江油市人民檢察院公開考調(diào)工作人員

PreventingCentralLine

AssociatedBloodstream

Infections(CLABSIs)WhatClinicalStaffShouldKnowPreparedbyAnnBaileyRNC-NIC,BSN,MBA,CICJoanneDixonMN,RN,CICGwenIrwin,RN,CRNIJudySmith,RN,BSN,CRNIDecember18,2009Objectives

Uponcompletionofthismodule,thelearnerwillbe ableto:SummarizetheJointCommission2010NationalPatientSafetyGoal07.04.01relatedtoCentralLineAssociatedBloodstreamInfections(CLABSIs),effective01/01/10Includesusing“Bundle”withrespecttopreventingCLABSIsDefine“Bundle”Name2wayspatientsgetCLABSIsList4evidence-basedpracticesthathavebeenshowntohelppreventCLABSIsTheJointCommission

2010NationalPatientSafetyGoal

(NPSG)NPSG07.04.01focusesonthepreventionofCLABSIs.AllthosewhomanagecentrallinesMUSThaveeducationabouttheimportanceofpreventingCLABSIs.Includesstaff,doctors,APNsorotherlicensedprovidersPatientsandfamiliesMUSTbeeducatedaboutCLABSIpreventionbeforeanycentrallineinsertion.CLABSIsurveillancewillbehospitalwide,nottargetedtoICUs.Foradults,NOfemoralcatheters,unlessothersitesaren’tavailable.PatientandFamilyEducation

BeforeCentralLineInsertionFAQCatheterAssociatedBloodstreamInfectionsfromJointCommissioncovers:ProvidersdoinghandhygieneStepsformaximumbarrierCVLinsertionCleanhandsbeforeusingCVLCleanconnectorswithantisepticsolutionbeforeusingCVLDecideeverydayifCVLisneeded.Askproviderstocleanhandsifpatientdoesn’tseethem.Tellnurseifdressingcomesofforwetordirty.AndmoreTheJointCommission

2010NationalPatientSafetyGoal

(NPSG)NPSG07.04.01focusesonthepreventionofCLABSIs.AlsoincludestheCVLinsertionbundle.Wehavehadinplaceforalmost5years.AlsoincludespartoftheCVLmaintenancebundle.Wehavehadinplaceforabout2years.WhatisaBundle?Agroupingofevidence-basedbestpracticesthatindividuallyimprovecare,butwhenappliedtogetherresultinsubstantiallygreaterimprovement.Sciencebehindthebundleelementsiswellestablished–thestandardofcare.Bundleelementcompliancecanbemeasuredas“yes/no.”“Allornone”approach.TheCVLInsertionBundle

Handhygieneimmediatelypriortoinsertion-washhandsor-usealcohol-basedhandgel/foamMaximalbarrierprecautions -fullbodysteriledrape -clinicianandassistantwearcap,mask,sterilegown,gloves -personswithin6feetwearhatandmaskSkinantisepsiswithchlorhexidine2%/70%isopropylalcohol.

Subclaviansiteconsidered1stchoice;avoidIJ&femoral. Exceptions:Shouldberareforadults -Hemodialysiscatheters -Whenhighriskforpneumothorax -Whenhighriskfornoncompressiblehematoma

