Risk and Prevention of CRBSI Associated with Acute Hemodialysis Catheters Faisal Masud MD, FCCP,...

Risk and Prevention of CRBSI Associated with Acute Hemodialysis Catheters

Faisal Masud MD, FCCP, FCCM

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Disclosures

• This event is sponsored by Teleflex Medical.

• Dr. Masud is a consultant for Teleflex Medical.

• Views and opinions expressed are those of Dr. Masud and do not necessarily represent the opinions and policies of Methodist Hospital and/or Methodist DeBakey Heart & Vascular Center.

• Dr. Masud did not disclose any conflicts of interest in relation to this presentation

Learning Objectives

• List the risks of bloodstream infections (BSI) associated with acute hemodialysis catheters.

• Describe evidence-based strategies to reduce BSI associated with hemodialysis catheters.

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Continuing Education Credits (CE)

• At the end of this webinar you can obtain 1.0 contact hour by going to www.saxetesting.com/vh

• Complete the post-test and evaluation form

• Upon successful submission, you will be able to print out your certificate of completion

• Provider (Saxe Communications) is approved by the California Board of Registered Nursing Provider # 14477

• No off-label use will be discussed in this presentation

Background

Acute kidney injury (AKI): sudden, temporary, and sometimes fatal loss of kidney function

Complications: • Fluid imbalance• High potassium levels• Metabolic acidosis• Damage to other organs

Treatment: •Supportive care•CRRT (Continuous Renal Replacement Therapy)•Hemodialysis

Background (cont’d)

Patients with AKI need acute hemodialysis (HD) catheters.

However, according to Maki: •Acute HD catheters have the highest risk among CVC devices•8% or 4.8 per 1,000 catheter days•From: The Risk of Bloodstream Infection in Adults With Different Intravascular Devices: A Systematic Review of 200 Published Prospective Studies.

Maki DG, et al. Mayo Clin Proc. 2006;81(9):1159-71.

Acute Catheters: Indications for Use

• Rapid fluid administration• Trauma (blood products, saline, volume expanders, etc.)• Septic shock ( saline, vasopressors, volume expanders, etc.)

• Hemodialysis• Extracorporeal removal of waste products from blood:

creatinine, urea and free water

• Hemofiltration/Continuous Renal Replacement Therapy (CRRT)• Similar to hemodialysis• Used almost exclusively in ICU settings• Done slowly over more extended time (12 – 24 hr)

• Apheresis• Extracorporeal therapy• Donor blood passed through an apparatus to separate one

particular component; the rest is returned to circulation

Placement of Acute Catheters

• Internal jugular

• External jugular

• Subclavian

• Femoral

• ARTERY OR VEIN? SPECIFY IF IT’S EITHER OR BOTH.

• ALSO: • Even if most of your audience knows that an acute

catheter = a central line, it needs to be stated somewhere here.

Incidence of Infections with Central Lines

• In 2009, about 18,000 bloodstream infections occurred in ICU patients with central lines.

• About 23,000 more patients who were treated in other areas of the hospital also developed similar infections.

• About 37,000 bloodstream infections occurred in 2008 in hemodialysis patients with central lines.

ADD CDC REF HERE

CDC Data

• In 2010, more than 380,000 U.S. patients relied on hemodialysis.

• 8 in 10 of those patients start treatment with a central line.

• A hemodialysis patient is 100x more likely to get a bloodstream infection from MRSA than other people.

• Rate of hospitalization in hemodialysis patients due to bloodstream infections has increased by 51% since 1993.

United Press International. Using CDC advice, dialysis infections down 32 percent. [Press release]. May 19, 2013 .

Need Title

Delete this and replace with a few bullet points regarding the goal of this report

Dudeck MA, et al. National Healthcare Safety Network (NHSN) Report, Data Summary for 2011, Device-associated Module. Posted online April 1, 2013.

Lab-confirmed Central Line-associated BSI Rates and Central Line Utilization Ratios, 2011


Do you have permission for chart — is it your redesign?

