Adam Low - CLABSI Best Practice and Bundles

18/10/2016
3M Health Care Academy

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CLABSI: Best Practices and Bundles

Adam Low Kok Seng
3M Health
Sept
2016 Care Academy
SM
3M 2015. All Rights Reserved
CLABSI AND CRBSI DEFINITION

CLABSI
CRBSI
Primary bloodstream infection in the

presence of a central line at the time
of, or within 48 hours before, onset of
the infection, with no other source of
infection evident other than the
catheter.
A rigorous clinical definition that is

used in diagnosing and treating
patients
CLABSI is a term used only for

surveillance purposes to identify
BSIs that occur in the population at
risk (patients with central lines).
Requires specific laboratory testing to

identify the catheter as the source of
the bloodstream infection, such as
culturing the catheter tip or finding
positive culture growth
www.inicc.org

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Scope of the problem

Approximately 90% of catheter related blood stream infections
(CRBSI) occur with central venous catheters.
Between 4% and 20% of patients with central venous catheters die
because of an infection (CRBSI).
Patients who dont die from CRBSI with a central venous catheter
remain hospitalized for approximately 7 days longer than expected.

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EXTRALUMINAL
CATHETER TRACT CONTAMINATION

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WWW.INICC.ORG
Peripheral catheter with no sterile
catheter dressing
Three ways stop cock

(open connector)
Central line with no sterile dressing
Multiple use vials with inserted

needles
CL insertion without maximal barriers
Single use vials, used multiple

times
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Are we doing it right at the bedside?
CENTRAL VENOUS CARE

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WHAT GUIDELINES SAY?

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Best Practices are defined as:
Strategies
Activities
Approach
Shown through research and evaluation to be effective / efficient in
reducing infection.
Also known as evidence-based practice
Agency for Healthcare Research and Quality

http://www.ahrq.gov
Infusion Nurses Society
http://ins1.org/standards/
INS
Centers for Disease Control
http://www.cdc.gov/ncidod/dhqp/gl_intravascular.html
Institute for Healthcare Improvement (IHI)
http://www.ihi.org/ihi

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2016 publications
5 Million
Lives
2011 publications
Procedure for Insertion of a

Central catheters and Accessing
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National infection prevention guidelines

3 core documents that compliment each other.
Bring together academia, clinical practice and government agenda
RCN Infusion Standards
EPIC2 Evidence Based Guidelines (now EPIC3)
Saving Lives combined bundle and audit
Organisations responsible for reviewing standards of care in hospitals ensure implementation of

the guidelines and adherence to the content through audit.

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Insertion and post insertion care

Audit
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Catheter Line Associated Blood Stream Infection

(CLABSI) is defined as:
CLABSI occurs in a patient who has a
centrally or peripherally inserted
central line
has had a central line removed within
48 hrs of blood stream infection
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Why Focus on CLABSI?

Why Now??
?
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CATHETER RELATED BLOOD STREAM INFECTION

(CRBSI) IMPACT
COST TO THE PATIENT
COST TO THE FACILITY
14,000 28,000 patient deaths

annually attributed to CRBSIs.
$34,508 - $56,000 estimated

cost per bloodstream infection
Extended hospital stays 18 days
Since October 2008, hospitals

are not reimbursed from insurance
for CRBSIs and certain hospital
acquired conditions that were
present on admission.
Extended days in ICU

Financial impact on families
Increased health complications
Decreased ability to work or
perform daily activities
1.
2.
3.
Maki DG. Mermel LA. Infections due to Infusion Therapy. Taken from Bennett JV, Brachman PS, eds. Hospital Infections, Philadelphia, PA:Lippincott-raven:1998;689-724
Muphy
Hollenbeak
CS, Dispelling the myths: the true cost of healthcare-associated infections. Healthcare Financial Manage, March 2007.
3MD,Whitting
HealthJ, Care
Academy
Rello J, Ochagavia A Sabanes E, at al. Evaluation of outcome of intravenous catheter related infections in critically ill patients. Am J Respir Crt Care Med. 2000;162:1027-30
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12-25% Mortality
3.4 CRBSI Rate per
1000 catheter days
250-300,000 CRBSI
each year / US
Estimated 2.1 million

receive CVCs at ICU/
US per year
Australia more than 3,500 intravenous BSIs occur annually
Estimated 7 million
CVC / US per year
CRBSI occurring at a rate of 23 per 1,000 catheters.

