guidelines for the prevention of intravascular ... · dopo fluido dopo contatto dopo ambiente 41.1...

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Lunedì 19 maggioLunedì 19 maggioOre 9.30 Ore 9.30 –– 13.0013.00

Corso precongressuale BCorso precongressuale B

Il valore diagnostico dell’emocoltura eIl valore diagnostico dell’emocoltura ela prevenzione delle infezioni CVC relatela prevenzione delle infezioni CVC relate

Il Il bundlebundle per la prevenzione delle infezioni CVC relate:per la prevenzione delle infezioni CVC relate:quali criticità nell’applicazione delle Linee Guidaquali criticità nell’applicazione delle Linee Guida

Dr. Andrea PatroniDr. Andrea Patroni(Brescia)(Brescia)

Guidelines for the Prevention of Intravascular Guidelines for the Prevention of Intravascular CatheterCatheter--related Infectionsrelated Infections

The system for categorizing recommendationsThe system for categorizing recommendationsis as follows: is as follows:

•• Category IACategory IA. Strongly recommended for implementation and strongly . Strongly recommended for implementation and strongly supported by wellsupported by well--designed experimental, clinical, or epidemiologic studies. designed experimental, clinical, or epidemiologic studies.

•• Category IBCategory IB. Strongly recommended for implementation and supported by . Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical some experimental, clinical, or epidemiologic studies and a strong theoretical rationale; or an accepted practice (e.g., aseptic technique) supported by limited rationale; or an accepted practice (e.g., aseptic technique) supported by limited evidence. evidence.

•• Category ICCategory IC. Required by state or federal regulations, rules, or standards. . Required by state or federal regulations, rules, or standards.

•• Category IICategory II. Suggested for implementation and supported by suggestive . Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale. clinical or epidemiologic studies or a theoretical rationale.

•• Unresolved issueUnresolved issue. Represents an unresolved issue for which evidence is . Represents an unresolved issue for which evidence is insufficient or no consensus regarding efficacy exists. insufficient or no consensus regarding efficacy exists.

Clinical Infectious Diseases 2011; 52(9): e162-e193


Category IA20%

Category IB34%Category IC

2%

Unresolved issue17%

Category II27%

Clinical Infectious Diseases 2011; 52(9): e162Clinical Infectious Diseases 2011; 52(9): e162--e193e193

2


Major areas of emphasisMajor areas of emphasisinclude:include:

1.1. educating and training healthcare personnel who insert and maintain educating and training healthcare personnel who insert and maintain catheters;catheters;

2.2. using maximal sterile barrier precautions during central venous using maximal sterile barrier precautions during central venous catheter insertion;catheter insertion;

3.3. using a > 0.5% chlorhexidine skin preparation with alcohol for using a > 0.5% chlorhexidine skin preparation with alcohol for antisepsis;antisepsis;

4.4. avoiding routine replacement of central venous catheters as a avoiding routine replacement of central venous catheters as a strategy to prevent infection;strategy to prevent infection;

5.5. using antiseptic/antibiotic impregnated shortusing antiseptic/antibiotic impregnated short--term central venous term central venous catheters and chlorhexidine impregnated sponge dressings if the rate catheters and chlorhexidine impregnated sponge dressings if the rate of infection is not decreasing despite adherence to other strategies.of infection is not decreasing despite adherence to other strategies.



Education, Training and StaffingEducation, Training and Staffing

1.1. Educate healthcare personnel regarding the indications for intravascular Educate healthcare personnel regarding the indications for intravascular catheter use, proper procedures for the insertion and maintenance of catheter use, proper procedures for the insertion and maintenance of intravascular catheters, and appropriate infection control measures to prevent intravascular catheters, and appropriate infection control measures to prevent intravascular catheterintravascular catheter--related infections. related infections. Category IACategory IA

2.2. Periodically assess knowledge of and adherence to guidelines for all Periodically assess knowledge of and adherence to guidelines for all personnel involved in the insertion and maintenance of intravascular personnel involved in the insertion and maintenance of intravascular catheters. catheters. Category IACategory IA

3.3. Designate only trained personnel who demonstrate competence for the Designate only trained personnel who demonstrate competence for the insertion and maintenance of peripheral and central intravascular catheters. insertion and maintenance of peripheral and central intravascular catheters. Category IACategory IA

