REDUCING CENTRAL VENOUS CATHETER RELATED BLOOD STREAM INFECTIONS

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REDUCING CENTRAL VENOUS CATHETER RELATED BLOOD
STREAM INFECTIONS

• Presented by Stephen Jaime, RN
• Juanita Martinez, RN
• Ashley Valencia, RN
• Jennifer Valenzuela, RN

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CATHETER RELATED BLOOD STREAM INFECTIONS(CRBSI)

• Morbidity 250,000 cases of central line
  associated bloodstream infections occur in US
  hospitals annually (CDC 2003).
• Mortality Approximately 30,000 to 62,000
  patients who get CRBSI die (CDC 2003).
• Reducing catheter related blood stream infections
  is a 2008 National Patient Safety Goal.

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CRBSIPORTS OF ENTRY
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CAUSES of HUB COLONIZATION

• Skin contamination
• Inadequate hand hygiene
• Failure to use aseptic technique
• Frequent opening and manipulation
• Failure to change needle-free system

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Needle-Free Access Devices
Split Septum
Neutral Displacement
Negative Pressure
Positive Pressure
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PICO

• Does the use of specific needle-free connectors
  decrease the incidence of central venous catheter
  related blood stream infections (CRBSI) in adult
  patients?

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PICO

• Population Adult patients with CVC
• Intervention Standardize the use of neutral
  displacement needle free connectors in all units
• Current Practice The use of positive pressure,
  negative pressure, and neutral displacement
  needle-free connectors
• Outcome Decrease CVC blood stream infections

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Staff Query

• In October 2008, clinical staff at ECRMC were
  unaware of the role that a needle-free connector
  has in reducing CRBSI
• Clinical staff were unaware of differences
  between needle-free connectors

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REVIEW OF LITERATURE

• Databases Used

• Key Search Terms

• CINAHL
• EBSCO Host
• Cochrane Library
• CDC
• Google Scholar
• Medline Plus
• Web MD

• Central venous catheters
• Blood stream infections
• Negative and positive pressure needle-free valves
• Mechanical valves
• CRBSI
• Hub colonization
• Needless IV access devices

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BODY OF EVIDENCE

• Out of 22 articles, 10 articles were relevant
  to the clinical issue

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EVIDENCE HIERARCHY

• Systems 1
• Synopses of Synthesis 9
• Synthesis 1
• Synopsis of Single Studies 8
• Single Studies 3

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RESEARCH ANALYSIS

• The most common cause of tip and hub colonization
  is frequent opening manipulation
• Improper maintenance techniques contribute to
  colonization
• In a randomized study of 352 heart surgery
  patients, CVCs with neutral displacement were
  less likely to have hub colonization p value
  0.0001 (Bouza, 2003)
• This is statistically significant.

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Research Continued

• Split septum
• May have increased occlusions
• Negative pressure at disconnect
• Negative pressure needle-free connectors
• Allow blood to infiltrate hub
• May increase BSI
• Positive pressure needle-free connectors
• May increase BSI
• May be linked to improper technique of clinical
  user, and mechanism failure

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RESEARCH CONTINUED

• Neutral displacement needle-free connectors
• Inhibit blood regression into hub
• Are associated with decreased BSI rates
• In one particular study, Johns Hopkins Hospital
  switched to positive pressure valves from neutral
  displacement and saw increased infection rates.
• Rates per 1,000 catheter days increased from 1.50
  with neutral displacement to 2.40 with positive
  pressure in the ICU p 0.05 (Jarvis, 2006)
• Johns Hopkins returned to neutral displacement

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Research Conclusions

• Neutral displacement needle-free connectors may
  reduce BSI.
• Conflicting research on positive pressure
  needle-free connectors exists
• Further research needs to be conducted on the
  issue

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CURRENT PRACTICE(Fall 2008)

• Neutral displacement needle-free connectors are
  not currently used on CVCs at ECRMC.
• No specific policy exists R/T changing
  connectors.
• Multiple connector types are used throughout the
  hospital

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INTERVENTIONS

• Standardize needle-free neutral displacement
  connectors throughout ECRMC.
• Institute a connector change policy per
  manufacturers recommendation.
• Implement proper disinfection technique every
  time port is accessed.
• Educate staff on maintaining line sterility.
• Using sterile caps when IV tubing is
  disconnected.
• Include the infection control specialist for
  standardization.

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CHANGE THEORY
Lewin/ Scheins Change Theory

• Stage 1 FROZEN
• Motivation to change
• Stage 2 UNFROZEN
• Change what needs to be changed
• Stage 3 REFREEZING
• Making a permanent change

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Stake holders

• Management

• Clinical

• Board of Trustees
• CEO
• Chief Nursing Officer
• Department Manager
• Case Manager
• Clinical Manager

• Clinical Educator
• Charge Nurses
• Clinical Staff
• Infection Control

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Swot Analysis

• Strength

• Weakness

• May decrease BSI
• Easy to implement
• Low cost

• Further research needed
• Conflicting research R/T
• positive pressure valves.

