OPENING LEARNING ZONE KEYWORDS CR-BSI / HCAI / Central venous catheter / Infection Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication November 2013
The management of central venous catheters and infection control:
is it time to change our approach? by H Langton
Correspondence address: Main Theatres, Great Western Hospital, Marlborough Road, Swindon, SN3 6BB. Email:[email protected]
Catheter related bloodstream infections (CR-BSIs) can lead to a number of serious conditions for the patient, including death. There is much recent evidence both in the UK and abroad which identifies the sources of CR-BSIs, yet they continue to occur. This article seeks to review some of the current evidence in relation to the prevention of CR-BSIs at insertion point. Introduction It is important that any healthcare worker coming into contact with a central venous catheter is aware of their critical role in the prevention of catheter related bloodstream infections (CR-BSIs). In particular, the ODP or anaesthetic nurse is responsible for preparing the anaesthetic environment, which plays a crucial role in the prevention of infection. This article will look at examples of good practice, the evidence base and how these relate to the role of the perioperative practitioner. It will briefly discuss the reasons for continued CR-BSIs when evidence abounds both in the UK and abroad.
What are central venous catheters (CVCs)? A CVC or vascular access device (VAD) is a catheter placed in a vein that leads directly to the heart (Dougherty 2006). In the theatre environment it is most commonly used for monitoring haemodynamic status or fluid and blood product administration in high risk patients (Phillips 2007). Caguioa et al (2012) described a variety of uses for CVCs such as: n Monitoring haemodynamic status n Fluid administration n Medication administration n Nutrition n Blood product administration n Plasma exchange n Apheresis
One of the main concerns with the use of CVCs is the risk of infection or CR-BSIs which, at worst, can have a significant impact on the mortality of patients (Borchardt & Raad 2012) and, at best, cause extended hospital stays and morbidities. There are a variety of desirable properties of catheters available, for example, antibacterial and antimicrobial coated, soft materials, Teflon or polyurethane coated, sterile packed, heparin coated and radio opaque (Phillips 2007, Wilson 2007). Some of these properties relate specifically to the prevention of CR-BSIs.
What are catheter related bloodstream Infections (CR-BSIs)? CR-BSIs, also called bacteraemia, are a form of healthcare associated infection (HCAI). An HCAI is an infection acquired as a result of a healthcare intervention (HPA 2012a). Since 2007 there has been a decline in the number of cases of bacteraemia, up until 2011 when there was a slight increase, arguably due to more reporting (HPA 2012b). Thibodeau and Patton (2005) and Porth (2011) described the process of infection as occurring when disease-producing bacteria or pathogens disrupt the homeostasis of the body’s natural distribution of bacteria. The invading bacteria then produce toxins that damage human tissue and disrupt cellular
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functions, leading to infection. Specifically, CR-BSIs occur when bacteria colonising the surface of the catheter are released into the bloodstream after insertion. This may be via the patient’s own skin as a result of unclean insertion technique, or it may be due to a contaminated lumen and/or unclean technique when using the lumen (Wilson 2007). A small number of micro-organisms are responsible for the majority of CR-BSIs: Staphylococcus epidermis, Staphylococcus aureus, Enterococcus spp, Klebsiella, pseudomonas, Escherichia coli, serratia and candida. A snapshot survey of HCAIs conducted between September and November 2011 by the Health Protection Agency (2012b) revealed that 6.4% of all patients in hospital had an HCAI (six patients out of every 100), but bacteraemia was not in the top three most prevalent infections. This survey also showed significant reductions in the most common bacteraemia since 2006, with methicillin resistant Staphylococcus aureus (MRSA) bloodstream infections down from 1.3% to less than 0.1% of patients. Clostridium difficile (C.difficile) infections were down from 2% to 0.4%. These statistics show a continuing downward trend in line with increasing activities to reduce HCAIs and CR-BSIs. Diagnosis of CR-BSI can vary in the literature (Wilson 2007) and this can sometimes make it difficult to compare evidence and establish fact. For example 141
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The management of central venous catheters and infection control: is it time to change our approach? Continued
Marik et al (2012) in their systematic review described finding randomised controlled trials and cohort studies using catheter positivity alone whilst others used a combination of peripheral and CVC culture positivity. This is supported by the Matching Michigan Collaboration & Writing Committee (MMCWC 2012) who noted inconsistency and a lack of clarity when reviewing literature on the subject. Such ambiguity reinforces the need for caution when evaluating the reported results of research papers. In 2006 Pronovost et al conducted a widely reported study using a definition generated by the National Nosocomial Infections Surveillance System in the USA. All hospitals participating in the study used this definition creating congruence and making evaluation of results much easier and more reliable. The same definition was subsequently used in the UK for a two-year programme entitled Matching Michigan (MMCWC 2012). To date in the UK there is no clearly defined guideline on what constitutes a CR-BSI.
Research into the prevention of CR-BSIs shows a common theme amongst all sources: poor and inconsistent practice in relation to hand hygiene (Pronovost et al 2006, Caguioa et al 2012, MMCWC 2012, Southworth et al 2012).
Factors affecting the development of a CR-BSI
Prevention of infection
Wilson (2007) suggested that the probability of acquiring a CR-BSI can be influenced by several factors: n Insertion technique (competency of aseptic non touch technique) n Density of local skin flora n Mechanical complications n Phlebitis n Type of catheter n Frequency of manipulation This was echoed by Caguioa et al (2012) and Kilpatrick et al (2012) in their reviews on prevention of CR-BSIs. Wilson (2007) also implied that the longer the catheter is in place the higher the risk of CR-BSI as the opportunity for infection rises. This is borne out by numerous research papers (Caguioa et al 2012, Kilpatrick et al 2012, MMCWC 2012, Southworth et al 2012) which have advocated the removal of CVCs once their use is no longer required. As a result of this it would be reasonable to say that a CVC should only be inserted when absolutely necessary, thus negating the risk of infection in patients who do not require them.
