Current Issues and Challenges in Vascular Access Device Related Infection Prevention

Current Issues and Challenges in
Vascular Access Device Related
Infection Prevention
© 2014 BD MSS0387-2 (10/14)
Lisa Gorski is a paid consultant for BD (Becton,
Dickinson and Company).
• The development of this presentation was
commissioned by BD.
• The contents of this presentation are
intended for general information purposes
only and the views expressed therein are
solely those of the presenter and not BD.
• Describe the concept of a care “bundle.”
• Discuss evidence supporting the need for postinsertion VAD care strategies.
• Identify current issues and challenges related to
needleless connector/catheter hub disinfection
Presentation Outline
Overview: Bloodstream infection
Success with the “Central Line” bundle
More about “bundles”
Post-insertion care issues
Focus on needleless connector disinfection:
current research & issues
• Challenges and successes in implementing
evidence-based practices
• Summary and conclusions
Bloodstream Infection
• A serious and life threatening complication of VADs
• 80,000 catheter related bloodstream infections occur in
ICUs annually in USA
▫ 250,000 per year if the entire hospital is included 1
• Little current data to estimate the rate of such infections
in alternate sites
• Most data related to CVADs; less is known about
peripheral IV infections
• One of the 10 hospital-acquired conditions considered a
preventable adverse event
• National Patient Safety Goal 2 -- prevention of CVAD
infections for both hospitals and long-term care
• A continuing research priority
TABLE 2. Estimated annual number of central line-associated blood stream infections (CLABSIs), by
health-care setting and year --- United States, 2001, 2008, and 2009 3
Health-care setting
Intensive-care units
A 58%
reduction in
2009 as
compared to
No. of infections (upper and lower
bound of sensitivity analysis)
43,000 (27,000--67,000)
18,000 (12,000--28,000)
Inpatient wards
23,000 (15,000--37,000)
Outpatient hemodialysis*
37,000 (23,000--57,000)
* Case definitions approximate current definition of CLABSI according to the National Healthcare Safety Network
Home Care & Infection Risk
• Risks of infection for patients with VADs believed to
be low – scarce recent data
• Home care advantages:
▫ Risk of transmission associated with multiple
patients/multiple providers in an institution
eliminated in the home setting
• Home care risks:
▫ Patients more active – bathing, exercising, gardening,
playing with pets
▫ Patient/caregiver care of VAD/infusion administration
-- may or may not be a risk
Patient Risk Factors for
Infection – Home Health
• Systematic literature review4
• 25 studies met inclusion criteria
• Great variation in risk factor identification and
infection rates
• Infusion therapy
▫ Patients receiving PN at greater risk than those
receiving other infusion therapies
Survey of Home Care Agencies
• Investigation of home care agency CLABSI
definitions and prevention policies5
• 25% (14/59) of surveyed agencies knew their overall
CLABSI rate (mean 0.40 CLABSIs per 1000 central
line days)
• Some discrepancies between home care policies and
pediatric bundle elements (focus on pediatric care)
• Limitations on ability to use sterile gloves, change
caps, tubing, dressing changes due to insurance
Infection Prevention: Catheter-Insertion
• The “Central Line Bundle” (hand hygiene, maximal
sterile barrier precautions, chlorhexidine skin antisepsis,
optimal site selection, daily review of need for CVAD)
• Aimed at catheter placement procedures and preventing
microbial access via the extraluminal route
• Other technologies and additional practices adopted
many organizations – examples…
▫ Antiseptic dressings
▫ Antiseptic/antimicrobial impregnated catheters
▫ Chlorhexidine bathing
Central Line Bundle
• Critically important … major impact on infection
▫ “Bundles that include checklists to prevent central lineassociated bloodstream infections”
 One of the top 10 “Strongly encouraged
patient safety practices” 6
• Incorporated in Joint Commission National Patient
Safety Goals2, INS 2011 Standards7, and CDC 2011
• … But not enough!
