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Central Venous Catheter

Care Bundle

Manual
A quality initiative
for the prevention of
Central Venous Catheter-Related Blood Stream Infection
(CVC-BSI)

April 2008

Prepared by

The National Audit on Adult Intensive Care Units (NAICU)


&
Quality in Medical Care Section,
Medical Development Division, Ministry of Health
Program Anestesiologi, Kementerian Kesihatan Malaysia.

CENTRAL VENOUS CATHETER


CARE BUNDLE

1. Hand hygiene
2. Maximal barrier precautions upon insertion
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

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CVC care bundle Task Force

Advisors:
Dr Kalsom bt Maskon
Deputy Director
Quality in Medical Care Section
Medical Development Division, Ministry of Health

Dr Ng Siew Hian
Head of Department of Anaesthesia and Intensive Care
Hospital Kuala Lumpur

Members:
Dr Tan Cheng Cheng
Consultant Intensivist
Department of Anaesthesia and Intensive Care
Hospital Sultanah Aminah, Johor Bahru

Dr Jenny Tong May Geok


Head of Department of Anaesthesia and Intensive Care
Hospital Tuanku Jaafar, Seremban

Dr Tai Li Ling
Consultant Intensivist
Department of Anaesthesia and Intensive Care
Hospital Kuala Lumpur

Secretariat
Dr Paa Mohamed Nazir bin Abd Rahman
Senior Principal Assistant Director
Quality in Medical Care Section
Medical Development Division, Ministry of Health

Dr Fakhruddin bin Amran


Principal Assistant Director
Quality in Medical Care Section
Medical Development Division, Ministry of Health

Matron Norhizan Othman


Sister Norwati Mohd
Quality in Medical Care Section
Medical Development Division, Ministry of Health

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CONTENTS

Page
Introduction 4

The Central Venous Catheter Care Bundle and its components 5

Implementing CVC care bundle 14

Conclusion 17

References 18

Appendices 21
1. Measurement
2. Diagnosis of central venous catheter related blood
stream infection
3. CVC care bundle checklist
4. Diagnosis of CVC-BSI form

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Introduction

This manual is intended as a guide for health care providers to implement the central
venous catheter care bundle as an effort to reduce central venous catheter-related
blood stream infections (CVC-BSI).

Intravascular devices are indispensable in modern day medical practice with central
venous catheters (CVCs) being commonly used in the intensive care units (ICUs). In
the European Prevalence of Infection in Intensive Care (EPIC) study 1, 78.3% of
critically ill patients had some form of intravenous catheterisation while in the
National Audit on Adult Intensive Care Units (NAICU) of Malaysia2, an average of
70% of patients in the intensive care unit (ICU) had CVCs inserted.

However, CVCs disrupt the integrity of the skin, making infections with bacteria
and/or fungi a possibility. These infections may spread to the bloodstream
(bacteremia) and haemodynamic changes and organ dysfunction (severe sepsis) may
ensue, possibly leading to death. CVC-BSI have been shown to be responsible for
about 62% of ICU acquired blood stream infections3 which added to the morbidity
and mortality of ICU stay4. In addition, CVC-BSI have been shown to increase both
ICU and hospital length of stay5, 6.

Data from National Nosocomial Infections Surveillance System from January 1992
through June 2004 showed that the median rate of CVC-BSI in ICUs of all types
ranged from 1.8 to 5.2 infections per 1000 catheter-days7. The only data available in
Malaysia was from Hospital Sultanah Aminah Johor Bahru which showed an
incidence of 9.43 infections per 1000 catheter in situ days8.

It is possible to decrease CVC-BSI rate and even achieve a zero CVC-BSI rate by
implementing evidence-based interventions grouped in the form of a care bundle9,10.
In the 103 ICUs in the state of Michigan which implemented this care bundle, the

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median rate of CVC-BSI per 1000 catheter-days decreased from 2.7 infections at
baseline to 0 at 3 months after implementation of the study intervention (p < 0.002),
and the mean rate per 1000 catheter-days decreased from 7.7 at baseline to 1.4 at 16 to
18 months of follow-up (p < 0.002)10.