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What is the impact on the patient? The critically ill patient is more vulnerable to CR-BSI as their body and immune system is already compromised (Wilson 2007). A CR-BSI can result in a number of serious conditions, for example, septicaemia, osteomyelitis and endocarditis. Illness as a consequence of CR-BSI often results in a stay in the intensive care unit (ICU) or high dependency unit (HDU) of a hospital, an increased hospital stay (Borchardt & Raad 2012) and even death. It is not difficult to understand how this would have psychological and financial implications not only for the patient but also for their loved ones.
Wilson (2007) believed that most CRBSIs can be prevented by appropriate practices and guidelines around insertion, management and removal. A key aspect of this is the use of a strict aseptic non touch technique (ANTT) and hand washing before handling, during insertion and when handling CVCs or component parts post insertion.
their cohort study for the same reasons as most other research into CR-BSIs, i.e. the cost to individuals and healthcare, the frequency of CR-BSIs and the deaths which result from CR-BSIs. The study was able to show a sustained reduction in CR-BSIs following the intervention. However, in their discussion of study limitations the authors made reference to not being able to make a causal connection between the CR-BSI rates and the intervention, or specific elements of the intervention. In the UK there has been a great deal of attention on the recommendations of Pronovost et al (2006) paper, resulting in campaigns to reduce the incidence not just of CR-BSIs, but of all HCAIs, for example ‘Matching Michigan’ (MMCWC 2012). However, it would be fair to say that prior to the work of Pronovost et al (2006) the UK was already taking steps to improve infection control (MMCWC 2012) and Figure 1 can add some historical context to this. Matching Michigan was a two-year interventional programme designed to minimise CR-BSIs in intensive care units in England utilising the methods reported by Pronovost et al (2006) plus additional work on cultural and systemic interventions. The programme ran from April 2009 to the end of March 2011 and was advised by the original Michigan project leads. It reported a sixty percent reduction in CR-BSIs. In the view of the authors this intervention was part of a growing trend and awareness of best practice and so they found it hard to
The following guidance by Key & Duffey (2009) details principles of insertion of CVCs in respect of infection control: n Full and strict observation of aseptic technique in an appropriate environment
Reflect
Reflect on current practice. Identify five infection prevention activities performed in your workplace to reduce the incidence of CR-BSI. How well do you adhere to these practices?
n Hat, mask, sterile gloves and gown n Sterile drapes and gauze swabs n Chlorhexidine in alcohol solution n Sterile dressing
Notional Learning Hours
There is a long history of evidence gathering in respect of HCAIs both in the UK and abroad with CR-BSIs being analysed within this wider grouping at a later time. The landmark paper published by Pronovost et al (2006) provided a strong case for standardisation of CR-BSI infection control practices. Pronovost et al (2006) undertook
30 minutes
Knowledge and skills dimension Core 3 Health safety and security Core 4 Service improvement Core 5 Quality
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The critically ill patient is more vulnerable to CR-BSI as their body and immune system is already compromised (Wilson 2007)
Date
Intervention 2001
Mandatory reporting to the Health Protection Agency (HPA) of MRSA bacteraemia
2003
Report to the chief medical officer. Winning ways: guidance to reduce healthcare associated infection in England
2004
Mandatory reporting of Clostridium difficile infection to the HPA
2004
Hospital in Europe link for infection control through surveillance of nosocomial infections in ICUs protocol
2004 to 2008
Health Foundation Safer Patients Initiative (24 hospitals: includes CVC bundle)
attribute the success to the intervention alone. Unlike the work in Michigan the Matching Michigan project was not clinician led and the authors advocated the introduction of a clinician led system for maintaining improvements, in line with the rest of the UK. In October 2009 Kings College Hospital NHS Foundation Trust set up an intra vascular (IV) team to improve standards of VAD insertion (Caguioa et al 2012). The team first conducted their own audit of variability in the insertion and care of VADs in spite of national guidance. The results of the intervention showed their greatest success to be an 87.5% reduction in CR-BSIs from 2011 to 2012. The results of this led to the development of seven basic standards to be adopted under the mnemonic of HANDS:
Department of Health Saving Lives programme – NHS High Impact Intervention (NHS-HII), modelled on Institute for Healthcare improvement bundles
Hand hygiene
2006
Health Act 2006. Department of Health code of practice gives new powers of inspection to the Healthcare Commission. Superseded by the Health & Social Care Act 2008
Scrub the hub for 15 seconds and allow to dry
2006
An intervention to decrease catheter-related bloodstream infections in the ICU – the Michigan project publication
2008
Health & Social Care Act 2008. Required registration with the Care Quality Commission: duty to protect patients against HCAIs. New code of practice
2008
Patient Safety First sponsored by National Patient Safety Agency, NHS HII, and Health Foundation, includes interventions to reduce CVC-BSIs
2005
ANtisepsis Daily inspections, date on a dressing, documentation
Project
2008
April 2009 to March 2011 2011
High quality care for all: NHS next stage review (Darzi report) states that the NPSA will run an ‘initiative to tackle central line catheter-related bloodstream infections’ Matching Michigan project
Mandatory reporting of MRSA and Escherichia coli bacteraemia
Visit the Patient Safety First! web pages for Matching Michigan http://www.patientsafetyfirst.nhs.uk/ Content.aspx?path=/interventions/ Perioperativecare/ Locate the ‘How to take action’ guidance for improving teamwork and communication. Compile a short description identifying how teamwork and communication contributes to CR-BSI prevention in your workplace.
