Using Infusion Therapy Standards to Enhance Prevention of Device-Associated Bloodstream Infections

As infection preventionists (IPs), the Centers for Disease Control and Prevention (CDC)’s Guidelines for the Prevention of Intravascular Device Associated Infections have long served as the cornerstone of much of our policy development. When the SHEA/IDSA Compendium documents were released those too served as a source of guidance.  What sometimes has been overlooked have been the Infusion Nurses Society standards which were updated most recently earlier this year and currently reflect the latest evidence based recommendations for all aspects of infusion therapy across all disciplines involved. To keep moving the needle beyond the status quo we need to expand our involvement beyond just hand and skin antisepsis (an over simplification of our role!) and help with all aspects of vascular access and infusion therapy to impact the overall quality of care for these prevalent devices.

By Chellie DeVries, MPH, CIC

As infection preventionists (IPs), the Centers for Disease Control and Prevention (CDC)’s Guidelines for the Prevention of Intravascular Device Associated Infections have long served as the cornerstone of much of our policy development. When the SHEA/IDSA Compendium documents were released those too served as a source of guidance.  What sometimes has been overlooked have been the Infusion Nurses Society standards which were updated most recently earlier this year and currently reflect the latest evidence based recommendations for all aspects of infusion therapy across all disciplines involved. To keep moving the needle beyond the status quo we need to expand our involvement beyond just hand and skin antisepsis (an over simplification of our role!) and help with all aspects of vascular access and infusion therapy to impact the overall quality of care for these prevalent devices.

Most of my study and focus in my career has centered around risks associated with peripheral IV catheters; the 2016 Infusion Therapy Standards of Practice provide a wealth of information specific to care and maintenance of those lines as well as the full range of vascular access devices available to support and protect our patients. As IPs, this document should be at the top of our reference list when examining best practices and integrating knowledge into our programs. Coupled with the MAGIC study published last year by Dr. Chopra these two documents offer many opportunities to enhance optimal vascular access – which is the umbrella we share with our peers throughout the hospital. Both offer thoughtful consideration of frameworks for helping select the right device for the right patient for the right infusate for the right length of time. This is not a simple task but one that our partners in vascular access can help us with as we continue with goals for reduction of unnecessary central line days and minimizing harm.   

For the last many years we have worked with our hospital teams to drive down central line days with daily review of line necessity to help drive prompt removal of unnecessary central lines. We can measure our own device utilization ratios within NHSN to see our progress (or remaining opportunities) with this goal. The Infusion Therapy Standards of Practice now extend that consideration of line necessity fully to peripheral lines as well, advocating for removal of peripheral lines that are no longer included in the plan of care or that have not been used in the last 24 hours. This underscores the reality that all devices carry with them some risk of infection (as well as other complications).This same reminder of risk beyond central lines is acknowledged in the APIC implementation guidance from last year as well as the SHEA/IDSA compendium despite both being CLABSI focused documents. MAGIC takes a “front end” approach to addressing what many believe has become the over-utilization of PICC lines in recent years. Rather than focusing on removal of lines, it offers suggestions for starting with the right (and many times least invasive) device at the onset of therapy. 

Depending on infusate, history of difficult access and anticipated length of therapy there is preference given to short peripheral catheters, ultrasound guided peripheral catheters and midlines over PICCs and other central lines for many patients as well as cautions and some consensus on what should be considered as inappropriate indications for PICC lines. With careful planning and monitoring, hospitals are demonstrating great success with longer dwelling peripheral lines with programs of protected clinical indication. Since 2011 INS has removed any reference to the traditional 72- to 96-hour interval for rotation and instead focuses on clinical indication which is removing or replacing a peripheral line based on patient needs rather than time based policies. It is important to note that this is different from the patient still having a “clinical indication” for a line. Both factors are important considerations but sometimes the two are confused. Complications are clinical indications to remove the catheter, whether or not the patient may still have a need for vascular access. Many facilities have also launched successful midline programs with a focus on reducing unnecessary central line days and decreasing repeated peripheral sticks. Both of these approaches are opportunities for true multi-disciplinary, patient focused initiatives. 

Expanding surveillance to include both peripheral and midline catheters (also suggested by INS) can help ensure that these strategies are employed safely and not used as an unethical strategy to simply shift risk to lines that escape public (and often internal) reporting.

Looking across all line types, there is support for strengthening our teams and our staff training within the standards.  For both insertion of peripheral IVs and care and maintenance of central lines, designated teams can reduce complications and improve outcomes.  In the absence of such teams, it is imperative that staff assigned tasks related to vascular access insertion, care and maintenance have demonstrated education, training and validated competencies. This also should take into consideration that findings that the majority of nurses are no longer taught the critical skill of IV insertion as part of their nursing curriculum, and the acknowledgement that successful insertion is far more than the physical act of inserting the catheter into a vein but requires a much more comprehensive assessment of patient needs and best choices. For the protection of our patients, initial competencies are to be completed prior to staff being assigned to these activities and are to be conducted by staff members who are competent in the skill or procedure themselves. Additionally, the use of managers for assessing competency of staff is discouraged due to the power dynamics that could shift the focus of the assessment.  

