Shannon Oriola, RN, CIC, COHN is the lead in infection prevention and clinical epidemiology at Sharp Metropolitan Medical Campus in San Diego, CA.

1. Has your institution/facility identified a facility-specific “bundle”(products, protocols) to reduce the occurrence of CABSI? What are the elements of that bundle?

We are using the IHI (Institute for Healthcare Improvement) bundle. It has 5 elements:

• hand hygiene
• maximal barrier precautions upon insertion
• skin antisepsis with chlorhexidine
• optimal catheter site selection, with the subclavian vein as the preferred site for non-tunneled catheters
• daily review of line necessity with prompt removal of unnecessary lines

2. How did your facility determine this bundle, and how was it implemented?

We were part of the 100,000 Lives Campaign, which created a platform for our cause for action. Also, California state legislation required us to report process measures with regard to infection control. We were engaged in developing a process module, but it was not yet implemented throughout the facility. When we looked at elements of the IHI bundle, it was the obvious choice.

We decided to implement it first in high-volume insertion areas: operating rooms, the emergency department, and interventional radiology suites, followed by the ICUs. We instituted a task force to manage implementation, because it was important to get all of the stakeholders to buy in to the concept. We began by getting key physicians and nurse educators involved.

There was a little controversy at first—for instance, intensivists were not happy about using long drapes; we now supply 2 half-drapes instead of 1 full drape. We were also faced with the fact that the vascular access team does not work after hours. We solved that by having each unit identify key people responsible for changing central venous catheter dressings when necessary. I’m not aware of any reluctance to participate in the audit process on the part of people such as nurses and doctors. We’ve been able to get everyone on board with the idea.

We haven’t quite finished implementing the bundle. The last element is the daily review of line necessity, something also required by the California Department of Health Services. The  relevant patients’ electronic medical record will prompt the nurse daily to evaluate the need for the central line. This will also make it easier to audit and document the process. We’re currently using exclusion criteria. If the patient does not meet criteria for a central line, the nurse will communicate with the physician to determine if the central line is still necessary.

3. What are the elements—products and procedures—of your organization’s bundle that have produced positive outcomes?

Because we’re still implementing the bundle, it’s hard to say for sure. One concept that our medical executive committee has embraced is that of having an observer for each procedure. In our hospital, a nurse observes the process each time a central line is inserted and can stop the procedure if the elements of the bundle are not being adhered to.

We also have infection-prevention associates (IPA) throughout the hospital. Each unit sends a nurse to meet once a month to discuss infection prevention and control issues, and the IPA is considered an infection-prevention resource on the unit. IPAs identify and report on practices that may not be in accordance with hospital policy; they also communicate unit-specific surveillance data to their peers. IPAs are also instrumental in communicating changes in policy that are related to infection prevention. Many participate in our quality improvement projects such as the ventilator-associated pneumonia (VAP) task force and central-line infection prevention efforts. We recently added other disciplines—imaging and respiratory care, for example—to our associates’ program. This program has been extremely helpful in communicating information to direct healthcare providers.

a) Can you tell us about site preparation, connectors, flushing protocols, etcetera?

We use a chlorhexidine gluconate and alcohol solution to prepare the site. Our clinicians have been using dressings impregnated with chlorhexidine for several years. Our IPAs audit central-line dressings to ensure that they’re done appropriately. One item of note: We have not introduced silver technology into our interventions designed to reduce bloodstream infections associated with central venous catheters (CVCs).

For Luer-lock injection caps, we’ve gone from positive-pressure to neutral-pressure devices. These neutral-pressure devices are flushed with saline solution. We’re still using positive-pressure devices in the NICU (neonatal intensive care unit), but there are issues that must be addressed separately in that environment. Making decisions for the NICU must be a separate process in itself.

There is not an abundance of literature on how long to clean the injection caps. An article on the topic1 gives evidence for scrubbing the hub for 15 seconds with alcohol or a chlorhexidine-alcohol solution; we use that as evidence for our practice recommendation. The Centers for Disease Control and Prevention (CDC) recommend using single-dose vials (Category II) and not using any leftover content in those vials (Category IA). We try to utilize single-dose vials when possible. Our facility has also developed an order set for flushing central venous catheters. The correct flushing protocol is selected on the order set by the physician or vascular access nurse.

b) Do you feel that a renewed emphasis on staff education may be necessary to reinforce good practice for antisepsis of valves? of any other elements?

Yes. We provide real-time feedback to a unit where a CVC-associated bloodstream infection occurs. We also offer Web-based self-learning modules. When we were implementing the bundle, there was a mandatory one-time Web-based module that each nurse was required to take.

c) What methods have proven most beneficial for you in improving decontamination of IV ports?

We require that the port be scrubbed with an alcohol pledget for 15 seconds. It’s difficult to audit decontamination of IV ports and of Luer-lock injection-cap changes. At our next IPA meeting we’ll be discussing how to increase compliance with our policies. We also plan to audit decontamination of the cap during our med pass audits.

4. What would you consider the reasons for your success in reducing CABSI? What do you feel still needs to be done?

Throughout the hospital we have the vascular access team place the majority of peripherally inserted central catheters (PICCs) and do the dressing changes. In the ICU the rate of CABSI has declined over time because of multiple interventions, some specifically mandated in the bundle. Incidence has declined by over 25% throughout the facility. We know that central-line insertions taking place outside the ICU can be problematic; for example, the required equipment is not always available. That’s one of our next areas of focus.

The decline in our CVC-associated bloodstream infections is occurring because administration, staff, and physicians are embracing the culture of patient safety. We have buy-in from all areas. And when there’s a problem, we aren’t punitive; we emphasize teaching, not blame.

5. Many think of blood reflux as a risk factor only for occluded lines. Do you feel enough attention has been paid to blood reflux and the role it can play in CABSI?

No, not enough attention has been paid to what the reasons may be for occlusion. I think that we need more research on central-line occlusion—for instance, it’s difficult to determine if there is blood left in the injection cap. At this time there is only one company that manufactures a clear injection cap that can be assessed for blood left after flushing, and further research in this area is needed. But we also have to look at why a line is placed in the first instance. As our organization improves in our adherence to our process measures, we’re hoping to reduce the number of central lines placed in our patients.

6. Is there anything else on this topic that you feel should be mentioned?

Of course, we advocate attention to patient safety for its own sake, but it’s also wise to keep in mind that increasingly fewer payors are underwriting the costs of CABSI. If you’re interested in doing more about CABSI prevention, APIC (Association for Professionals in Infection Control and Epidemiology) offers the toolkit Eliminating Catheter-related Complications; it’s available from the APIC website at www.apic.org. The CDC offers helpful guidelines at http://www.cdc.gov/ncidod/dhqp/gl_intravascular.html.

Reference
Kaler W, Chinn R. Successful disinfection of needleless access ports: a matter of time and friction. J Assoc Vascular Access. 2007;12(3):140-142.