Notional Learning Hours
Figure 1 Historical context of infection control initiatives in UK in relation to Matching Michigan (adapted from Matching Michigan Collaboration & Writing Committee 2012)
45 minutes
Knowledge and skills dimension Core 1 Communication Core 2 Personal and people development
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The standards are a combination of the Saving Lives guidance (DH 2007), existing IV care bundles, a targeted education programme, documentation, standardised practice and equipment with identification of champions to act as disseminators between the IV team and the frontline.
n skin antisepsis: chlorhexidine or 2% chlorhexidine in 70% isopropyl alcohol
Caguioa et al (2012) showed great attention to the psychosocial elements of poor infection control by using a collaborative approach, combining types of education, using project champions and full staff engagement to strengthen the opportunities for success. Trust staff, from executives to the frontline, including the purchasing and supply departments responsible for ensuring availability of standardised equipment, were involved. Each staff member, including medical directors, was trained and assessed according to a competency framework in infection control measures and performance of ANTT. The authors provided evidence in support of the approach and how they measured success.
n standardisation of procedure, monitoring and equipment.
The evidence reviewed so far refers to the low cost of interventions. The consistent recommendations for successful reduction of CR-BSIs include: n maximal sterile precautions and adherence to basic infection control standards n hand hygiene, gown, gloves, hat, mask plus eye protection when indicated
Elliott (2009) described other barriers to change, such as cognitive dissonance, cognitive economy and unrealistic optimism. Elliott was saying that the degree of success of interventions will vary if we ignore the psychosocial elements of change. As Southworth et al (2012) pointed out:
n avoiding the femoral route n aseptic technique for any use n daily site review n removing the CVC at the earliest opportunity
Whilst recently published articles advocate consistent and standardised practice, the WHO (2012a,b,c) makes reference to consistency within its guidelines but advocates adaptation to local regulation, settings, needs and resources. This may to some degree reflect the varying economic and cultural nature throughout the world, but conflicts with recommendations from other sources.
Factors affecting compliance with best practice and the need for change Elliott (2009) has written on the psychosocial aspects of infection control i.e. the behavioural and psychological reasons for success or failure of change. In each of the papers discussed above there is evidence of consideration of some of these factors. According to Elliott (2009) factors that will hinder behavioural change are: n being told you must change without involvement in the process n beliefs that conflict with the required change
Reflect
Reflect upon changes in practice. Consider the attitudes and behaviours that you and your colleagues experience when changes to existing practice and new ways of working are implemented. How do these attitudes impact your practice?
n a change that conflicts with the beliefs of your peer group n lack of consultation with those affected by the change n no perceived advantage to the individual n lack of perceived need for change n there will be no consequences to the individual if they fail to change.
Notional Learning Hours 1 hours
Knowledge and skills dimension Core 2 Personal and people development Core 4 Service improvement Core 5 Quality
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Caguioa et al (2012) showed that they have taken these factors into consideration when designing and implementing their HANDS initiative. They described the removal of some of the obstacles that lead to the failure to complete a task, such as by implementing collaboration with clinical areas and the procurement department.
‘The evidence is important, but people (practitioners) make the difference.’ Continued monitoring and follow-up of the success of interventions will either confirm or oppose this view provided that it is not only the results that are analysed but also the way they were achieved.
In the UK, current recommendations for CVC insertion originate from the DH Saving Lives campaign in 2005 and incorporate a care bundle called High Impact Intervention No 1 central venous catheter bundle (HII1). This care bundle gives a background to the subject, evidence base and purpose, followed by actions for good practice. The guideline is similar in recommendations to the HANDS initiative (Caguioa et al 2012) but less comprehensive. For example HII1 does not tell the practitioner how long to prepare the skin or clean the hub of ports, whereas Caguioa et al (2012) does. WHO SAVES LIVES: Clean Your Hands (WHO 2012b,c) is a global campaign which began in 2009 following on from the Clean Care is Safer Care initiative (WHO 2005). It was designed to help healthcare workers understand that good hand hygiene is the key to reducing HCAIs and launched My 5 Moments For Hand Hygiene (WHO 2012b), the effects of which can be seen throughout the NHS.
The role of the perioperative practitioner A perioperative practitioner may come into contact with a patient with a CRBSI who already has a CVC in situ and is presenting for surgery, or the practitioner may be expected to prepare the anaesthetic environment or theatre for the insertion of a CVC. This involves preparing the sterile field. The Infection Control in Anaesthesia guidelines (AAGBI 2008) also advocate maximal sterile precautions for the insertion of CVCs, namely:
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A perioperative practitioner may come into contact with a patient with a CR-BSI who already has a CVC in situ and is presenting for surgery
n opening the sterile equipment in a safe manner n ensuring a private and calm environment n protection of the sterile field, anaesthetist and patient n maintaining a safe, calm and sterile environment during the insertion procedure n care for the patient whilst undergoing surgery including positioning and draping n caring for the patient in the post anaesthetic care unit (PACU) following surgery. Whilst the practitioner may not discover if this process leads to a CR-BSI postoperatively, due to incubation time (Thibodeau & Patton 2005), it is essential that they are educated to understand best practice in relation to the prevention of CR-BSIs and working to the HCPC (2012) code of conduct. The code states that we must not do or allow others to do something which may cause harm to a service user. We must also understand the need to establish and maintain a safe practice environment (Standards of proficiency 3a.3).
Conclusion
References
The many initiatives in the fight against CR-BSIs and HCAIs in the UK and worldwide have not yet eradicated them. Evidence on their causes is available, so perhaps Elliott (2009) was right when he suggested a need to challenge our attitudes and the way we think and not just our knowledge. His opinions were echoed by the sentiments of Caguioa et al (2012) and Southworth et al (2012) in their approach to full staff engagement and ownership.
