Catheter Related Blood Catheter Related Blood Stream InfectionStream Infection

Presented by:Presented by:

Mrs. Lima Aboul HosnMrs. Lima Aboul Hosn

Dubai Hospital- UAEDubai Hospital- UAE

IntroductionIntroduction

Intravascular catheters represents an essential part of Intravascular catheters represents an essential part of the management of critically ill patients who present the management of critically ill patients who present as acute emergency. However, their use is often as acute emergency. However, their use is often complicated by serious infections, mostly catheter complicated by serious infections, mostly catheter related-blood stream infections (CRBSIs), which are related-blood stream infections (CRBSIs), which are associated with increased morbidity, increase in associated with increased morbidity, increase in duration of hospitalization, and additional medical duration of hospitalization, and additional medical costs.costs.

The incidence of CRBSIs varies considerably by the type The incidence of CRBSIs varies considerably by the type of catheter, frequency of catheter manipulation, and of catheter, frequency of catheter manipulation, and patient related factors, such as underlying disease patient related factors, such as underlying disease and severity of illness.and severity of illness.

(Centers for Disease Control and Prevention, 2002)(Centers for Disease Control and Prevention, 2002)

Objectives:Objectives:

1.To identify problems related to vascular 1.To identify problems related to vascular catheter infections & dysfunction.catheter infections & dysfunction.

2.To educate the concerned staff about 2.To educate the concerned staff about strategies for prevention of catheter strategies for prevention of catheter related blood stream infection.related blood stream infection.

3.To reduce patient morbidity & mortality 3.To reduce patient morbidity & mortality rates and hence this will reduce hospital rates and hence this will reduce hospital length stay and total cost.length stay and total cost.

GOAL:GOAL:

To reduce catheter related To reduce catheter related blood stream infection in blood stream infection in the dialysis unit based on the dialysis unit based on the international standard the international standard measures.measures.

Indications for Venous Catheters

Temporary PermanentAcute emergency access in the sitting of acute renal failure, overload, metabolic disturbance

Cuffed Catheters for long time

Sudden loss Vascular Access Children

Transfer temporarily from PD Multiple access failures

No access Patient Medical Condition as elderly or patients with generalized atherosclerosis.

For CVVH/CVVHD/Plasma Exchange

Permanent Vs. Permanent Vs. Temporary Catheters Temporary Catheters

PROBLEMS COMMONLY IDENTIFIED, PROBLEMS COMMONLY IDENTIFIED, IN THE DIALYSIS UNIT OF DUBAI IN THE DIALYSIS UNIT OF DUBAI HOSPITAL RELATED TO VASCULAR HOSPITAL RELATED TO VASCULAR CATHETER:CATHETER:

1. CATHETER DYSFUNCTION1. CATHETER DYSFUNCTION

2. INFECTION2. INFECTION

PROBLEMS COMMONLY IDENTIFIED, PROBLEMS COMMONLY IDENTIFIED, IN THE DIALYSIS UNIT OF DUBAI IN THE DIALYSIS UNIT OF DUBAI HOSPITAL RELATED TO VASCULAR HOSPITAL RELATED TO VASCULAR CATHETER:CATHETER:1. 1. CATHETER CATHETER

DYSFUNCTIONDYSFUNCTION EARLYEARLY

KinksKinks Catheter MalpositionCatheter Malposition Patient position Patient position Catheter integrity – holes, Catheter integrity – holes,

crackscracks

LATELATE ThrombosisThrombosis

Assessment of Assessment of Catheter Dysfunction:Catheter Dysfunction:

Blood pump rate < 300 ml/minBlood pump rate < 300 ml/min Unable to aspirate blood freelyUnable to aspirate blood freely Frequent pressure alarmsFrequent pressure alarms URR progressively < 65% (or Kt/V < 1.2)URR progressively < 65% (or Kt/V < 1.2) Arterial pressure increased (< - 250 Arterial pressure increased (< - 250

mmHg)mmHg) Venous pressure increased (> 250 Venous pressure increased (> 250

mmHg)mmHg)

Method for treatment based on Dubai Hospital Protocol ThrombolyticsThrombolytics, using either an , using either an

intraluminal thrombolytic. intraluminal thrombolytic.

