manitoba renal program.(2) - kidney health · kdoqi clinical practice guidelines and clinical...
TRANSCRIPT
3M Health Care AcademySM
© 3M 2015. All Rights Reserved
3M Health Care AcademySM
Antiseptic Use in HemodialysisManitoba Renal Program
November 2016
Kathy McGhie RN, BScN, CIC
3M Health Care AcademySM
© 3M 2015. All Rights Reserved
Centre for Disease Control (CDC) Dialysis Collaborative17 Facilities reporting to National Healthcare Safety Network (NHSN)
Core Interventions1
1.Surveillance & feedback using NHSN;
2.Hand hygiene observations;
3.Catheter/vascular access care observations;
4.Staff education & competency;
5.Patient education/engagement;
6.Catheter reduction –Identified & addressed barriers to permanent access;
7.Chlorhexidine for skin antisepsis;
8.Catheter hub disinfection;
9.Antimicrobial ointment to catheter exit sites with dressing change.
54%54%54%54% Reduction
in access related bloodstream infections2
37,000Bloodstream
infections every year2
1.CDC.Dialysis Bloodstream Infection (BSI) Prevention Collaborative. http://www.cdc.gov/dialysis/prevention-tools/core-interventions.html2.Patel PR, Yi SH, Booth S, et al. Bloodstream infection rates in outpatient hemodialysis facilities participating in a collaborative prevention effort: a quality improvement report. Am J Kidney Dis. 2013;62:322-330
3M Health Care AcademySM
© 3M 2015. All Rights Reserved 3
Hemodialysis Patients
Why are they at high risk?• Presence and frequent manipulation of devices for
venous/arterial access
• Weakened immune systems
• Proximity to other patients in dialysis centres
• Frequent contact with healthcare workers
• Increased incidence of diabetes
• Colonization with Staphylococcus aureus
Are receiving hemodialysis and
are at risk for developing
bloodstream infections*
23,188CANADIANS*
* http://www.kidney.ca/document.doc?id=1376
CDC.Dialysis Bloodstream Infection (BSI) Prevention Collaborative. http://www.cdc.gov/dialysis/collaborative/
3M Health Care AcademySM
© 3M 2015. All Rights Reserved 4
Why are we here?
Reports of skin irritation
Practice review
requested to ensure
products were being used correctly
Goals: Review appropriate skin
antiseptics for access sites
Decrease incidence of irritation
Provide refresher on the use of skin antiseptics
3M Health Care AcademySM
© 3M 2015. All Rights Reserved 5
Observations of 3M antiseptic useSt. Boniface, Health Sciences Centre, Seven Oaks – May 2016
Total Observations: Total Observations: Total Observations: Total Observations: 15 patients with chlorhexidine gluconate skin antisepticProcedures Observed: Procedures Observed: Procedures Observed: Procedures Observed: Central Line dressing change, Fistula cannulation
Key Observations related to the use of 3M antiseptic:1. Multiple swabs used for dressing change (range 2-7)2. Multiple layers of antiseptic applied3. Excessive friction used4. Antiseptic not allowed to dry before procedure begins or dressing applied
Additional Observations related to irritation:1. Patients experiencing irritation are Non-Caucasian2. Patients reported no other known skin sensitivities3. Program policy & procedures not followed re 2nd, 3rd choice of product4. Perceptions of “allergy to CHG” and discontinuation of use
Povidone Iodine was the antiseptic of choice
3M Health Care AcademySM
© 3M 2015. All Rights Reserved 6
Intolerance of chlorhexidine in Patients Undergoing Hemodialysis
Surveyed facilities participating in CDC Dialysis Collaborative
• Facility demographics
• Chlorhexidine use practices
• Prevalence of chlorhexidine-intolerant patients
Intolerance – “a patient who was unable to use chlorhexidine because of perceived adverse
reaction”
17% intolerant (12% central lines, 21% Fistula, 23% Grafts)
Data suggests variations in practice may explain some intolerance – recommend standardized
practices for antiseptics and better defining what constitutes an adverse reaction
Preliminary work suggests ↑ drying, ↓ friction will ↓ adverse reactions
Kallen, et.al., Intolerance of chlorhexidine as a skin antiseptic in patients undergoing hemodialysis. 2011, Infection Control and Hospital Epidemiology, 32:11, 1144-1146
3M Health Care AcademySM
© 3M 2015. All Rights Reserved 7
What is it?