Association of Anaesthetists of Great Britain and Ireland 2008 Infection control in anaesthesia Anaesthesia 63 1027-36
Examples of attempting to adopt a more psychosocial approach to this topic have been discussed but perhaps more research is needed to bring attitudes and behaviour to the fore after a long period of time focussing mainly on education and standardisation of processes.
Using examples briefly write some definitions in your own words which explain the terms cognitive dissonance, cognitive economy and unrealistic optimism. Identify three ways in which this knowledge will inform your clinical practice.
1 hour
Knowledge and skills dimension Core 3 Health safety and security Core 4 Service improvement Core 5 Quality
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Elliott P 2009 Infection control: a psychosocial approach to changing practice Oxford, Radcliffe Publishing
Key W, Duffey M 2009 Central venous cannulation: anaesthesia tutorial of the week 138 Available from: www.frca.co.uk/Documents/138%20Central%20 Venous%20Cannulation.pdf http://totw. anaesthesiologists.org/2009/06/15/central-venousaccess-138/ [Accessed February 2014]
45 minutes
Knowledge and skills dimension
Dougherty L 2006 Central venous access devices care and management Oxford, Blackwell Publishing Ltd
Health Protection Agency 2012b Snapshot survey of healthcare associated infections (HCAI) reveals overall drop in infections down to 6.4 per cent Available from:www.hpa.org.uk/NewsCentre/ NationalPressReleases/2012PressReleases/ 120523Snapshotsurveyhcai/ [Accessed February 2014]
Notional Learning Hours Notional Learning Hours
Department of Health 2007 Saving lives: Reducing infection, delivering clean and safe care London, DH Available from: http://webarchive.nationalarchives. gov.uk/+/www.dh.gov.uk/en/ Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_078134 [Accessed February 2014]
Health Protection Agency 2012a Healthcare associated infections (HCAI) Available from: www. hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/ HCAI/ [Accessed February 2014]
Project
Locate the relevant HCPC or NMC statements of proficiency that relate to infection prevention of CR-BSIs. Consider how your practice adheres to these and the practice you observe in colleagues.
Caguioa J, Pilpil F, Greensitt C, Carnan D 2012 HANDS: standardised intravascular practice based on evidence British Journal of Nursing 21 (14) (IV supplement)
Health and Care Professions Council 2012 Standards of conduct, performance and ethics London, HCPC
The equivalent Nursing and Midwifery Council code (2008) states that we must provide a high standard of practice and care at all times and deliver care based on the best available evidence or best practice.
Review
Borchardt RA, Raad I 2012 The risks and benefits of intravascular catheters Journal of the American Academy of Physician Assistants 25 (8) 21-22
Core 1 Communication Core 2 Personal and people development Core 4 Service improvement Core 5 Quality
Kilpatrick C, Murdoch H, Storr J 2012 Importance of hand hygiene during invasive procedures Nursing Standard 26 (41P) 42-46 Available from: http:// rcnpublishing.com/doi/abs/10.7748/ ns2012.06.26.41.42.c9158 [Accessed February 2014] Marik PE, Flemmer M, Harrison W 2012 The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis Critical Care Medicine 40 2479-85 Matching Michigan Collaboration & Writing Committee 2012 Matching Michigan: a 2- year stepped interventional programme to minimise central venous catheter-blood stream infections in intensive care units in England Available from: http://qualitysafety.bmj.com/content/ early/2012/09/20/bmjqs-2012-001325.full.pdf+html [Accessed February 2014]
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Nursing and Midwifery Council 2008 The code: standards of conduct, performance and ethics for nurses and midwives London, NMC Phillips N 2007 Berry & Kohn’s operating room technique St Louis, Mosby Elsevier Porth CM 2011 Essentials of pathophysiology Philadelphia, Lippincott Williams & Wilkins Pronovost MD, Needham D, Berenholtz S et al 2006 An intervention to decrease catheter-related bloodstream infections in the ICU New England Journal of Medicine 355 (26) 2725-32 Available from: www. nejm.org/doi/pdf/10.1056/NEJMoa061115 [Accessed February 2014] Southworth SL, Henman LJ, Kinder LA, Sell JL 2012 The journey to zero central catheter-associated bloodstream infections: culture change in an intensive care unit Critical Care Nurse 32 (2) 49-54 Available from: www.ncbi.nlm.nih.gov/pubmed/22467612 [Accessed February 2014]
Thibodeau GA, Patton KT 2005 The human body in health and disease St Louis, Elsevier Mosby
About the author
World Health Organisation 2005 Clean care is safer care: the first global challenge Available from: www. who.int/patientsafety/information_centre/ICHE_ Nov_05_CleanCare_1.pdf [Accessed February 2014] World Health Organisation 2012a WHO guidelines on hand hygiene in healthcare Available from: http:// whqlibdoc.who.int/publications/2009/9789241597906_ eng.pdf [Accessed February 2014] World Health Organisation 2012b About SAVE LIVES: Clean your hands. My 5 moments for hand hygiene Available from: www.who.int/gpsc/5may/ background/5moments/en/ [Accessed February 2014]
Helen Langton DipHE Operating Department Practice Theatre practitioner/ODP Great Western Hospital, Swindon No competing interests declared Members can search all issues of the BJPN/JPP published since 1998 and download articles free of charge at www.afpp.org.uk. Access is also available to non-members who pay a small fee for each article download.
