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REDUCING CENTRAL VENOUS CATHETER RELATED BLOOD STREAM INFECTIONS

REDUCING CENTRAL VENOUS CATHETER RELATED BLOOD STREAM INFECTIONS. Presented by: Stephen Jaime, RN Juanita Martinez, RN Ashley Valencia, RN Jennifer Valenzuela, RN. CATHETER RELATED BLOOD STREAM INFECTIONS (CRBSI).

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REDUCING CENTRAL VENOUS CATHETER RELATED BLOOD STREAM INFECTIONS

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  1. REDUCING CENTRAL VENOUS CATHETER RELATED BLOOD STREAM INFECTIONS Presented by: Stephen Jaime, RN Juanita Martinez, RN Ashley Valencia, RN Jennifer Valenzuela, RN

  2. CATHETER RELATED BLOOD STREAM INFECTIONS(CRBSI) • Morbidity: 250,000 cases of central line associated bloodstream infections occur in US hospitals annually (CDC 2003). • Mortality: Approximately 30,000 to 62,000 patients who get CRBSI die (CDC 2003). • Reducing catheter related blood stream infections is a 2008 National Patient Safety Goal.

  3. CRBSIPORTS OF ENTRY

  4. CAUSES ofHUBCOLONIZATION • Skin contamination • Inadequate hand hygiene • Failure to use aseptic technique • Frequent opening and manipulation • Failure to change needle-free system

  5. Needle-Free Access Devices Split Septum Negative Pressure Neutral Displacement Positive Pressure

  6. PICO • Does the use of specific needle-free connectors decrease the incidence of central venous catheter related blood stream infections (CRBSI) in adult patients?

  7. PICO • Population: Adult patients with CVC • Intervention: Standardize the use of neutral displacement needle free connectors in all units • Current Practice: The use of positive pressure, negative pressure, and neutral displacement needle-free connectors • Outcome: Decrease CVC blood stream infections

  8. Staff Query • In October 2008, clinical staff at ECRMC were unaware of the role that a needle-free connector has in reducing CRBSI • Clinical staff were unaware of differences between needle-free connectors

  9. REVIEW OF LITERATURE Databases Used: Key Search Terms: • CINAHL • EBSCO Host • Cochrane Library • CDC • Google Scholar • Medline Plus • Web MD • Central venous catheters • Blood stream infections • Negative and positive pressure needle-free valves • Mechanical valves • CRBSI • Hub colonization • Needless IV access devices

  10. BODY OFEVIDENCE Out of 22 articles, 10 articles were relevant to the clinical issue

  11. EVIDENCEHIERARCHY • Systems: 1 • Synopses of Synthesis: 9 • Synthesis: 1 • Synopsis of Single Studies: 8 • Single Studies: 3

  12. RESEARCH ANALYSIS • The most common cause of tip and hub colonization is frequent opening & manipulation • Improper maintenance techniques contribute to colonization • In a randomized study of 352 heart surgery patients, CVC’s with neutral displacement were less likely to have hub colonization *p value = 0.0001 (Bouza, 2003) • This is statistically significant.

  13. Research Continued • Split septum • May have increased occlusions • Negative pressure at disconnect • Negative pressure needle-free connectors • Allow blood to infiltrate hub • May increase BSI • Positive pressure needle-free connectors • May increase BSI • May be linked to improper technique of clinical user, and mechanism failure

  14. RESEARCH CONTINUED • Neutral displacement needle-free connectors • Inhibit blood regression into hub • Are associated with decreased BSI rates • In one particular study, Johns Hopkins Hospital switched to positive pressure valves from neutral displacement and saw increased infection rates. • Rates per 1,000 catheter days increased from 1.50 with neutral displacement to 2.40 with positive pressure in the ICU p = 0.05 (Jarvis, 2006) • Johns Hopkins returned to neutral displacement

  15. Research Conclusions • Neutral displacement needle-free connectors may reduce BSI. • Conflicting research on positive pressure needle-free connectors exists • Further research needs to be conducted on the issue

  16. CURRENT PRACTICE(Fall 2008) • Neutral displacement needle-free connectors are not currently used on CVCs at ECRMC. • No specific policy exists R/T changing connectors. • Multiple connector types are used throughout the hospital

  17. INTERVENTIONS • Standardize needle-free neutral displacement connectors throughout ECRMC. • Institute a connector change policy per manufacturer’s recommendation. • Implement proper disinfection technique every time port is accessed. • Educate staff on maintaining line sterility. • Using sterile caps when IV tubing is disconnected. • Include the infection control specialist for standardization.