▫ Does not address care and maintenance
practices aimed at reducing intraluminal
introduction of microbes
A little bit more about “bundles”…
• Defined by the Institute for Healthcare
Improvement (IHI): A small set of evidencebased interventions for a defined patient
population and care setting8
• The IHI Central Line Bundle was one of the first
2 bundles developed
• Compliance measured as “all or none” – all
elements must be delivered unless medically
Designing a bundle
• 3-5 interventions
▫ Already recommended interventions
▫ Accepted in national guidelines and by local
consensus of clinicians
• Each intervention is relatively independent
• Used with a defined patient population in one
• Developed by the multidisciplinary team
• Descriptive rather than prescriptive - allows for
local customization
• Goal of 95% or greater compliance8
Post-insertion care
• The term bundle is often used but there is no well
established, well-tested post-insertion care bundle
• More challenging than the central line insertion
▫ Central line bundle mainly focused during time of
▫ Post-insertion care focused during entire dwell time
 Involves many clinicians and potentially several health
care settings
 Involves every catheter access/care procedure
 Challenging to monitor care behaviors
Data suggest the need to focus
attention on post-insertion care
• More comprehensive data collection submitted to and
analyzed by the NHSN is useful in designing infection
prevention programs
• Example:
▫ In 2010 it was found that in the state of Pennsylvania,
71.7% of CLABSIs occurred more than five days after
insertion, suggesting internal lumen contamination
and the need to pay more attention to catheter
maintenance procedures 9
Another example: Poor compliance
with dressing changes
• N=420 CVADs evaluated in a single hospital10
• N=130 (31%) of CVAD dressings suboptimal and
needed changing (e.g. blood under dressing,
exposed insertion site, visible moisture)
• No correlation with BSI
▫ Researchers believe infections complex and
require multi-modal preventative programs
▫ Efforts must address CVAD maintenance –
beyond the central line insertion bundle
Dressings and Risk for Infection
• Secondary analysis of a randomized controlled trial
1636 patients (ICU) in initial trial; 1419 with at least
one dressing change included in analysis11
• 11,036 dressing changes, 67% unplanned due to
• More than 2 dressing changes for disruption were
associated with a greater than threefold increase in
risk of infection/BSI
• Risk factors for dressing disruption included
femoral/jugular sites
• Post-insertion bundles are insufficiently
implemented/ study reinforces need
Some potential components of a postinsertion care bundle aimed at
infection prevention
The main
Hand hygiene
focus of
Regular site care
Dressing changes
IV administration set changes
Accessing the needleless connector for
catheter flushing/medication/solution
• Maintaining catheter patency
Needleless Connectors (NC)12
• Many different NC products -- categorized into:
▫ Simple: No internal mechanisms; fluid flows
straight through the internal lumen. Includes
those with a split septum
▫ Complex: Characterized by an internal mechanism
that controls the flow of fluid through the device,
allowing both infusion and aspiration of blood
Attention to needleless connectors
and catheter hubs
• Needleless connectors and stopcocks are known
sources of contamination1
• Disinfection of the NC is recognized as a critical
prevention strategy1
• Adequacy of disinfection dependent upon
antiseptic agent, contact time, method of
application (friction and chemical kill critical)
▫ Consistency problems!
Accessing the needleless connector
• Steps include
▫ Gathering supplies
▫ Performing hand hygiene
▫ Scrubbing/disinfecting NC
What solution?
How long?
Dry time?
Prior to each access?