4.4. Ensure appropriate nursing staff levels in ICUs. Ensure appropriate nursing staff levels in ICUs. Category IBCategory IB


Country statistical profile: ItalyCountry statistical profile: Italy

Total population('000 persons)

5500056000570005800059000600006100062000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

3


78

79

80

81

82

83

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Life expectancy at birth(Years)


16

17

18

19

20

21

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Elderly population aged 65 and over (% of population)


Selection of Catheters and SitesSelection of Catheters and Sites

1.1. Weigh the risks and benefits of placing a central venous device at a Weigh the risks and benefits of placing a central venous device at a recommended site to reduce infectious complications against the risk for recommended site to reduce infectious complications against the risk for mechanical complications (e.g., pneumothorax, subclavian artery puncture, mechanical complications (e.g., pneumothorax, subclavian artery puncture, subclavian vein laceration, subclavian vein stenosis, hemothorax, subclavian vein laceration, subclavian vein stenosis, hemothorax, thrombosis, air embolism, and catheter misplacement). thrombosis, air embolism, and catheter misplacement). Category IACategory IA

2.2. Avoid using the femoral vein for central venous access in adult patients. Avoid using the femoral vein for central venous access in adult patients. Category IACategory IA

3.3. Use a subclavian site, rather than a jugular or a femoral site, in adult Use a subclavian site, rather than a jugular or a femoral site, in adult patients to minimize infection risk for nontunneled CVC placement. patients to minimize infection risk for nontunneled CVC placement. Category IBCategory IB


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4.4. No recommendation can be made for a preferred site of insertion to No recommendation can be made for a preferred site of insertion to minimize infection risk for a tunneled CVC. Unresolved issueminimize infection risk for a tunneled CVC. Unresolved issue

5.5. Avoid the subclavian site in hemodialysis patients and patients with Avoid the subclavian site in hemodialysis patients and patients with advanced kidney disease, to avoid subclavian vein stenosis. advanced kidney disease, to avoid subclavian vein stenosis. Category IACategory IA

6.6. Use a fistula or graft in patients with chronic renal failure instead of a CVC Use a fistula or graft in patients with chronic renal failure instead of a CVC for permanent access for dialysis. for permanent access for dialysis. Category IACategory IA

7.7. Use ultrasound guidance to place central venous catheters (if this Use ultrasound guidance to place central venous catheters (if this technology is available) to reduce the number of cannulation attempts and technology is available) to reduce the number of cannulation attempts and mechanical complications. Ultrasound guidance should only be used by mechanical complications. Ultrasound guidance should only be used by those fully trained in its technique. those fully trained in its technique. Category IBCategory IB




8.8. Use a CVC with the minimum number of ports or lumens essential for the Use a CVC with the minimum number of ports or lumens essential for the management of the patient. management of the patient. Category IBCategory IB

9.9. No recommendation can be made regarding the use of a designated lumen No recommendation can be made regarding the use of a designated lumen for parenteral nutrition. Unresolved issue for parenteral nutrition. Unresolved issue

10.10. Promptly remove any intravascular catheter that is no longer essential. Promptly remove any intravascular catheter that is no longer essential. Category IACategory IA

11.11. When adherence to aseptic technique cannot be ensured (i.e catheters When adherence to aseptic technique cannot be ensured (i.e catheters inserted during a medical emergency), replace the catheter as soon as inserted during a medical emergency), replace the catheter as soon as possible, i.e, within 48 hours. possible, i.e, within 48 hours. Category IBCategory IB


Catheters and Sites

0%

20%

40%

60%

80%

100%

Not hemodialysis Hemodialysis

ArterialFemoralJugularSucclavian

13%13%

56%56%

29%29%

2%2%

7%7%

64%64%

29%29%

Dati CIO 2013Dati CIO 2013

BedsBeds 294294

Hospitalization/YearHospitalization/Year 92499249

CathetersCathetersNot hemodialysisNot hemodialysis

HemodialysisHemodialysis

308308210210

9898

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Hand Hygiene and Aseptic TechniqueHand Hygiene and Aseptic Technique