  18. CHANGE THEORY • Stage 1: FROZEN • Motivation to change • Stage 2: UNFROZEN • Change what needs to be changed • Stage 3: REFREEZING • Making a permanent change Lewin/ Schein’s Change Theory

  19. Stake holders Management: Clinical: • Board of Trustees • CEO • Chief Nursing Officer • Department Manager • Case Manager • Clinical Manager • Clinical Educator • Charge Nurses • Clinical Staff • Infection Control

  20. Swot Analysis Strength Weakness • May decrease BSI • Easy to implement • Low cost • Further research needed • Conflicting research R/T positive pressure valves. Opportunities Threats • 2009 Safety Goal • Better patient outcomes • Implementation ease • Low cost change • Hospital Savings • Resistance to change • Knowledge deficit

  21. COST/BENEFITS • Blood stream infections extend hospital stay with a cost of $33,000 to $35,000 per patient. • Medi-care/ Medi-cal will no longer reimburse for hospital acquired infections. • Saline flush instead of heparin flushes are required for neutral displacement connectors. • Specific type of neutral displacement connectors are as low as $1.07 each (Hospital Materials Management, 2008)

  22. TIME LINE

  23. References • 1. David, V. E. A. (2008, October 14). Cost-Effectiveness of antiseptic-Impregnated central venous catheters for the prevention of catheter-Related bloodstream infection. American Medical Association, 282(6). • 2. E, B. E. A. (2003, March 1). A neeleless closed system device (Clave) protects from intravascular catheter tip and hub colonization: A prospective randomized study. Journal of Hospital Infection, 26(2), 54;279-287. Retrieved from www.sciencedirect.com. • 3. J. R. Gowardaman Et Al. (1998, February 1). Central venous catheter-related bloodstream infections: An anaylsis of incidence and risk factors in a cohort of 400 patients [Electronic version]. Intensive Care Med, 24, 1034-1039. . • 4. Jeffrey, B. E. A. (2007, July 1). Prevention of intravascular catheter-related infections. Retrieved from Up to Date: www.uptodate.com/online/content/topic/.do?topicKey=hosp_inf/7730&view=print. • 5. Juan, Y. E. A. (2003). Resistance to the Migraton of Microorganisms of a Needle-Free Disinectable Connector, 31(8). • 6. Meredit Desmond. (2006, February 3). CDC recommendations to rduce central line infecitions. American Family Journal, 73(3), 546-547. • 7. Mermel, L. A. (2001, April 1). New technologies to prevent intravascular catheter-Related blood stream infections [Electronic version]. Emerging Infectious Diseases, 7(2), 197-199. . • 8. Maki, D. M., Stolz, S. M., Wheeler, S. R., & Mermel, L. D. (1997). Prevention of Central • Venous Catheter-Related Bloodstream Infection by Use of an Antiseptic-Impregnated Catheter. Annals of Internal Medicine, 257-266. • 9. Pagani, J. E. (2008, April 16). Management of Catheter-related Infection. Retrieved November 7, 2008, from Medscape: http://www.medscape.com/viewarticle/571265 • 10. Sadoyama, G. F. (2003). Comparison Between the Jugular and Subclavian Vein as Insertion Site of Central Venous Catheters: Microbiological Aspects and Risk Factors for Colonization and Infection. The Brazilian Journal of Infectious Diseases , 142-148. • 11. Sadoyma, G. F. (2006). Central Venous Catheter-Related Bloodstream Infection Caused by Staphylococcus aureus: Mircrobiology and Risk Factors. The Brazilian Journal of Infectious Diseases , 100-106. • 12. Safdar, N. M. (2004). The Pathogenesis of catheter-related bloodstream infection with noncuffed short-term central venous catheters. Intensive Care Med , 62-67.

  24. References Continued 13. Yebenes, J. M., Delgado, M. M., Sauca, G. M., Serra-Prat, M. M., Solsona, M. M., Almirall, J. M., et al. (2008). Efficacy of three different valve systems of needle-free closed connectors in avoiding access of microorganisms to endovascular catheters afte incorrect handling. Crit Care Med , 2558-2561. 14. Yebenes, J. P.-P. (2003). Prevention of catheter-related bloodstream infection in critically ill patients using a disinfectable, needle-free connector: A randomized controlled trial. AJIC, 291-295. 15. Akmal, A., Hasan, M., & Mariam, A. (2007). The Incidence of Complications of Central Venous Catheters at an Intensive Care Unit. Annals of Thoracic Medicine, 2, 61-63. 16. Maragakis, L., Bradley, K., Song, X., Beers, C., Miller, M., Cosgrove, S., & Perl, T. (2006). Increased Catheter-Related Bloodstream Infection Rates After the Introduction of a New mechanical Valve Intravenous Access Port. Infection Control and hospital Epidemiology, 27, 67-70. 17. Marschall, J., Mermel, L., Classen, D., & Arias, M. (2008). Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care hospitals. Infection Control and Hospital Epidemiology, 29, 522-530. 18. Shannon, R., Frndak, D., Grunden, N., & Lloyd, J. (2006). Using Real-Time Problem Solving to Eliminate Central Line Infections. Journal on Quality and Patient Safety, 32, 479-487. 19. Shorr, A., Humphreys, C., & Helman, D. (2003). New Choices for Central Venous Catheters. Chest Journal, 124, 275-284. 20. Templeton, A., Schegel, M., Fleisch, F., Rettenmund, S., Henz, S., & Eich, G. (2008). Multilumen Central Venous Catheters Increase Risk for Catheter-Related Bloodstream Infection: Prospective Surveillance Study. Infection, 36, 322-327. 21. Yebenes, J., Martinez, R., Serra-Prat, M., Sauca, G., Capdevila, J., Balanzo, X., & Palomar, M. (2003). Resistance to the Migration of microorganisms of a Needle-free Disinfectable Connector. American Journal of Infection Control, 31, 462-4.

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