CREATE A TITLE THAT EXPLAINS WHAT THIS CHART SAYS


Do you have permission for chart — is it your redesign?

Impact of Vascular Catheter-related BSI

• What is the rate of CRBSI at your institution? Especially dialysis patients

• Do you know how much CRBSI is costing your institution?

• Is that an acceptable rate?

• What is your goal?

• Have you done everything you can in your facility to achieve your target?

• How can you sustain your effort?

The Seven Deadly Sins

• Deviance• Inattention• Lack of ability• Process inadequacy• Task challenges• Process complexity• Uncertainty• Hypothesis testing• Exploratory testing

Consequences of The Seven Deadly Sins

ADD REF

Poor HumanSystem Interface

TimeShortage

Misperceptionof Risk

Inexperience (notlack of training)

Management Unresponsiveor not Concerned

Unfamiliarity

“Bad outcomes don’thappen here”

Pathogenesis of Medical device-related Infections

Meakins JL, Masterson BJ. Prevention of postoperative infection. ACS Surgery. 2003.

CHAIN OF INFECTIONSusceptible Host

Infectious Agent

PortalOf Entry

Colonization

Infection

Pathogenesis / Technology-based Protocols!



Infectious Agent

PortalOf Entry

Colonization

Infection

Treatment Prevention

Diagnosis

Pathogenesis of Medical Device-related Infections



Infectious Agent

PortalOf Entry

Colonization

Infection

Source Control

Model for Improvement

• What are we trying to accomplish?

• How will we know that a change is an improvement?

• What changes can we make that will result in an improvement?

Act Plan

Study Do

Source: The 5 Million Lives Campaign: Prevent Central Line Infections© Institute for Healthcare Improvement

Role of Leadership

• COMMIT: staff cannot improve without supportive leadership

• SET THE STANDARD: “This is how we will practice”

• FACILITATE RESOURCES: make time to work on testing

• SHARE DATA: to motivate staff for change

Source: The 5 Million Lives Campaign: Prevent Central Line Infections© Institute for Healthcare Improvement

To Be Successful

• SET AN AIM: “Reduce the incidence of central line catheter-related bloodstream infections using the central line bundle.”

• SET A GOAL: “The rate of CRBSI will decrease by 50% in one year using the central line bundle.”

• PLAN WELL: Adopt a change methodology that accelerates improvement such as The Model for Improvement.

Institute for Healthcare Improvement. The 5 Million Lives Campaign: Prevent Central Line Infections.

Extraluminal

Intraluminal

70%*

20-30%*

*Estimated

5 Sources of CLABSI

CITE SOURCE(S) OF IMAGES AND PERMISSION

CDC 2011 GUIDELINES (Complete Title)

• Major areas of emphasis• Provide education/training to clinicians who insert and manage lines.

• Perform periodic assessments of knowledge and adherence to established policies.

• Weigh risks/benefits of placing a central venous device at a recommended site to reduce infectious complications against the risk for mechanical complications.

• Avoid the subclavian site in hemodialysis patients and patients with advanced kidney disease to avoid risk of stenosis.

• Use ultrasound guidance to place central venous catheters to reduce number of cannulation attempts and mechanical complications. U/S guidance should only be used by those fully trained in its technique.

CDC GUIDELINES (cont’d)

• Use maximal sterile barrier precautions: a cap, mask, sterile gown, sterile gloves and a sterile full-body drape for the insertion of CVCs, PICCs, or guide wire exchanges.

• Prepare clean skin with a > 0.5% chlorhexidine preparation with alcohol before central venous catheter and peripheral arterial catheter insertion and during dressing changes. If there is a contraindication to chlorhexidine, use tincture of iodine, an iodophor, or 70% alcohol as alternatives.

• If previous successful implementation of CLABSI reduction strategy is not decreasing:

• Use a chlorhexidine/silver sulfadiazine or minocycline/rifampin impregnated CVC in patients whose catheter is expected to remain in place > 5 days.