A directly attributable mortality for all intravenous BSIs is
reported as 12 per cent3
Estimated 160 million

PVL / US per year

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RISK FACTORS
Patient Condition
CMS Changes
Site Selection
Catheter Selection
Mandatory
Reporting
Clinician Education

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Treatment with
Antibiotics or
Steroids
Underlying Illness
Surgery
Stay in ICU
Immunocompromised
Prolonged (>5days)
CVC Placement
Transplant
Cancer
CVC Placement: Femoral

or IJ
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Dialysis
Hemodialysis
WHICH?
CVC insertion site associated with lower
infection rates:
CVC insertion site associated with highest

infection rates:
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Subclavian Vein
Femoral vein
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Which type of catheters have been associated with fewer bloodstream infections?
Mean CRBSI
per 1000 Catheter Days
Catheter Type
Arterial
Non-Cuffed
CVC
2.9
2.8
2.3
Cuffed
PIV
PICC

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1.1
0.6
0.4
Which education and/or care delivery structures have been shown to

reduce the risk of developing CRBSI?
Use of infusion therapy teams

for catheter insertion?
Use of infusion therapy teams for catheter maintenance?
WHY?
Involvement of clinical staff in more educational

programs?

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Well-informed
and educated nurses form a strong front line of

defense against vascular site infections
1A

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The first Specialist nursing team placing PICC

established in Sept 2012
2013: Study conducted for PICC and Midline
Catheter
Pt
Category
Duration
catheter
insertion
Infection
Rate
Vein
Thrombosis
Catheter
Occlusion
Catheter
Displacement
PICC 167
lines
Oncology
91 days
0.3/1000
days
0.4/1000 days
0.4/1000 days
0.33/1000
days
14 days
1.4/1000days 5.2/1000 days
2.6/1000 days
2.2/1000 days
Midline 162 General

lines
wards

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SURVEILLANCE
ZERO CLABSI publication
Routine checks:
Check for general signs of infection.
Check condition of dressing/plan dressing change.
Look for extraluminal and intraluminal sources.
Review nursing practice.
Offer patient a feedback opportunity.
If suspected line infection:.
Peripheral and central cultures.
Time to positivity. Time-to-positivity (TTP) is defined

as the length of time from the beginning of culture
incubation to the detection of bacterial growth by an
Jackson, A. and Cooper, S. (2012) Zero central-
automated system
line infections in a 550-bedded district general

hospital. British Journal of Nursing. 21(14),
supplement p.S24 S28.
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Multilumen? Krause et al (2012) 17% of CRBSI

originating from an alternative lumen to the one
suspected Tip (if removed).
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What are Central Line Bundles?

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1B

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HAND HYGIENE
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HAND HYGIENE
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MAXIMAL BARRIER PRECAUTION
1B
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Risk Factors for IV Catheter-Related Infections
Inadequate barriers precautions

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1B

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Transparent Flat Film Dressing to 3M Tegaderm IV Advanced Dressing
Transparent Film Dressing

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3M Tegaderm I.V Advanced 1685

Dressing
3M Tegaderm CHG 1657 Dressing

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3M Tegaderm CHG Chlorhexidine Gluconate IV Securement

Dressings
Proven to be as effective as, or better at, reducing skin flora on healthy volunteers
for up to 10 days
Proven to be more effective at preventing re-growth of Skin Flora on healthy volunteers at 7 days
Transparent, allowing continuous visualization of insertion site.
Transparency Enables Continuous Visual Inspection
Integrated design of dressing and CHG gel pad reduces application steps and minimizes potential for
application error.
As easy-to-use and easy-to-train as a Tegadermdressing
Large surface area to provide coverage of Catheter and suture sites
Absorbs Fluids (3x Blood & 8x Saline)

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DRESSING COMPARISON

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Protects Better
Tegaderm CHG Dressing is effective against organisms including those
most commonly associated with CRBSIs.*
Broad-spectrum Antimicrobial Activity

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*3M Tegaderm CHG Dressings have not been studied in a randomized clinical study as to their effectiveness in preventing CRBSIs.
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3M Tegaderm CHG Dressing

