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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

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aap things that work prevention of catheter related bloodstream infections

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

introduction
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
the problem
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
strategies for prevention adult experience
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

what is pediatric best practice
What Is Pediatric Best Practice?
  • No studies published in pediatric literature
  • Assume adult data holds for children
    • Exception is optimal site of line insertion
bsi intervention
BSI Intervention
  • Education on best practices
  • “Line cart”
  • Nursing check list for CL insertion
  • Empowerment of nurses to stop procedures if best practices breached
hand hygiene the data
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

alcohol based hand cleansers
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

hand hygiene be a role model
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

hand hygiene best practice
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
do i really need maximal barrier precautions
Do I Really Need Maximal Barrier Precautions ?
  • Am J Med 1991;91(3B):197S-205S
    • Infect Control Hosp Epidemiol 1994;15:231-8
what are maximal barrier precautions
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
who needs to be dressed in mbp
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
skin prep
Skin Prep
  • Chlorhexidine 2% is more effective than povidone iodine (Betadine) because it dries quickly and has longer residual action
skin prep17
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!
dressing the line
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
maintaining the line
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
what site is best
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
what site is best21
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)
what site is best22
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

what site is best23
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
what site is best for children
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
summary of best practices
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
bsi intervention26
BSI Intervention
  • Education on best practices
  • “Line cart”
  • Nursing check list for CL insertion
  • Empowerment of nurses to stop procedures if best practices breeched
bsi intervention29
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
lessons learned
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