Central Line Bundle Prevention of Catheter-Related Infections

Central Line Bundle Prevention of Catheter-Related Infections

Self-Paced Learning (SLP) Program

Click here to begin

2 Exit

How to Navigate this Tutorial

Use the MAIN MENU button to return to the menu of tutorial topics.

Use the BACK button to move to the previous slide.

Use the NEXT button to move to the next slide.

Use the EXIT button to close this tutorial. You can always return to finish this SLP at a later time.Exit

3 Exit

Our Assumptions

• You are already familiar with using a mouse to navigate through the various screens.

• Have printed the necessary/additional resources and have them available.

• You have allowed sufficient time to complete this tutorial. You should allow at least 45 minutes.

4 Exit

Instructions

• Read the SLP and answer the Self-Test questions as prompted.

• When finished, record the name of this SLP, the date you completed it, and the number of contact hours on your education profile.

• This Self-paced Learning Packet provides the knowledge component of competencies for the Central Line Bundle .

5 Exit

Questions

• During this SLP, you’ll be prompted to answer questions. You just have to click on the correct answer.

• If you answer incorrectly, you’ll see the following:

Sorry! The answer was “a”

You might want to revisit the [Section Name].

• Just click on the hyperlink and you’ll be redirected back to that topic.

The words “Section Name” are colored and underlined. That’s a

hyperlink. Just move the mouse over it and the

mouse changes to a hand. Click and you’ll be

redirected to that section.

6 Exit

Objectives

• Upon completion of this self-paced, the participant should be able to apply the knowledge towards the reduction and prevention of catheter-related bloodstream infections and central line infections.

• Participant should have knowledge on implementing all five components of care called the “central line bundle”.

• Participant should have knowledge of each of the five components of care in the central line bundle.

7 Exit

Let’s get Started!

Click GO to proceed

8 Exit

Main Menu

• Section 1: Introduction

• Section 2: Pathogenesis

• Section 3: Central Line Bundle

• Section 4: Hand Hygiene

• Section 5: Maximal Barrier Protection

• Section 6: Skin Antisepsis

• Section 7: Site Selection

• Section 8: Daily Review of Central Line Necessity

• Section 9: Impregnated Catheters

• Section 10: Replacement of Catheters

• Section 11: Catheter Site Dressings

9 Exit

Introduction (Section 1)

• Intravascular catheters are indispensable in modern-day medical practice, particularly in intensive care units (ICUs). Although such catheters provide necessary vascular access, their use puts patients at risk for local and systemic infectious complications, including local site infection, CRBSI (Catheter related blood stream infection), septic thrombophlebitis, endocarditis, and other metastatic infections (e.g., lung abscess, brain abscess, osteomyelitis, and endophthalmitis).

• Peripheral venous catheters are the devices most frequently used for vascular access. Although the incidence of local or bloodstream infections (BSIs) associated with peripheral venous catheters is usually low, serious infectious complications produce considerable annual morbidity because of the frequency with which such catheters are used. However, the majority of serious catheter-related infections are associated with central venous catheters (CVCs).

• A total of 250,000 cases of CVC-associated BSIs (CRBSI)have been estimated to occur annually. In this case, attributable mortality is an estimated 12%--25% for each infection, and the marginal cost to the health-care system is $25,000 per episode.

• Types of organisms that most commonly cause hospital-acquired BSIs are coagulase-negative staphylococci, followed by Staphylococcus aureus, enterococci, Candida spp and gram-negative bacilli.

10 Exit

Pathogenesis (Section 2)

• Migration of skin organisms at the insertion site into the cutaneous catheter tract with colonization of the catheter tip is the most common route of infection for peripherally inserted, short-term catheters.

• The adherence properties of a given microorganism also are important in the pathogenesis of catheter-related infection. For example, S. aureus can adhere to host proteins (e.g., fibronectin) commonly present on catheters.

• Coagulase-negative staphylococci adhere to polymer surfaces more readily than do other pathogens. Certain strains produce an extracellular polysaccharide often referred to as "slime“. In the presence of catheters, this slime potentiates the pathogenicity of coagulase-negative staphylococci by allowing them to withstand host defense mechanisms (e.g., acting as a barrier to engulfment and killing by polymorphonuclear leukocytes) or by making them less susceptible to antimicrobial agents (e.g., forming a matrix that binds antimicrobials before their contact with the organism cell wall) .

• Candida spp., in the presence of glucose-containing fluids, might produce slime similar to that of their bacterial counterparts, potentially explaining the increased proportion of BSIs caused by fungal pathogens among patients receiving parenteral nutrition fluids.

11 Exit

Central Line Bundle(Section 3)

• Central Line Bundle: Care bundles, in general, are groupings of best practices with respect to a disease process that individually improve care, but when applied together result in substantially greater improvement. The Central Line (CL) bundle is a group of evidence –based interventions for patients with intravascular central catheters that, when implemented together, result in better outcomes than when implemented individually.

