To what extent are guidelines of CLABSI prevention in HSCT implemented in Europe. The possible connection with 100 day mortality and GvHD and self-reported practice of CLABSI prevention bundle as judged from questionnaires

30. The European Group for Blood and Marrow Transplantation Involved people Infectious Diseases Working Party/EBMT-Nurses Group Investigators Emilian Snarski Medical University of Warsaw POLAND Eva Johansson Associate Professor, Senior Lecturer Division of Nursing | Karolinska Institute Stockholm SWEDEN Arno Mank, nurse researcher past president EBMT Nurses Group Academic Medical Centre Amsterdam The Netherlands Statistician Simona Iacobelli Study coordinator Jennifer Hoek Study Coordinator European Group for Blood and Marrow Transplantation idwp.ebmt@lumc.nl

31. The European Group for Blood and Marrow Transplantation QUESTIONS?