TheCVLMaintenanceBundlePerformgoodhandhygiene,priortohandlingline -Handwashingor -Usealcohol-basedhandgel/foamAssessdressing/sitewithroutineassessmentScrubconnectorvigorouslywithalcoholx15seconds -AllowtodrybeforeaccessingAssesslinepatencyforbriskreturnandeasyflushingAssesstodetermineifpatientmeetscriteriaforlinenecessityWhyPreventCLABSIs?Nationallyandannually:80,000centrallineassociatedbloodstreaminfectionsoccurinICUs250,000hospital-wide,includingICUsSetonFamilyofHospitalsThemajorityofCLABSIsoccuroutsideofthecriticalcareunitsCheckyourunit’sCLABSIswithyourinfectionpreventionist,ifyouareinterestedinmoreinformationIncreasesthepatient’sriskofdeathsignificantlyCLABSIsleadtolongerlengthofstay(LOS)NationalestimatesshowthecostofaBSIcanbeashighas$25,000perepisode(MMWR,August9,2002Vol.51,No.RR-10)HowdoCLABSIshappen?IntroductionofpathogensintothebloodstreamfromtheskinaroundinsertionsiteIntroductionofpathogensintothebloodstreamfromthehuborconnectorofthecatheter.MostfrequentcausenationallyAlsotrueatSetonCVLsinareasthathaveincreasedcolonizationoforganismssuchastheinternaljugularorfemoralsitesMultiplelumens:Moremanipulationandcontamination.(MMWR,August9,2002Vol.51,No.RR-10)Useofstopcocks(MMWR,August9,2002Vol.51,No.RR-10)ContaminationofIVtubingorconnectors(caps)LongerdwelltimeofCVCFactorsThatIncreaseRiskofBSIsSelectsubclaviansiteoverinternaljugularorfemoralsites,ifPICCnotusedPerformhandhygieneUsemaximumbarrierprecautionsSkinprepwithchlorhexidineratherthanpovidone-iodineSkinpreponcleanskinMaintainpatencyofalllumensFreeofsluggishnessorocclusion;briskbloodreturnRemovelinewhennolongernecessaryFactorsThatLowerRiskofBSIsFemoralVeinLastchoiceSubclavianVeinFirstChoiceInternalJugularSecondchoiceCVLInsertionBundleComponent:

CVLSiteChoices

HandHygiene–TheMostImportantWaytoPreventAnyInfection

Handwashing-10-15secondsofsoapandfriction,rinse,dryandturnofffaucetwithcleanpapertowelAlcohol-basedhandgel/foam-applyproducttopalmofonehandandrubhandstogether,coveringallsurfacesofhandsandfingersuntilhandsaredryImmediatelybeforeaccessingthecentrallineCVLInsertionBundleComponent:

MaximumSterileBarrierPrecautionsHatandmaskPersonswithin6feetalsowearhatandmaskSterilegownSterileglovesCVLInsertionBundleComponent:

Chloraprep?Grossdebrisordirtshouldberemovedwithanalcoholpad,priortousingtheskinprep.

bywashingwithsoapandwater,priortousingtheskinprep.

Cleanwithfrictionforminimumof30seconds.AllowChloraprep?tocompletelydry,beforeprocedureforbestresults.DONOTREMOVEChloraprep?aftertheprocedureiscompleted.Exception:neonates<2months.CVLMaintenanceBundleComponent:

Assesslinepatencyforbriskreturn

andeasyflushingResearchstudiesindicateadirectcorrelationwithocclusions,fibrinsheaths,andriskofCLABSIsNobloodreturn?Flusheseasily?ProbablefibrinsheathorfibrintailTreatassoonaspossibleTreatwithAlteplaseperdeclottingprotocolCatheterFibrinsheathInfusingaroundsheathAttemptingtowithdrawbloodCVLMaintenanceBundleComponent:

DailyReviewforLineNecessityRemovewhenNoLongerIndicatedIndicationsforaCVLHemodynamicmonitoringAdministrationofcertainmedicationsthatrequirecentraladministration,e.g.vasopressors,chemotherapy,TPNLongtermIVtherapy,e.g.antibioticsorinotropesPlasmapheresis,apheresis,hemodialysis,orcontinuousrenalreplacementtherapyPoorperipheralvenousaccess,whenIVtreatmentisstillneededCVLMaintenanceBundleComponent:

ScrubtheHubwithAlcoholfor15seconds,

priortoaccessingVigorousscrubbingisnecessarytoremovepathogensResearchshowsthat5secondsisnotenough.67%ofpathogensarestilltransferred.Researchshowsthat15secondswithfrictionis100%effectiveindisinfection.Ifthisstepisskipped,thepatientisinoculatedwiththeorganismsofhissurroundings.CVLMaintenanceBundleComponent:

