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jenneking
Maintenance vs. Insertion induced infections with PICC lines

Our hospital is evaluating the probable cause of infections regarding PICC lines.  We believe that PICC lines are not being cared for properly after insertion which is the result of infection.  Our PICC team uses aseptic technique to place PICC lines and as the supervisor I feel that all necessary means are being taken to prevent infection on our end.  But because of the infection rate, infection control is concerned that we could possibly be infecting the patient during insertion.  Is anyone else facing these infection control issues and if so what has the outcome been for you? 

Any suggestions on where to find statistics about this issue?

Thanks

lynncrni
At what point after

At what point after insertion do these infections occur? What are the signs and symptoms and what are the means of diagnosing this as a CRBSI? How are they showing that the PICC is the cause?

Catheters that have dwelled for less than 7 to 10 days have more biofilm on the external surfaces and infection in these patients would be related to skin antisepsis and insertion procedures.

Catheters that have dwelled longer than 10 days have more biofilm on the internal surfaces and infection in those patients would be directly related to hub management issues such as hub cleaning, changing tubing or injection caps properly, etc. Lynn 

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

lisayrn
When you say aseptic
When you say aseptic technique what exactly does that entail?  Are you following the CLAB bundle?--Maximun barriers--large drape--cap--mask--chloraprep, etc? 

Lisa Y., RN, BSN University of Pittsburgh Medical Center/Horizon IV Therapy

jenneking
Yes, we treat our patients

Yes, we treat our patients as if they are having major surgery.  We sterile glove and gown, mask, drape, chloraprep, etc to minimize the risk of infection.  PICC line placements have increased in the past two quarters but infections have also increased which is how they are linking the two together I assume.

 

Thanks for the comments so far.

kratz
We use a central line

We use a central line dressing tech that changes all of our PICC and central lline dressings. She changes the dressing in the same manner that we place them, wearing mask, bonnet , sterile gown, sterile gloves and a large drape. Our infection rates are extremely low,  We place an average of 110 PICC's per month.

Karen Ratz,RN St. Lukes Hospital, Cedar Rapids,IA

kokotis
First off I would have to

First off I would have to ask you what the rate is

that is I mean the rate by catheter days?

that is I mean the rate by confirmed peripheral blood culture and culture from the catheter

You see I find that the definition of infection rate differs in all facilities and does not necessarily follow the CDC definition

Kathy Kokotis

Bard Access Systems

Linda Lembo
At our institution we have
At our institution we have also had a problem with infections over the years. Our infection control Director keeps close records on PICC related infections. It is interesting that the majority are over the 10 day time period. we too feel that it is a care and maintenance issue. we have been trying to do an extensive education for all the nurses . Every one of the RN's in our hospital have been trained to do PICC line dressing changes.The other issue comes in the cleaning off the caps with alcohol before accessing the lines. I am sure that this is not consistantly being done.If anyone else has suggestions I would love to hear it. Linda New Jersey.

Linda Lembo CRNI

Valley Hospital

Ridgewood, New Jersey

momdogz
     It is good to be
     It is good to be VERY involved in the surveillance process in your facility - and education.  When I was hired, I analyzed our data very carefully.  

     When the ID MD and chair of the infection control committee reported that of 480 of PICCs that IV Therapy placed in 5 months, 21 had primary BSI's associated with them, and most of those were placed by our senior PICC nurses, I knew something wasn't right.  We've been using the IHI bundle practices for years, and have OR trained staff that review sterile technique and consciousness with our team regularly.  We are committed to evolving - our individual clinical practice and our team.

     Turned out 4 of the lines were either subclavian lines placed by MDs, or were IR PICCs.  7 of them were in patients that had a concurrent serious infection for many of whom it was their admitting diagnosis (and therefore not primary).  7 or more of them were diagnosed well beyond 14 days of the insertion date (not insertion related), and 7 of them also had concurrent other CVCs - including dialysis lines that had been accessed inappropriately by staff RNs, femoral lines, subclavian lines, etc.  I discovered other issues important to the surveillance process, and I presented all of this and more to the IC committee.

     Our lab does not do quantitative cultures at this time.  They didn't know what sonication was.  Clearly there is a lot of work to be done with surveillance and data analysis.

     I also presented an anecdotal list of serious problems we encounter on a regular basis on the units:  no swabbing.  Syringe pumps/intermittant infusion tubing left on needleless caps, keeping them engaged.  Visible blood in extension leg of PICC (and the ICU nurse saying "I didn't know that was a problem"!).  No cap changes.  An anesthesiologist not swabbing the hub for one of our IV RN's about to have surgery, and when she pointed it out to him, he set the antibiotic syringe on her bed without a cap on it.  A student nurse removing the needleless caps from a DL PICC before sending the patient into the shower (wha???).  

     Our PICC insertion infection rate is zero to .02 (we strive for zero).  I have since been invited to be a member of the infection control committee and a CVC quality control committee and am grateful.   Our state legislation requires that we document line necessity on a daily basis, and we feel that it would be a perfect job for the IV team so that we can continue to watch our lines, and dialogue with our MD and other colleagues.  Our IV team does the PICC dressing changes - we don't want to give that up.  

     We support multidisciplinary, accurate assessment of all aspects of CVC placement - it's not about blame, it's about what is best for the patient.

     It's essential to monitor all aspects, including insertion technique, and I think you've hit the nail on the head:  education.  Our team has regular education programs, and we'll be adding the central line checklist to our PICC insertion process.  Each PICC RN knows what their 'stats' are, and everyone is supported positively in their performance improvment.  I'd love to see "SVAT" (special vascular access team) teams on every unit - a small team of dedicated unit staff, including MD's and RN's, that work with the IV Therapy department on a regular basis to review CVC data and improve education for RNs and MDs throughout the facility.  We could make it fun, interesting, and empowering.  

     It may be a challenge:  nurses are already finding it difficult to accomplish everything they need to in a day and for this reason the Nursing department may not be very supportive of the SVAT plan, but I think it's worth a try.  When each of us feel empowered with information and support, and that we're an owner of our individual clinical practice, we'll strive for quality!

Mari Cordes, BS RN 
Nurse Educator IV Therapy
Fletcher Allen Health Care

Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center

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