RepositioningRepositioning of a malpositioned of a malpositioned catheter. catheter.

Catheter exchangeCatheter exchange

MANAGEMENT OF CATHETER DYSFUNCTION

2. INFECTION:2. INFECTION: BREAK IN ASEPTIC TECHNIQUE DURING BREAK IN ASEPTIC TECHNIQUE DURING

INSERTION AND PRIOR CANNULATIONINSERTION AND PRIOR CANNULATION

SITE AND QUALITY OF THE CATHETER SITE AND QUALITY OF THE CATHETER

DRESSING MATERIALSDRESSING MATERIALS

PATIENT LACK OF EDUCATION/NON PATIENT LACK OF EDUCATION/NON COMPLIANCECOMPLIANCE

PROBLEMS COMMONLY IDENTIFIED, PROBLEMS COMMONLY IDENTIFIED, IN DIALYSIS UNIT OF DUBAI IN DIALYSIS UNIT OF DUBAI HOSPITAL RELATED TO VASCULAR HOSPITAL RELATED TO VASCULAR CATHETER:CATHETER:

Types of Infections:Types of Infections:

EXIT SITE INFECTIONSEXIT SITE INFECTIONS

TUNNEL INFECTIONSTUNNEL INFECTIONS

BLOOD STREAM INFECTIONBLOOD STREAM INFECTION

Exit Site InfectionExit Site Infection

•Localized, negative blood Localized, negative blood culturescultures•Local treatment measuresLocal treatment measures

Removal of catheter:Removal of catheter:•Failure to respond to Failure to respond to treatmenttreatment•sepsissepsis

Tunnel & Port Pocket Tunnel & Port Pocket InfectionInfection

•Infection above the cuffInfection above the cuff•Negative blood cultureNegative blood culture•TreatmentTreatment

Catheter removal if Catheter removal if persist.persist. Intravenous antibioticsIntravenous antibiotics

Definition of CRBSIDefinition of CRBSI

Catheter related blood stream Catheter related blood stream infection resulting from bacterial infection resulting from bacterial colonization of an intravascular colonization of an intravascular catheter.catheter.

CATHETER RELATED CATHETER RELATED BACTEREMIABACTEREMIA Positive blood culturesPositive blood cultures No other obvious sourceNo other obvious source Variable symptoms.Variable symptoms. Different degrees of severityDifferent degrees of severity

SIGNS & SYMPTOMS OF SIGNS & SYMPTOMS OF Catheter-Related Bloodstream Catheter-Related Bloodstream Infection:Infection:

LOCAL INFECTIONSLOCAL INFECTIONS

LOCAL LOCAL INFLAMMATIONINFLAMMATION

DISCHARGE DISCHARGE AROUND THE AROUND THE CATHETER CATHETER EXIT/TUNNEL SITEEXIT/TUNNEL SITE

ERYTHEMAERYTHEMA PAINPAIN

SYSTEMIC SYSTEMIC INFECTIONSINFECTIONS

FEVERFEVER RIGORS MAINLY RIGORS MAINLY

WHEN THE LINE IS WHEN THE LINE IS USEDUSED

TACHYCARDIATACHYCARDIA METASTATIC METASTATIC

INFECTIONINFECTION

The blood should be free from microbes

CATHETER RELATED CATHETER RELATED BACTEREMIABACTEREMIA

Healthcare interventions, like the use of Central Vascular Catheters

make patients exposed to infection – as organisms can get

direct entry to the blood.

CATHETER RELATED CATHETER RELATED BACTEREMIABACTEREMIA

Infections start locally at the catheter insertion site,, but

then…

CATHETER RELATED CATHETER RELATED BACTEREMIABACTEREMIA

CATHETER RELATED CATHETER RELATED BACTEREMIABACTEREMIA

If the infection is not treated effectively, the organisms can

infect the blood

Once the organisms are in the blood a Staph aureus bacteraemia has occurred

(Usual organisms are Staph. aureus, however gram (Usual organisms are Staph. aureus, however gram negative, polymicrobial can occur)negative, polymicrobial can occur)

CATHETER RELATED CATHETER RELATED BACTEREMIABACTEREMIA

The best way to prevent microbes from getting into the blood is….