Assessdressing/sitewithroutineassessment

KeepdressingcleandryandintactLooseandwetdressingsaresitesofpotentialinfection.CHANGETHEM!Coverthesitedressingandtheconnectorsduringshowers.Aquaguardisavailable:7”x7” Lawsonnumber080204Potentialwaysofcontamination Thetopofthemedicationvialisnotsterile.Thetopisa“dustcover.”Cleanvigorouslywithalcohol

beforeaccessingthevialwiththebluntfillneedle.DisconnectingtubingSterileendcapinplaceNotrecommendedbymanufacturer.Off-labeluse.Howdoyouknowifthetubingtipisstillsterile?IndicatestipsterilitymaintainedSomePrefilledSalineSyringes

AreforFlushingONLYThesalineflushsyringesintheclearcellophanepackageisONLYforflushingAccordingtothemanufacturer,DONOTuseformedicationdilution.Theinsideofthebarrel&thefluidpathwayisallthatissterileonthesesyringes.Whenyoupushoutsaline,theoutersideoftheplungercontaminatestheinsideofthebarrel.Then,whenyoudrawbackintothesyringe,youarepullingtheplungeroverareasthatwerejustcontaminated.Ifyoudothis,youcouldbepushingpathogensintothepatients’bloodstreams.Thesalineflushsyringesinthesterilepeelpackmaybeusedformedicationdilution.YourRole Followthebundlecomponentsspecifictoyourroleinthepatient’scareProvideappropriate/indicatedpatientteachingregardingthesebundlecomponentandotherrecommendedpracticesDocumentpatienteducationrelatedtothegoalofCLABSIpreventionPatienteducationmaterialsrelatedtoCLABSIpreventioncanbefoundontheIntranet:/polandproc/infectcontrol/docs/clabsi.pdf/polandproc/infectcontrol/docs/clabsi_largertext.pdf/polandproc/infectcontrol/docs/clabsi_spanish.pdf/polandproc/infectcontrol/docs/clabsi_span_lg_txt.pdfRemindpeersoftheimportanceoffollowingthebundlecomponentsandotherrecommendedpracticesiftheyareobservedtobenon-compliantPoliciesCentrallineinsertionanddressingpolicies:

CaringforCentralVenousCatheters(CVC),(adultpatients)

CaringforCentralVenousCatheters(CVC),e.g.Broviac,Hickman,Groshong,Hohn,PeripherallyInsertedCentralCatheter(PICC)(pediatricpatients)

CaringforPeripherallyInsertedCentralCatheter(PICC)inNeonatalPatients

CaringforTemporaryandPermanentHemodialysisCatheters,e.g.QuintonorPermCath

DeclottingCentralVenousCatheterswithAlteplase,PartialorTotalOcclusion

References/ncidod/dhqp/gl_intravascular.html/ihi/search/searchresults.aspx?searchterm=clabsi&searchtype=basic/NR/rdonlyres/868C9E07-037F-433D-8858-0D5FAA4322F2/0/RevisedChapter_HAP_NPSG_20090924.pdf

Pronovost,MDPhD,Peter,Needham,MD,PhD.,Dale….AnInterventiontoDecreaseCatheter-RelatedBloodstreamInfectionsintheICU(MichiganKeystoneProject),NewEnglandJournalofMedicineDecember28,2006;Vol.355,#26.MakiDG,MermelL,GenthnerD,HuaS,ChiacchieriniRP.AnevaluationofBIOPATCHAntimicrobialDressingcomparedtoroutinestandardofcareinthepreventionofcatheter-relatedbloodstreaminfection.Johnson&JohnsonWoundManagement,adivisionofETHICON,INC.,2000.Dataonfile.MenyhaySZ,MakiDG.Disinfectionofneedlelesscatheterconnectorsandaccessportswithalcoholmaynotpreventmicrobialen