1.1. Perform hand hygiene procedures, either by washing hands with Perform hand hygiene procedures, either by washing hands with conventional soap and water or with alcoholconventional soap and water or with alcohol--based hand rubs (ABHR). based hand rubs (ABHR). Hand hygiene should be performed before and after palpating catheter Hand hygiene should be performed before and after palpating catheter insertion sites as well as before and after inserting, replacing, accessing, insertion sites as well as before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter. Palpation of the insertion repairing, or dressing an intravascular catheter. Palpation of the insertion site should not be performed after the application of antiseptic, unless site should not be performed after the application of antiseptic, unless aseptic technique is maintained. aseptic technique is maintained. Category IBCategory IB

2.2. Maintain aseptic technique for the insertion and care of intravascular Maintain aseptic technique for the insertion and care of intravascular catheters. catheters. Category IBCategory IB

3.3. Wear clean gloves, rather than sterile gloves, for the insertion of peripheral Wear clean gloves, rather than sterile gloves, for the insertion of peripheral intravascular catheters, if the access site is not touched after the application intravascular catheters, if the access site is not touched after the application of skin antiseptics. Category ICof skin antiseptics. Category IC



Hand Hygiene and Aseptic TechniqueHand Hygiene and Aseptic Technique

4.4. Sterile gloves should be worn for the insertion of arterial, central, and Sterile gloves should be worn for the insertion of arterial, central, and midline catheters. midline catheters. Category IACategory IA

5.5. Use new sterile gloves before handling the new catheter when guidewire Use new sterile gloves before handling the new catheter when guidewire exchanges are performed. Category II exchanges are performed. Category II

6.6. Wear either clean or sterile gloves when changing the dressing on Wear either clean or sterile gloves when changing the dressing on intravascular catheters. Category ICintravascular catheters. Category IC


Aderenza all’igiene della maniAderenza all’igiene della mani

5245

66

3021

48

0102030405060708090

100

%

Nurse Nurseaide &student

Midwife Doctors Others Total

Pittet D et al, Ann Intern Med 1999

5952

47 48

36

0102030405060708090

100

%

Pediatrics Medicine Surgery Abs/Gyn ICU

Problema tempoProblema tempo

“Non ci penso”“Non ci penso”

Pittet D et al, Ann Intern Med 1999

Mancanza di struttureMancanza di strutture

6

Adesione (%) =Adesione (%) =Azioni positiveAzioni positive

OpportunitàOpportunità100 =100 =*

125125

218218100 =100 =* 57.3%57.3%

Categoria professioneCategoria professione Tasso di adesione (%)Tasso di adesione (%)

Infermieri UTIInfermieri UTI

Infermieri esterniInfermieri esterni

Infermieri totaliInfermieri totali

Medici UTIMedici UTI

Medici esterniMedici esterni

Medici totaliMedici totali

StudentiStudenti

63.863.8

37.537.5

62.662.6

40.040.0

20.020.0

33.333.3

47.147.1

TotaleTotale 57.357.3

Totale UTITotale UTI 61.261.2

Tipo di indicazioneTipo di indicazione Tasso di adesione (%)Tasso di adesione (%)

Primo contattoPrimo contatto

Prima asepsiPrima asepsi

Dopo fluidoDopo fluido

Dopo contattoDopo contatto

Dopo ambienteDopo ambiente

41.141.1

42.942.9

71.471.4

79.079.0

63.463.4

MarzoMarzo--maggio 2012maggio 2012


Maximal Sterile Barrier Precautions Maximal Sterile Barrier Precautions

1.1. Use maximal sterile barrier precautions, including the use of a cap, mask, Use maximal sterile barrier precautions, including the use of a cap, mask, sterile gown, sterile gloves, and a sterile full body drape, for the insertion of sterile gown, sterile gloves, and a sterile full body drape, for the insertion of CVCs, PICCs, or guidewire exchange. CVCs, PICCs, or guidewire exchange. Category IBCategory IB

2.2. Use a sterile sleeve to protect pulmonary artery catheters during insertion. Use a sterile sleeve to protect pulmonary artery catheters during insertion. Category IBCategory IB


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Skin Preparation Skin Preparation