CATHETER RELATED CATHETER RELATED BACTEREMIABACTEREMIA

To Reduce Device Days

& Optimise Care

CATHETER RELATED CATHETER RELATED BACTEREMIABACTEREMIA

CATHETER RELATED CATHETER RELATED BACTEREMIABACTEREMIA

Secondary complicationsSecondary complicationsPneumoniaPneumoniaSeptic arthritisSeptic arthritisEndocarditisEndocarditisEpidural abscessEpidural abscessDeath Death

Indication for Removal of HD Catheter

1. Persistence of fever and positive blood culture while being on appropriate Antibiotics for 36-48 hrs .

2. Exit site infection extending to catheter tunnel with sever sepsis.

3. CRBSI associated with hypotension or signs of cerebral hypoperfusion.

4. Septic thrombosis of great veins as determined by Doppler flow study.

5. Infective Endocarditis and systemic embolisation.

Based upon NKF – DOQI clinical practice Guidelines for vascular access

CR-BSI/ 1000 CATHETER DAYSCR-BSI/ 1000 CATHETER DAYS RESULTS:RESULTS:

BSI

Jan Feb Mar

Apr May

Jun Jul Aug

Sep

Oct Nov

Dec

2/362

3/392

2/542

1/505

8/501

2/528

4/560

3/550

2/507

2/518

2/619

2/674

5.52

7.65

3.69

1.68

15.9

3.78 7.14

5.45

3.94

3.86

3.23

2.96

CDC and JCAHO recommended that CRBSI be reported in terms ofinfections per 1000 catheter days

Infection rateInfection rate

CATHETER RELATED INFECTION RATE/2008

0

5

10

15

20

1 2 3 4 5 6 7 8 9 10 11 12

Month

Ra

te

Series1

RECOMMENDATIONS:RECOMMENDATIONS:1.1. GOOD HAND HYGIENEGOOD HAND HYGIENE

2.2. STRICT ASEPTIC TECHNIQUE DURING CHANGING OF DRESSINGSSTRICT ASEPTIC TECHNIQUE DURING CHANGING OF DRESSINGS

3.3. RELEVANT OBSERVATION OF THE EXIT SITE/DOCUMENTATIONRELEVANT OBSERVATION OF THE EXIT SITE/DOCUMENTATION

4.4. MAXIMAL STERILE BARRIER PRECAUTIONS DURING CATHETER MAXIMAL STERILE BARRIER PRECAUTIONS DURING CATHETER INSERTIONINSERTION

5.5. USE STERILE DEVICE ON MULTI DOSE VIAL USE STERILE DEVICE ON MULTI DOSE VIAL

6.6. THE USE OF CATHETER LOCKING SOLUTIONS/TAUROLOCK AND THE USE OF CATHETER LOCKING SOLUTIONS/TAUROLOCK AND HEPARINHEPARIN

7.7. NASAL SWAB SCREENING FOR STAPH AUREUS BEFORE INSERTION NASAL SWAB SCREENING FOR STAPH AUREUS BEFORE INSERTION OF CATHETEROF CATHETER

8.8. CATHETER REMOVAL WHEN NO LONGER INDICATEDCATHETER REMOVAL WHEN NO LONGER INDICATED

9.9. TO AVAIL THE 2% CHLORHEXIDINE GLUCONATE AS SKIN TO AVAIL THE 2% CHLORHEXIDINE GLUCONATE AS SKIN ANTISEPSISANTISEPSIS

10.10. QUALITY OF CATHETER AND DRESSING MATERIALSQUALITY OF CATHETER AND DRESSING MATERIALS

11.11. CONTINUING STAFF AND PATIENT EDUCATIONCONTINUING STAFF AND PATIENT EDUCATION

12.12. MONTHLY SURVEILLANCS AND AUDIT. MONTHLY SURVEILLANCS AND AUDIT.

o Evaluation: The central line audit tool was utilized to track the number and nature of infections , via the monthly audit , report and analysis. monthly audit , report and analysis.

o Action and follow up: continuous monthly audit , report and analysis of the outcomes.continuous monthly audit , report and analysis of the outcomes. Monitor Staff compliance with hospital policies and procedures mainly the Monitor Staff compliance with hospital policies and procedures mainly the

Standard precaution policy.Standard precaution policy. Reduction of the temporary CVC .Reduction of the temporary CVC .

o Results: Seven consecutive months reduction in the CVC infections were noted following the practice change. Only one month went raised up again due to un availability of Vascular surgeon so the use of temporary catheter increased.