Opportunities
Threats

• 2009 Safety Goal
• Better patient outcomes
• Implementation ease
• Low cost change
• Hospital Savings

• Resistance to change
• Knowledge deficit

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COST/BENEFITS

• Blood stream infections extend hospital stay with
  a cost of 33,000 to 35,000 per patient.
• Medi-care/ Medi-cal will no longer reimburse for
  hospital acquired infections.
• Saline flush instead of heparin flushes are
  required for neutral displacement connectors.
• Specific type of neutral displacement connectors
  are as low as 1.07 each (Hospital Materials
  Management, 2008)

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TIME LINE
December 2008 January 2009 February 2009
Product Introduction Purchasing Clinical educators in-services. Present concept at unit staff meetings. Implement product. Complete implementation Maintain education via clinical educators Monitor policy compliance
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References

• 1. David, V. E. A. (2008, October 14).
  Cost-Effectiveness of antiseptic-Impregnated
  central venous catheters for the prevention of
  catheter-Related bloodstream infection. American
  Medical Association, 282(6).
• 2. E, B. E. A. (2003, March 1). A neeleless
  closed system device (Clave) protects from
  intravascular catheter tip and hub colonization
  A prospective randomized study. Journal of
  Hospital Infection, 26(2), 54279-287. Retrieved
  from www.sciencedirect.com.
• 3. J. R. Gowardaman Et Al. (1998, February 1).
  Central venous catheter-related bloodstream
  infections An anaylsis of incidence and risk
  factors in a cohort of 400 patients Electronic
  version. Intensive Care Med, 24, 1034-1039. .
• 4. Jeffrey, B. E. A. (2007, July 1). Prevention
  of intravascular catheter-related infections.
  Retrieved from Up to Date www.uptodate.com/onlin
  e/content/topic/.do?topicKeyhosp_inf/7730viewpr
  int.
• 5. Juan, Y. E. A. (2003). Resistance to the
  Migraton of Microorganisms of a Needle-Free
  Disinectable Connector, 31(8).
• 6. Meredit Desmond. (2006, February 3). CDC
  recommendations to rduce central line
  infecitions. American Family Journal, 73(3),
  546-547.
• 7. Mermel, L. A. (2001, April 1). New
  technologies to prevent intravascular
  catheter-Related blood stream infections
  Electronic version. Emerging Infectious
  Diseases, 7(2), 197-199. .
• 8. Maki, D. M., Stolz, S. M., Wheeler, S. R.,
  Mermel, L. D. (1997). Prevention of Central
• Venous Catheter-Related Bloodstream
  Infection by Use of an Antiseptic-Impregnated
  Catheter. Annals of Internal Medicine, 257-266.
• 9. Pagani, J. E. (2008, April 16). Management of
  Catheter-related Infection. Retrieved November
  7, 2008, from Medscape http//www.medscape.com/v
  iewarticle/571265
• 10. Sadoyama, G. F. (2003). Comparison Between
  the Jugular and Subclavian Vein as Insertion Site
  of Central Venous Catheters Microbiological
  Aspects and Risk Factors for Colonization and
  Infection. The Brazilian Journal of Infectious
  Diseases , 142-148.
• 11. Sadoyma, G. F. (2006). Central Venous
  Catheter-Related Bloodstream Infection Caused by
  Staphylococcus aureus Mircrobiology and Risk
  Factors. The Brazilian Journal of Infectious
  Diseases , 100-106.
• 12. Safdar, N. M. (2004). The Pathogenesis of
  catheter-related bloodstream infection with
  noncuffed short-term central venous catheters.
  Intensive Care Med , 62-67.

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References Continued

• 13. Yebenes, J. M., Delgado, M. M., Sauca, G. M.,
  Serra-Prat, M. M., Solsona, M. M., Almirall, J.
  M., et al. (2008). Efficacy of three different
  valve systems of needle-free closed connectors in
  avoiding access of microorganisms to endovascular
  catheters afte incorrect handling. Crit Care Med
  , 2558-2561.
• 14. Yebenes, J. P.-P. (2003). Prevention of
  catheter-related bloodstream infection in
  critically ill patients using a disinfectable,
  needle-free connector A randomized controlled
  trial. AJIC, 291-295.
•  
• 15. Akmal, A., Hasan, M., Mariam, A. (2007).
  The Incidence of Complications of Central Venous
  Catheters at an Intensive Care Unit. Annals of
  Thoracic Medicine, 2, 61-63.
• 16. Maragakis, L., Bradley, K., Song, X., Beers,
  C., Miller, M., Cosgrove, S., Perl, T. (2006).
  Increased Catheter-Related Bloodstream Infection
  Rates After the Introduction of a New mechanical
  Valve Intravenous Access Port. Infection Control
  and hospital Epidemiology, 27, 67-70.
• 17. Marschall, J., Mermel, L., Classen, D.,
  Arias, M. (2008). Strategies to Prevent Central
  Line-Associated Bloodstream Infections in Acute
  Care hospitals. Infection Control and
• Hospital Epidemiology, 29, 522-530.
• 18. Shannon, R., Frndak, D., Grunden, N.,
  Lloyd, J. (2006). Using Real-Time Problem Solving
  to Eliminate Central Line Infections. Journal on
  Quality and Patient Safety, 32, 479-487.
• 19. Shorr, A., Humphreys, C., Helman, D.
  (2003). New Choices for Central Venous Catheters.
  Chest Journal, 124, 275-284.
• 20. Templeton, A., Schegel, M., Fleisch, F.,
  Rettenmund, S., Henz, S., Eich, G. (2008).
  Multilumen Central Venous Catheters Increase
  Risk for Catheter-Related Bloodstream
• Infection Prospective Surveillance Study.
  Infection, 36, 322-327.
• 21. Yebenes, J., Martinez, R., Serra-Prat, M.,
  Sauca, G., Capdevila, J., Balanzo, X., Palomar,
  M. (2003). Resistance to the Migration of
  microorganisms of a Needle-free Disinfectable
  Connector. American Journal of Infection Control,
  31, 462-4.