The Bundle and Beyond

At the Infusion Nursing Society (INS) meeting in May 2009 a panel discussion was held to address methods of reducing central line-associated bloodstream infections (CLABSI). This article presents results experienced by clinicians in their continuing efforts to reduce CLABSIs  and to improve patient outcomes at their facilities. These statements are in no way intended to be product endorsements.

Debbie Campbell, MSN, RNC, CCRN

Our journey started in 2004 when we had a CLABSI rate that our team was not satisfied with, even though it was about average for a PICU. In 2008 we lowered our CLABSI rate to 0.42. I’m a firm believer that there is not one thing that causes a reduction. The PICU is a complex environment. The national average (NHSN mean) for CLABSI rates in the PICU is 6.6. Our rates are now much lower than the national average. Our first step was to look at the IHI Central Line Bundle (CLB) and we “pediatricized” it and adopted it into our PICU. We reeducated on hand hygiene, increased our number of audits, employed a “secret shoppers” program to watch and report on nursing practice, and we implemented a swabable, positive displacement needleless connector. In addition we worked on occlusion management and used alteplase when clots began to form. We also joined the National Association of Children’s Hospitals and Related Institutions (NACHRI) collaborative. We developed and implemented the standardized bundle that is related to insertion but with greater emphasis on sustaining maintenance practices. Most of our maintenance practices came from CDC and INS guidelines. We took the usual steps such as sterile insertion, daily assessment of line necessity and education on hand hygiene. We also implemented standardization for catheter site care with a pre-packaged dressing change kit and standardization of practice for tubing changes which requires all IV tubing sets to be changed in the cleanest manner possible. For cap changes we use cap change kits and standardized this process as well. Any tube or cap with blood exposure is changed every 24 hours. Additionally, we spent a lot of time on scrub the hub practice because we found that the policy to scrub the hub with alcohol or in some cases CHG exists, but actual practice often does not reflect the policy. Our auditing actually counted how long people were scrubbing and it very rarely met the standard of 15 seconds with a 15-second dry time. Utilizing the swabable needleless access device, which allows for complete and thorough disinfection, made gaining compliance with our “scrub the hub” campaign easier. We utilized educational programs, e-mails and posters to remind staff of our initiative and rewarded each success. Currently, our CLABSI rate is .42 and we are still improving. The implementation of new and improved products and standardized kits and the ability to sustain the practices we added resulted in a significant CLABSI rate reduction.

Karen Anderson, MT, CIC

Our facility started an initiative to reduce bloodstream infection rates in 2007. At that time the rate in our four adult ICUs was 2.5 per 1,000 catheter days. In 2008, we reduced the CLABSI rate to 1.3. Three of the adult ICUs have been at zero for over 15 months. From 2007 to 2008, we had a 36 percent reduction in CLABSI house-wide, and the rate reduction for the largest ICU was 48 percent. We have worked hard to reduce the total number of central line days through daily line assessment.

Reducing the number of line days has helped reduce the overall CLABSI rate. We implemented many interventions along the way, including the central line bundle, dressing change kits, proper line assessment and documentation, and the swabable, positive displacement, clear cap. We are still working to reduce our rate further and have continuing challenges.

One of the most important things you can do is to continually remind staff about the importance of line care and let them know the CLABSI rate their unit is experiencing. You can’t just perform education and walk away and think it’s going to stick. It’s not going to. People do drift over time. We continue to strive for zero infections and now see that it is possible.

Victor Lange, CRC, MSPH

I wanted to discover what kept germs out of the catheters and connectors, but what really makes one stand out from the rest? When used appropriately, the theory is that connectors should keep the bugs out. Over the past few years we have all listened to a lot of experts and read a lot of articles. There’s so much debate as to what type of connector works best that I wanted to test the connectors myself and understand how they operate. We know that preventing bacterial transmission through needleless connectors is key; they should provide a barrier because the patient has contaminants on their skin or normal skin flora, but also, our hand hygiene isn’t up to par. Studies have shown that up to 70 percent of healthcare workers wash their hands before and after patient care, so there is 30 percent who don’t and that is a major risk. I first looked at the data available from various regulatory agencies. The Food and Drug Administration’s document, “Guidance for Industry and FDA Staff – Intravascular Administration Sets Pre-Market Notification [510(k)]” was developed to assist industry in preparing pre-market notification (510(k)) submissions for intravascular administration sets and accessories. In the guidance document issued April 15, 2005, test methodology is recommended to challenge the microbial ingress properties of a needleless access device that facilitates any type of bidirectional fluid flow. Bidirectional fluid flow may increase the patient’s risk of infection by allowing the entry of microorganisms into the sterile fluid path.

