A California hospital reported that its vascular access team has gone nearly seven years without a central line-associated bloodstream infection (CLABSI) in any of its peripherally inserted central catheter (PICC) lines. The facility has recorded no CLABSIs, which are potentially deadly, in any PICC line placed by the team at Sutter Roseville Medical Center since January 2006, when a new bundle of central line practices and devices was implemented.
A central line bundle is a collection of evidence-based practices and devices, and other best practices, designed to prevent bloodstream infections.
The accomplishment at Sutter Roseville Medical Center (SRMC), in Roseville, Calif., is notable for several reasons:
- This is the longest span without CLABSIs ever reported by a hospital.
- Central intravenous therapy (IV) lines, including PICCs, have a much higher risk for bloodstream infections than any other type of IV line.
- CLABSIs are frequently fatal, with an attributable mortality rate of 12 percent to 25 percent.
SRMC’s record span without CLABSIs was reported in a scientific poster presented at the annual conference of the Institute for Healthcare Improvement (IHI). Author Sophie A. Harnage, RN, BSN, VA-BC, who is clinical educator for infusion services, heads the hospital’s vascular access team and supervised creation of the bundle.
The poster describes seven elements of the bundle that are key to preventing CLABSIs:
- Ultrasound-guided PICC placement, which aids proper location of the catheter.
- Maximum barrier precautions. Use of gloves, gown, mask, drapes, and related precautions helps prevent transmission of pathogens.
- Central line kit revision. SRMC’s central line kit was expanded to include three new elements: a patient skin preparation solution (ChloraPrep®, CareFusion Corporation) containing chlorhexidine gluconate (CHG), a broad-spectrum antiseptic; a catheter stabilization device (StatLock® Stabilization Devices, CR Bard) to help prevent catheter migration, insertion site trauma, and extraluminal migration of bacteria; and a foam disc (BioPatch® Protective Disk with CHG, Ethicon) that protects the catheter site and releases CHG for up to seven days.
- Change to zero displacement IV connector. Sutter switched the type of IV connector (a sophisticated plastic device that connects an IV catheter to tubing and helps deliver medications and nutrition). The hospital went from a so-called positive displacement connector to a zero displacement connector (InVision-Plus®, RyMed Technologies). Positive placement connectors are associated with higher rates of CLABSIs, according to several studies. The zero displacement connector, by contrast, prevents blood reflux (the backflow of blood into the connector). Blood reflux creates a breeding ground for dangerous bacterial colonization in the connector’s interior pathway.
- IV connector septum disinfection. Nurses access connectors through an external part called a septum to draw blood or administer medications and other fluids. SRMC mandated thorough disinfection of the septum before every line access with a “scrub the hub” campaign.
- Standardized catheter flushing protocol. Sutter revised its flushing policy, requiring all central line catheters to be flushed with 10 mL of normal saline every eight hours and as needed.
- Daily monitoring. This daily site check of the line to evaluate its necessity makes it possible prevent complications and to remove central lines as soon as they are no longer needed.
“I think the biggest piece of our success is the comprehensiveness of what we do,” says Harnage. “I can’t point to a single element of our bundle that we could do without and still give our patients the protection they deserve. Nor can I imagine having this kind of success without a team who is passionate, dedicated, and committed to the delivery of safe patient care, from top to bottom. Everyone works together here to make our zero-infection goal an achievable reality.”
The switch to a zero displacement IV connector is particularly notable because connector types are rarely addressed in central line bundles -- even though widely used connector designs such as positive and negative displacement connectors are associated with higher CLABSI rates.
The zero displacement connector used at SRMC was designed to avoid the pitfalls of previous connector types. For instance, the connector has a straight fluid pathway with no dead spaces so it is easy to flush clean. Other connector types can trap blood in the pathway, leading to bacteria colonization.
The poster also described several human factors that are crucial for preventing CLABSIs. These include catheter placement and care by a specialized vascular access team that “owns” the lines. Owning these lines, including initial assessment of the patient, insertion, care and maintenance, which includes daily site checks, has been the consistent practice of this Vascular Access Team, and a notable component of this central line bundle.
The poster at IHI reports that hospital-wide including all central lines, there has been one CLABSI since 2007, involving a dialysis catheter placed by a team from outside the hospital that did not follow the PICC teams’ protocol.
SRMC also promotes a patient safety culture that involves all interested personnel from top administrators to materials managers to infection control professionals and front-line clinical staff.
IHI’s 24th National Forum on Quality Improvement in Healthcare was held Dec. 9-12 in Orlando, Fla.
Source: RyMed Technologies