World Health Organisation 2012c About SAVE LIVES: Clean your hands Available from: www.who.int/ gpsc/5may/background/en/ [Accessed February 2014] Wilson J 2007 Infection control in clinical practice Philadelphia, Bailliere Tindall Elsevier
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The management of central venous catheters and infection control:
is it time to change our approach? by H Langton
Correspondence address: Main Theatres, Great Western Hospital, Marlborough Road, Swindon, SN3 6BB. Email:[email protected]
Catheter related bloodstream infections (CR-BSIs) can lead to a number of serious conditions for the patient, including death. There is much recent evidence both in the UK and abroad which identifies the sources of CR-BSIs, yet they continue to occur. This article seeks to review some of the current evidence in relation to the prevention of CR-BSIs at insertion point. Introduction It is important that any healthcare worker coming into contact with a central venous catheter is aware of their critical role in the prevention of catheter related bloodstream infections (CR-BSIs). In particular, the ODP or anaesthetic nurse is responsible for preparing the anaesthetic environment, which plays a crucial role in the prevention of infection. This article will look at examples of good practice, the evidence base and how these relate to the role of the perioperative practitioner. It will briefly discuss the reasons for continued CR-BSIs when evidence abounds both in the UK and abroad.
What are central venous catheters (CVCs)? A CVC or vascular access device (VAD) is a catheter placed in a vein that leads directly to the heart (Dougherty 2006). In the theatre environment it is most commonly used for monitoring haemodynamic status or fluid and blood product administration in high risk patients (Phillips 2007). Caguioa et al (2012) described a variety of uses for CVCs such as: n Monitoring haemodynamic status n Fluid administration n Medication administration n Nutrition n Blood product administration n Plasma exchange n Apheresis
One of the main concerns with the use of CVCs is the risk of infection or CR-BSIs which, at worst, can have a significant impact on the mortality of patients (Borchardt & Raad 2012) and, at best, cause extended hospital stays and morbidities. There are a variety of desirable properties of catheters available, for example, antibacterial and antimicrobial coated, soft materials, Teflon or polyurethane coated, sterile packed, heparin coated and radio opaque (Phillips 2007, Wilson 2007). Some of these properties relate specifically to the prevention of CR-BSIs.
What are catheter related bloodstream Infections (CR-BSIs)? CR-BSIs, also called bacteraemia, are a form of healthcare associated infection (HCAI). An HCAI is an infection acquired as a result of a healthcare intervention (HPA 2012a). Since 2007 there has been a decline in the number of cases of bacteraemia, up until 2011 when there was a slight increase, arguably due to more reporting (HPA 2012b). Thibodeau and Patton (2005) and Porth (2011) described the process of infection as occurring when disease-producing bacteria or pathogens disrupt the homeostasis of the body’s natural distribution of bacteria. The invading bacteria then produce toxins that damage human tissue and disrupt cellular
June 2014 / Volume 24 / Issue 6 / ISSN 1750-4589
functions, leading to infection. Specifically, CR-BSIs occur when bacteria colonising the surface of the catheter are released into the bloodstream after insertion. This may be via the patient’s own skin as a result of unclean insertion technique, or it may be due to a contaminated lumen and/or unclean technique when using the lumen (Wilson 2007). A small number of micro-organisms are responsible for the majority of CR-BSIs: Staphylococcus epidermis, Staphylococcus aureus, Enterococcus spp, Klebsiella, pseudomonas, Escherichia coli, serratia and candida. A snapshot survey of HCAIs conducted between September and November 2011 by the Health Protection Agency (2012b) revealed that 6.4% of all patients in hospital had an HCAI (six patients out of every 100), but bacteraemia was not in the top three most prevalent infections. This survey also showed significant reductions in the most common bacteraemia since 2006, with methicillin resistant Staphylococcus aureus (MRSA) bloodstream infections down from 1.3% to less than 0.1% of patients. Clostridium difficile (C.difficile) infections were down from 2% to 0.4%. These statistics show a continuing downward trend in line with increasing activities to reduce HCAIs and CR-BSIs. Diagnosis of CR-BSI can vary in the literature (Wilson 2007) and this can sometimes make it difficult to compare evidence and establish fact. For example 141
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The management of central venous catheters and infection control: is it time to change our approach? Continued
Marik et al (2012) in their systematic review described finding randomised controlled trials and cohort studies using catheter positivity alone whilst others used a combination of peripheral and CVC culture positivity. This is supported by the Matching Michigan Collaboration & Writing Committee (MMCWC 2012) who noted inconsistency and a lack of clarity when reviewing literature on the subject. Such ambiguity reinforces the need for caution when evaluating the reported results of research papers. In 2006 Pronovost et al conducted a widely reported study using a definition generated by the National Nosocomial Infections Surveillance System in the USA. All hospitals participating in the study used this definition creating congruence and making evaluation of results much easier and more reliable. The same definition was subsequently used in the UK for a two-year programme entitled Matching Michigan (MMCWC 2012). To date in the UK there is no clearly defined guideline on what constitutes a CR-BSI.
Research into the prevention of CR-BSIs shows a common theme amongst all sources: poor and inconsistent practice in relation to hand hygiene (Pronovost et al 2006, Caguioa et al 2012, MMCWC 2012, Southworth et al 2012).
Factors affecting the development of a CR-BSI
Prevention of infection
Wilson (2007) suggested that the probability of acquiring a CR-BSI can be influenced by several factors: n Insertion technique (competency of aseptic non touch technique) n Density of local skin flora n Mechanical complications n Phlebitis n Type of catheter n Frequency of manipulation This was echoed by Caguioa et al (2012) and Kilpatrick et al (2012) in their reviews on prevention of CR-BSIs. Wilson (2007) also implied that the longer the catheter is in place the higher the risk of CR-BSI as the opportunity for infection rises. This is borne out by numerous research papers (Caguioa et al 2012, Kilpatrick et al 2012, MMCWC 2012, Southworth et al 2012) which have advocated the removal of CVCs once their use is no longer required. As a result of this it would be reasonable to say that a CVC should only be inserted when absolutely necessary, thus negating the risk of infection in patients who do not require them.
