1. AAP Things That Work: Prevention of Catheter Related Bloodstream Infections Marlene R. Miller, M.D., M.Sc. Christopher T. McKee, DO Ivor Berkowitz, M.D. Claire Beers, R.N., M.S.N. Johns Hopkins Children’s Center Hospital Epidemiology and Infection Control Center for Innovations in Quality Patient Care

2. Introduction Review Epidemiology Define Standard of Care –Hand Hygiene –Maximal Barrier Precautions –Proper Antisepsis –Insertion Sites of Choice Describe our intervention and results to date

3. The Problem 250,000 cases of central venous catheter related bloodstream infections (CR-BSI) per year in US 80,000 cases per year in ICU’s Attributable mortality: 12-25% Attributable cost: $25,000 per episode

5. Strategies For Prevention: Adult Experience Hand Hygiene Use of Maximal Barrier Precautions Chlorhexidine for Skin Antisepsis Subclavian Site as First Choice Remove Unnecessary Lines MMWR. 2002;51:RR-10

6. What Is Pediatric Best Practice? No studies published in pediatric literature Assume adult data holds for children –Exception is optimal site of line insertion

7. BSI Intervention Education on best practices “Line cart” Nursing check list for CL insertion Empowerment of nurses to stop procedures if best practices breached

8. Hand Hygiene: The Data Since 1977, 7 of 8 prospective studies have shown that improvement in hand hygiene significantly decreases infection rates Clin Infect Dis 1999;29:1287-94

9. Alcohol-Based Hand Cleansers Non-medicated soap used; alcohol was mixture of n-propanol and isopropanol; hands contaminated under clinical conditions Am J Infect Control 1999; 27:258-61 Soap and Water Alcohol Solution # of HCWsn = 43 Reduction in CFUs 50%88%

10. Hand Hygiene: Be A Role Model HCWs in a room with a senior medical staff person or peer who did not wash their hands were significantly less likely to wash their own hands (OR = 0.2, p <.001) Use of gloves does not obviate the need for hand hygiene Emerg Infect Dis 2003; 9:217-23

11. Hand Hygiene Best Practice Purell for routine hand cleaning Soap and water when hands are soiled and at start of day One of these types of cleanings should be done before inserting a central line

12. Maximal Barrier Precautions

13. Do I Really Need Maximal Barrier Precautions ? Author & Year Study DesignType of Line OR for infection without MBP Mermel 1991 Prospective Cross-sectional SG2.2 (p=0.03) Raad 1994 Prospective Randomized Central3.3 (p=0.03) Am J Med 1991;91(3B):197S-205S Infect Control Hosp Epidemiol 1994;15:231-8

14. What Are Maximal Barrier Precautions? For You –Hand hygiene –Non-sterile cap and mask All hair should be under cap Mask should cover nose and mouth tightly –Sterile gown and gloves For the Patient –Cover patient’s head and body with a large sterile drape

15. Who Needs To Be Dressed In MBP? The operator The assistant Anyone else who crosses the sterile field NOT people in the same room who are not involved with the procedure

16. Skin Prep Chlorhexidine 2% is more effective than povidone iodine (Betadine) because it dries quickly and has longer residual action

17. Skin Prep If you must use Betadine –Allow Betadine to dry completely (at least 2 minutes) –Do not blow on, fan, or blot the site to make it dry faster!

18. Dressing The Line Apply dressing immediately after placement when site is still sterile Use transparent dressing (Sorbaview) unless site is oozing or pt is allergic

19. Maintaining The Line Change transparent dressing weekly, gauze dressing daily, and any dressing that is damp, bloody, or non-occlusive Do not use topical ointment or cream at insertion site Do not leave a line undressed Lines examined daily by medical staff

20. What Site Is Best? “No randomized trial satisfactorily has compared infection rates for catheters placed in jugular, subclavian, and femoral sites.” MMWR, 8/9/02

21. What Site Is Best? The Hopkins Experience—retrospective analysis of SICU IJ & SC catheters that grew  15 cfu –IJ position was the only predictive factor of  15 cfu (OR 1.83, p <.001)

22. What Site Is Best? RCT of femoral and SC lines in the ICU –145 pts femoral/144 pts SC Outcomes –Similar rates of mechanical complication: 17.3% vs 18.8% (p = NS) –Higher rate of infectious complications (colonization and BSI combined) in femoral grp: 19.8% vs 4.5% (p <.001) –Higher rate of thrombotic complications in femoral grp: 21.5% vs. 1.9% (p <.001); complete thrombosis 6% vs 0% JAMA; 2001,286:700-7

23. What Site Is Best? Based on these and other studies, the JHH VAD policy recommends that the preferred order of line placement is SC  IJ  F Other factors to consider in site choice –Anatomic deformity –Coagulopathy –Operator experience

24. What Site Is Best For Children? Traditionally femoral vein is site of first choice for all pediatric patients –Operator experience is determining factor for placement of lines elsewhere Infectious data does not hold true in children –Site of insertion does not correlate with infectious complications Same or fewer mechanical complications noted with femoral line placement No thrombotic risk with femoral line placement

25. Summary of Best Practices Wash your hands or use waterless hand cleaners Use sterile technique and maximal barrier precautions when placing central lines Use chlorhexidine for line insertion and dressing changes Use femoral site if possible Don’t put in lines that are not needed and take out lines that are not needed

26. BSI Intervention Education on best practices “Line cart” Nursing check list for CL insertion Empowerment of nurses to stop procedures if best practices breeched

28. BSI effort starts

29. BSI Intervention Education on best practices –Hand Hygiene –Use of Maximal Barrier Precautions –Chlorhexidine for Skin Antisepsis –Femoral Site as First Choice –Remove Unnecessary Lines “Line cart” Nursing check list for CL insertion Empowerment of nurses to stop procedures if best practices breeched

30. Lessons Learned Actual and reported practices vary People may not know what you think they know Team work helps Maximized preparation helps (line cart) Need to be on alert for ‘next best thing’ in new equipment