▫ Attaching syringe/IV administration set maintaining
sterility of syringe/set tip and no touch contamination
of disinfected NC
Infusion Nurses Society Standards
“The needleless connector should
be consistently and thoroughly
disinfected using alcohol, tincture
of iodine, or chlorhexidine
gluconate/alcohol prior to each
access. The optimal technique or
disinfection time has not been
• 13
A 5 second scrub with 70% alcohol
• Inpatient setting/prospective observational study 13
• Cultures performed on CVADs with NC (split
septum type) and no active infusion
▫ Prior to disinfection, and after vigorous scrub with
70% alcohol for 5, 10, 15, 30 seconds
▫ 5 second dry time, cultures by pressing NC onto agar
• In vitro assessment
▫ Sterile NC inoculated with S. epidermidis and allowed
to dry for 3 hours
▫ Vigorous scrub with 70% alcohol for 0, 5, 10, 15, 30
seconds, 5 second dry time and then cultured
• 363 NCs sampled in clinical phase13
▫ 58/87 NCs cultured without disinfection showed
bacterial contamination
▫ 5 second scrub (n=71) – one (1.4%) yielded
microbial growth
▫ Similar results with 10, 15, 30 second scrub times
▫ No significant differences in microbial
contamination rates between 5, 10, 15, 30 second
disinfection times
• In vitro results
▫ 100% of NCs sampled after no disinfection showed
heavy microbial growth
▫ When inoculum size was smaller, all NCs had sterile
cultures when scrubbed for 5 or more seconds with
70% alcohol
▫ For larger inoculum, minimal growth after 5 second
scrub, sterile culture for 10 second or longer scrub
• Implications
▫ The 5 second scrub was effective with the type of NC
used – cannot be generalized to other types of NCs13
• Laboratory study 14
• Mechanical NC (one type) inoculated with a variety
of bacteria and yeast and dried for 24 hours at room
• Scrubbed with 70% alcohol or 3.14%
chlorhexidine/70% alcohol for less than one second,
5, 15, 30 seconds and allowed to dry for 30 seconds
• With ≥5 second scrub, both performed similarly
• Residual disinfectant activity up to 24 hours with
chorhexidine/alcohol solution
2014 SHEA/IDSA Guidelines:
Disinfecting NCs
• Disinfect catheter hubs, needleless connectors, and injection ports
before accessing the catheter (quality of evidence: II) 15
a. Before accessing catheter hubs, needleless connectors, or
injection ports, vigorously apply mechanical friction with an
alcoholic chlorhexidine preparation, 70% alcohol, or povidoneiodine. Alcoholic chlorhexidine may have additional residual
activity compared with alcohol for this purpose.
b. Apply mechanical friction for no less than 5 seconds to reduce
contamination. It is unclear whether this duration of
disinfection can be generalized to needleless connectors not
tested in these studies.
c. Monitor compliance with hub/connector/port disinfection
since approximately half of such catheter components are
colonized under conditions of standard practice.
Alternative Solutions
• Consideration for special products as an
alternative to “scrubbing” the needleless
▫ Protective alcohol caps for needleless
connectors (and the male luer end of IV
administration sets)
 Emerging research documenting effectiveness
 “Special approach” -- SHEA/IDSA Guidelines 201415
▫ Scrub products that require minimal scrubbing
2014 SHEA/IDSA Guidelines: Alcohol
Disinfection Caps
• Use an antiseptic-containing hub/connector
cap/port protector to cover connectors (Grade I)
▫ Recommended as a “special approach” i.e.
recommended in locations/populations with
unacceptably high CLABSI rates despite
implementation of basic practice
recommendations 15
One of the studies supporting alcohol
disinfection caps …
• Use of an alcohol disinfection cap placed on the
needleless connector significantly reduced line
contamination, density of organisms, and CLABSIs16
• 3 phases:
▫ phase 1 baseline – standard scrub of needleless connector,
▫ phase 2 – disinfection cap placed on all CVADs
▫ phase 3 – back to standard scrub.
• Contamination and organism density were measured
via an aspirate from the PICC.
When no one is
looking, do you and
your colleagues
ALWAYS scrub the
Most nurses KNOW
that the needleless
connector must be
scrubbed before each
access but what affects
our decision to do it?
“Missed Nursing Care: Errors of
• Sample of 459 nurses in 3 hospitals completed a survey
– “Missed Nursing Care Survey” 17
• Assessment (overall) reported to be missed by 44% of
▫ IV site care and assessment according to hospital
policy missed 62% of the time
▫ Hand hygiene missed 30% of the time
• Reasons: labor resources, material resources,
• Conclusions: Patients being placed in jeopardy; critical
problem which calls for strategies/interventions
“Intention” to Disinfect the NC
• Cross-sectional study 18
• N = 171 nurses from 4 Magnet hospitals
• Survey:
▫ Demographic data
▫ Autonomy and self-efficacy scales
▫ “Smith-Becker Attitudes towards Disinfection
Techniques” scale
“Intention” to Disinfect the NC
• Findings and some implications 18
▫ There was a strong relationship between concern for
preventing bacterial migration into bloodstream and
propensity to use best practice
 Teaching should focus not only on knowledge and skills but also
address the affective domain of learning (caring, patient
▫ Experienced nurses have greater autonomy and self-efficacy
▫ But recent graduates were more likely to disinfect every time
▫ Tenured staff – do they avail themselves of educational
opportunities that newer graduates have received?