The Central Venous Catheter Care Bundle

The National Healthcare Safety Network (NHSN) of the US defined a central venous
catheter (CVC) as a catheter with its tip terminating in a great vessel. The great vessels
include the pulmonary artery, superior vena cava, inferior vena cava, brachiocephalic
veins, internal jugular veins, subclavian veins, external iliac veins and common
femoral veins. Hence, peripherally inserted central lines (PICC) and femoral lines are
considered CVCs.

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 science supporting each bundle component is
sufficiently established to be considered as the standard of care.

The central venous catheter care bundle is a group of evidence-based interventions for
patients with CVCs that, when implemented together, result in better outcomes than
when implemented individually.

The CVC care bundle consists of five evidence-based procedures recommended by the
CDC (Center of Disease Control and Prevention) and identified as having the greatest
effect on the rate CVC-BSI and the lowest barriers to implementation.

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The five evidence-based components of the CVC care bundle are:

1. Hand hygiene
2. Maximal barrier precautions upon insertion
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

Berenholtz et al. demonstrated that ICUs that have implemented multifaceted


interventions similar to the CVC care bundle have nearly eliminated CVC-BSIs.11

Figure: Rate of CVC-BSI per catheter days from 1998 to 2003 in ICU
Rate per 1000 cath days

25
20
15
10
5
0
1998 - Qtr1

1998 - Qtr3

1999 - Qtr1

1999 - Qtr3

2000 - Qtr1

2000 - Qtr3

2001 - Qtr1

2001 - Qtr3

2002 - Qtr1

2002 - Qtr3

2003 - Qtr1

The success of these interventions is perhaps due to a mindfulness that develops


when regularly applying the elements of the bundle.

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Preventing Central Venous Catheter-Related Bloodstream Infections

Five Components of Care

1. Hand Hygiene

The transmission of healthcare-associated pathogens most often occurs via the


contaminated hands of healthcare workers. Accordingly, hand hygiene (i.e.
handwashing with antimicrobial soap and water or use of a waterless, alcohol-based
hand rub) is one of the most important infection control measures for preventing
health-care-associated infections including CVC-BSI12.

When washing hands with antimicrobial soap and water, one is to wet the hands first
with water, apply an amount of product recommended by the manufacturer to hands,
and rub hands together vigorously for at least 15 seconds to cover all surfaces of the
hands and fingers. Rinse hands with water and dry thoroughly with a disposable
towel.

When performing hand hygiene with alcohol-based hand rub, always use sufficient
volume to cover all surfaces (palm, back of hand, fingers, fingertips, and fingernails)
and rub till dry for at least 15 seconds.

Healthcare workers should clean their hands according to the recommendations listed
in the CDC Guideline for Hand Hygiene in Healthcare Settings13. When caring for
CVCs, hand hygiene should be performed:

Before and after palpating catheter insertion sites


Before donning gloves and gown
Before and after inserting, replacing, accessing, or dressing a catheter

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After removing gloves (Gloved hands can also become contaminated due to
tiny punctures in the glove material or during glove removal; therefore, hand
hygiene must be performed immediately after glove removal)

Some recommended measures to improve compliance to hand hygiene in


relation to care of CVC are:
Include hand hygiene as part of checklist for CVC placement
Empower nurses to stop doctors from performing catheterisation if hand
hygiene is not observed
Create an environment where reminding each other about hand hygiene is
encouraged.

2. Maximal Barrier Precautions Upon Insertion

Maximal barrier precautions during CVC insertion are the same as for any other
surgical procedure that carries a risk of infection. They consist of the use of a cap,
mask, sterile gloves and long-sleeved gowns by the operator and those assisting in the
procedure. The cap should cover all hair and the mask should cover the nose and
mouth tightly.