142
What is the impact on the patient? The critically ill patient is more vulnerable to CR-BSI as their body and immune system is already compromised (Wilson 2007). A CR-BSI can result in a number of serious conditions, for example, septicaemia, osteomyelitis and endocarditis. Illness as a consequence of CR-BSI often results in a stay in the intensive care unit (ICU) or high dependency unit (HDU) of a hospital, an increased hospital stay (Borchardt & Raad 2012) and even death. It is not difficult to understand how this would have psychological and financial implications not only for the patient but also for their loved ones.
Wilson (2007) believed that most CRBSIs can be prevented by appropriate practices and guidelines around insertion, management and removal. A key aspect of this is the use of a strict aseptic non touch technique (ANTT) and hand washing before handling, during insertion and when handling CVCs or component parts post insertion.
their cohort study for the same reasons as most other research into CR-BSIs, i.e. the cost to individuals and healthcare, the frequency of CR-BSIs and the deaths which result from CR-BSIs. The study was able to show a sustained reduction in CR-BSIs following the intervention. However, in their discussion of study limitations the authors made reference to not being able to make a causal connection between the CR-BSI rates and the intervention, or specific elements of the intervention. In the UK there has been a great deal of attention on the recommendations of Pronovost et al (2006) paper, resulting in campaigns to reduce the incidence not just of CR-BSIs, but of all HCAIs, for example ‘Matching Michigan’ (MMCWC 2012). However, it would be fair to say that prior to the work of Pronovost et al (2006) the UK was already taking steps to improve infection control (MMCWC 2012) and Figure 1 can add some historical context to this. Matching Michigan was a two-year interventional programme designed to minimise CR-BSIs in intensive care units in England utilising the methods reported by Pronovost et al (2006) plus additional work on cultural and systemic interventions. The programme ran from April 2009 to the end of March 2011 and was advised by the original Michigan project leads. It reported a sixty percent reduction in CR-BSIs. In the view of the authors this intervention was part of a growing trend and awareness of best practice and so they found it hard to
The following guidance by Key & Duffey (2009) details principles of insertion of CVCs in respect of infection control: n Full and strict observation of aseptic technique in an appropriate environment
Reflect
Reflect on current practice. Identify five infection prevention activities performed in your workplace to reduce the incidence of CR-BSI. How well do you adhere to these practices?
n Hat, mask, sterile gloves and gown n Sterile drapes and gauze swabs n Chlorhexidine in alcohol solution n Sterile dressing
Notional Learning Hours
There is a long history of evidence gathering in respect of HCAIs both in the UK and abroad with CR-BSIs being analysed within this wider grouping at a later time. The landmark paper published by Pronovost et al (2006) provided a strong case for standardisation of CR-BSI infection control practices. Pronovost et al (2006) undertook
30 minutes
Knowledge and skills dimension Core 3 Health safety and security Core 4 Service improvement Core 5 Quality
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The critically ill patient is more vulnerable to CR-BSI as their body and immune system is already compromised (Wilson 2007)
Date
Intervention 2001
Mandatory reporting to the Health Protection Agency (HPA) of MRSA bacteraemia
2003
Report to the chief medical officer. Winning ways: guidance to reduce healthcare associated infection in England
2004
Mandatory reporting of Clostridium difficile infection to the HPA
2004
Hospital in Europe link for infection control through surveillance of nosocomial infections in ICUs protocol
2004 to 2008
Health Foundation Safer Patients Initiative (24 hospitals: includes CVC bundle)
attribute the success to the intervention alone. Unlike the work in Michigan the Matching Michigan project was not clinician led and the authors advocated the introduction of a clinician led system for maintaining improvements, in line with the rest of the UK. In October 2009 Kings College Hospital NHS Foundation Trust set up an intra vascular (IV) team to improve standards of VAD insertion (Caguioa et al 2012). The team first conducted their own audit of variability in the insertion and care of VADs in spite of national guidance. The results of the intervention showed their greatest success to be an 87.5% reduction in CR-BSIs from 2011 to 2012. The results of this led to the development of seven basic standards to be adopted under the mnemonic of HANDS:
Department of Health Saving Lives programme – NHS High Impact Intervention (NHS-HII), modelled on Institute for Healthcare improvement bundles
Hand hygiene
2006
Health Act 2006. Department of Health code of practice gives new powers of inspection to the Healthcare Commission. Superseded by the Health & Social Care Act 2008
Scrub the hub for 15 seconds and allow to dry
2006
An intervention to decrease catheter-related bloodstream infections in the ICU – the Michigan project publication
2008
Health & Social Care Act 2008. Required registration with the Care Quality Commission: duty to protect patients against HCAIs. New code of practice
2008
Patient Safety First sponsored by National Patient Safety Agency, NHS HII, and Health Foundation, includes interventions to reduce CVC-BSIs
2005
ANtisepsis Daily inspections, date on a dressing, documentation
Project
2008
April 2009 to March 2011 2011
High quality care for all: NHS next stage review (Darzi report) states that the NPSA will run an ‘initiative to tackle central line catheter-related bloodstream infections’ Matching Michigan project
Mandatory reporting of MRSA and Escherichia coli bacteraemia
Visit the Patient Safety First! web pages for Matching Michigan http://www.patientsafetyfirst.nhs.uk/ Content.aspx?path=/interventions/ Perioperativecare/ Locate the ‘How to take action’ guidance for improving teamwork and communication. Compile a short description identifying how teamwork and communication contributes to CR-BSI prevention in your workplace.