The FDA recommends that manufacturers conduct a microbial ingress test in order to determine if the device provides good barrier properties. This testing is usually conducted in a laboratory environment under in vitro conditions that exposes these valves to a stringent environment to simulate a normal clinical setting in a hospital. Through this FDA recommended Microbial Ingress Testing process, I hoped to learn which valve offers better barrier properties. In the first phase of the study, three different devices were tested according to the FDA recommendation.

Our goal was to see if these connectors (or valves) when swabbed with 70 percent IPA for approximately a three-second swab time can be disinfected. Twenty-two samples from each manufacturer (66 total) were tested. Two of each type were utilized as positive and negative controls. Each connector was attached to a sterile collection container. The top of the each valve was inoculated with 103 colony-forming units (CFUs) of S. epidermidis, common bacteria found in skin flora. Four minutes after applying the inoculant, the connectors were swabbed with 70 percent IPA in a circular motion for three seconds. We know that people don’t do it for longer than three seconds on our floors, so we wanted to replicate a real-life scenario. Allowing the alcohol to dry for one minute thereafter, we then activated each of the valves, in this case 66 valves, using a sterile syringe containing 10 cc of sterile saline. For three days, all these samples had undergone the same process of inoculating, swabbing and activating repeatedly 24 times a day. We wanted to access these devices as often as they may be accessed in an ICU setting. Eight of the 24 inoculations per day were prolonged activations where the syringe remained in the valve for one hour or greater. This was done to simulate intermittent antibiotic infusion, for example.

The results were revealing. Day one through three we looked at the different comparisons of the three different products. We collected the saline that was pushed through the valves after they were swabbed and we cultured that sterile solution. Our findings were consistent with other published studies, the device with obvious gaps and intricacies on the access surface had 17 out of 20 contaminated specimens, meaning a failure rate of 85 percent. The second device, featuring a clam shell top with a slit had a 100 percent failure rate. I like to compare it to a clamshell as once it traps bacteria inside, there’s no way of cleaning it out. The third product, which featured a very swabable surface free of indentations and gaps had no failures, zero out of 20 contaminant events. I’ve actually used this third device in clinical practice and had the best success with the product that offers a smooth surface, nonporous, with the least intricate fluid pathway as possible. In conclusion, needleless access devices with gaps, slits, and open spaces may not pass the FDA recommended microbial ingress testing. In my testing, these devices did not disinfect as well during a three-second swab as the device that featured the smoothest surface.

Barbera Herzog Taft, RNC, MS, NNP, CNS

My presentation focuses on the contribution of the central line bundle (CLB) approach to reducing CRBSI in the NICU. Each year we have about 40 premature babies born at less than 3.3 pounds and these babies typically have a central line in place for at least several weeks. Having a central line in place and being immune-suppressed are a combination that places these babies at very high risk for acquiring a CRBSI. When we reviewed our rate of CRBSI for our NICU, we recognized the opportunity we had for improvement. In 2005, the Vermont Oxford Network (VON) offered a web collaborative, “Reducing Nosocomial Infections in the NICU” and we were eager to participate. The VON is based out of Dartmouth University and has about 800 NICUs from around the U.S. participating in their data collection and reporting service. Our goal going into the collaborative was to reduce our number of CRBSI by 50 percent the first year, and another 50 percent the following year. By the end of the first year, we adopted a “zero tolerance” philosophy and set our sites at achieving zero infections from central lines. As we completed each of the six Web sessions, we evaluated and modified our clinical practice. The top priority for our performance improvement was to reduce our CRBSI. We adopted potentially better practices that other NICUs were using and developed our own CLB to reduce catheter related infections in our NICU. The CLB was comprised of several key clinical practices and the first and most important care practice to improve was the consistent performance of hand hygiene by all the caregivers. We used signage and an audit to assist in educating staff on the importance of excellent hand hygiene practice in the NICU. We identified the need to have more than one type of hand hygiene product available, so that there would always be a product that would work for everyone. Due to our crowded environment of care and the design of our NICU, it was also a challenge to find a way to mount hand hygiene dispensers at every bedside so that access to product would always be convenient. The CLB also included placing boxes of gloves and a canister of disinfectant wipes at every bedside as well as having the option of using a pocket hand hygiene product.

In addition to improving our hand hygiene practice, we adopted the daily routine while reviewing the medical plan of care, to defend the need to keep a central line in place for another day. Care of all central lines was modified as well. We used a dedicated PICC team, maximum barrier protection while placing all central lines, and improved practices when IV tubing and dressings were changed. We also reduced the exposure of our babies to antibiotics by decreasing the number of hours of treatment for the first course of empiric therapy to rule out sepsis.

