Transcript LC-0359_E_Truly Getting to Zero Talk[...]

TRULY GETTING TO ZERO
Central Line Associated Bloodstream Infections
CLABSI = 0
LC-0359 Rev E
Historical Considerations
The Myth: “The Michigan study, published in the New England Journal of
Medicine, demonstrated the achievement of ZERO CLABSI using the CVC
BUNDLE.”
The Facts: The Provonost study (NEJM 2006; 355(26):2725-2732.) saved
lives and got clinicians talking.
“MEDIAN CLABSI RATE = ZERO”
“Mean CLABSI rate = 1.4 /1000 catheter-days”
(Assume 1000 catheters with average dwell time of 10 days)
ZERO—IS IT EVEN POSSIBLE?
DO NOT PLACE CENTRAL LINES.
Answer: There is only one fool-proof (BUT
WHOLLY IMPRACTICABLE) way of preventing
central line bloodstream infections.
If you must place PICCs and CVCs/ REDUCE
TOTAL CENTRAL LINE DAYS.
“The Incidence of Central Line Associated Bacteremia after introduction of
Midline Catheters in a Ventilator Unit Population.”
(Infect Dis in Clin Pract 2015)
The Interventions:
1)
2)
Standing order for all patients, with or without CVC/PICC, to receive ASTplaced midline
All CVCs removed in 7 days or less.
The Outcomes:
1) 37% Reduction in Central Line days
2) 100% Reduction in CLABSI
3) $448,000 annual savings in one ICU
The Lesson: To reduce central line days =>
a)
b)
IMPLEMENT A MIDLINE POLICY
REMOVE CVADs ≤ 7 DAYS
MIDLINE CATHETER EVIDENCE
But which midline? Are all midlines equal?
Study
Midline Material
Trimmable
Published BSI Rate
Thrombosis
Total
Complications
Maki
Polyurethane
Yes
0.2/1000 c-d
N/R
N/R
Fabrizio
Polyurethane
Yes
N/R (N=50)
20.9%
34.6%
Dumont
Polyurethane
Yes
0.86/1000 c-d
1.6%
9.6%
Dumont
Polyurethane
No
3.2%
3.2%
22.6%
Pathak
ChronoFlex™
No
0.0/1000 c-d
0.13/1000 c-d
N/R
Moureau
ChronoFlex™
No
0.0/1000 c-d
N/R
N/R
Warrington
ChronoFlex™
No
0.0/1000 c-d
1.3%
8.3%
Caparas
ChronoFlex™
No
0.0/1000 c-d
0.0%
As below
Caparas**
ChronoFlex™
No
0.0/1000 c-d
0.0%
2.7%
*Not power-injectable, PICC-style hub, 20 cm.
**In press
What Makes Midlines Different?
Thrombosis:
A. All high DVT midlines are trimmable
B. All low DVT midlines have manufactured tips
and full length guidewires
Steele*: Cut catheters 300-500% greater DVT
What Makes Midlines Different?
Infection:
• All the higher BSI midlines are polyurethane
(or silicone)
• All the lower BSI midlines are not
polyurethane
Bottom Line
I. Implement MIDLINE STANDING ORDER in
ICUs
II. Make EVIDENCE-BASED midline choice
OTHER THAN REDUCING
CENTRAL LINE DAYS…
WHAT OTHER MEASURES GET TO ZERO CLABSI???
LET’S FIRST TAKE A MOMENT TO UNDERSTAND HOW CLABSIs REALLY
HAPPEN….
Axiom I: Bacteria, though called “bugs,” do not crawl.
• They extend the reach of their colonies by cellular division-- an inch truly is a
mile
Axiom II: Transient bacteremia, generally, is not the cause of overwhelming
sepsis.
• 25% of the time you brush teeth, you experience bacteremia
• Placing any VAD can cause a transient bacteremia
Axiom III: Overwhelming device-related infection results from a mature
biofilm dispersing billions of bacteria continually by means of planktonic
eruptions. This process requires several days to reach maturity.
WATCH A BIOFILM FORMING
ON THE SURFACE OF A CATHETER
Three minutes after a
catheter is placed in the vein
Thirty minutes after a
catheter is placed in the vein
UNDERSTANDING CLABSI ETIOLOGY
Axiom #4: Skin is NEVER STERILE.