Notional Learning Hours
Figure 1 Historical context of infection control initiatives in UK in relation to Matching Michigan (adapted from Matching Michigan Collaboration & Writing Committee 2012)
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Knowledge and skills dimension Core 1 Communication Core 2 Personal and people development
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The management of central venous catheters and infection control: is it time to change our approach? Continued
The standards are a combination of the Saving Lives guidance (DH 2007), existing IV care bundles, a targeted education programme, documentation, standardised practice and equipment with identification of champions to act as disseminators between the IV team and the frontline.
n skin antisepsis: chlorhexidine or 2% chlorhexidine in 70% isopropyl alcohol
Caguioa et al (2012) showed great attention to the psychosocial elements of poor infection control by using a collaborative approach, combining types of education, using project champions and full staff engagement to strengthen the opportunities for success. Trust staff, from executives to the frontline, including the purchasing and supply departments responsible for ensuring availability of standardised equipment, were involved. Each staff member, including medical directors, was trained and assessed according to a competency framework in infection control measures and performance of ANTT. The authors provided evidence in support of the approach and how they measured success.
n standardisation of procedure, monitoring and equipment.
The evidence reviewed so far refers to the low cost of interventions. The consistent recommendations for successful reduction of CR-BSIs include: n maximal sterile precautions and adherence to basic infection control standards n hand hygiene, gown, gloves, hat, mask plus eye protection when indicated
Elliott (2009) described other barriers to change, such as cognitive dissonance, cognitive economy and unrealistic optimism. Elliott was saying that the degree of success of interventions will vary if we ignore the psychosocial elements of change. As Southworth et al (2012) pointed out:
n avoiding the femoral route n aseptic technique for any use n daily site review n removing the CVC at the earliest opportunity
Whilst recently published articles advocate consistent and standardised practice, the WHO (2012a,b,c) makes reference to consistency within its guidelines but advocates adaptation to local regulation, settings, needs and resources. This may to some degree reflect the varying economic and cultural nature throughout the world, but conflicts with recommendations from other sources.
Factors affecting compliance with best practice and the need for change Elliott (2009) has written on the psychosocial aspects of infection control i.e. the behavioural and psychological reasons for success or failure of change. In each of the papers discussed above there is evidence of consideration of some of these factors. According to Elliott (2009) factors that will hinder behavioural change are: n being told you must change without involvement in the process n beliefs that conflict with the required change
Reflect
Reflect upon changes in practice. Consider the attitudes and behaviours that you and your colleagues experience when changes to existing practice and new ways of working are implemented. How do these attitudes impact your practice?
n a change that conflicts with the beliefs of your peer group n lack of consultation with those affected by the change n no perceived advantage to the individual n lack of perceived need for change n there will be no consequences to the individual if they fail to change.
Notional Learning Hours 1 hours
Knowledge and skills dimension Core 2 Personal and people development Core 4 Service improvement Core 5 Quality
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Caguioa et al (2012) showed that they have taken these factors into consideration when designing and implementing their HANDS initiative. They described the removal of some of the obstacles that lead to the failure to complete a task, such as by implementing collaboration with clinical areas and the procurement department.
‘The evidence is important, but people (practitioners) make the difference.’ Continued monitoring and follow-up of the success of interventions will either confirm or oppose this view provided that it is not only the results that are analysed but also the way they were achieved.
In the UK, current recommendations for CVC insertion originate from the DH Saving Lives campaign in 2005 and incorporate a care bundle called High Impact Intervention No 1 central venous catheter bundle (HII1). This care bundle gives a background to the subject, evidence base and purpose, followed by actions for good practice. The guideline is similar in recommendations to the HANDS initiative (Caguioa et al 2012) but less comprehensive. For example HII1 does not tell the practitioner how long to prepare the skin or clean the hub of ports, whereas Caguioa et al (2012) does. WHO SAVES LIVES: Clean Your Hands (WHO 2012b,c) is a global campaign which began in 2009 following on from the Clean Care is Safer Care initiative (WHO 2005). It was designed to help healthcare workers understand that good hand hygiene is the key to reducing HCAIs and launched My 5 Moments For Hand Hygiene (WHO 2012b), the effects of which can be seen throughout the NHS.
The role of the perioperative practitioner A perioperative practitioner may come into contact with a patient with a CRBSI who already has a CVC in situ and is presenting for surgery, or the practitioner may be expected to prepare the anaesthetic environment or theatre for the insertion of a CVC. This involves preparing the sterile field. The Infection Control in Anaesthesia guidelines (AAGBI 2008) also advocate maximal sterile precautions for the insertion of CVCs, namely:
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A perioperative practitioner may come into contact with a patient with a CR-BSI who already has a CVC in situ and is presenting for surgery
n opening the sterile equipment in a safe manner n ensuring a private and calm environment n protection of the sterile field, anaesthetist and patient n maintaining a safe, calm and sterile environment during the insertion procedure n care for the patient whilst undergoing surgery including positioning and draping n caring for the patient in the post anaesthetic care unit (PACU) following surgery. Whilst the practitioner may not discover if this process leads to a CR-BSI postoperatively, due to incubation time (Thibodeau & Patton 2005), it is essential that they are educated to understand best practice in relation to the prevention of CR-BSIs and working to the HCPC (2012) code of conduct. The code states that we must not do or allow others to do something which may cause harm to a service user. We must also understand the need to establish and maintain a safe practice environment (Standards of proficiency 3a.3).
Conclusion
References
The many initiatives in the fight against CR-BSIs and HCAIs in the UK and worldwide have not yet eradicated them. Evidence on their causes is available, so perhaps Elliott (2009) was right when he suggested a need to challenge our attitudes and the way we think and not just our knowledge. His opinions were echoed by the sentiments of Caguioa et al (2012) and Southworth et al (2012) in their approach to full staff engagement and ownership.