Although we were able to improve several vital care practices, there was one aspect of the bundle that we had not been able to tackle, and that was our method for entering our central lines for blood draws, medication administration, and connecting IV tubing. There was concern regarding the bedside nurse’s ability to properly clean and keep clean the access port on central lines. For umbilical catheters we had always used stopcocks with reusable caps. A closed blood draw system seemed like the best option to explore. Four different systems were compared for ease of use and cost, and we embarked on a clinical trial with the closed blood draw system that was our first choice.

Early in the trial, information on a NICU list.serv described using a swabable, positive displacement needleless access device on central lines. We investigated the recommendation for use of this device at the large, research-based, NICU and this lead us to consider this device as a better alternative for our NICU. We set up the trial and the staff eagerly and easily adopted the clear valve system. The superior method for protecting the entry into our central lines was apparent, and the ease of using the device was appealing to the nursing staff. We were pleased to finally have a complete central line bundle, and our outcomes have demonstrated the synergistic effect; we were able to achieve results that were even better than the sum of the individual parts. We have had more than one stretch of 10 months without a CRBSI and are proud of our excellent practice and clinical outcomes.

Tim Royer, BSN, CRNI

We started using the swabable, positive displacement, clear valve in January 2007. During the first several months we conducted education and in-services. We stressed: flushing until the valve is clear, or if the valve cannot be flushed clear, remove it. We demonstrated a five-fold decrease in the CLABSI rate. The objective was to reduce contamination of these valves not only to prevent infection, but also to stop contaminated blood cultures which adds up quite considerably when you look at the whole process of treating false blood cultures. We brought in the clear valve and provided intense education on either flushing the valve clear or changing it. What is great about the clear valve and why it is such an important tool is that it serves as a cue for changing the cultural habit of how to properly maintain, swab and flush valves. The goals were to decrease contaminated blood cultures, decrease CLABSI rates, and decrease patient care costs. I worked very closely with the ICPs at my facility, we reviewed every bloodstream infection to see if it was catheter related, we define our CLABSI per 1,000 catheter days.

The following changes were implemented to reach these goals: we replaced the standard opaque valves with Clear ones; we instituted flushing these valves until they were clear and we educated the staff on the importance of scrubbing the hub and flushing appropriately. We know valves may become contaminated with infusion residue. There is one published study that reports when you have residue inside a line or in a valve, and then you draw blood back over it, the fibrin forms a more intense matrix and it’s harder to dislodge and everybody knows that blood is a great growth medium. Clear valves provide the macroscopic inspection of residue.

At our facility, we reduce residue with 20 mls of flush. This only applies to the adult population, not to neonates or pediatrics. Clear valves can be visually inspected to ensure proper flushing. Risk of residue should be revealed and not hidden. This is the reason I truly believe we were able to decrease our infection rate five-fold. We dropped it down from 7.4 to 1.5 in 2007. Our blood culture contamination rate dropped 60 percent. Now if you look at the cost, that’s a total cost savings of $200,000. Actually we saved more money not having to deal with the contaminated or false positive blood cultures than we did in preventing bloodstream infections. So after blood draws, blood residue not flushed from the valve might serve as a growth medium. Most valves are opaque and blood residue cannot be visualized. Changing to the clear valve revealed residue. We have realized a five fold decrease in our CLABSI rate and are currently running at over 400 days with a rate of zero.

Lee Steininger, RN, CIC

In 2001, when I began working at Kindred Hospital Tucson, our CLABSI rates were over the national benchmark. We started out by changing the hand hygiene products in the facility and added an alcohol-based hand gel because cleaner hands will reduce the risk of contamination. We also started using CHG-eluding patches. Later that year we discovered that manufactured catheter securement devices were available which prevent the catheter from sliding back and forth, reducing the introduction of bacteria into the vein and in 2002 we introduced in these devices into our facility. The first year I was there, the rates dropped from 7.8 to 3.53. Bear in mind at that time the benchmark was near 5.0. In 2002, it dropped again and it kept dropping so that by the end of 2004 we were at 2.87. In 2005 our rates started to climb again. During this time we had increased our use of agency nurses. I learned that agency nurses were conducting dressing changes. They had no vested interest in the program. They came in, they worked a shift and then they left. We made the decision that agency nurses would no longer be allowed to do central line dressing changes. In 2006, we actively recruited staff nurses; we have not had agency nurses in our facility since 2006. We started doing detailed staff education programs, as we felt that they needed to understand what could cause bloodstream infections.