• Non-allergic irritation resulting from chemical irritant: redness, swelling, blistering usually in area exposed to adhesive
• May look similar to allergic dermatitis
Non-allergic irritant contact dermatitis
What is it?
• Rare, cell-mediated immunological response to a particular component of antiseptic, tape adhesive, or backing
• Erythema, edema, itching, wheals, vesicles
• Similar appearance to non-allergic dermatitis
Allergic dermatitis
3M Health Care AcademySM
© 3M 2015. All Rights Reserved 8
Isopropyl Alcohol1,2
• Most rapid
• Greatest reductions
• Rapid drying
• No persistence
• Flammable
• Least expensive
Chlorhexidine2,4,5
• Greatest persistence & residual action
• Low skin irritancy
• Good broad spectrum coverage
• No absorption
• Incompatible with anions (soaps, dyes)
• Not inactivated by blood, serum proteins
Povidone Iodine2,3
• Minimal persistence
• Good broad spectrum coverage
• ~ 1-5 min. contact
• Skin irritation & absorption
• Neutralized by organic material
• Documented contamination 8
Combination Products: Alcohol & Chlorhexidine Gluconate, Alcohol & Povidone Iodine
(shown to be superior in several comparison studies) 1. Ali, Y., Fendler, J., Larson, E., (2001). Alcohols, in Block, SS., Disinfection, Sterilization and Preservation, (5th Ed.), Philadelphia, PA: Lippincott and Wilkins2. Larson, E., (1988). Guideline for use of topical antimicrobial agents. American Journal of Infection Control, 16(6), 253-266.3.Gottardi, W., (2001). Iodine and iodine compounds, in Block, SS., Disinfection, Sterilization and Preservation, (5th Ed.), Philadelphia, PA: Lippincott and Wilkins4.Denton, G., (2001). Chlorhexidine, in Block SS., Disinfection, Sterilization and Preservation, (5th Ed.), Philadelphia, PA: Lippincott and Wilkins5.Edwards, PS., Lipp, A., Holmes, A., (2004). Preoperative skin antiseptics for preventing surgical wound infections after clean surgery. Cochrane Database of Systematic Reviews. DOI.10.1002/14651858.CD003949.pub2 8Weber JD, Rutala WA Sickbert-Bennett EE Outbreaks associated with contaminated antiseptics and disinfectants. Antimicrobial Agents and Chemotherapy 2007;51:4217-4224.
3M Health Care AcademySM
© 3M 2015. All Rights Reserved 9
1. Right Product
3M Health Care AcademySM
© 3M 2015. All Rights Reserved
Guideline & Standards Recommendations
• CDC, INSCDC, INSCDC, INSCDC, INS:
• use alcohol-based chlorhexidine (>0.5%) solution
for insertion and during dressing changes.1, 2
• KDOQIKDOQIKDOQIKDOQI:
• 2%CHG/70%IPA preferred for long-term catheter
sites3
• Sensitivities to 2%CHG/70%IPA → use 2%
Aqueous CHG, → use PI3
• AV Access- Wash site with antibacterial soap &
water, use 2% CHG/70% IPA or 70% IPA3
1. O’Grady et al.Guidelines for the Prevention of Intravascular Catheter-related Infections. Recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC). American Journal of Infection Control 2011; 39:4 (1 Suppl): S1- 34. 2. Infusion Nurses Society. Infusion Nurses Standards of Practice. Journal of Infusion Nursing 2016; Suppl to Jan/Feb 2016V39, Number 1S3. KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for 2006 Updates: Hemodialysis Adequacy, Peritoneal Dialysis Adequacy and Vascular Access. Am J Kidney Dis 48:S1-S322, 2006 (suppl 1).
