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Instructions for use

 Understand the impact and causes of infection associated with vascular access  Identify signs and symptoms of infection in vascular access  Explain procedures involved with safe insertion, maintenance and removal of intravascular devices to reduce the risks of infection

Objectives

 9% of hospital inpatients at any one time will acquire an infection during their stay1  There are at least 100,000 HAI a year1  5,000 deaths a year2  Financial impact

• 1. Auditor General (2000) the management and control of Hospital Acquired Infection in Acute NHS in England.
• 2. DOH CMO (England) (2002) Getting ahead of the curve

The Impact of Healthcare Associated Infection (HCAI)

 National Audit Office

– Suggests that 10-15% of HCAI can be prevented – Good application of Infection Control policies and principles

National Audit Office 2000

Preventing HCAI

 Incidence of blood stream infections

– 0-15% (Elliott 1993) – Central catheters responsible for 31% hospital bacteraemias, peripheral lines 7% (PHLS 2000) – Paediatrics: 3-11 / 1000 catheter days (Seguin et al. 1994)

The extent of the problem

 Up to 80% of hospitalised patients will receive some form

• f I.V. therapy (Wilkinson 1996)

 Nystrom et al. (1983) studied 10,616 surgical patients.

– 63% had an I.V. device – 10.34% thrombophlebitis

The extent of the problem (2)

General Principles of Infection Control

 Remove the source of infection  Block routes of spread  Enhance the patient’s resistance to infection

 Patient Factors  External Factors

Risk Factors for Infections

 Local infection

– Local inflammation – Discharge around line – Erythema – Pain/discomfort

 Systemic infection

– Fever – Rigors when line is in use – Tachycardia – Metastatic infection

Vascular Access Associated Infections

 Coagulase – Negative Staphylococci (CNS) 30-40%  Staphylococcus aureus 5-10%.  Enterococcus 4-6%.  Pseudomonas aeruginosa 2-6%.  Candida 2-5%; Enterbacter 1-4%; Acinetobacter 1-2%; Serratia <1%

Centres for disease Control and Prevention (2002) Guidelines for the Prevention of Intravascular catheter – related Infections. Morbidity and Mortality weekly report. Vol. 51/ No. RR-10.

Common pathogens in bacteraemia

 Endogenous

– Infection arising from patient’s own organisms

 Exogenous

– Infection originating from organism outside of the patient’s body including environment, equipment & staff hands

Routes of Infection

 Intrinsic contamination occurs prior to the use of the equipment

– manufacturing problem, poor storage

 Extrinsic contamination occurs at any point during the insertion, use or removal of the device

– Poor hand hygiene, poor aseptic technique

Sources of Exogenous Infection

 Extraluminal

– Organisms access the vein via outside of catheter

 Intraluminal

– Organisms access the vein via lumen of catheter

 Haematogenous

– Organisms from other sites transferred by blood flow to catheter

Extraluminal, intraluminal & haematogenous routes

HAEMATOGENOUS SEEDING SKIN COLONISATION

 epic National Evidence Guidelines for Infection Control  NICE Infection Control prevention of HCAI in primary and community care  ICNA Guidelines for Preventing Intravascular Catheter- Related Infections

Guidelines

Other national resources

 Winning Ways  Savings Lives

 Provide service in best interest to patient / client

– Policies based on national standards and guidelines

 Necessary skills and competence  Provide care in partnership

– Patient / carer information

 Evaluate

– Practice, clinical outcomes

 Report

– Adverse outcomes, limitations

Professional Issues

 Assessment of need  Line choice  Insertion site choice  Insertion technique  Site care  Line management  Asepsis  Hand hygiene

Principles of PIVA

 Does the patient need I.V. access

– Alternative administration of therapy

 What treatment is to be administered

– Influence catheter type

Assessment of need

 Peripheral line (PVC)

 Ported vs. unported

 Peripherally Inserted Central Catheter (PICC)  Other alternative e.g. vascuports  Paediatric: Umbilical catheters

Line choice

 Central line (CVC)