Summary of PDCA /Haemodialysis unit -DH

CONCLUSION:CONCLUSION:

MANY CATHETER RELATED BLOOD STREAM MANY CATHETER RELATED BLOOD STREAM INFECTIONS ARE PREVENTABLE INFECTIONS INFECTIONS ARE PREVENTABLE INFECTIONS THAT NEED TO BE APPROACHED THAT NEED TO BE APPROACHED SYSTEMATICALLY AT A MULTIDISCIPLINARY SYSTEMATICALLY AT A MULTIDISCIPLINARY LEVEL THAT EMPHASIZE THE PATIENT SAFETY LEVEL THAT EMPHASIZE THE PATIENT SAFETY AND QUALITY IMPROVEMENT, THEREFORE ALL AND QUALITY IMPROVEMENT, THEREFORE ALL STAFF INVOLVE IN THE MANAGEMENT OF THE STAFF INVOLVE IN THE MANAGEMENT OF THE VASCULAR CATHETER MUST BASED THEIR VASCULAR CATHETER MUST BASED THEIR PRACTICE ON WHAT IS AGREED IN THE PRACTICE ON WHAT IS AGREED IN THE LITERATURE AND RECOMMENDATIONS AS LITERATURE AND RECOMMENDATIONS AS BEING EFFECTIVE IN REDUCING THE RISKS OF BEING EFFECTIVE IN REDUCING THE RISKS OF CATHETER RELATED BLOOD STREAM CATHETER RELATED BLOOD STREAM INFECTIONS.INFECTIONS.

THANK YOU!THANK YOU!

REFERENCESREFERENCES

1.1. Centers for Disease Control and Prevention(2002): Guidelines for the Centers for Disease Control and Prevention(2002): Guidelines for the prevention of intravascular catheter-related infections.prevention of intravascular catheter-related infections.

MMWR Reccom, MMWR Reccom, 51 (RR-10): 1-2951 (RR-10): 1-29

2. 2. Chaiyakunapruk N, Veenstra D, Lipsky B, Sullivan S, Saint S(2003) Vascular Chaiyakunapruk N, Veenstra D, Lipsky B, Sullivan S, Saint S(2003) Vascular catheter site care:The clinical and economic and benefits of chlorhexidine catheter site care:The clinical and economic and benefits of chlorhexidine gluconate compared with povidone-iodine,gluconate compared with povidone-iodine,Clinical Infectious Clinical Infectious Disease,Disease,Volume 37,764-771.Volume 37,764-771.

3. 3. Drewett, SR.(2002), Complications of central venous catheters: Nursing care, Drewett, SR.(2002), Complications of central venous catheters: Nursing care, British Journal of Nursing, Volume 9(8), pages 466-478.British Journal of Nursing, Volume 9(8), pages 466-478.

4. Dogra, G.(2006) Preventing catheter related infections with antibiotic lock 4. Dogra, G.(2006) Preventing catheter related infections with antibiotic lock solutions: are we spoilt for choice? solutions: are we spoilt for choice? Nephrology,Nephrology,11: 297-29811: 297-298

5. Dougherty L. (2000), Central venous access devices,5. Dougherty L. (2000), Central venous access devices,Nursing Nursing Standard,Standard,14(43),45-50,July 12.14(43),45-50,July 12.

6. Field J.(2002), Prevention of Infection:central venous catheters, 6. Field J.(2002), Prevention of Infection:central venous catheters, Nursing Nursing Standard,Standard, 16(38)42-44,June 5. 16(38)42-44,June 5.

7. Pittet D, Tarara D, Wenzel RP (1994), Nosocomial blood stream infection in 7. Pittet D, Tarara D, Wenzel RP (1994), Nosocomial blood stream infection in critically ill patients:excess length of stay, extra cost and attributable critically ill patients:excess length of stay, extra cost and attributable mortality,mortality,Journal of the American Medical Association(JAMA),Journal of the American Medical Association(JAMA),271(20),1598-271(20),1598-16021602

8.8. NKF – DOQI clinical practice Guidelines for vascular access