• Five Key Components:

1. Hand Hygiene

2. Maximal barrier precautions

3. Chlorhexidine skin antisepsis

4. Optimal catheter site selection, with subclavian vein as the preferred site for non-tunneled catheters

5. Daily review of line necessity, with prompt removal of unnecessary lines

• Compliance: Compliance with the central line bundle is measured by assessing completion of each item. A composite compliance is calculated based on the number of bundle components implemented per line placed divided by the total number of bundle components. The approach is most successful when all components are executed together.

12 Exit

Hand Hygiene (Section 4)

• Hand Hygiene and Aseptic Technique

– For short peripheral catheters, good hand hygiene before catheter insertion or maintenance, combined with proper aseptic technique during catheter manipulation, provides protection against infection. Gloves are required by the Occupational Safety and Health Administration as standard precautions for the prevention of bloodborne pathogen exposure. Use of gloves does not obviate the need for hand hygiene.

– Observe proper hand-hygiene procedures either by washing hands with conventional antiseptic-containing soap and water or with waterless alcohol-based gels or foams.

– Appropriate times for hand hygiene include:

• Before and after palpating insertion sites

• Before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter

• When hands are obviously soiled or contaminated

• Before and after invasive procedures

• Between patients

• Before donning and after removing gloves

• After using the bathroom

13 Exit

Maximal Barrier Precaution(Section 5)

• Aseptic Technique during catheter insertion: Maximal sterile barrier precautions during the insertion of CVCs substantially reduces the incidence of Catheter Related Blood Stream Infections (CRBSI) and local site infections. For operator placing the central line and for those assisting in the procedure, maximal barrier precautions means strict compliance with hand hygiene and wearing:

• cap – should cover all hair

• mask – should cover nose and mouth tightly

• sterile gown

• sterile gloves

– Patient must be covered head to toe with a large sterile full body drape, with a small opening for the site of insertion

• When adherence to aseptic technique cannot be ensured (i.e., when catheters are inserted during a medical emergency), replace all catheters as soon as possible and not to exceed 48 hours.

14 Exit

Skin Antisepsis (Section 6)

• Skin Antisepsis – Chlorhexidine gluconate (CHG): preparation of central venous and arterial sites with

a 2% chlorhexidine gluconate (CHG) has been proven to provide better skin antisepsis than other antiseptic agents such as povidone-iodine solutions.

– Cutaneous antisepsis

1. Prepare skin with antiseptic/detergent chlorhexidine 2% in 70% alcohol

2. Pinch wings on the chlorhexidine applicator to break open the ampule. Hold the applicator down to allow the solution to saturate the pad.

3. Press sponge against skin, apply chlorhexidine solution using a back-and-forth friction scrub for at least 30 seconds. Do not wipe or blot

4. Allow antiseptic solution time to dry completely before puncturing the site (2 minutes)

• Do not routinely use arterial or venous cutdown procedures as a method to insert catheters.

• Providone-iodine or 70% alcohol may be used with chlorhexidine sensitive patients

• Chlorhexidine is contraindicated for procedures involving the meninges and on children >2 months.

15 Exit

Site Selection(Section 7)

• Optimal Site Selection– Subclavian vein site, when not contraindicated, is the preferred site of non-tunneled catheters in

adults to reduce the risk for infection.

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

– Phlebitis has long been recognized as a risk for infection. For adults, lower extremity insertion sites are associated with a higher risk for infection than are upper extremity sites. In addition, hand veins have a lower risk for phlebitis than do veins on the wrist or upper arm.

– The density of skin flora at the catheter insertion site is a major risk factor for CRBSI. Catheters inserted into an internal jugular vein have been associated with higher risk for infection than those inserted into a subclavian.

– Femoral catheters have been demonstrated to have relatively high colonization rates when used in adults. Femoral catheters should be avoided, when possible, because they are associated with a higher risk for deep venous thrombosis than are internal jugular or subclavian catheters and because of a presumption that such catheters are more likely to become infected.

16 Exit

Daily Review of Central Line Necessity(Section 8)

• Prompt removal of unnecessary lines: Daily review of central line necessity will prevent unnecessary delays in removing lines that are no longer needed. Many times, central lines remain in place simply because they provide reliable access and because personnel have not considered removing them. However, it is clear that the risk of infection increased over time as the line remains in place and that the risk of infection decreases if the line is removed.

• Daily review of line necessity should be included as part of multi-disciplinary rounds.

• Assessment for removal of central lines should be included as part of the patient’s daily goal sheets

• Date and time of line placement should be recorded for record keeping purposes and evaluation by staff to aid in decision making.

17 Exit

Impregnated Catheters(Section 9)

• Antimicrobial/Antiseptic Impregnated Catheters and Cuffs: Certain catheters and cuffs that are coated or impregnated with antimicrobial or antiseptic agents can decrease the risk for CRBSI and potentially decrease hospital costs associated with treating CRBSIs, despite the additional acquisition cost of an antimicrobial/antiseptic impregnated catheter.

• Chlorhexidine/Silver sulfadiazine: Catheters coated with chlorhexidine/silver sulfadiazine only on the external luminal surface have been studied as a means to reduce CRBSI. The benefit for the patients who receive these catheters will be realized within the first 14 days.

• IV injection ports:

– Clean injection ports with 70% alcohol or an iodophor before accessing the system.