1.1. Prepare clean skin with an antiseptic (70% alcohol, tincture of iodine, or Prepare clean skin with an antiseptic (70% alcohol, tincture of iodine, or alcoholic chlorhexidine gluconate solution) before peripheral venous alcoholic chlorhexidine gluconate solution) before peripheral venous catheter insertion. catheter insertion. Category IBCategory IB

2.2. Prepare clean skin with a >0.5% chlorhexidine preparation with alcohol Prepare clean skin with a >0.5% chlorhexidine preparation with alcohol before central venous catheter and peripheral arterial catheter insertion and before central venous catheter and peripheral arterial catheter insertion and during dressing changes. If there is a contraindication to chlorhexidine, during dressing changes. If there is a contraindication to chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol can be used as alternatives. tincture of iodine, an iodophor, or 70% alcohol can be used as alternatives. Category IACategory IA

3.3. No comparison has been made between using chlorhexidine preparations No comparison has been made between using chlorhexidine preparations with alcohol and povidonewith alcohol and povidone--iodine in alcohol to prepare clean skin. iodine in alcohol to prepare clean skin. Unresolved issue.Unresolved issue.



Skin Preparation Skin Preparation

4.4. No recommendation can be made for the safety or efficacy of chlorhexidine No recommendation can be made for the safety or efficacy of chlorhexidine in infants aged <2 months. Unresolved issue in infants aged <2 months. Unresolved issue

5.5. Antiseptics should be allowed to dry according to the manufacturer’s Antiseptics should be allowed to dry according to the manufacturer’s recommendation prior to placing the catheter. recommendation prior to placing the catheter. Category IBCategory IB



Catheter Site Dressing Regimens Catheter Site Dressing Regimens

1.1. Use either sterile gauze or sterile, transparent, semipermeable dressing to Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site. cover the catheter site. Category IACategory IA

2.2. If the patient is diaphoretic or if the site is bleeding or oozing, use a gauze If the patient is diaphoretic or if the site is bleeding or oozing, use a gauze dressing until this is resolved. Category II dressing until this is resolved. Category II

3.3. Replace catheter site dressing if the dressing becomes damp, loosened, or Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled. visibly soiled. Category IBCategory IB

4.4. Do not use topical antibiotic ointment or creams on insertion sites, except Do not use topical antibiotic ointment or creams on insertion sites, except for dialysis catheters, because of their potential to promote fungal infections for dialysis catheters, because of their potential to promote fungal infections and antimicrobial resistance. and antimicrobial resistance. Category IBCategory IB


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5.5. Do not submerge the catheter or catheter site in water. Showering should be Do not submerge the catheter or catheter site in water. Showering should be permitted if precautions can be taken to reduce the likelihood of introducing permitted if precautions can be taken to reduce the likelihood of introducing organisms into the catheter (e.g., if the catheter and connecting device are organisms into the catheter (e.g., if the catheter and connecting device are protected with an impermeable cover during the shower). protected with an impermeable cover during the shower). Category IBCategory IB

6.6. Replace dressings used on shortReplace dressings used on short--term CVC sites every 2 days for gauze term CVC sites every 2 days for gauze dressings. Category IIdressings. Category II

7.7. Replace dressings used on shortReplace dressings used on short--term CVC sites at least every 7 days for term CVC sites at least every 7 days for transparent dressings, except in those pediatric patients in which the risk for transparent dressings, except in those pediatric patients in which the risk for dislodging the catheter may outweigh the benefit of changing the dressing. dislodging the catheter may outweigh the benefit of changing the dressing. Category IBCategory IB




8.8. Replace transparent dressings used on tunneled or implanted CVC sites no Replace transparent dressings used on tunneled or implanted CVC sites no more than once per week (unless the dressing is soiled or loose), until the more than once per week (unless the dressing is soiled or loose), until the insertion site has healed. Category II insertion site has healed. Category II

9.9. No recommendation can be made regarding the necessity for any dressing No recommendation can be made regarding the necessity for any dressing on wellon well--healed exit sites of longhealed exit sites of long--term cuffed and tunneled CVCs. term cuffed and tunneled CVCs. Unresolved issue Unresolved issue

10.10. Ensure that catheter site care is compatible with the catheter material. Ensure that catheter site care is compatible with the catheter material. Category IBCategory IB