Axiom #5: An Introducer Sheath (e.g. a peel-away sheath) is
a STERILE CONDUIT INTO THE BLOODSTREAM.
ONE OF THE MOST
IMPORTANT STUDIES EVER DONE
Livesley MA: Eur J Clin Microbiol Infect Dis 1998
Sixty open-heart patients were randomly assigned to
receive CVCs, either percutaneously or via a Swan
sheath. Hearts opened, SVCs accessed, catheters
were cultured within 90 minutes of placement.
Results:
30 CVCs (percutaneous/Seldinger)
16.66% Impacted Surface Bacteria
30 CVCs (via Sheath Introducer)
3.33 % Surface Bacteria
The LESSON: Placing a CVC through a peel-away
sheath offers an 80% reduction in the risk of CLABSI
from surface contamination.
WHAT PROOF IS THERE?
1. Why do PICCs almost NEVER infect from the external
surface?
PICCs are placed through introducer sheaths. Their external
surfaces are sterile when fibrin sheath forms.
2. Why do CVCs and arterial lines have the same BSI rate?
These lines are placed through skin. Their external surfaces have
“impacted” bacteria that is quickly wrapped/protected by fibrin.
Bacteria → fibrin sheath → biofilm
GIVEN THE LIVESLEY STUDY, AND THE
PRESSURE TO REDUCE CLABSIS:
1. Why aren’t CVCs, like PICCs, placed through
peel-away sheath introducers?
ANSWER: A non-valved 7Fr peelable sheath
introducer risks air embolism – Never Event
WHAT ARE THE AVAILABLE
VALVED PEELABLE SHEATHS?
AirGuard®
•
•
•
•
8-16.5 Fr—Applicable for variety of hemodialysis catheters
“This introducer is not designed to prevent air embolism resulting from a sudden venous pressure
change….”
0.15 cc/sec air leakage at -12 mmHg:
NOTE: A single breath from a healthy male generates a negative pressure up to -124 mm Hg, 10X the
stated vacuum.
FlowGuard®
•
•
•
7-17Fr – Capable of providing reduced blood loss for hemodialysis catheter placement
At -12 mmHg, the valve will allow up to 4cc/sec of air passage
One published report of air embolism: Seminars in Dialysis 2004; 17(1): 65-68.
CVC WAND®
•
•
•
7 Fr only—Intended for 7Fr CVCs, not useful for hemodialysis catheters
At -57mmHg, the valve allows less than .0017 cc/sec: THIS IS THE ONLY “AIR-COMPETENT” VALVED
PEELABLE SHEATH CURRENTLY ON THE MARKET
Also incorporates: Capped, integrated guidewire; pressure-detection valve, micro-access (21g) and
ultra-bright echogenic needle.
ADVANTAGES OF VALVED PEELABLE SHEATH
Reduces or eliminates 2 “Never Events”
1. CLABSI ($56K)
2. Air Embolism ($71K)
PLUS: Reduces healthcare worker exposure to
bloodborne pathogens
SO…WHAT HAVE WE LEARNED?
I.
REDUCE CENTRAL LINE DAYS
A.
Do NOT place a central line (PICC/CVC) unless it is indicated
– Difficult Access is NOT an indication—place a midline
– pH (e.g. vancomycin) is NOT an indication—dilute safely and administer through a midline
– If placing a midline, make an EVIDENCE-BASED selection
– Then, implement a Midline Policy & Procedure
B.
If a central line is indicated, get it out ASAP < 7days
Recall: Richmond Medical Center – Midline Standing Order
– 37% Reduction in Central Line Days
– 100% Reduction in CLABSI (ICU)
II.
PLACE CVADS ONLY THROUGH “STERILE CONDUITS”
A.
If a central line is required
– PICC vs CVC—make an informed clinical decision based on vein preservation, duration of
therapy, access issues, DVT risk, prior history, etc.
– Insert both PICC and CVC through peelable sheath introducer (“a sterile conduit”). For CVC,
especially if done at bedside where Trendelenburg may be difficult, use a valved peelable
sheath introducer: REDUCES RISK OF CLABSI BY 80%.
TRULY GETTING TO ZERO CLABSI
IS IT REALLY EVEN POSSIBLE?
ZERO CLABSI IS POSSIBLE
WE ALL NEED TO ABANDON OLD HABITS
AND FOLLOW THE SCIENCE
OUR PATIENTS’ TRUST REQUIRES IT