Association of Anaesthetists of Great Britain and Ireland 2008 Infection control in anaesthesia Anaesthesia 63 1027-36
Examples of attempting to adopt a more psychosocial approach to this topic have been discussed but perhaps more research is needed to bring attitudes and behaviour to the fore after a long period of time focussing mainly on education and standardisation of processes.
Using examples briefly write some definitions in your own words which explain the terms cognitive dissonance, cognitive economy and unrealistic optimism. Identify three ways in which this knowledge will inform your clinical practice.
1 hour
Knowledge and skills dimension Core 3 Health safety and security Core 4 Service improvement Core 5 Quality
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Elliott P 2009 Infection control: a psychosocial approach to changing practice Oxford, Radcliffe Publishing
Key W, Duffey M 2009 Central venous cannulation: anaesthesia tutorial of the week 138 Available from: www.frca.co.uk/Documents/138%20Central%20 Venous%20Cannulation.pdf http://totw. anaesthesiologists.org/2009/06/15/central-venousaccess-138/ [Accessed February 2014]
45 minutes
Knowledge and skills dimension
Dougherty L 2006 Central venous access devices care and management Oxford, Blackwell Publishing Ltd
Health Protection Agency 2012b Snapshot survey of healthcare associated infections (HCAI) reveals overall drop in infections down to 6.4 per cent Available from:www.hpa.org.uk/NewsCentre/ NationalPressReleases/2012PressReleases/ 120523Snapshotsurveyhcai/ [Accessed February 2014]
Notional Learning Hours Notional Learning Hours
Department of Health 2007 Saving lives: Reducing infection, delivering clean and safe care London, DH Available from: http://webarchive.nationalarchives. gov.uk/+/www.dh.gov.uk/en/ Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_078134 [Accessed February 2014]
Health Protection Agency 2012a Healthcare associated infections (HCAI) Available from: www. hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/ HCAI/ [Accessed February 2014]
Project
Locate the relevant HCPC or NMC statements of proficiency that relate to infection prevention of CR-BSIs. Consider how your practice adheres to these and the practice you observe in colleagues.
Caguioa J, Pilpil F, Greensitt C, Carnan D 2012 HANDS: standardised intravascular practice based on evidence British Journal of Nursing 21 (14) (IV supplement)
Health and Care Professions Council 2012 Standards of conduct, performance and ethics London, HCPC
The equivalent Nursing and Midwifery Council code (2008) states that we must provide a high standard of practice and care at all times and deliver care based on the best available evidence or best practice.
Review
Borchardt RA, Raad I 2012 The risks and benefits of intravascular catheters Journal of the American Academy of Physician Assistants 25 (8) 21-22
Core 1 Communication Core 2 Personal and people development Core 4 Service improvement Core 5 Quality
Kilpatrick C, Murdoch H, Storr J 2012 Importance of hand hygiene during invasive procedures Nursing Standard 26 (41P) 42-46 Available from: http:// rcnpublishing.com/doi/abs/10.7748/ ns2012.06.26.41.42.c9158 [Accessed February 2014] Marik PE, Flemmer M, Harrison W 2012 The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis Critical Care Medicine 40 2479-85 Matching Michigan Collaboration & Writing Committee 2012 Matching Michigan: a 2- year stepped interventional programme to minimise central venous catheter-blood stream infections in intensive care units in England Available from: http://qualitysafety.bmj.com/content/ early/2012/09/20/bmjqs-2012-001325.full.pdf+html [Accessed February 2014]
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The management of central venous catheters and infection control: is it time to change our approach? Continued
Nursing and Midwifery Council 2008 The code: standards of conduct, performance and ethics for nurses and midwives London, NMC Phillips N 2007 Berry & Kohn’s operating room technique St Louis, Mosby Elsevier Porth CM 2011 Essentials of pathophysiology Philadelphia, Lippincott Williams & Wilkins Pronovost MD, Needham D, Berenholtz S et al 2006 An intervention to decrease catheter-related bloodstream infections in the ICU New England Journal of Medicine 355 (26) 2725-32 Available from: www. nejm.org/doi/pdf/10.1056/NEJMoa061115 [Accessed February 2014] Southworth SL, Henman LJ, Kinder LA, Sell JL 2012 The journey to zero central catheter-associated bloodstream infections: culture change in an intensive care unit Critical Care Nurse 32 (2) 49-54 Available from: www.ncbi.nlm.nih.gov/pubmed/22467612 [Accessed February 2014]
Thibodeau GA, Patton KT 2005 The human body in health and disease St Louis, Elsevier Mosby
About the author
World Health Organisation 2005 Clean care is safer care: the first global challenge Available from: www. who.int/patientsafety/information_centre/ICHE_ Nov_05_CleanCare_1.pdf [Accessed February 2014] World Health Organisation 2012a WHO guidelines on hand hygiene in healthcare Available from: http:// whqlibdoc.who.int/publications/2009/9789241597906_ eng.pdf [Accessed February 2014] World Health Organisation 2012b About SAVE LIVES: Clean your hands. My 5 moments for hand hygiene Available from: www.who.int/gpsc/5may/ background/5moments/en/ [Accessed February 2014]
Helen Langton DipHE Operating Department Practice Theatre practitioner/ODP Great Western Hospital, Swindon No competing interests declared Members can search all issues of the BJPN/JPP published since 1998 and download articles free of charge at www.afpp.org.uk. Access is also available to non-members who pay a small fee for each article download.
World Health Organisation 2012c About SAVE LIVES: Clean your hands Available from: www.who.int/ gpsc/5may/background/en/ [Accessed February 2014] Wilson J 2007 Infection control in clinical practice Philadelphia, Bailliere Tindall Elsevier
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