 Single lumen unless multiple ports essential  Use tunnelled catheter or implantable port for long term devices

(more than 30 days)

 Consider antimicrobial impregnated CVC for high risk adult

patients who require short-term treatment (less than 10 days)

Line choice (2)

 Assess risks for infection against risk of mechanical complications  Use subclavian line as a preference unless medically contraindicated  Consider using PICC as alternative to subclavian or jugular access  PVC – site choice where least mechanical irritation

Insertion site choice (adult)

 Assess risks for infection against risk of mechanical complications  Most CVCs will be jugular or femoral (subclavian

• ccasionally)

 Consider using PICC as alternative to subclavian or jugular access  PVC – site choice where least mechanical irritation

Insertion site choice (paediatric)

 Aseptic technique  Standard precautions utilised  70% Isopropyl Alcohol skin preparation

Insertion technique – PVC

 Full aseptic technique  Full body drape with access to insertion site only  Full surgical attire by operator and assistant (epic 2001)  Alcoholic chlorhexidine skin preparation (alcoholic poviodine-iodine solution for patients with history

• f chlorhexidine sensitivity)

Allow the antiseptic to dry before inserting catheter

Insertion technique – CVC

 Intact sterile, transparent, semi-permeable polyurethane dressing  CVC dressing changed every 7 days or sooner if it becomes wet, loose or soiled  Before accessing the system disinfect external surfaces of the catheter hub and connection ports with alcoholic chlorhexidine gluconate or povidone-iodine unless contraindicated by manufacturer

Site care

 Insertion sites should be checked at least daily for signs of inflammation and document using VIP score

Site care (2)

 Lines should be handled as little as possible  Injection ports should be disinfected with alcohol wipes  Replace all tubing when vascular device is changed  Change tubing, stopcocks etc no more frequently than every 72-96 hours (unless clinically indicated)  Replace tubing from blood transfusion within 24 hours of initiation and on completion  Replace tubing following infusion of lipids within 24 hours of initiation

Line management

 Asepsis is defined as the method by which microbial contamination is prevented during invasive procedures or

• f breaches in the skin’s integrity

 Aseptic techniques are methods that have been developed to ensure that only uncontaminated objects / fluids make contact with sterile / susceptible sites

Asepsis

Full compliance with aseptic technique is essential for handling any line

 Compliance with aseptic technique must be used to insert all central lines  Skin should be disinfected before inserting any catheter

– Alcoholic chlorhexidine gluconate (alcoholic povidone-iodine in sensitivity) for CVC and PICC – Alcohol wipe for PVC – Allow preparation to dry before insertion

 Use sterile gloves for CVC manipulation (based on risk assessment)  Hands must be decontaminated prior to any line manipulation / intervention

Aseptic technique

 Hand hygiene is the principle factor to reduce risks of introducing micro-organisms  Hands must be washed / decontaminated before and after any manipulation / intervention associated with the line

– Administering drugs, changing infusions, inserting lines, changing dressings

 Hands must be washed after removing gloves

Hand hygiene

 Soap and water

 Wet hands  Wash using Ayliffe 6 step technique  Rinse  Dry thoroughly

– To remove physical dirt / organic matter

 Alcohol based hand rubs

– Physically clean hands – In absence of appropriate hand washing facilities

 Hand care

Hand hygiene (2)

Hand hygiene (3)

 Patients / carers should be trained how to look after a long term line

– Reducing risks of infection – Identifying signs and symptoms of infection – How to report concerns

Patient information

 Surveillance

– Site infection surveillance (incidence, rates) – Bloodstream infection associated with vascular devices

 Mandatory bacteraemia reporting

– Root-cause analysis

Infection prevented?

 Audit

– Practices, local and organisational

 Insertion, management, documentation

 Department of Health, ICNA audit tool  Saving Lives

– High impact intervention No. 1 & 2

 PIVA audit tools

Infection prevented? (2)

Infection prevention and control is everybody’s responsibility every day!

Any Questions? Thank you for listening!