Blood Reflux: Backflow, Biofilm, and Slime Oh My!

Transcription

1 Blood Reflux: Backflow, Biofilm, and Slime Oh My! Wednesday, April 2 7:00 8:45 AM Rosen Shingle Creek Panzacola F 1/2 Supported by an educational grant from Smiths Medical A Symposium Held in Conjunction with the 2014 NHIA Annual Conference & Exposition 2014 NHIA Annual Conference & Exposition Thriving Amid The Turbulent Ride

2 03 S. Blood Reflux: Backflow, Biofilm, and Slime Oh My! Wednesday, April 2 7:00 8:45 AM Rosen Shingle Creek Panzacola F 1/2 Supported by an educational grant from Smiths Medical Pharmacist, Pharmacy Technician and Nurse Continuing Education Contact Hours: 1.5 ACPE Pharmacist and Pharmacy Technician Program #: L01 P & T Knowledge Based Learning Activity Education Overview: For the home based patient receiving infusion therapy, a patent vascular access device (VAD) represents a lifeline to treatment. Maintaining that lifeline to allow uninterrupted delivery of the prescribed infusion therapy is a goal of every home infusion provider, and requires an understanding of the catheter complications that can arise and their potential impact on patient outcomes. This program will provide a comprehensive overview of VAD thrombotic occlusions, from the effect of vascular pressure, to the pathophysiology of thrombus formation, and the relationship between occlusions, bloodstream infection and biofilms. Walk through published clinical guidelines from groups such as the Centers for Disease Control and Prevention (CDC), and Standards of Practice from the Infusion Nurses Society (INS), as you consider the evidence behind best practices in the prevention of catheter occlusions. Faculty: Connie Nadeau, MBA BSN RNC NIC, Manager, Clinical Education Services, and Karen A. Tomlin, BS, MT(ASCP), CIC, Infection Preventionist, Smiths Medical, Norwell, MA Faculty Biographical Statement: Connie Nadeau, MBA BSN RNC NIC, has over 40 years of nursing experience covering emergency, transport, neonatal and education arenas. Connie moved into industry 12 years ago and is currently the Clinical Education Manager for Smiths Medical. She and her team of registered nurses are responsible for facilitating customer education and successful product adoption on multiple Smiths Medical product portfolios across the US. In her role, Connie also is involved in new product development, process improvement, marketing activities and is a continuing education nurse planner/presenter. Connie received her BSN and MBA from Wilmington University [DE] and maintains a certification in Neonatal Intensive Care Nursing. Karen A. Tomlin, BS, MT(ASCP), CIC is an Infection Preventionist with Smiths Medical. Certified by the Board of Infection Control, Karen is a Medical Technologist with over 28 years of infection prevention expertise in both the hospital environment and industry. Karen has participated in biofilm studies on medical devices developed a sharp safety program that has been implemented both in the US and Europe. She has contributed to performance improvement projects for reducing infection rates for surgical site and central line blood stream infections. In addition, she facilitated the implementation of evidence based best practice resulting in reduction in MRSA and ventilator associated pneumonia. She received her Bachelor of Science degree in Medical Technology for Alderson Broaddus College and the Myers Clinic Broaddus Hospital School of Medical Technology. She worked as a Medical Technologist prior to being commissioned in the United States Air Force where she was the Assistant Chief of Laboratory Service, attaining the rank of Captain. She ensured the quality of over 540,000 annual laboratory procedures. Karen speaks nationally on the subjects of sharp safety and blood reflux. Pharmacist, Pharmacy Technician and Nurse Education Objectives: 1. Describe how blood reflux in vascular access catheters contributes to thrombotic catheter occlusions and bloodstream infections. 2. List two quality initiatives to prevent blood reflux complications. 3. Identify two strategies for preventing complications created by blood reflux in the vascular access catheter NHIA Annual Conference & Exposition 1

3 Learning Assessment Questions: 1. Preventing blood reflux into a catheter can reduce occlusions. a. True b. False 2. Biofilms are a survival mechanism for bacteria and yeast. a. True b. False 3. There is a relationship between thrombosis and infection. a. True b. False 4. Factors that influence hemodynamics include: a. Syringe connection/disconnection b. IV bag running dry c. Patient movement d. All of the above 5. The flush clamp sequence, flushing volume and disinfection is the same for all connectors approved by the FDA. a. True b. False Answers can be found on the last page of this booklet NHIA Annual Conference & Exposition

