There is very little data but several years ago, Dr. Maki did publish a paper on this. Sorry, can't remember the exact name. There is a lot of information in the literature about the fact that there is more biofilm on the extraluminal side of the catheter during the first week. After the first week, there is more biofilm on the intraluminal surfaces. Biofilm is what produces the BSI. Lynn
there is no magic date or time stamp in the liiterature and it is all anecdotal. The problem is when a line is placed the skin is not sterile so organisms from the skin are dragged in via wire, introducer, dilator sheath, catheter etc at insertion. Therefore yoiu cannot really tell from what source the infection is from. care and maintenance or insertion can happen at any time during dwell
Our infection control department is using 48 hours for insertion related?? Seems to me I recall 72 hours discussed at AVA 2012. Anyone have any additional thoughts?
I think they are getting things confused. For a CLABSI, the definition is signs and symptoms that appear within 48 hours of insertion or admission to your facility. This is coming from CDC and has not changed I don't think. Check out CDC website to verify this definition.
To be considered insertion related as the cause of a CRBSI, this time period is 7 to 10 days. After that the risk shifts to the catheter hub as the most common cause of CRBSI. Lynn
The CDC new definition is 2 calendar days- day 1 is the actual date of insertion .... day 2 is when the element starts (i.e fever, leukocytosis etc...) Please keep in mind that other factors has to be considered- does the patient have any other lines( I.e Foleys) in place?
There are numerous articles stating this. I would need to actually look them up and review to give you a good one, and this could be done by you or anyone. Sorry but I can't get to this anytime soon since I am very far behind with projects now. Look for publications by Isaam Raad, Leonard Mermel, or Dennis Maki. Lynn
I would like the chime in on this very interesting discussion. The infection control Czars are always looking at CLBSI's and looking for that root cause. The problem there is NO way to definitively say it's from insertion. Ok, maybe I shouldn't say no way. I would think that if I insert a PICC using the establiished method of insertion. The PICC is not disburbed for 48 -72 hours then blood is taken and a positive culture of Staph is found. Then , I guess you can say insertion related. But we all know that not to be true. Those lines are almost immediately used by multible nurses. So now, 48-72 hours later how would know that its not because a nurse didn't wipe of the cap that has been resting on his skin and just pushed the bacterial into the line????
No one is saying that this 7-10 days is definitive. However, looking at the pathogenesis of CRBSI, then it is easy to apply this as a guideline. Please note that CLABSI is a surveillance definition applied to a group of patients and it is known that this definition OVERestimates the number of actual infections in the patient group.
CRBSI is a diagnostic definition applied to one patient when you are trying to decide how to treat a specific patient. See CDC Guidelines for a short discussion of this difference.
A few organisms injected into the catheter lumen are probably not going to be the immediate cause of CRBSI. These organisms hit the catheter wall, immediately begin to secrete adhesins to firmly attach to the wall. Then they begin to grow. Once the biofilm is well established, it is the clumps or clusters of biofilm breaking off and floating into the bloodstream that leads to a BSI.
Studies have demonstrated that within the first 7-10 days there is more biofilm on the outer catheter surface. Skin can never be rendered sterile, so these organisms from the lower layers of the epidermis attach upon insertion and grow into a biofilm. After this 7-10 day period, there is a greater amount of biofilm on the intraluminal surface. For needleless connectors, there is one study showing that the biofilm reaches a steady state by 5 days, meaning that the growth of biofilm is equal to what is breaking off.
I think this should be presented at AVA as it is still very confusing. Our infection control practitioner follows CDC guidelines for determining CLABSI. Then nursing is to perform a root cause analysis to determine how the infection possibly occurred and if it was preventable in their best judgement. How should we proceed to determine this? I think this would be a great topic for AVA 2014.
