Bloodstream Infections related to Central Lines

1
Bloodstream Infections related to Central Lines

• LMCs goal for 2011
• 0 infections for 11 months out of this year

2
What are the facts?

• Since 2008, the CDC has published information
  estimating that 92,011 central line associated
  bloodstream infections (CLABSIs) occur annually
  just in the United States.
• Each case can increase hospital costs by 5,734
  up to 25,546.
• CLABSIs cause an estimated 28,000 deaths in ICU
  patients annually.
• (APIC, 2009)

3
So what can we do?

• As always, we at LMC want the best outcomes for
  our patients. LMC has set goals for 2011 to
  significantly reduce any bloodstream infections.
• Our central line policy and procedure has been
  updated to include the most recent evidence based
  information.
• LMC is also implementing care bundling for
  central line insertion and care to decrease
  CLABSIs.

4
Central Line-Definition

• An intravascular catheter that terminates into
  the inferior vena cava used for infusion,
  withdrawal of blood, or for hemodynamic
  monitoring (APIC, 2009).

5
Indications for Central Lines

• Blood loss
• Hypotension
• Hemodialysis access
• Total parenteral nutrition or other hyperosmolar
  solutions
• Lack of peripheral venous access
• Infusion of medicines long-term
• Volume measurements

6
Anatomy Physiology

• Veins used for Central Venous Access
• Internal jugular vein
• Subclavian vein
• Femoral vein
• Basilic or Cephalic vein
• (Scales, 2010)

7
Subclavian Vein

• Subclavian vein is a continuation of the axillary
  vein and then joins the internal jugular vein to
  become the innominate vein.
• In front of the clavicle.
• Behind and above the subclavian artery and
  separated medially by
• the Scalenus anterior and
• the phrenic nerve.
• Below it sits at the first rib
• and the pleura (Gray, 2000,
• para 15).

8
Internal Jugular Vein

• The internal jugular vein receives blood from the
  brain, the superficial parts of the face, and the
  neck and has its origin at the compartment of the
  jugular foramen, at the base of the skull.
• Glossopharyngeal hypoglossal nerves pass
  forward between the vein and artery.
• Vagus nerve is between and
• behind the internal jugular vein
• and artery in a common sheath.

9
Internal Jugular Vein (cont)

• It runs in vertical direction on the side of
  neck.
• Lateral to internal carotid artery
• Lateral to common carotid
• Unites with subclavian vein to become the
  innominate vein.

10
Internal Jugular Vein (cont)

• At origin and termination there is a small
  dilation bulb
• Above, internal jugular lies on Rectus capitis
  lateralis, behind internal carotid artery and
  nerves passing through jugular foramen
• At the root of the neck, the right internal
  jugular vein, there is very little distance from
  the common carotid artery and crosses the
  beginning of the subclavian artery.
• Left vein usually smaller than the right (Gray,
  2000, para 6).

11
Femoral Vein

• The neurovascular bundle consists of the femoral
  vein, artery, and nerve, and lies within the
  triangle in a medial-to-lateral position. The
  femoral sheath encloses the femoral artery and
  vein, and the nerve lies outside the
  sheathDistally in the leg, the femoral vein lies
  almost posterior to the artery (Pal, 2009, para
  6-9).

12
Basilic Veins

• Runs up the posterior surface of the ulnar side
  of the forearm.

http//www.learnerhelp.com/images/cubital20fossa
202.JPG
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The Best Site ?

• Subclavian vein may have lower risk of central
  line-associated bloodstream infection (CLBSI)
• Increased risk of pneumothorax
• Increased bleeding
• Internal jugular vein less risk of pneumothorax
• Disadvantage with obese patients
• Femoral vein increased risk of infection and deep
  venous thrombosis in adults
• Hematoma
• Femoral artery puncture
• Basilic vein increased risk of thrombosis
• (Wiegand Carlson, 2005)

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Types of Catheters

• Nontunneled catheters indicated for short-term
  use
• Tunneled catheters
• Implanted catheters (ports)
• Peripheral inserted central catheters (PICC)