Every six months, education on the causes of CLABSI and various prevention strategies is given to ensure all nurses are competent on our CLABSI reduction initiative and on the supplies we have implemented. Each year our rates dropped and administration was happy. But, I wasn’t happy with the rates, because remember a benchmark is the 50th percentile. Just being near benchmark is not good enough. So, in 2007, I was at one of my sister facilities where I was introduced to a swabable, positive displacement clear needleless connector. It was different. It was going to prevent the lines from clotting off, it was going to help reduce our bloodstream infections, and it almost sounded too good to be true to me at the time. When I was at the 2007 APIC conference I talked with colleagues and gathered more data. I was convinced that this connector, if used appropriately, would help reduce the problems. Unfortunately, when I came back, the hospital had started trialing a new IV pump which required the use of a different connector. I didn’t want to introduce something else that might skew the results, so I held off. Incidentally, during the trial of the new pumps, our infection rates increased. I needed other data because the connector I suggested we bring in was more expensive than the one on the pump agreement or the one we had been using before the pump trial.

The data I collected demonstrated that we had spent more than $10,000 the previous year on alteplase to declot our lines. I also emphasized the need to lower the bloodstream infections in light of the CMS payment system. I reminded the committee of the Joint Commission’s National Patient Safety Goal to reduce the number of multiple doses of heparin in the facility. I suggested that we introduce the product in our facility that would help us move away from heparin flushes as well; we trialed it for two months. In that time we only used 11 doses of alteplase compared to the 56 doses we used in the same period during the previous year. That alone, never mind the other savings associated with reducing infections, was enough for the committee to say that we could switch.

We went into full time use of the swabable clear connector in April 2008. A lot of time and energy was spent on education on the device and on catheter care and maintenance. We had all the company educators to help. We also had 15 of our staff nurses, including our nursing supervisors, trained as super users so that they could continue the education program for the staff. Alteplase use continued to drop. Bloodstream infections dropped. Contaminated blood cultures dropped and we were doing less blood cultures because we weren’t contaminating lines. During the first quarter of 2008 when the swabable clear connector was not in use, we had six central line associated blood stream infections. During the next three quarters of the year, the number of infections dropped by 66 percent. Our year end infection rate (including the higher rate from the first quarter) was 1.76. The rate for just the last nine months of 2008 was 1.18. We realized a 67 percent reduction in alteplase expenditures. The thing here is we all know any device initially is going to give results. What is most important, as we’ve all emphasized here, is a sustainable positive result. The clear valve has been in our facility for one year and right now, our infection rate is 0.86 per 1,000 central line days, and we will keep working on reduction strategies until we get it to zero.

Andre Schotte, RN, PhD

When I first started here we had high infection and occlusion rates. Catheters were placed in intervention radiology resulting in delayed catheterization. We had been using Groshong catheters with a standard cap then we decided to implement the Power PICC with a neutral cap. After this change, our occlusion rate increased significantly. I personally placed over 50 PICCs on my own which led me to think there must be something wrong and it couldn’t be the catheter, it must be the cap. This realization led me to consider infusion nursing practices over the last few decades. In the late 80s and early 90s, we always flushed using a positive-pressure technique. With the new neutral caps, you flush and disconnect and the positive bolus is lost. I challenged my facility as to why we were using a neutral displacement device in the first place. To me it made no sense! We had already figured out 20 years ago, when we practiced manual positive pressure flushing that it’s good to have positive displacement at the end of the line at disconnect. Open-ended catheters have a clamp right? And the only reason for the clamp is for safety. So why do we have to use this safety feature (the clamp) on a second device (the catheter) to make a third device (the negative or neutral cap) work correctly? This simply made no sense to me. I really started to look into all the different types of caps and I decided it is possible to achieve a lower occlusion rate with the right device. I said last year during my AVA oral abstract presentation you can have a $500 catheter but if the nurse at the bedside is not doing her job properly the catheter will not matter. So we started to replace the neutral cap with the positive displacement cap and our occlusion rate went down. In the ICU we had almost reached zero occlusions. During this time on the regular floors, I noticed several dual lumen catheters had a mix of caps, some were capped with the positive displacement connector and others were capped with the neutral device we had previously been using. I looked at this and said, “Oh that’s a perfect way to study the true effects of these different caps.”

So I decided to embark on a small study. On 50 dual lumen Power PICCS, we placed the positive displacement connector on one lumen and the so-called neutral device on the other and began to collect occlusion data by lumen and by cap. The results of this small study were very conclusive. Only one of the lumens with the positive pressure device had a partial occlusion compared with 11 lumens with the neutral cap. We had no total occlusions in the lumens capped with the positive displacement connector and nine total occlusions were reported on the lumens capped with the neutral device.