For the patient, applying maximal barrier precautions means covering the patient
with a full-sized sterile drape, with a small opening for the site of insertion. The
rationale for a large sterile drape is to ensure that sterile field is maintained and that
the catheter is not exposed to contamination during the procedure.

In two studies, the odds of developing a CVC-BSI are increased if maximal barrier
precautions were not used. For pulmonary artery catheters, the odds ratio for
developing infection was more than two times greater for placement without maximal

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barrier precautions14. A study of similar design found that this rate was six times
higher for placement of CVCs15.

Some interventions that have been proven in studies to increase compliance with the
use of full barrier precautions and decrease catheter-related infections are:
a.
preparation of standardized procedure carts or kits that contain all supplies
necessary for a sterile procedure16
b. creation of a dedicated team for placement of CVCs17
c. 1-day course on the prevention of vascular catheter infection, emphasising
the use of full-size sterile drapes for physicians-in-training18.

3. Chlorhexidine Skin Antisepsis

Microbial populations on the skin are routinely suppressed by the use of antiseptic
agents prior to catheter insertion. Using an antiseptic solution for skin disinfection at
the catheter insertion site helps to prevent catheter-related infections.

Both chlorhexidine gluconate and povidone-iodine have broad spectrum


antimicrobial activity. Chlorhexidine works by disrupting bacterial cellular wall
content while povidone-iodine acts by destroying microbial protein and DNA.
Chlorhexidine has a rapid onset of bactericidal action and prolonged antimicrobial
efficacy by binding to the protein of the skin and, thus, being available for residual
activity over a relatively long period of time. Furthermore, chlorhexidine is not
inactivated by blood or serum proteins. Alcoholic solutions are more effective than
aqueous solutions of the same antimicrobial agents.

Several studies have compared the efficacy of povidone-iodine and chlorhexidine


gluconate solutions in reducing vascular catheter-related infections. Chlorhexidine

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skin antisepsis has been proven to provide better skin antisepsis than other antiseptic
agents such as povidone-iodine solutions.

Maki et al. randomised skin preparation solution for 668 catheters comparing 2%
chlorhexidine, 10% povidone-iodine, and 70% alcohol19. Chlorhexidine 2% was
associated with the lowest incidence of CVC-BSI (2.3 per 100 catheters, p=0.02).
Alcohol 70% and povidone-iodine 10% were associated with 7.1 and 9.3 infections per
100 catheters respectively. In a recent meta-analysis, Chaiyakunapruk analyzed 8
studies involving a total of 4,143 catheters20. This meta-analysis identified a risk
reduction for CVC-BSI = 0.49 with 95% CI (0.28 - 0.88). Chlorhexidine gluconate
decreased CVC-BSI by 50% compared with povidone-iodine (1% vs. 2%). The results
in this same study also demonstrated expected cost savings when chlorhexidine
gluconate was used as skin antiseptic.

The CDC Guidelines for the prevention of intravascular catheter-related infections


recommends that the skin be disinfected with 2% chlorhexidine-based preparation
before catheter insertion and during dressing changes.

The proper method of sterilising an insertion site with chlorhexidine 2% involves


scrubbing in a back and forth motion for 30 seconds rather than prepping in a circle as
this method may be more effective in reducing the bacterial burden prior to the
puncture of the skin and subsequently under the dressing. Also, note that only one
application of the chlorhexidine solution is necessary. The antiseptic solution must be
allowed to dry completely before puncturing the site.

Irritation, sensitisation, and generalised allergic reactions have been reported with
chlorhexidine-containing products, especially in the genital areas. Maki et. al found
erythema at the insertion site in 28.3% of catheters in the povidone-iodine group and
in 45.3% of catheters in the chlorhexidine gluconate group (p=0.0002) 19.