11.11. Use a sterile sleeve for all pulmonary artery catheters. Use a sterile sleeve for all pulmonary artery catheters. Category IBCategory IB




12.12. Use a chlorhexidineUse a chlorhexidine--impregnated sponge dressing for temporary shortimpregnated sponge dressing for temporary short--term term catheters in patients older than 2 months of age if the CLABSI rate is not catheters in patients older than 2 months of age if the CLABSI rate is not decreasing despite adherence to basic prevention measures, including decreasing despite adherence to basic prevention measures, including education and training, appropriate use of chlorhexidine for skin antisepsis, education and training, appropriate use of chlorhexidine for skin antisepsis, and MSB. and MSB. Category IBCategory IB

13.13. No recommendation is made for other types of chlorhexidine dressings. No recommendation is made for other types of chlorhexidine dressings. Unresolved issueUnresolved issue




14.14. Monitor the catheter sites visually when changing the dressing or by Monitor the catheter sites visually when changing the dressing or by palpation through an intact dressing on a regular basis, depending on the palpation through an intact dressing on a regular basis, depending on the clinical situation of the individual patient. If patients have tenderness at the clinical situation of the individual patient. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations insertion site, fever without obvious source, or other manifestations suggesting local or bloodstream infection, the dressing should be removed suggesting local or bloodstream infection, the dressing should be removed to allow thorough examination of the site. to allow thorough examination of the site. Category IBCategory IB

15.15. Encourage patients to report any changes in their catheter site or any new Encourage patients to report any changes in their catheter site or any new discomfort to their provider. Category IIdiscomfort to their provider. Category II


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Patient Cleansing Patient Cleansing

•• Use a 2% chlorhexidine wash for daily skin cleansing to reduce CRBSI. Use a 2% chlorhexidine wash for daily skin cleansing to reduce CRBSI. Category IICategory II

Catheter Securement Devices Catheter Securement Devices

•• Use a sutureless securement device to reduce the risk of infection for Use a sutureless securement device to reduce the risk of infection for intravascular catheters. Category IIintravascular catheters. Category II



Antimicrobial/Antiseptic Impregnated Catheters and Cuffs Antimicrobial/Antiseptic Impregnated Catheters and Cuffs

•• Use a chlorhexidine/silver sulfadiazine or minocycline/rifampinUse a chlorhexidine/silver sulfadiazine or minocycline/rifampin--impregnated impregnated CVC in patients whose catheter is expected to remain in place >5 days if, after CVC in patients whose catheter is expected to remain in place >5 days if, after successful implementation of a comprehensive strategy to reduce rates of successful implementation of a comprehensive strategy to reduce rates of CLABSI, the CLABSI rate is not decreasing. The comprehensive strategy CLABSI, the CLABSI rate is not decreasing. The comprehensive strategy should include at least the following three components: educating persons who should include at least the following three components: educating persons who insert and maintain catheters, use of maximal sterile barrier precautions, and a insert and maintain catheters, use of maximal sterile barrier precautions, and a >0.5% chlorhexidine preparation with alcohol for skin antisepsis during CVC >0.5% chlorhexidine preparation with alcohol for skin antisepsis during CVC insertion. insertion. Category IACategory IA


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Systemic Antibiotic Prophylaxis Systemic Antibiotic Prophylaxis

•• Do not administer systemic antimicrobial prophylaxis routinely before Do not administer systemic antimicrobial prophylaxis routinely before insertion or during use of an intravascular catheter to prevent catheter insertion or during use of an intravascular catheter to prevent catheter colonization or CRBSI. colonization or CRBSI. Category IBCategory IB

Antibiotic/Antiseptic Ointments Antibiotic/Antiseptic Ointments

•• Use povidone iodine antiseptic ointment or bacitracin/gramicidin/ polymyxin Use povidone iodine antiseptic ointment or bacitracin/gramicidin/ polymyxin B ointment at the hemodialysis catheter exit site after catheter insertion and at B ointment at the hemodialysis catheter exit site after catheter insertion and at the end of each dialysis session only if this ointment does not interact with the the end of each dialysis session only if this ointment does not interact with the material of the hemodialysis catheter per manufacturer’s recommendation. material of the hemodialysis catheter per manufacturer’s recommendation. Category IBCategory IB



