Reducing Risk of Primary Bloodstream Infection : Key Reminders
By Michelle DeVries , MPH , CIC , VA-BC
Prevention of bloodstream infections , with a focus on central line-associated bloodstream infections ( CLABSI ) has been a top priority for infection prevention and control ( IP & C ) teams for years , with enhanced attention added when these outcomes became federally reportable to Centers for Medicaid and Medicare Services ( CMS ) as part of the Value Based Purchasing program ( Prevention , 2019 ). Years later , many programs are still facing the continued occurrences of bloodstream infections . While much emphasis has been placed on CLABSI , there is an increasing awareness of the risk of infection across all vascular access devices ( Mermel , 2017 ). While currently not included in the scope of all IP & C programs and still absent in federal reporting mandates , there is value in realizing that many of the same concepts of best practice for improving central line outcomes likely remain valid for peripheral ( short , long and midline ) catheters as well . This article will review those key strategies and discuss the role of prospective process surveillance as well as continued collection of outcome data to help guide improvements .
Insertion
Often overlooked in insertion related considerations is perhaps one of the most important questions : Is this the correct device ? A provider may order a particular line type based on familiarity with a product ( i . e ., peripherally inserted central catheter ) and its placement ( i . e ., bedside insertion under ultrasound by a specialty insertion team ) without being fully aware of the more complex decisions the specialist will use to guide device and lumen selections including but not limited to : available vasculature ( size , health and quantity of available veins ), infusate characteristics , length of prescribed and anticipated therapy and care setting ( Bozaan , et al ., 2019 ; Cawcutt , Hankins , et al ., 2019 ; Chopra , et al ., 2015 ). Developing practice support tools whether through a consultative vascular access service , algorithms embedded in the electronic medical record or independent application-based programs can help standardize these points .
There has been much written about central line insertion bundles , which gained significant uptake following the then-groundbreaking work of Pronovost in reducing CLABSI in the intensive care unit setting ( Pronovost , et al ., 2006 ). The key features of that project involved implementation of key aspects of the existing CDC guidelines , specifically : hand hygiene , maximum sterile barrier precautions , chlorhexidine gluconate in alcohol for pre-procedure skin preparation , avoiding the femoral site if possible , and removing unnecessary catheters . Additionally , insertion checklists and carts / kits were introduced and observers were empowered to stop the procedure ( unless emergent ) for observed lapses in sterile technique . More than 15 years following this collaborative , these remain the foundation of insertion related infection prevention strategies for central lines with little variation beyond continuing discussion of optimal site selection to balance infectious and mechanical risks .
Prevention of all hospital-onset bacteremia , particularly those associated with vascular access devices , should be explored as a quality indicator for all organizations . There has been considerable discussion of this topic in recent years , including a still-unresolved proposal by CDC to expand NHSN surveillance protocols to include all hospital-onset bloodstream infections ( Blauw et al ., 2019 ; Dantes et al ., 2019 ; Kovacs and Fatica , et al ., 2016 ; Rock et al ., 2016 ). Learning from what has proven successful with central lines and reviewing available data from non-central line-associated infections and current evidence based recommendations , there is a similar theme ( hand hygiene , chlorhexidine for insertion , optimal site selection and removal of idle catheters ) for peripheral vascular access devices ( short and long ) ( Association , 2019 ; Gorski , 2016 ; O ’ Grady , et al ., 2011 ) along with expanding standardization of aseptic non-touch technique ( ANTTR ) for vascular access procedures ( Rowley , 2019 ). Recent meta-analysis , however , has yet not defined the optimal elements for inclusion in insertion and maintenance bundles for peripheral catheters ( Ray-Barruel , et al ., 2019 ).
Maintenance While significant focus has been on insertion of devices , appropriate care and maintenance is necessary
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The key features of that project involved implementation of key aspects of the existing CDC guidelines , specifically : hand hygiene , maximum sterile barrier precautions , chlorhexidine gluconate in alcohol for preprocedure skin preparation , avoiding the femoral site if possible , and removing unnecessary catheters .