3M Health Care AcademySM
© 3M 2015. All Rights Reserved 11
Manitoba Renal ProgramPolicies & Procedures
Central Venous Catheter, Dressing Change, 2015
Antiseptic of Choice: 1 package
antiseptic swab stick (2% CHG
70% IPA)
If there are documented allergies to
2%CHG/70%IPA use Aqueous
CHG
If there are documented
allergies to CHG, use Povidone
Iodine
Skin prep/barrier as needed
When using CHG apply using back & forth motion
Begin at exit site, in circular motion extending to the area outside the dressing X 2
Do not blot
Allow to dry completely, at least 2 minutes
Excessive adhesive residue may be removed using adhesive remover followed by a sterile 0.9% NaCl rinse
Drying time is important for antiseptic effect and to minimize skin reaction when adhesive
from dressing comes in contact with antiseptic
3M Health Care AcademySM
© 3M 2015. All Rights Reserved 12
Manitoba Renal ProgramPolicies & Procedures
Venipuncture of Arteriovenous Fistula/Graft, 2015
Antiseptic of Choice: 2
packages of 2% CHG.70% IPA)
If there are documented allergies to
2%CHG/70%IPA use Aqueous
CHG
If there are documented
allergies to CHG, use Povidone
Iodine
Wash or have patient wash access site with CHG soap and water. Dry with single-use paper towel
Apply antiseptic using back & forth rubbing motion
CHG/IPA cleansing is at least 30 seconds
Allow to dry completely prior to access
3M Health Care AcademySM
© 3M 2015. All Rights Reserved
Manitoba Renal Program 3M SoluPrepTM Formats
Small Swab• 2%CHG/70%IPA• 2%CHG Aqueous
Wipe• 2%CHG/70%IPA• 2%CHG Aqueous
3M Health Care AcademySM
© 3M 2015. All Rights Reserved 14
2. Right Volume for Treatment Area
3M Health Care AcademySM
© 3M 2015. All Rights Reserved
Treatment Area
Assess size of area to be preppedAssess size of area to be prepped
Choose product format that will deliver the
surface coverage required
Choose product format that will deliver the
surface coverage required
• What is the stated coverage area?
• Coverage is more important than volume
Too much product increases the risk of irritation and increases the length of time required for the antiseptic to dry
3M Health Care AcademySM
© 3M 2015. All Rights Reserved 16
3. Right Application Time
4. Right Application Technique
3M Health Care AcademySM
© 3M 2015. All Rights Reserved 17
Swabs and Wipes
* 3M 1301-00230B 2_70 Instructions for Use.© 2013
Demonstrated persistence for up to 7 days on dry skin under semi-occlusive dressing
*
*
*
*
3M Health Care AcademySM
© 3M 2015. All Rights Reserved 18
Swabs and Wipes
Demonstrated persistence for up to 72 hours on dry skin under semi-occlusive dressing
* 3M 1211-03381B Instructions for Use.© 2013
*
*
*
2% CHG
SoluPrep™Brand Products
Please note: Application time must be increased to 4 minutes for use pre-surgery or on a moist body site.
Large Wipe (5cm x 5cm)Small Swab (5cm x 6cm)
3M Health Care AcademySM
© 3M 2015. All Rights Reserved
Modified application ‘option’ (around a catheter or device)
Side 1 – back & forth vertical strokes around catheter (15 seconds)
Flip Swab
Side 2 – back & forth horizontal strokes around catheter (15 seconds)
3M Health Care AcademySM
© 3M 2015. All Rights Reserved 20
5. Let it Air Dry! (no blowing, fanning, wiping)
3M Health Care AcademySM
© 3M 2015. All Rights Reserved 21
“Dry time Varies!”Influencing Factors:HostDry or moist body site?Presence of hairSkin type
EnvironmentAmbient humidityVolume of product used, size of treatment area, prepping technique
FormulationAlcohol or not?
Importance of drying:
Efficacy
Minimizing irritation
Safety (flammability)
Lack of thorough drying before applying dressing, increases the risk of skin irritation
3M Health Care AcademySM
© 3M 2015. All Rights Reserved 22
1. Right Product
2. Right Volume
3. Right Time
4. Right Technique
5. Let it Dry!
3M Health Care AcademySM
© 3M 2015. All Rights Reserved
Thank you
The materials are provided as general information for the healthcare professional. The materials contain statements, technical information, and guidance which are based on current literature and clinical information at the time the materials were produced, and which we believe were reliable when the materials were created. These materials should be used as a guide only. In all cases, professional clinical judgment must be used for assessment, intervention, and evaluation in each clinical situation. 3M Canada shall not be liable or responsible for the consequences of any actions taken on the basis of the information provided in, or errors or omissions from , these materials. These materials may not be copied or used in part or full without the express permission from 3M Canada. ©2015, 3M. All rights reserved.