Antibiotic Lock Prophylaxis, Antimicrobial Catheter Flush and Catheter Antibiotic Lock Prophylaxis, Antimicrobial Catheter Flush and Catheter Lock ProphylaxisLock Prophylaxis

•• Use prophylactic antimicrobial lock solution in patients with long term Use prophylactic antimicrobial lock solution in patients with long term catheters who have a history of multiple CRBSI despite optimal maximal catheters who have a history of multiple CRBSI despite optimal maximal adherence to aseptic technique. Category II adherence to aseptic technique. Category II

AnticoagulantsAnticoagulants

•• Do not routinely use anticoagulant therapy to reduce the risk of catheterDo not routinely use anticoagulant therapy to reduce the risk of catheter--related infection in general patient populations. Category IIrelated infection in general patient populations. Category II



Replacement of CVCs, Including PICCs and Hemodialysis Catheters Replacement of CVCs, Including PICCs and Hemodialysis Catheters

1.1. Do not routinely replace CVCs, PICCs, hemodialysis catheters, or Do not routinely replace CVCs, PICCs, hemodialysis catheters, or pulmonary artery catheters to prevent catheterpulmonary artery catheters to prevent catheter--related infections. related infections. Category Category IBIB

2.2. Do not remove CVCs or PICCs on the basis of fever alone. Use clinical Do not remove CVCs or PICCs on the basis of fever alone. Use clinical judgment regarding the appropriateness of removing the catheter if judgment regarding the appropriateness of removing the catheter if infection is evidenced elsewhere or if a noninfectious cause of fever is infection is evidenced elsewhere or if a noninfectious cause of fever is suspected. Category II suspected. Category II

3.3. Do not use guidewire exchanges routinely for nonDo not use guidewire exchanges routinely for non--tunneled catheters to tunneled catheters to prevent infection. prevent infection. Category IBCategory IB



Replacement of CVCs, Including PICCs and Hemodialysis Catheters Replacement of CVCs, Including PICCs and Hemodialysis Catheters

4.4. Do not use guidewire exchanges to replace a nonDo not use guidewire exchanges to replace a non--tunneled catheter tunneled catheter suspected of infection. suspected of infection. Category IBCategory IB

5.5. Use a guidewire exchange to replace a malfunctioning nonUse a guidewire exchange to replace a malfunctioning non--tunneled tunneled catheter if no evidence of infection is present. catheter if no evidence of infection is present. Category IBCategory IB

6.6. Use new sterile gloves before handling the new catheter when guidewire Use new sterile gloves before handling the new catheter when guidewire exchanges are performed. Category IIexchanges are performed. Category II


11


Replacement of Administration Sets Replacement of Administration Sets

1.1. In patients not receiving blood, blood products or fat emulsions, replace In patients not receiving blood, blood products or fat emulsions, replace administration sets that are continuously used, including secondary sets and administration sets that are continuously used, including secondary sets and addadd--on devices, no more frequently than at 96on devices, no more frequently than at 96--hour intervals, but at least hour intervals, but at least every 7 days. every 7 days. Category IACategory IA

2.2. No recommendation can be made regarding the frequency for replacing No recommendation can be made regarding the frequency for replacing intermittently used administration sets. Unresolved issue intermittently used administration sets. Unresolved issue

3.3. No recommendation can be made regarding the frequency for replacing No recommendation can be made regarding the frequency for replacing needles to access implantable ports. Unresolved issueneedles to access implantable ports. Unresolved issue



Replacement of Administration Sets Replacement of Administration Sets

4.4. Replace tubing used to administer blood, blood products, or fat emulsions Replace tubing used to administer blood, blood products, or fat emulsions (those combined with amino acids and glucose in a 3(those combined with amino acids and glucose in a 3--inin--1 admixture or 1 admixture or infused separately) within 24 hours of initiating the infusion. infused separately) within 24 hours of initiating the infusion. Category IBCategory IB

5.5. Replace tubing used to administer propofol infusions every 6 or 12 hours, Replace tubing used to administer propofol infusions every 6 or 12 hours, when the vial is changed, per the manufacturer’s recommendation (FDA when the vial is changed, per the manufacturer’s recommendation (FDA website Medwatch). website Medwatch). Category IACategory IA