• In patients older than 2 months, use a chlorhexidine-impregnated sponge dressing for temporary short-term catheters and appropriate use of Chlorhexidine for skin antisepsis and MSBs.

ADD CDC REF HERE

Key Change: Central Line Checklist (Strategies & NPSG)

• Have identified staff member document compliance with insertion criteria at the time of insertion

• Serves as a reminder of steps vital to central line placement

• Establishes a clear understanding of when breaches should be stopped and effectively defines the reasons for an event report

• Serves as an investigation tool to help learn what factors may have contributed to a complication

• Create a culture of safety and prevention

• Empowers staff to stop line placement if improper techniques are used

• Instruct staff in use of critical communication strategies to facilitate important exchanges

• e.g., “The sterile field has been contaminated,” rather than, “You contaminated the catheter!”


Hand Hygiene 101

• Wash hands if they are obviously soiled

• Wash hands or use an alcohol-based waterless hand cleaner

• Before and after invasive procedures

• Between patients

• After removing gloves

• Before eating

• After using the bathroom

• If contamination is suspected

Centers for Disease Control and Prevention. MMWR. 2002;51(No. RR-16):1-34.Institute for Healthcare Improvement. The 5 Million Lives Campaign: Prevent Central Line Infections.

Evidence-based Best Practices (Strategies & NPSG)

Image provided by author

• Prepping• Cleanse area prior to prep• CDC and nine other organizations prefer a 2%

chlorhexidine-based preparation

• Use back-and-forth strokes for a minimum of 30 seconds

• Completely wet treatment area

• Allow to air-dry for approximately 30 seconds

• Do not blot or wipe dry

• Proper drying promotes maximum activity of the prep as well as best adherence of dressings


What are Maximal Barrier Precautions?

For Provider:

• Hand hygiene

• Non-sterile cap and mask

• All hair under cap

• Mask covers nose and mouth tightly

• Sterile gown/gloves

Improper Proper




For the Patient:

• Cover patient’s head and body with a large sterile drape

What are Maximal Barrier Precautions?

Evidence-based Best Practices



• Use an all-inclusive catheter cart or kit (B-II).

• A catheter cart or kit that contains all necessary components for aseptic catheter insertion is to be available and easily accessible in all units where CVCs are inserted.

At Insertion ( strategies recommendation & NPSG)

The ErgoPack System: Taking the Safest Approach to Catheter Insertion


Maximum Barrier ErgoPack System Complies with CDC, SHEA/IDSA, IHI, INS, JCAHO, NHSN, OSHA Guidelines:• Latex-free components Include: • 21-Step insertion checklist for clinical record• Procedural stop sign• Alcohol hand gel• Hi-lite orange Chloraprep• Biopatch• Tegaderm dressing• Exclusive: 54″ x 96″ head-to-toe drape w/ 18″ x 18″ clear

window with a 4″ fenestration• Cap, gown, mask• Sharps safety features (Safety Glide needles, SharpsAway II

Locking Disposal Cup, Safety Scalpel)• HemoHopper• ARROWg+ard Blue® Catheter (chlorhexidine/silver

sulfadiazine catheter)

Use antiseptic- or antimicrobial-impregnated CVCs for

adult patients (A-I).•The risk of CLABSI is reduced with some currently marketed catheters impregnated with antiseptics (e.g., chlorhexidine-silver sulfadiazine) or antimicrobials (e.g., minocycline-rifampin).•Consider the use of such catheters in these circumstances: •Hospital units or patient populations have a CLABSI rate higher than the institutional goal, despite compliance with basic CLABSI prevention practices. •Patients have limited venous access and a history of recurrent CLABSI. •Patients are at heightened risk for severe sequelae from a CLABSI (e.g., patients with recently implanted intravascular devices, such as a prosthetic heart valve or aortic graft).