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Chlorhexidine 2% is contraindicated for use near the meninges, in the genital area,
and near the eyes and ears. At the 2% concentration, it can cause serious and
permanent injury on contact with the eye or if instilled through a perforated eardrum.
As a scrub it is not recommended for persons under two months of age. Extensive
skin burns after the use of alcoholic chlorhexidine as a skin antiseptic has been
reported in a premature baby21.

4. Optimal Catheter Site Selection, with Subclavian Vein as the Preferred Site
for Non-Tunneled Catheters

The site of catheter placement influences the subsequent risk for CVC-BSI and
phlebitis. The influence of site on the risk of catheter infections is related in part to the
risk for thrombophlebitis and density of local skin flora12.

The Cochrane Collaboration has recently published a review article on central venous
access sites for the prevention of infection22. The authors found only one high quality
block randomized controlled trial23 comparing mechanical, infectious and thrombotic
complications of femoral and subclavian venous catheterisation. The results of the
study in relation to infectious complications were as follows:
a. infectious complication (colonisation with or without sepsis): the relative
risk (RR) was 4.57 (95% CI 1.95 - 10.71) favouring subclavian over femoral
access.
b. major infectious complications (sepsis with or without bacteremia): the RR
was 3.04 (95% CI 0.63 - 14.82) favouring subclavian access.
c. colonised catheter (> 103 colony-forming units/ml of gram positive
microorganisms): the RR was 3.65 (95% CI 1.40 - 9.56) favouring subclavian
access.

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d. colonised catheter (> 103 colony-forming units/ml of gram negative


microorganisms): the RR was 5.41 (95% CI 1.61 - 18.15) favouring subclavian
access.
In a systematic review on complications of central venous catheters: internal jugular
versus subclavian access24, three trials (707 catheters) reported on bloodstream
infection. The incidence was 8.6% with the jugular access and 4.0% with the
subclavian access. (RR 2.24, CI 0.62 - 8.09).

Whenever possible, and not contraindicated, the subclavian approach is preferred to


the jugular or femoral approach.

However, for the inexperienced clinician, the subclavian site may present a significant
risk of pneumothorax, subclavian artery puncture, subclavian vein laceration,
subclavian vein stenosis, haemothorax, thrombosis, air embolism and catheter
misplacement12. The subclavian approach may also be unavailable due to chest injury.
In a meta-analysis of eight studies, the use of bedside ultrasound for the placement of
subclavian CVCs substantially reduced mechanical complications compared with the
standard landmark placement technique (RR 0.22, 95% CI 0.10 - 0.45)25.

Hence, maintenance of asepsis, patient-specific factors (e.g. preexisting catheters,


anatomic deformity and bleeding diathesis), relative risk of mechanical complications
(e.g. bleeding and pneumothorax), the availability of bedside ultrasound and the risk
for infection should guide site selection12.

One may ask why are subclavian lines preferred over peripherally inserted central
lines (PICC) if the standard is lowest infection risk? Data is still lacking on infection
rates for PICC lines in acute care settings as opposed to chronic or home care settings.
The most recent evidence suggests that infection rates rival those of subclavian or
internal jugular catheters placed in the acute care setting 26. No head-to-head

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comparison has yet been done to make a definitive conclusion. In addition, PICCs are
more vulnerable to thrombosis and dislodgment27, and are less useful for drawing
blood specimens. Moreover, PICCs are not advisable in patients with renal failure and
impending need for dialysis, in whom preservation of upper-extremity veins is
needed for fistula or graft implantation given a possibly greater risk of subclavian
vein stenosis.

5. Daily Review of Line Necessity with Prompt Removal of Unnecessary CVCs

Duration of catheterisation has been suggested as an important risk factor in the


development of CVC-BSI in several studies8,28,29,30. Any intravascular catheter that is
no longer essential should be promptly removed.

Daily review of central line necessity will prevent unnecessary delays in removing
lines that are clearly not needed for the care of the patient. Many times, central lines
remain in place simply because they provide reliable access and because medical
personnel have not considered removing them. Thus the daily review of line
necessity should be included in multidisciplinary rounds.