– Cap all stopcocks when not in use.

18 Exit

Replacement of Catheters(Section 10)

• Selection and replacement of intravascular catheters

– Replace all catheters inserted during a medical emergency or when adherence to aseptic technique cannot be ensured.

– Do not routinely replace CVCs, PICCs, hemodialysis catheters, or pulmonary artery catheters to prevent catheter-related infections.

– Use clinical judgment to determine when to replace a catheter that could be a source of infection (e.g., do not routinely replace catheters in patients whose only indication of infection is fever). Do not routinely replace venous catheters in patients who are bacteremic or fungemic if the source of infection is unlikely to be the catheter

– Select the catheter, insertion technique, and insertion site with the lowest risk for complications (infectious and noninfectious) for the anticipated type and duration of IV therapy

19 Exit

Catheter-Site Dressings(Section 11)

• Catheter-site dressing regimens

• Replace the catheter-site dressing when it becomes damp, loosened, soiled or when inspection of the site is necessary

• Use either sterile gauze or sterile transparent, semi-permeable dressing to cover the catheter site

• Change dressings at least weekly for adult and adolescent patients depending on the circumstances of the individual patient

• Do not use topical antibiotic ointment or creams on insertion sites (except when using dialysis catheters) because of their potential to promote fungal infections and antimicrobial resistance

20 Exit

Test Question #1

Click on the line which is correct

1. A total of 250,000 cases of CVC-associated BSIs (CRBSI) have been estimated to occur annually. What is the estimated attributable mortality for each infection, and the marginal cost to the health-care system per episode? completion of the entire composite bundle

a. 12-25% per infection and $25,000 per episode

b. 25-35% per infection and $25,000 per episode

c. 12-25% per infection and $50,000 per episode

24 Exit

Test Question #2

Click on the line which is correct

2. Micro-organisms that can produce an extracellular polysaccharide often referred to as “slime” that can adhere to the polymer surface of catheters is :

a. coagulase negative staphylococci

b. Staphylococcus aureus

c. Escherichia coli

28 Exit

Test Question #3

Click on the line which is correct

Maximal barrier precautions for the for operator placing the central line and for those assisting in the procedure include:

a. cap (should cover all hair), mask (should cover nose and mouth tightly), sterile gloves

b. cap (should cover all hair), mask (should cover nose and mouth tightly), sterile gown

c. cap (should cover all hair), mask (should cover nose and mouth tightly), sterile gown, sterile gloves

32 Exit

Test Question #4

Click on the line which is correct

Five key components of the Central Line Bundle are

a. Hand Hygiene, gowns, chlorhexidine skin antisepsis, optimal catheter site, and daily review of line necessity

b. Hand Hygiene, maximal barrier precautions, chlorhexidine skin antisepsis, optimal catheter site, and daily review of line necessity

c. Hand Hygiene, maximal barrier precautions, chlorhexidine skin antisepsis, jugular vein site, and daily review of line necessity

36 Exit

Test Question #5

Click on the line which is correct

When having a central line inserted, the patient must be covered head to toe with:

a. a large sterile full body drape, with a small opening for the site of insertion

b. a small sterile drape, with a small opening for the site of insertion

c. a sterile half drape

40 Exit

Test Question #6

Click on the line which is correct

Prior to inserting a central venous or arterial catheter, the best product to antiseptically clean the site is:

a. Providone-iodine

b. 2% chlorhexidine gluconate (CHG)

c. 70% alcohol

41 Exit

Correct! The answer is

b

Answer Question #6

Prior to inserting a central venous or arterial catheter, the best product to antiseptically clean the site is:

a. Providone-iodine

b. 2% chlorhexidine gluconate (CHG)

c. 70% alcohol

44 Exit

Test Question #7

Click on the line which is correct

The preferred site of non-tunneled catheters in adults to reduce the risk for infection is:

a. Femoral vein

b. Internal jugular

c. Sub-clavian

48 Exit

Test Question #8

Click on the line which is correct

In order to prevent unnecessary delays in removing lines that are no longer needed and reduce the risk of infection, central lines should be reviewed for necessity :

a. Daily

b. Weekly

c. At shift change

52 Exit

Test Question #9

Click on the line which is correct

Compliance with the central line bundle is measured by assessing:

a. completion of each item

b. a.  completion of the number of bundle components implemented per line placed divided by the total number of bundle components

c. completion of each item and completion of the number of bundle components implemented per line placed divided by the total number of bundle components

56 Exit

Test Question #10

Click on the line which is correct

Catheters inserted during a medical emergency or when adherence to aseptic technique cannot be ensured should be:

a. replaced when convenient

b. replaced as soon as possible and not to exceed 48 hours

c. removed when no longer needed

60 Exit

Additional Resources

References:

Information for this SLP is from

– Guidelines for the Prevention of Intravascular Catheter-Related Infections, CDC MMWR, April 9, 2002, 51(RR10);1-26

– Institute for Healthcare Institute 100,000 Lives campaign www.ihi.org

61 Exit

Thank you!

Give us your feedback

• We hope you have found this tutorial useful.

62 Exit

Thank you.

Click the Exit button to exit this tutorial.