4 2014 NHIA Annual Conference & Exposition 3

5 2014 NHIA Annual Conference & Exposition 4 Objectives Describe how blood reflux in vascular access catheters contributes to thrombotic catheter occlusions and bloodstream infections. List two quality initiatives to prevent blood reflux complications. Identify two strategies for preventing complications created by blood reflux in the vascular access catheter. occlusions and bloodst catheters contribut how blood re Describe lusions and bloodstream infections. ributes to thrombotic blood reflux in vascular ac Objectives ions. catheter ular access catheter. blood re created by two st Identify complications. wo quality tw List vascular ac blood reflux in the rategies for preventing c initiatives to prevent y ular access ing complications blood reflux nt

6 Reflux & Bloodstream Infections heoretically, blood reflux into either the IV catheter or needlelesss connector ctor increases both the risk of occlusion and biofilm formation. Both also increase the risk of Health Care Associated sociated Blood Stream Infections. Infection Control Today August 2010 Vol. 14 No 8, Choosing the Best Design for Intravenous Needleless Connector to Prevent HA-BSI By: William R. Jarvis, MD Blood Reflux Uncontrolled backflow of blood into the catheter lumen 2014 NHIA Annual Conference & Exposition 5

7 Blood Reflux Because the catheter ter tip is inside the body and not visible, we are not always aware when reflux occurs Or is it right in front of us? Blood Reflux NHIA Annual Conference & Exposition

8 THROMBOSIS Hypercoagulability of blood Virchow s Triad Vessel Wall Damage Hemodynamic changes in blood flow 2014 NHIA Annual Conference & Exposition 7

9 2014 NHIA Annual Conference & Exposition 8 Hypercoagulability Acquired Pregnancy Diabetes Trauma or Surgery Cancer Obesity Prolonged immobility Nephrotic Syndrome Dehydration Genetic Genetic clotting factor disorders Hemoglobin deficiencies Vessel Wall Damage Injuries or trauma Hypertension, chronic inflammation Catheter placement and size Catheter composition Stabilization Preserve integrity of access device Minimize catheter movement at insertion site Prevent catheter dislodgement d Acquir Hypercoag Genetic Hypercoagulabilit y lity Obesity Cancer Trauma or Surge Diabetes Pregnancy quired Ac deficiencie Hemoglobin disorders c Genetic Genetic Trauma or Surgery ies moglobin clotting factor Dehydration Syndrome Nephrotic Prolonged immobilit ndrome d immobility Catheter plac Hypertension, c Injuries or t Vess and size r placement inflammation nsion, chronic s or trauma sel Wall Damag ion el Wall Damage Prevent cat c Minimize int Preserve Stabilization Catheter composit Catheter plac atheter dislodgement at insert atheter movement of access device integrity ion omposition and size r placement rtion site

10 Science of Fluid Dynamics In Physics, Fluid Dynamics deals with fluid flow. Fluid is a substance that flows under pressure, which includes liquids and gases. Water is a fluid, air is a fluid, the sun is a fluid, even honey is a viscous fluid. Science of Fluid Mechanics Fluid Mechanics is the study of fluids, ranging from fluids at rest, to fluids in motion, to forces applied to and exerted by other fluids. Gravity IV Pumped IV Power Injected IV 2014 NHIA Annual Conference & Exposition 9

11 Fluid Mechanics in the Circulatory System Human Physiology The circulatory system is a closed pressure sure system The pathway taken by blood within the heart is called cardiac circulation. culation. The pathway taken by blood from the heart to the lungs and back is called pulmonary circulation. culation. The pathway taken by blood from the heart to the rest of the body and back is called systemic circulation. culation. Science of Fluid Pressure Fluid Pressure Is caused by gravity, acceleration, or forces in a closed container Pressure changes are constant nt during IV therapy Blood reflux occurs promptly when venous pressure is greater than external infusion pressure Fluid will equalize atmospheric pressure in an open system creating back flow NHIA Annual Conference & Exposition

12 Hemodynamics: Influencing Factors Mechanical Syringe connection/ disconnection Syringe plunger rebound IV bag running dry Low infusion rates External pressure Ventilators/other hospital equipment Physiological Patient Movement Coughing Crying Sneezing Respiration Vomiting Dynamics of Vascular Pressure Pressure mm Hg Example (rounded pressure values) Pressure psi 2-20mm Hg Central Venous pressure range psi 10-30mm Hg Peripheral Venous pressure range psi mm Hg Extravasation risk > 2 psi 75mm Hg Gravity pressure of fluid 100cm 1.5 psi (39 inches) above cannulation site 36 height above the heart = 1.33 psi overcomes the patient s vascular pressure with gravity infusion 2014 NHIA Annual Conference & Exposition 11