After this study, it was clear that we needed to return to positive displacement. I also decided to conduct a laboratory experiment on my findings because I simply do not believe what I read from vendors. I like to test their claims on my own, research it for myself. I acquired all the caps on the market and tested them for the effect of displacement of fluid at the catheter tip during disconnection from the cap. This testing has led me to believe there’s no such thing as neutral. In addition we are now using the clear version of the positive displacement connector and you really can see what’s going on in the cap. You can see and keep nurses responsible for their catheter maintenance actions or non-actions. Before, they just placed the cap on the catheter and you couldn’t see what’s going on. Now with the clear connector we can see our flushing, swabbing, and priming practices and it really makes a difference for patients. My occlusion rate right now is the lowest ever; our infection rate is 0.29 percent. So far this year, we have had a total of three occlusions compared to almost 10 times that amount when we were using the neutral device.

Panel members:

Karen Anderson, MT, CIC, is the infection control manager at one of the largest private, not-for-profit, academic medical centers in California; an acute tertiary-care teaching facility with a network of four campuses and over 1,500 beds. She is also member of the Association for Professionals in Infection Control and Epidemiology (APIC).

Lee Steininger, RN, CIC, is an infection preventionist at a 51-bed, (including a four-bed ICU) long-term acute care hospital in Arizona. She is responsible for all the infection prevention and control activities at this facility. She is a member of the society

of Healthcare Epidemiology of America (SHEA) and APIC.

Tim Royer, BSN, CRNI, has many years of vascular access experience. Currently he is the secretary of the Association of Vascular Access (AVA) and he just recently retired as nursing manager of vascular access and diagnostic services at a VA Health Care System in Seattle, a 350-bed, 28-bed ICU, acute-care hospital. He is an active member of the AVA and the Infusion Nursing Society (INS).

Debbie Campbell, MSN, RNC, CCRN, is the clinical manager of the 26-bed PICU at a children’s hospital in Kentucky.

Barbera Herzog-Taft, RNC, MS, NNP, CNS, has been involved in neonatal care for over 30 years. She is currently the clinical nurse specialist and nurse practitioner of a 26-bed level-three NICU in Oregon.

Andre Schotte, RN, PhD, is the IV team leader at a 337-bed, 36-bed ICU, county facility, detention center and level-two trauma center. He is the chapter president of the Riverside County Chapter of the Association of Vascular Access (RIVAN) and an active member of the AVA and INS.

Victor Lange, CRC, MSPH, is the director of infection control at a long-term care network of facilities in Southern California. He has published numerous abstracts and white papers on hospital epidemiology and has been involved in product research and testing for the past 10 years.

References

1. O’Flynn J, et al. Collaboration within the CA-BSI collaborative. NACHRI 2008 annual meeting poster presentation.

2. Gorski L, et al. Symposium: The IHI central-line bundle: members of the Infusion Nurses Society discuss its impact. Infection Control Resource. Vol. 51 No. 2.

3. Knight T, et al. Reducing central venous catheter infections in the intensive care unit: A multidisciplinary approach. Building Quality in Health Care. 2008;2(1):18-20.

4. Lange V. Infection risk associated with a luer-activated device. Oral abstract presentation, 2009 APIC annual meeting.

5. Royer T, et al. Attaining zero central line associated bloodstream infection rate using enhanced education and care of central venous catheters. Poster presentation, 2009 AVA annual conference.

6. Schotte A. Luer activated device performance: Comparing positive pressure, neutral and negative pressure devices clinically and with follow-up laboratory testing. Clinical research poster. INS 2008 annual conference.

7. Costello JM, et. al. Systematic intervention to reduce central line associated bloodstream infection rates in a pediatric cardiac intensive care unit. Pediatrics. 2008;121;(5):915-923.

8. Garcia R, et al. A study of the effects on bacteremia and sharps injury rates after introduction of an advanced luer activated device for intravascular access in a large hospital setting. Am J Infect Control., Vol. 35, No. 5. June 2007.

9. Joint Commission. 2010 National Patient Safety Goals NPSG.07.04.01.

10. CDC. Guidelines for the prevention of intravascular catheter-related infections. Morbidity and Mortality Weekly Report. Aug. 9, 2002. Vol. 51, No. RR-10.

11. Murphy C, et al. Guide to the Elimination of Catheter-Related Bloodstream Infections APIC Elimination Guide 2009.