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Implementing Central Venous Catheter Care Bundle

1. Main objective:

To prevent CVC-BSI by implementing the five components of care called the CVC
care bundle

Specific objectives:

To determine the CVC-BSI rate of Ministry of Health ICUs

To determine the organisms which commonly cause CVC-BSI

To achieve 95% compliance with CVC care bundle i.e. 95% of all patients with
CVCs should receive all 5 elements of the CVC care bundle

To reduce the rate of CVC-BSIs by 50% within 12 months of implementation of


the CVC care bundle

2. Getting Started

2.1 Formation of a multi-disciplinary team (doctors, nurses, pharmacist etc)

The Institute of Healthcare Improvement (IHI) recommends a multi-disciplinary team


approach to patient care in the ICU. Improvement teams comprising of doctors,
nurses and other allied health care providers should be heterogeneous in make-up,
but homogeneous in mindset. The value of bringing diverse personnel together is that
all members of the care team are given a stake in the outcome and can work to achieve
the same goal. For example, teams without nurses are bound to fail. Teams led by
nurses may be successful, but often lack leverage. Therefore doctors (MOs and
specialists) must also be part of the team.

The team needs encouragement and commitment from an authority in the ICU.
Identifying a champion in the unit increases a teams motivation to succeed. When
measures are not improving fast enough, the champion re-addresses the problems

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with staff and helps to keep everybody on track toward the aims and goals.
Eventually, the changes that are introduced become established.

2.2 Execution of all components of CVC care bundle


All components of the care bundle must be executed together, in an all or none
strategy.

Assess where you/your ICU stand presently. What precautions have been
taken presently when placing CVC? Is there a need for change in the process?

Ensure that all of the needed equipment and supplies for execution of the care
bundle are available at the point of care. These include chlorhexidine 4% in 4%
isopropyl alcohol scrub for hand antisepsis, sterile sets, drapes and gown, caps,
masks, chlorhexidine 2% (chlorhexidine 2% in 70% alcohol preferable if
available) for skin antisepsis.

Organise a meeting for ICU nurses and all doctors of the department. Start with
an educational program about CVC-BSI, incidence, outcomes, preventive
strategies and then introduce the CVC care bundle to them. There may be a
need for change in the process of placing CVCs.

2.3 Measurement of performance


Measurement is the only way to know whether a change represents an improvement.
There are two measures of interest for CVC-BSI: the compliance to the components of
CVC care bundle and the rate of CVC-BSI (Appendix 1).

For this purpose there are 2 forms.

(i) CVC care bundle compliance checklist

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The first form is called the CVC care bundle compliance checklist. This must be
filled up for the first 20 consecutive CVCs inserted in every month.

Each patient who receives a CVC, haemodialysis catheter, PA catheter and


PICC will have the CVC care bundle compliance checklist form filled up by the
attending nurse and medical officer/specialist who is inserting the line, at the
time of insertion. The attending nurse will observe the doctor who is inserting
the CVC and assess for compliance to individual component (indicate yes or
no).

Nurses will be empowered to supervise the preparations using the checklist


prior to line insertion, stop the process if necessary and fill in the form.

After insertion, the patient will be reviewed daily by the doctor (doing the
morning rounds) for the necessity of continued CVC placement. The form is to
be charted daily as to reasons for continued CVC placement till the CVC is
removed. Indications for continued CVC placement include continued use of
vasopressors/inotropes, parenteral nutrition, hypertonic solutions, dialysis,
difficult peripheral venous access and the need for continued central venous
pressure /cardiac output readings). Absence of these indications should
prompt removal.

(ii) Diagnosis of CVC-BSI form

This form is for diagnosing CVC-BSI, determining the CVC-BSI rate per 1000
catheter days and identifying common infecting organism/s. The diagnosis of
CVC-BSI will be based on the commonly used definition31 with modifications
to accommodate local situations (Appendix 2)

Each form can accommodate up to 3 CVCs.

