I need some help from my fellow picc experts. We have recently had an increase in CLABSI's over the past two months(PICC lines and other central lines included). We have not changed anything with the exception of adding a biopatch to every dressing change. Nearly every one of the infections are 7 days or longer post-insertion, yet our IC department keeps requesting a root cause analysis from us - the PICC team. We have informed them that most likely these are related to catheter care and manipulation (i.e. failure to perform handwashing, maintaing integrity and sterility of dressing, scrubbing the hubs properly etc. etc.) and that if the infection was insertion related, it should occur withing 24 - 48 hours. Are we correct, can you give me some published studies/documentation about this. I really want to work with IC to resolve this problem, but can't get past the fact they seem to place the blame on the picc insertion nurses. Our team only consists of myself and one other nurse, hence we are not able to have a dedicated team to follow the picc lines through the patients entire LOS - I am going to start pushing for this, but with budget cuts, may not be successful yet. I know this is a start, I just need some more powerful information to provide to my IC. thanks for your help.
You are correct about insertion or skin related causes of CRBSI occurring within the first week of dwell. After the first week, the cause is commonly hub related. Here is a list of all the nursing actions that can increase the risk of intraluminal biofilm and therefore the subsequent CRBSI:
Failure to clean the hub and connection surface of a needleless connector, although there are no studies that provide any direction on the best agent, technique, cleaning time or drying time
Design of the needleless connector - some have greater risk than others and SHEA is the only set of guidelines that states to avoid use of positive displacement connectors unless you have performed a detailed risk-benefit analysis
Use of intermittent IV sets beyond 24 hours - no evidence to support this as a safe practice
Using catheters for drawing blood samples - increases hub manipulation
Anything and everything you do to the catheter hub increased the risk of infection
There is a study from Dr. Maki's group that identifies the causes of CRBSI. I can not locate the exact reference, but about 40% were found to be from extraluminal sources, about 25% from intraluminal sources, and the rest was undetermined. You must look at all causes, not just insertion issues.
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Lynn
thank you for your reply and help. I am confused though. I understand what you mean by there are no studies regarding the agent to cleanse with, the amount of time needed to cleanse and time to dry; however, is the 10 - 15 second scrub recommended by CDC just that - a recommendation, how did they come up with that time frame? Also, didn't one of our colleagues (I am sorry I can't remember her name) present a study at AVA in Phoenix in 2007 about a study she did regarding cleansing times of hub caps using alcohol - I know she stated she had taken many of these caps home and worked on this study, maybe it wasn't published? One other question, you stated SHEA has a set of guidelines to avoid the use of positive displacement connectors unless an analysis has been performed about the risk-benefit, I thought we wanted positive displacement? Is a neutral displacement cap the way to go? Thanks for your input
To my knowledge, CDC has not recommendations including a time for cleaning. So I don't know what CDC document you are referring to. There is a study from JAVA a couple of years ago which tested 15 seconds scrub with CHG/IPA and IPA alone and found both were acceptable. They tested for a 2 log reduction of organisms, however the new guidance document from the FDA requires manufacturers to test for a 4 log reduction. That study choose 15 seconds because she thought that was the "standard of care" but it has never been established as that. Actually, the studies and reports continue to show that split septum devices have a lower rate of infection. A positive displacement mechanical valve is not the standard of care. Positve displacement can be achieved by flushing technique which is required with all of the negative displacement devices. If you will be at AVA, I am giving 2 presentations related to this topic. Hope to see you there. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Lynn,
I respectfully agree and disagree with your above comments regarding needleless connectors. I think that we can all agree that positive displacement can be achieved by flushing technique with a negative displacement connector. However, this is completely dependent on human intervention.
The one area that I respectfully disagree on is regarding the SHEA/IDSA guidelines and positive displacement connectors.
BII).
88-91
a. Routine use of the currently marketed devices that
are associated with an increased risk of CLABSI is not
recommended.
Not all positive displacement connectors are asccoiated with increased risk of CLABSI. Actually, there are some positive displacement connectors that have shown reduction in CLABSI compared to split septum connectors. Personally, I dont care if we talk about positive, negative, or neutral. I think we all need to start looking at "Device Design" If we really look at the literature....device design influences outcomes. Unfortunately, for the positive displacement connector class there are a number of very poorly designed connectors. However, not all of them fall in that category. The same is true for every class.....positive, negative, and neutral.
The data references on the SHEA/IDSA guidelines do not point to all positive displacement connectors. They point to positive displacement connectors that have been involved with increases in CLASBSI. Not all positive displacement connectors are included in this literature review.
Many facilities have experienced very good outcomes with each class of connector. I think we need to get away from Positive, Negative, Neutral and look at device design. My opinion is it is the device design that truly influences the outcome. Again, this is just my opinion and I have always repected the opinions of those that have contributed to this board.
CR-BSI reduction is complicated. The best place to start the investigation is with the micro-organism. It tells you a great deal. For instance a fungal infection takes longer to occur so it may be caused at insertion but will not surface until after your 48 hour time period. Also fake nails and chipped nail polish have been associated with fungal infections. One issue that is often missed is the June and July is when there is a lot of hospital turnover and vacations. While I can quote one - it would be older- it has been shown that July commonly has poorer rates than some other months. The intraluminal fluid pathway has been identified as a nidus for infection. With the use of the IV route of administration almost exclusively in the practice setting, it is paramount that septum disinfection and strategies to prevent wall conditioning with fibrin be instituted. Some of these strategies can be technology such as the biopatch you are currently using and zero fluid displacment connector such as offered by RyMed technologies but thes add redundancy to nursing practice not replace nursing practice. Prevention must include numerous actions. The entire CR-BSI cascade must be attacked - disinfection and adhesion prevention must be the cornerstones.
Denise Macklin
Karen your team is not the fault if an CLABSI happens after 48 hrs then it is care and maitenance that is causing the infection. You need to evaluate the cap you are using and have a strong policy on flushing and swabbing! What cap are you using?
Karen,
We struggled with our CVC BSI group for months about this. I finally insisted that they run the report on the number of days from insertion that the BSI occurred. They found that 85-89% of all CRBSIs (non-tunnelled and PICC) occurred after 7 days and they were in agreement that we needed to focus on the care and maintenance. We had 0 PICC infections occur within the 7 day time period.
We proceeded with massive education about care and maintenance and then began to show the decrease in CRBSIs.
I understand your discomfort at this time. I would challenge them to provide information that would indicate that the CRBSIs are insertion related.
Gwen Irwin
Austin, Texas