15
Tunneled Catheters

• Associated with lower infection rates than
  nontunelled
• More complex insertion and removal
• Indicated for chemotherapy, antibiotics,
  parenteral feeding, blood products, and frequent
  blood draws
• Long-term (gt30 days) central venous access
• With and without Dacron anchoring cuffs

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Non-Tunneled Catheters

• Large-bore catheters 6-8 in. long
• One to four lumens
• Short-term (lt10 days) central venous access
• Highest risk of infection
• Easy to insert and remove

17
Implanted Ports

• Lowest rates of CLBSI
• Surgical insertion and removal
• Long-term intermittent therapy.
• No external catheter
• Low maintenance

18
PICC

• Ambulatory or outpatient therapy
• Easy to insert and remove
• Longevity
• Incidence of malposition greater

19
What is care bundling?

• 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 (www.ihi.org). 
• Evidence based research on care bundling has
  shown positive impact.

20
Central Line Bundle

• Defined as A group of evidence-based
  interventions for patients with intravascular
  central catheters that, when implemented
  together, result in better outcomes than when
  implemented individually (www.ihi.org).

21
Central Line Insertion Bundle

• Cleanse hands (ask if unsure)
• Use chlorhexidine
• Use maximal barrier precautions
• Wear sterile gloves, cap, mask, gown (for the
  physician placing the central line)
• Large drape to cover patient
• All personnel in room wear a mask

22
Central Line Maintenance Bundle

• Review daily for continuous need
• Maintain occlusive dressing
• Change dressing per hospital protocol
• Scrub hub for minimum of 15 seconds prior to
  accessing the line
• Hand hygiene before after procedure

23

• Performing each bundling step in order when
  either assisting with a central line insertion or
  caring for a central line will help to reduce
  your patients risk for infection.

24
Instructional Video
http//lexloop/videopages/Central_line_dressing_ch
ange2010.html 
Right click on link above and choose open in new
window. This will allow you to return to the
PowerPoint after viewing video.
25
Another Safety Feature with Central Lines

• In dealing with central line and patient safety
  another concern is making sure you as the
  practitioner are certain of the type of central
  line placed.
• LMC has an increasing number of patients
  presenting with ports that are power-rated and
  there are special needs to be considered.

26
PowerPort Implanted Infusion Devices

• Implanted ports that are PowerPorts or
  power-rated (able to withstand higher psi, such
  as with CT contrast) have to be identified using
  specific criteria.
• It can be very detrimental to mistake these
  devices and use with too much psi with a non
  power-rated port. Patient safety is our utmost
  focus here.

27
Power Port

• Power needles for power ports will only be used
  when the RN is able to verify that the port in
  place is in fact a power port.
• Verification must be done as follows
• The patient has a card/ documentation verifying
  that it is a power port.
• The patients medical record indicates they have
  a power port.
• Note Verbalization from the patient is not
  acceptable confirmation.

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If documentation not available

• If the RN is unable to verify the port as a power
  port through acceptable documentation, then only
  the Huber Plus Safety needle will be used.
• Again one of the two documentation criteria
  provided must be present to access port with a
  power needle.

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THANK YOU!!!

• Again quality patient outcomes are our focus at
  LMC.
• Thank you for taking time to put patient safety
  first.

30
References

• APIC. (2009). Guide to the elimination of
  catheter-related bloodstream infections.
  Washington APIC.
• Gray, H. (2000). The veins of the neck. In W. H.
  Lewis (Ed.), Anatomy of the human body. Retrieved
  from http/www.bartleby.com/107/168.html
  (Original work published 1918)
• Implement the Central Line Bundle (nd) Institute
  for Healthcare Improvement. Retrieved from
  www.ihi.org.
• Pal, N. (2009, April). Central Venous
  Access,Femoral Vein. Emedicine. Retrieved from
  http//emedicine.medscape.com/article/80279-overvi
  ew
• Scales, K. (2010). Central venous access devices
  part 1Devices for acute care. British Journal of
  Nursing,19(2), 88-92. Retrieved from CINAHL Plus
  with Full Text
• Wiegand, D. Carlson, K. (2005). AACN Procedure
  manual for critical care. St. Louis Elsevier
  Saunders.