6.6. No recommendation can be made regarding the length of time a needle used No recommendation can be made regarding the length of time a needle used to access implanted ports can remain in place. Unresolved issueto access implanted ports can remain in place. Unresolved issue



Needleless Intravascular Catheter Systems Needleless Intravascular Catheter Systems

1.1. Change the needleless components at least as frequently as the Change the needleless components at least as frequently as the administration set. There is no benefit to changing these more frequently administration set. There is no benefit to changing these more frequently than every 72 hours. Category II than every 72 hours. Category II

2.2. Change needleless connectors no more frequently than every 72 hours or Change needleless connectors no more frequently than every 72 hours or according to manufacturers’ recommendations for the purpose of reducing according to manufacturers’ recommendations for the purpose of reducing infection rates. Category II infection rates. Category II

3.3. Ensure that all components of the system are compatible to minimize leaks Ensure that all components of the system are compatible to minimize leaks and breaks in the system. Category II and breaks in the system. Category II



Needleless Intravascular Catheter Systems Needleless Intravascular Catheter Systems

4.4. Minimize contamination risk by scrubbing the access port with an Minimize contamination risk by scrubbing the access port with an appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70% appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70% alcohol) and accessing the port only with sterile devices. alcohol) and accessing the port only with sterile devices. Category IACategory IA

5.5. Use a needleless system to access IV tubing. Category ICUse a needleless system to access IV tubing. Category IC

6.6. When needleless systems are used, a split septum valve may be preferred When needleless systems are used, a split septum valve may be preferred over some mechanical valves due to increased risk of infection with the over some mechanical valves due to increased risk of infection with the mechanical valves. Category II mechanical valves. Category II


12


Performance Improvement Performance Improvement

•• Use hospitalUse hospital--specific or collaborativespecific or collaborative--based performance improvement based performance improvement initiatives in which multifaceted strategies are "bundled" together to improve initiatives in which multifaceted strategies are "bundled" together to improve compliance with evidencecompliance with evidence--based recommended practices. based recommended practices. Category IBCategory IB


The interventionThe intervention

Five evidenceFive evidence--based procedures recommended by the CDCbased procedures recommended by the CDC•• identified as having the greatest effect on the rate of CRidentified as having the greatest effect on the rate of CR--BSIBSI•• identified as having the lowest barriers to implementationidentified as having the lowest barriers to implementation

1.1. Hand washingHand washing2.2. Using fullUsing full--barrier precautions during the insertion of CVCbarrier precautions during the insertion of CVC3.3. Cleaning the skin with chlorhexidineCleaning the skin with chlorhexidine4.4. Avoiding the femoral site if possibleAvoiding the femoral site if possible5.5. Removing unnecessary cathetersRemoving unnecessary catheters

The interventionThe intervention

•• Clinicians were educated about practices to control infection Clinicians were educated about practices to control infection and harm resulting from CRand harm resulting from CR--BSIBSI

•• A centralA central--line cart with necessary supplies was createdline cart with necessary supplies was created•• A checklist was used to ensure adherence to infectionA checklist was used to ensure adherence to infection--control control

practicespractices•• Providers were stopped (in nonemergency situations) if these Providers were stopped (in nonemergency situations) if these

practices were not being followedpractices were not being followed•• The removal of catheters was discussed at daily roundsThe removal of catheters was discussed at daily rounds•• The teams received feedback regarding the number and rates of The teams received feedback regarding the number and rates of

CRCR--BSI at monthly and quarterly meetings, respectivelyBSI at monthly and quarterly meetings, respectively

13

ResultsResults -- 66% di CR66% di CR--BSIBSI

Hand hygieneHand hygiene

MaximalMaximalbarrierbarrier

precautionsprecautions

ChlorhexidineChlorhexidineskinskin

antisepsisantisepsis

OptimalOptimalcatheter sitecatheter site

selectionselectionDaily reviewDaily review

of lineof linenecessitynecessity

The central line bundle has five key components:

Grazie!Grazie!Grazie!Grazie!Grazie!Grazie!Grazie!Grazie!

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