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Conclusions

1. All ICU teams should make the CVC care bundle initiative an established daily
practice. Doctors who insert CVC should question as to whether a CVC is truly
necessary instead of being part of a routine ICU procedure.

2. If CVC is deemed necessary, the ICU team should make daily review of the
continued need for the CVC and remove it when it is no longer necessary.

3. Measurement is important. However, do not be too pre-occupied with


measurement. Assist your team if there are contraindications to bundle
elements.

4. Emphasise compliance with all the elements of the bundle and not just few
simple ones. Your aim should be 100% compliance with every bundle element
for every patient. Partial compliance is non-compliance.

5. Post updates to results regularly and prominently.


Enthusiasm for the project will wane over time. It is essential to update all ICU
staff on their work on the monthly level of compliance and the monthly change
in CR-BSI rates.

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2. SH Ng, LL Tai, CC Tan, Jenny MG Tong. The National Audit on Adult Intensive
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3. Edgeworth J, Treacher DF, Eykyn SJ. A 25-year study of nosocomial bacteremia in


an adult intensive care unit. Crit Care Med 1999; 27(8):1421-1428

4. Laupland KB, Zygun DA, Davies HD Church DL, Louie TJ, Doig CJ. Population-
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5. Dimick JB, Pelz RK, Consunji R, Swoboda SM, Hendrix CW, Lipsett PA. Increased
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6. Rello J, Ochagavia A, Sabanes E et al. Evaluation of outcome of intravenous


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9. Berenholtz SM, Pronovost PJ, Lipsett PA et al. Eliminating catheter-related


bloodstream infections in the intensive care unit. Crit Care Med 2004; 32(10):2014-
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11. Berenholtz SM, Pronovost PJ, Lipset PA et al. Eliminating catheter-related

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bloodstream infection in the intensive care unit. Crit Care Med 2004; 32:2014-2020

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21. Upadhyayula et al. Safety of anti-infective agents for skin preparation in


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26. Safdar N, Maki DG. Risk of catheter-related bloodstream infection with


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28. Pearson ML, Hierholzer WJ, Garner JS et al. Guideline for prevention of intra-
vascular device-related infections. Am J Infect Control 1996 Aug; 24(4):262-293

29. Tacconelli E, Tumbarello M, Pittiruti M et al. Central venous catheter-related


sepsis in a cohort of 366 hospitalised patients. Eur J Clin Microbiol Infect Dis 1997
Mar; 16(3):203-209

30. Arruda E, Marinho IS, Rodrigues E et al. Central venous catheter-related


infections in intensive care units. Braz J Infect Dis 1997 Aug; 1(4) :182-185

31. Mermel LA, Farr BM, Sherertz RJ et al. Guidelines for the Management of
Intravascular CatheterRelated Infections. Clinical Infectious Diseases 2001;
32:124972

Central Venous Catheter Care Bundle Manual, 2008.


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Program Anestesiologi, Kementerian Kesihatan Malaysia.

Appendix 1

Measurement

1. Rate of central venous catheter-related bloodstream infection (CVC- BSI)


No. of cases of CVC-BSI
______________________________________________ X 1000 = Rate of CVC-BSI

Total no. of catheter days for all patients with CVCs

The incidence will be reported as the number of CVC-BSI per 1000 catheter
days.

2. Central venous catheter (CVC) care bundle compliance rate

Compliance measurements are taken for the entire bundle of care


components, not just parts of the bundle. Undertake the audit for all
patients, to a maximum of 20 patients in the month with CVCs and assess
their care for compliance with the CVC bundle.

Number of patient receiving all components


___________________________________________ X 100 = % compliance
Number of patient with CVCs assessed

Central Venous Catheter Care Bundle Manual, 2008.


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Program Anestesiologi, Kementerian Kesihatan Malaysia.