You follow the basic process to do a root cause analysis. You look at all actions, interventions, manipulations, connections, etc. performed on that catheter and patient. Then assess the most likely cause. Then address that specific problem. Lynn
there is no published magic number for insertion versus dwell time CLA-BSI
I would look at the organism for starters as some are definitely not associated with insertion and are rare for insertion
As Lynn does point out over 7-10 days is more likely associated wth insertion but that is not a guarantee as it can be from very bad care as well in the short term of under that time period
Yiou need to trace the patient thorugh the hospital to get an idea of the breaks in technique
There is very little data but several years ago, Dr. Maki did publish a paper on this. Sorry, can't remember the exact name. There is a lot of information in the literature about the fact that there is more biofilm on the extraluminal side of the catheter during the first week. After the first week, there is more biofilm on the intraluminal surfaces. Biofilm is what produces the BSI. 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
there is no magic date or time stamp in the liiterature and it is all anecdotal. The problem is when a line is placed the skin is not sterile so organisms from the skin are dragged in via wire, introducer, dilator sheath, catheter etc at insertion. Therefore yoiu cannot really tell from what source the infection is from. care and maintenance or insertion can happen at any time during dwell
Our infection control department is using 48 hours for insertion related?? Seems to me I recall 72 hours discussed at AVA 2012. Anyone have any additional thoughts?
I think they are getting things confused. For a CLABSI, the definition is signs and symptoms that appear within 48 hours of insertion or admission to your facility. This is coming from CDC and has not changed I don't think. Check out CDC website to verify this definition.
To be considered insertion related as the cause of a CRBSI, this time period is 7 to 10 days. After that the risk shifts to the catheter hub as the most common cause of CRBSI. 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
The CDC new definition is 2 calendar days- day 1 is the actual date of insertion .... day 2 is when the element starts (i.e fever, leukocytosis etc...) Please keep in mind that other factors has to be considered- does the patient have any other lines( I.e Foleys) in place?
Lynn,
Can you share a reference or study related to time frame of CRBSI- 7 to 10 days? Thank you.
There are numerous articles stating this. I would need to actually look them up and review to give you a good one, and this could be done by you or anyone. Sorry but I can't get to this anytime soon since I am very far behind with projects now. Look for publications by Isaam Raad, Leonard Mermel, or Dennis Maki. 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
I would like the chime in on this very interesting discussion. The infection control Czars are always looking at CLBSI's and looking for that root cause. The problem there is NO way to definitively say it's from insertion. Ok, maybe I shouldn't say no way. I would think that if I insert a PICC using the establiished method of insertion. The PICC is not disburbed for 48 -72 hours then blood is taken and a positive culture of Staph is found. Then , I guess you can say insertion related. But we all know that not to be true. Those lines are almost immediately used by multible nurses. So now, 48-72 hours later how would know that its not because a nurse didn't wipe of the cap that has been resting on his skin and just pushed the bacterial into the line????
Just very hard to prove.
Jack Diemer, RN, VAT Coordinator
No one is saying that this 7-10 days is definitive. However, looking at the pathogenesis of CRBSI, then it is easy to apply this as a guideline. Please note that CLABSI is a surveillance definition applied to a group of patients and it is known that this definition OVERestimates the number of actual infections in the patient group.
CRBSI is a diagnostic definition applied to one patient when you are trying to decide how to treat a specific patient. See CDC Guidelines for a short discussion of this difference.
A few organisms injected into the catheter lumen are probably not going to be the immediate cause of CRBSI. These organisms hit the catheter wall, immediately begin to secrete adhesins to firmly attach to the wall. Then they begin to grow. Once the biofilm is well established, it is the clumps or clusters of biofilm breaking off and floating into the bloodstream that leads to a BSI.
Studies have demonstrated that within the first 7-10 days there is more biofilm on the outer catheter surface. Skin can never be rendered sterile, so these organisms from the lower layers of the epidermis attach upon insertion and grow into a biofilm. After this 7-10 day period, there is a greater amount of biofilm on the intraluminal surface. For needleless connectors, there is one study showing that the biofilm reaches a steady state by 5 days, meaning that the growth of biofilm is equal to what is breaking off.
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
I think this should be presented at AVA as it is still very confusing. Our infection control practitioner follows CDC guidelines for determining CLABSI. Then nursing is to perform a root cause analysis to determine how the infection possibly occurred and if it was preventable in their best judgement. How should we proceed to determine this? I think this would be a great topic for AVA 2014.
You follow the basic process to do a root cause analysis. You look at all actions, interventions, manipulations, connections, etc. performed on that catheter and patient. Then assess the most likely cause. Then address that specific problem. 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
there is no published magic number for insertion versus dwell time CLA-BSI
I would look at the organism for starters as some are definitely not associated with insertion and are rare for insertion
As Lynn does point out over 7-10 days is more likely associated wth insertion but that is not a guarantee as it can be from very bad care as well in the short term of under that time period
Yiou need to trace the patient thorugh the hospital to get an idea of the breaks in technique
Kathy Kokotis