▫ Easy intervention: ready access to supplies
 “ensure adequate supply of alcohol swabs at bedside”
Challenges of Implementing
Evidence-based practices 19,20
• Lack of time
• Lack of autonomy to change practice
• Too much reliance on education and
transmission of information as a change strategy
Policies versus Adherence
• Snapshot look at US Hospitals enrolled in the
National Health & Safety Network (NHSN) 21
• 975 hospitals provided data on presence of
policies in 1,534 ICU units
• In relation to CLABSI prevention, widespread
presence of policies (87-97%)
• However, adherence to such policies ranged
from 37-71%
SHEA/IDSA Implementation Strategies15
• A helpful framework
▫ Engage
 Involve organization champions
▫ Educate
 Address knowledge, critical thinking, behavior , psychomotor
skills, attitudes, beliefs
 Documented competency
▫ Execute
 Standardize care processes – implement guidelines, bundles,
▫ Evaluate
 Link process and outcome data to competency assessments
 Surveillance
Example: Post-Insertion Care Bundle
Success Outside of the ICU
• Six hospitals, 3-phase study over 4.5 years 22
• Development of a maintenance bundle:
Hand hygiene
Aseptic technique during NC use (10-15 sec. scrub)
CVAD dressing changes
Frequency of NC, IV tubing, dressing changes
Assessment of CVAD need
• Some issues identified
▫ Policies did not address NC disinfection
▫ Nurse survey: < 20% reported using 10-15 sec. scrub
• Phases of study:
▫ 1: Pre-intervention, introduction of CVC maintenance
bundle after 6 months of CLABSI surveillance; online
teaching module
▫ 2: Collaborative team expanded – nursing leadership,
MDs etc.
▫ 3: Post-intervention – repeat nurse survey
 Data collection: 3-4 audits/unit per month (250 of direct
observations; 800 dressing integrity observations); also
documentation reviews
• Outcomes:
▫ Nurse survey – increase from 20-70% report of NC
disinfection; during audits 82% compliance with this
aspect of bundle; 90% compliance with other bundle
▫ CLABSI: 2.6 to 2.1 to 1.3 per 1000 line days
(pre-intervention, during intervention, postintervention) 22
Some conclusions:
• “standardized education and the hard wiring of
processes into the daily work flow were key to
developing a self-sustaining CLABSI prevention
• Attribute success to
▫ Education to improve nursing knowledge
▫ Engagement and increased awareness of burden of
▫ Multidisciplinary review of each affected patient –
making infection “more relevant” to staff
▫ Interventions in conjunction with audits and
Another example:
• Quality improvement data; seven years of zero bloodstream
infections in PICCs placed by the PICC team. 23
• An innovative catheter bundle that addresses not only the central
line insertion bundle but also a focus on post-insertion care and
maintenance by a dedicated vascular access team and attention to
RN education
• Interventions included in the care bundle included:
100% use of ultrasound guidance during placement
maximal barrier precautions
chlorhexidine skin preparation
use of a chlorhexidine-impregnated dressing
catheter stabilization
neutral needleless connector
a standard flushing protocol
daily line monitoring.
• Disinfection of NC should be one component of a postinsertion bundle
▫ Established guideline for scrub duration still lacking
▫ Adherence difficult to monitor
 Staff teaching techniques to foster patient advocacy important
• Scrubbing with 70% alcohol most prevalent
▫ Easy & cost-effective
• Scrubbing with chlorhexidine/alcohol
▫ Implemented by some organizations
▫ Acceptable disinfectant per INS 2011, CDC 2011, SHEA/IDSA 2014
▫ More expensive
• Alcohol disinfection caps
Studies showing efficacy
Saves time
Less dependent on “human factors”
More expensive – issue especially for home care, long-term care settings
“True nursing
ignores infection,
except to prevent it”
Florence Nightingale, Notes on Nursing
Questions, Comments, and
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