© 2009 On the CUSP: STOP BSI Evidence for Best Practices for Placement and Maintenance of Central Lines.

© 2009

On the CUSP: STOP BSI On the CUSP: STOP BSI Evidence for Best Practices for Placement Evidence for Best Practices for Placement

and Maintenance of Central Linesand Maintenance of Central Lines

© 2009

Learning ObjectivesLearning Objectives

• Review evidence for the 5 key best practices for CLABSI prevention

– Remove unnecessary lines– Hand hygiene– Use of maximal barrier precautions– Chlorhexidine for skin antisepsis– Avoid femoral lines

• Review approaches for central line site care

MMWR. 2002;51:RR-10

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Hand Hygiene: The EvidenceHand Hygiene: The Evidence

Clin Infect Dis 1999;29:1287-94

Lancet 2000;356:1307-1312

Since 1977, 7 prospective studies have shown that improvement in hand hygiene significantly decreases a variety of infectious complications

© 2009

What are Maximal Barrier What are Maximal Barrier Precautions?Precautions?

• For Provider:– 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

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Maximal Barrier PrecautionsMaximal Barrier Precautions

© 2009

Maximal Barrier Precautions: Maximal Barrier Precautions: The Evidence The Evidence

Author & Year

Study Design Type of

Catheter

OR for Infection

without MBP

Mermel1991

ProspectiveNon-randomized

Swan-Ganz 2.2 (p=0.03)

Raad 1994

Prospective Randomized

Central 3.3 (p=0.03)

Lee2008

ProspectiveNon-randomized

Central 5.2 (p=0.02)

Am J Med 1991;91(3B):197S-205S Infect Control Hosp Epidemiol 1994;15:231-8Infect Control Hosp Epidemiol 2008; 29:947-950

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Skin Prep: ChlorhexidineSkin Prep: Chlorhexidine

Ann Intern Med. 2002;136:792-801

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What Site is Best?What Site is Best?

• RCT of femoral (N = 145) and subclavian (N = 144) lines in the ICU

• Outcomes– Higher rate of infectious complications in femoral

group: 19.8% vs. 4.5% (p < .001) – Higher rate of thrombotic complications in femoral

group: 21.5% vs. 1.9% (p < .001); complete thrombosis 6% vs 0%

– Similar rates of mechanical complications: 17.3% vs 18.8% (p = NS)

JAMA 2001;286:700-7

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Strategies for Prevention: Strategies for Prevention: 5 Key “Best Practices”5 Key “Best Practices”

• Remove unnecessary lines

• Hand hygiene

• Use of maximal barrier precautions

• Chlorhexidine for skin antisepsis

• Avoid femoral lines

MMWR. 2002;51:RR-10

© 2009

Catheter Site and Hub CareCatheter Site and Hub Care

• Clean catheter hubs & injection ports with 70% alcohol or chlorhexidine/alcohol before accessing

• Change transparent dressings and perform site care with chlorhexidine– Routinely every 5-7 days– If the dressing is loose, soiled or damp

• Replace administration sets not used for blood products or lipids at least every 96 hours

Infect Control Hosp Epidemiol 2008;29:S22-30

© 2009

Action ItemsAction Items

• Assess compliance with best practices for catheter insertion

• Assess compliance with best practices for catheter site care

• Address solutions for barriers to best practice

© 2009

ReferencesReferences

• Guidelines for the Prevention of Intravascular Catheter-Related Infections; August 2002.

– www.journals.uchicago.edu/doi/abs/10.1086/344188

• Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals; October 2008.

– www.journals.uchicago.edu/doi/pdf/10.1086/591059