Impact of Catheter ( strategies/recommendations)

ADD REF(S)

Most Common Pathogens of CLABSIs

• CDC: the most commonly reported causative pathogens are• Coagulase-negative staphylococci (S. aureus) • Enterococci • Candida spp. • Gram-negative bacilli accounted for 19% and 21% of

CLABSIs reported to CDC.• Migration of skin organisms at the insertion site into the

cutaneous catheter tract and along the surface of the catheter with colonization of the catheter tip is the most common route of infection for short-term catheters

ADD REF(S)

.

ARROWg+ard Blue

• AGB Chlorhexidine/silversulfadiazine fights infection by inhibiting microorganisms from migrating along the exterior surface of the catheter

• > 30 studies and reviews since 1992 demonstrate that it protects against CLASBIs

• Reduces bacterial colonization by 60%

• Reduces catheter-related bacteremia by 80%

Target Zero: Support Evidence-based Practices

.

Pittet D, et al. JAMA. 1994;271(20):1598-1601.

David Redo

The Catheter’s Role in Interrupting Pathogenesis

CITE SOURCE OF IMAGE

• Maximal sterile barrier with effective prepping

• Correct catheter size and tip

• Aseptic care

• Assess and dress

ADD REF

Additional Layer of Protection in Preventing Pathogenesis

CITE SOURCE OF IMAGE AND ACKNOWLEDGE THAT YOU HAVE PERMISSION TO USE IT

• Barrier precautions

• Correct catheter size and tip

• Aseptic care

• Assess and dress

• Antimicrobial catheter

ADD REF

Our Goal

CITE SOURCE OF IMAGE AND PERMISSION

After Insertion ( strategies recommendation and NPSG)

Disinfect catheter hubs, needleless connectors, and injection ports before accessing the catheter (B-II).

NOTE: Before accessing catheter hubs or injection ports, clean them with an alcoholic chlorhexidine preparation or 70% alcohol to reduce contamination.

Important Points re. Dressing

•Allow prep to dry completely

•Maximizes activity of prep

•Allows dressing to stick to skin

•Follow sterile technique•Do not use antibiotic ointment or creams on

insertions sites, except for dialysis catheters•Chlorhexidine-impregnated dressings: Biopatch,

Tegaderm, etc.

• Transparent occlusive dressing; leave in place up to 7 days if clean and dry

Performance Measures (strategies/recommendation)

• Compliance with CVC insertion guidelines as documented on an insertion checklist

• Compliance with documentation of daily assessment regarding the need for continuing CVC access

• Compliance with cleaning of catheter hubs and injection ports before they are accessed

• Compliance with avoiding the femoral vein site for CVC insertion in adult patients

Good Guys Do Win

• A recent study shows that, following CDC recommendations, there Vascular Access-related BSI in hemodialysis patients was reduced by 54%.

• That represented $23,000 in cost savings.

• Data show that 58% fewer bloodstream infections occurred in hospital ICU patients with central lines in 2009 than in 2001.

• Overall, the decrease in infections saved up to 27,000 lives and is associated with $1.8B in excess medical costs. In 2009 alone, reducing infections saved about 3,000-6,000 lives and about $414 million in extra medical costs compared with 2001.

ADD REFS

Summary

• Key Points

• Prevention is the goal

• Right Care, Right Now (for the) Right Patient

• Save Lives, Save Money

• Make business case an issue for hospital administrators

• Make patient care an issue for physicians

• Quality care for both

• Persevere―Change is hard

Continuing Education Credits (CE)

• At the end of this webinar you can obtain 1.0 contact hour by going to www.saxetesting.com/vh

• Complete the post-test and evaluation form

• Upon successful submission, you will be able to print out your certificate of completion

• Provider (Saxe Communications) is approved by the California Board of Registered Nursing Provider # 14477

This webinar will be available for on-demand viewing at

www. Vesselhealth.org

Questions?

Risk and Prevention of CRBSI Associated with Acute Hemodialysis Catheters Faisal Masud MD, FCCP,...

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