Appendix 2

The diagnosis of CVC-BSI

The commonly used definition31 of CVC-BSI is as follows:

Bacteremia or fungemia in a patient who has an intravascular device and 1


positive result of culture of blood samples obtained from the peripheral vein, clinical
manifestations of infection (e.g., fever, chills, and/or hypotension), and no apparent
source for bloodstream infection (with the exception of the catheter). One of the
following should be present: a positive result of semiquantitative (15 cfu per catheter
segment) or quantitative (102 cfu per catheter segment) catheter culture, whereby the
same organism (species and antibiogram) is isolated from a catheter segment
and a peripheral blood sample; simultaneous quantitative cultures of blood samples
with a ratio of 5:1 (CVC vs. peripheral); differential time to positivity (i.e., a positive
result of culture from a CVC is obtained at least 2 h earlier than is a positive result of
culture from peripheral blood)

As most microbiology laboratories do not do semiquantitative nor quantitative culture


nor differential time to positivity, the task force of CVC care bundle decided to modify
the diagnosis to be based on the following:
(i) there should be a suspicion of CVC-BSI
(ii) the CVC must be more than 48 hours in situ
(iii) the patient must have signs of sepsis / shock ie infection plus > 2 of
the following: Temp > 380C or < 360C
HR > 90 /min
RR > 20 /min or MV > 10 L/min in ventilated patient
PaCO2 < 32 mm Hg
WCC > 12000 /ml or < 4000 /ml or >10% immature
forms
(iv) there is no apparent source for bloodstream infection with the
exception of the catheter
(v) similar organism/s are grown from paired blood culture taken from
the CVC lumen and the peripheral vein

A flow chart has been developed to help you diagnose CVC-BSI.

Central Venous Catheter Care Bundle Manual, 2008.


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Program Anestesiologi, Kementerian Kesihatan Malaysia.

Flow chart for the


?CVC-BSI
Diagnosis of Central
Venous Catheter-
Yes
Related
Bloodstream No
Infection (CVC-BSI) CVC in-situ CVC-BSI unlikely
> 48hrs

Yes

Signs of No
sepsis/ CVC-BSI unlikely
shock

Yes
Other
identifiable Yes
CVC-BSI unlikely
source of
infection

No
Perform paired blood C&S
From CVC lumen
From peripheral vein

Likelihood of
CVC-BSI
Highly likely Less likely

Can keep CVC while


Remove CVC awaiting paired culture
immediately results

Similar organism in No CVC-BSI


paired blood cultures
unlikely

Yes
Remove CVC
CVC-BSI immediately

Central Venous Catheter Care Bundle Manual, 2008.


23
Appendix 3

Central Venous Catheter Care Bundle Compliance Checklist


Hospital _________________________

No. : Month : .
Name of patient: R/N : ..
Name of Dr. : .. Name of attending SN:.

Indicate Yes/ No for each of the following


1. Hand hygiene
Did the doctor wash his/her hands with chlorhexidine 4% with 4% isopropyl alcohol? Yes / No
2. Maximal barrier precautions
Did the doctor doing the procedure,
wear cap? Yes / No
wear mask to cover nose and mouth? Yes / No
wear sterile gown? Yes / No
wear sterile gloves? Yes / No
use large drapes to cover the site of insertion? Yes / No
Did the assistant dropping items onto the field,
wear cap? Yes / No
wear mask to cover nose and mouth? Yes / No
Is there any other doctor assisting in the insertion? Yes / No
If Yes, did he/she follow all the above barrier precautions? Yes / No
3. Chlorhexidine skin antisepsis
Did the doctor clean the site of insertion with chlorhexidine 2% aqueous or
chlorhexidine 2% in 70% alcohol? Yes / No
4. Catheter site selection
Is the subclavian route of insertion chosen? Yes / No
If No, doctor to fill the reason/s :-
High risk of bleeding Yes / No
Failed subclavian insertion Yes / No
Infected insertion site Yes / No
Inexperience Yes / No
Distorted anatomy Yes / No
No more subclavian site Yes / No
Risk of subclavian vein thrombosis in dialysis catheters Yes / No
Risk outweighs benefit Yes / No
5. Daily review of CVC (at 8pm everyday until the catheter is removed)
Is there still an indication for CVC? Fill the box with Y if Yes and N if No

