Achieving Zero Catheter Related BSIs

Submitted by Carolyn Johnston IVNNZ Inc. Educator. Orginally printed in IVNNZ Inc. Newsletter March 2008

Achieving Zero Catheter Related Blood Stream Infections

Sophie Harnage, (Clinical Manager Infusion Therapy Services) at Sutter Roseville Medical Center (SRMC) California, presented this paper at the 21st Annual Association Vascular Access (AVA) Conference in September 2007.

"Achieving Zero Catheter Related Blood Stream Infections: 15 month success in a community based medical center". The following is an account of how SRMC achieved such success.

Historically it has been acceptable for a hospital's rate of catheter-related blood stream infections (CRBSI's), to be at or below the Centers for Disease Control's (CDC's) rate of 5.7 per 1,000 catheter days. (Centers for Disease Control and Prevention, 1998). In the United States, multiple organisations, including the Institute for Healthcare Improvement, The Joint Commission, and the Agency for Healthcare Research and Quality, have undertaken improvement initiatives to help clinicians attain the goal of zero tolerance.

SRMC is a 180 bed acute care, with 32 critical care beds, a 31 bed emergency department and level two trauma centre. During 2005, the infusion therapy team at SRMC inserted 767 Peripherally Inserted Central Catheters (PICCs) using Modified Seldinger technique without ultrasound guidance. Insertion success rate was 92%, with 8% insertion by the interventional radiology department. There were eleven occurrences of CRBSI in 2005. The following areas were identified as attributing factors;

• Inconsistency in Central Venous Catheter (CVC) management
• Inadequate site preparation to maintain sterility during catheter placement
• Failing to properly disinfect needleless access ports
• Lack of basic hand hygiene.

It was necessary to review current practice and develop a consistent standard of care for all staff working at SRMC, based on best practice models. Lowering the CRBSI rate decreases inpatient length of stay and improves patient satisfaction (Rickard, 2003). A central line bundle* was implemented in January 2006. Seven practices were identified. Three extraluminal and three intraluminal practices, plus constant PICC team monitoring were chosen; Extraluminal Practices

• Maximal barrier precautions including addition of full body drape for all central line insertions
• All PICC's placed by ultrasound guidance / basilica vein, upper arm vein of choice
• Central venous line dressing pack to include an antimicrobial dressing, Chlorhexidine based swabs and a securement device

Intraluminal Practices

• Cleanse IV connector ports with 70% isopropyl alcohol for 5-10 seconds with a vigorous back and forth motion
• Positive Displacement Device
• Turbulent flushing technique with 10mls of 0.9% sodium chloride every 8 hrs

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 (Institute of Health Care Improvement).

The infusion therapy team claimed ownership of PICC insertion and maintenance of vascular access devices. From January 2006 through to March 2007, the infusion therapy team inserted 2,083 PICC lines per ultrasound guidance. This was a 172% increase in PICC insertions over a 15 month period. Insertion success rate by the infusion team was 98%, a 6% improvement, with 2% requiring interventional radiology PICC insertion. From January 2006 to March 2007 there were zero occurrences of CRBSI.

The development and implementation of a central line bundle reduced the numbers of CRBSI's to zero at SRMC. Seven practices became standardised, and key factors were identified and incorporated into this implementation process. These included a back to basic's approach with hand hygiene and aseptic technique. Appropriate education and one to one training provided to all staff who were involved in the management of PICC's. And the management PICC's was overseen daily by a dedicated PICC team member.

A full report is now available in the Journal of the Association for Vascular Access. Winter Edition (2007) Vol,12,(4).

References:

Center for Disease Control and Prevention. (1998). National Nosocomial Infections Surveillance (NISS) System report, data summary from October 1986- April 1998, issued June 1998. American Journal of Infection Control 26(5):522-533.

Harnage, S. (2007). Achieving Zero Catheter Related Blood Stream Infections: 15 Months Success in a Community Based Medical Center. The Journal of Association for Vascular Access.12(4), 218-224.

Institute of Health Care Improvement - Care bundle definition retrieved 25/01/08

http://www.ihi.org/ihi/topics/criticalcare/intensivecare/changes/implementthecentrallinebundle.htm

Rickard, N (2003). Reducing infections associated with central venous catheters.  British Journal of Nursing. Mar 13-Mar 26, 12,(5).  pg. 274, 8 pgs