Reduces Skin Flora
Shown to be better than BIOPATCH at reducing skin flora on healthy adult
subjects for up to 10 days.
A Novel Integrated Chlorhexidine-impregnated Transparent Dressing for
Prevention of Vascular Catheter-related Bloodstream Infection: A
Prospective Comparative Study in Healthy Subjects
Suppresses Re-growth
Proven more effective than BIOPATCH at preventing re-growth of skin flora on
healthy adult subjects at
day 7.
A Novel Integrated Chlorhexidine-impregnated Transparent Dressing for
Prevention of Vascular Catheter-related Bloodstream Infection: A
Prospective Comparative Study in Healthy Subjects
Tegaderm CHG Dressings maintained significantly lower counts than

BIOPATCH or control dressings
after 7 days on healthy adult subjects.
Suppression of Re-growth of Normal Skin Flora under Chlorhexidine
Gluconate Dressings Applied to CHG Prepped Skin
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IV Hub Care Infection Prevention

Bacteria coated
hub
Scrubbed hub
15 Seconds can Save a Life!

Just Do It, Scrub that Hub!
Make a difference every time!
15 second hub scrub & let it dry!
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WHY IS IT IMPORTANT
TO ALLOW
SKIN PREP DRYING

FOR
2 MINUTES?
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ADHESIVE TRAUMA
Wet Prep Under Dressing
Can be caused by inadequate drying time
Adhesive Trauma Protection

Use to protect skin from adhesive damage
Adhesive Trauma

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Infusion sites
SKIN IRRITATION
Tension Blister
Can be caused by
mechanical force or
chemical irritant
Skin Maceration
Can be caused by
not allowing preps or other products to
dry completely

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DAILY REVIEW OF LINE NECESSITY

Routine Observation and Monitoring
1B
INS
Central
Line
Bundle
Monitor catheter sites on a regular basis visibly or by palpation as per

needs of individual patients
Nursing documentation shall contain complete information regarding
infusion therapy and vascular access in the patients medical record
Daily Review Sites for Line Necessity
5 Million
Lives

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Catheter Site Dressing Regimens (CDC Guidelines

IV Catheter Related Infections 2011)
1B
1B
II

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Monitor the catheter sites visually when changing the

dressing or by palpation through an intact dressing on a regular basis.
If patients have tenderness at the insertion site, fever without obvious

source, or other manifestations suggesting local or bloodstream infection,
the dressing should be removed to allow thorough examination of the site
Encourage patients to report any changes in their catheter site or any new
discomfort to their provider
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18/10/2016
Thank you

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18/10/2016

3M Health Care Academy

CLABSI: Best Practices and Bundles

3M 2015. All Rights Reserved

CLABSI AND CRBSI DEFINITION

Primary bloodstream infection in the

A rigorous clinical definition that is

CLABSI is a term used only for

Requires specific laboratory testing to

3M Health Care Academy

3M 2015. All Rights Reserved

3M Health Care Academy

3M 2015. All Rights Reserved

3M Health Care Academy

3M 2015. All Rights Reserved

3M Health Care Academy

3M 2015. All Rights Reserved

Scope of the problem

3M Health Care Academy

3M 2015. All Rights Reserved

3M Health Care Academy

3M 2015. All Rights Reserved

CATHETER TRACT CONTAMINATION

3M Health Care Academy

3M 2015. All Rights Reserved

Three ways stop cock

Central line with no sterile dressing

Multiple use vials with inserted

CL insertion without maximal barriers

Single use vials, used multiple

3M Health Care Academy

3M Health Care Academy

3M 2015. All Rights Reserved

3M Health Care Academy

Are we doing it right at the bedside?

CENTRAL VENOUS CARE

3M Health Care Academy

3M 2015. All Rights Reserved

3M Health Care Academy

3M 2015. All Rights Reserved

3M Health Care Academy

3M 2015. All Rights Reserved

3M Health Care Academy

3M 2015. All Rights Reserved

WHAT GUIDELINES SAY?

3M Health Care Academy

3M 2015. All Rights Reserved

Best Practices are defined as:

Agency for Healthcare Research and Quality

Infusion Nurses Society

Centers for Disease Control

Institute for Healthcare Improvement (IHI)

3M Health Care Academy

Procedure for Insertion of a

3M 2015. All Rights Reserved

3M Health Care Academy

3M 2015. All Rights Reserved

National infection prevention guidelines

Organisations responsible for reviewing standards of care in hospitals ensure implementation of

3M Health Care Academy

Insertion and post insertion care

3M 2015. All Rights Reserved

3M Health Care Academy

3M 2015. All Rights Reserved