Date
Day of CVC 2 3 4 5 6 7 8 9 10 11 12 13 14 15
On inotropes in the last 24 h
On TPN in the last 24 h
On dialysis
Unable to set peripheral
venous lines
Need for monitoring
Need for infusion of
hypertonic solution
Catheter removed
Signature of nurse
Appendix 4
Diagnosis of Central Venous Catheter-Related Bloodstream Infection (CVC-BSI)
ICU Hospital _________________________

Name : R/N : ....


Date & Time of ICU admission : __ __ /__ __ /__ __ __ __ & __ __ __ __ h Date & Time of ICU discharge / death : __ __ /__ __ /__ __ __ __ & __ __ __ __ h

1 2 3
Catheter type Central venous Dialysis Pulm. artery PICC Central venous Dialysis Pulm artery PICC Central venous Dialysis Pulm artery PICC

Location of insertion ICU Non-ICU ICU Non-ICU ICU Non-ICU

No of lumens 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

Insertion site R L subclavian R L int jugular R L subclavian R L int jugular R L subclavian R L int jugular
R L femoral R L cubital R L ext jugular R L femoral R L cubital R L ext jugular R L femoral R L cubital R L ext jugular

Date & time of insertion __ __/__ __/__ __ __ __ & __ __ __ __ h __ __/__ __/__ __ __ __ & __ __ __ __ h __ __/__ __/__ __ __ __ & __ __ __ __ h

Date & time of removal/death __ __/__ __/__ __ __ __ & __ __ __ __ h __ __/__ __/__ __ __ __ & __ __ __ __ h __ __/__ __/__ __ __ __ & __ __ __ __ h
Discharged with catheteri in-situ Discharged with catheter in-situ Discharged with catheter in-situ

Reasons for removal 1 2 3 4 1 2 3 4 1 2 3 4


5 6 7 8. 5 6 7 8. 5 6 7 8.
1 2 3 1 2 3 1 2 3
Suspect CVC-BSI
Y N Y N Y N Y N Y N Y N Y N Y N Y N
Signs of sepsis/septic shock
Y N Y N Y N Y N Y N Y N Y N Y N Y N
No other identifiable source
Y N Y N Y N Y N Y N Y N Y N Y N Y N
Blood from CVC lumen sent
Y N Y N Y N Y N Y N Y N Y N Y N Y N
If Yes, Date sent

Organism/s

Blood from peripheral vein sent


Y N Y N Y N Y N Y N Y N Y N Y N Y N
If Yes, Date sent

Organism/s

Are both organisms the same? Y N Y N Y N Y N Y N Y N Y N Y N Y N

Reasons for removal: Causative organisms:


1. Tip not in desired position 1. Pseudomonas aeruginosa 9. Methicillin-sensitive Staphylococcus aureus
2. Blocked / leaking lumen 2. Pseudomonas non-aeruginosa 10. Methicillin-resistant Staphylococcus aureus
3. Not intravascular/ slipped out 3. Acinetobacter spp 11. Coagulase negative Staphylococcus
4. Pus/ inflammation at insertion site 4. Klebsiella spp 12. Enterococcus spp
5. ? CVC-BSI 5. Stenotrophomonas maltophilia 13. Candida albicans
6. Insufficient lumen 6. Burkholderia cepacia 14. Candida non-albicans
7. No more indicated 7. Enterobacter spp 15. Other gram negative organisms
8. Others (please specify) .. 8. Escherichia coli 16. Other gram positive organisms

Central Venous Catheter Care Bundle Manual, 2008. 25


Central Venous Catheter Care Bundle Manual, 2008. 26