When planning for optimum device success for protected clinical indication, there are many recommendations in the standards to help increase the success of such a policy change.  All too frequently hospitals are choosing to adopt clinical indication policies with the allure of saving time and money, without giving attention to the numerous other recommendations in the standards that can make that goal more achievable. Starting with site selection, there is strong wording in the new standards to consider the forearm as the preferred site for a variety of reasons including reduced complications, better securement, less pain and better success at extending dwell time. The Infusion Therapy Standards of Practice suggest that we consider the use of sterile gloves for insertion. Some hospitals (St Joseph’s Hospital in Patterson, N.J., Matt Ostroff’s vascular access program) have begun reporting great success using sterile, ultrasound guided PIV insertions to help make the concept of a one-stick hospitalization a real possibility in some settings. Reducing the number of peripheral IV attempts is now capped at four total, and keeps with the recommendation of no more than two per clinician – and also a suggestion for ultrasound for failed attempts and difficult sticks. Clear guidance is given for stabilization devices based on type of catheter used and the importance of securing and maintaining an intact dressing. Flushing protocols and aligning site assessment schedules to the latest rather than old habits leaves many opportunities for improvement. With so many programs now using electronic medical records we have the ability to monitor some of these process measures much more effectively than previously possible. (A caveat, however, is that direct observation in my opinion is still very key – chart review is a great start but with the gaps between charting and reality I am a strong advocate for point prevalence studies done at the bedside in conjunction with our vascular access experts to collaborate and illustrate where our biggest opportunities lie. And remember, a picture truly is worth a thousand words when it comes to describing our findings.)  

In my own institution when we launched our protected clinical indication initiative two and half years ago we introduced an IV start bundle with our components we felt would help us safely extend our dwell time, for us that includes sterile gloves, neutral connectors, alcohol caps, a securement dressing, a chlorhexidine sponge and alcohol caps. With the data recently published on the contribution of PIVs to S. aureus (and MRSA) infections in hospitals, we believe this approach helps reduce those risks for our patients and can directly impact hospital metrics included in Value-Based Purchasing considerations.

With so many different guidelines, standards and recommendations regarding vascular access it can be a daunting task to know where to focus. The 2016 Infusion Therapy Standards of Practice give us so many different approaches to integrate into our programs to help truly enhance the overall patient experience and outcomes. Take some time to partner with your vascular access teams to review them and other recent publications to see where your journey can take you next.

Chellie DeVries MPH, CIC has been involved in infection prevention and control for more than 20 years, spanning university, federal and community healthcare systems. Her passion is connecting evidence with bedside staff to improve patient outcomes. She presents nationally and internationally on bloodstream infection prevention, particularly with peripheral lines.  

References:

Gorski L, Hadaway L, Hagle ME, McGoldrick M, Orr M, Doellman D. Infusion therapy standards of practice. J Infus Nurs.  2016;39(suppl 1):S1-S159.

Chopra V, Flanders S, Saint S, et al, The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method. Ann Intern Med. 2015;163:S1-S39. doi:10.7326/M15-0744.

Moureau N, Sigl G, Hill M. How to Establish an Effective Midline Program: A Case Study of 2 Hospitals. Journal of the Association for Vascular Access. 2015.  20(3):179-188. http://dx.doi.org/10.1016/j.java.2015.05.001
 
O'Grady, N.P., et al. Guidelines for the Prevention of Intravascular Catheter-Related Infections. American Journal of Infection Control. 2011; 39 (4 Suppl 1):S1-34.

APIC Implementation Guide: Guide to Preventing Central-Line Associated Bloodstream Infections. 2015, Association for Professionals in Infection Control and Epidemiology, Inc.

Marschall, et. al. Strategies to Prevent Central Line–Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update. ICHE, Vol. 35, No. 7 (July 2014), pp. 753-771

Kovacs C, Fatica C, Butler R, et al. Hospital-acquired Staphylococcus aureus primary bloodstream infection: A comparison of events that do and do not meet the central line–associated bloodstream infection definition.  American Journal of Infection Control. 2016.  http://dx.doi.org/10.1016/j.ajic.2016.03.038.  In press.   Published online May 2016. 

DeVries, M, Valentine M, Mancos, P.   Protected Clinical Indication of Peripheral Lines: Successful Implementation.  Journal of the Association for Vascular Access.  Summer 2016.   21(2): 89-93.  http://dx.doi.org/10.1016/j.java.2016.03.001

Davis J, Peripheral Vascular Catheter–Related Infection: Dwelling on Dwell Time. Pa Patient Saf Advis 2014. Mar;11[1]:30-5.

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