13 Type of Thrombotic Occlusions: Fibrin sheath thrombus Fibrin tail Mural thrombus Intraluminal thrombus Occlusion Expulsion Study NHIA Annual Conference & Exposition

14 21 THROMBOSIS AND INFECTION What is Biofilm? Bacteria Yeast Algae Fungi Dynamic ecosystem stem of microorganisms embedded in a matrix of extracellular polymeric substances (Slimy Matrix) Biofilm bacteria are 1000X more resistant to antibiotics than free-floating bacteria Share and transfer resistance to other organisms 2014 NHIA Annual Conference & Exposition 13

15 The Five Stages of Biofilm Formation 1. 1 Initial reversible attachment of free swimming microorganisms to surface 2. Permanent chemical attachment, single layer, bugs begin making slime 3. Early vertical development 4. Multiple towers with channels between, een, maturing biofilm 5. Mature biofilm with seeding / dispersal of more free swimming microorganisms Graphic by Peg Dirckx and David Davies 2003 Center for Biofilm Engineering Montana State University. What does this all mean? Microbes colonize intravascular catheters ers and connectors ors and form biofilms Organisms shown to cause healthcare-associated associated infections (HAIs) may be present in these biofilm communities Microbial communities on these devices es are highly diverse, may contain organisms from skin and gastrointestinal mircobiomes or from the environment, and will likely contain substantial numbers of organisms that cannot or have not been cultured NHIA Annual Conference & Exposition

16 What does this all mean? The presence of a device-associated d biofilm does not necessarily result in a device-associated d infection Biofilm organisms may be pathogens or opportunistic pathogens, and multi-drug resistant Biofilm associated organisms do not respond to therapeutically achievable concentration and may elicit disease processes by detachment of cells or aggregates or by production of endotoxins or other pyrogenic substances Biofilms, Medical Devices and Anti-Biofilm Technology Challenges and Opportunities FDA Public Workshop (February 20, 2014) Dr. Rodney Donlan, Director, CDC Biofilms Laboratory Relationship between Thrombosis and Infection Shortly after insertion, intravascular catheters ters are coated with a conditioning film, consisting of fibrin, plasma proteins, and cellular elements, such as platelets and red blood cells. Microbes interact with the conditioning film, resulting in colonization of the catheter. There e is a close association sociation between thrombosis of central venous catheters and infection. CDC Guidelines for the Prevention of Intravascular Catheter-Related Infection, 2011 O Grady NP, Alexander, M, Burns LA, et al NHIA Annual Conference & Exposition 15

17 Relationship Between Thrombosis and Sepsis The presence of CRS (catheter-related sepsis) or significant catheter colonization was more frequent in patients whose catheter-related central vein thrombosis was diagnosed. d. Chest 1998; 114; Central Vein Catheter-Related ed Thrombosis in Intensive Care Patients: Incidence, Risk Factors, and Relationship with Catheter-Related Sepsis. By: Jean-Francois Timset, MD, PhD IMPLICATIONS IONS NHIA Annual Conference & Exposition

18 Predictors of Occlusions/ Infiltration Hand Female IV Antibiotics Any Infection P<0.001 Risk Factors for PIV Catheter Failure: A multivariate analysis of data from a randomized controlled study. Wallis M, McGrail M, Webster J, Marsh N, Gowardman J, Playford G, Rickard CM. Infection Control and Hospital Epidemiology. Implications of Occlusion Patient discomfort High risk of DVT (deep vein thrombosis) Increased risk of embolism Delay in treatment Increased length of stay Nursing time Increase in medication and supply cost Increased risk of infection 2014 NHIA Annual Conference & Exposition 17

19 Impact of Central Line-Associated Bloodstream Infections (CLABSI) In the United States, 15 million central vascular catheter (CVC) days occur in intensive care units (ICUs) each year Outcomes associated with hospital-acquired CLABSI Mortality rate of 12%-25% Increased length of hospital stay 6-10 days Excess health care cost of $16,550 Morbidity and Mortality Weekly Report, Vital Signs: Central Line Associated Blood Stream Infections United States, March 1, 2011, Vol. 60 Bloodstream Infections: By Device No. of Prospective Studies Pooled Mean per/1000 catheter days Arterial catheters Short-term non-medicated CVC Long-term tunneled and cuffed CVC Peripheral venous catheters Peripherally inserted CVC (PICC) Subcutaneous central venous port Crnich, CJ, Maki DG, The Promise of Novel Technology for the Prevention of Intravascular Device-Related Bloodstream Infections. I Pathogenesis and Short-Term Devices. CID NHIA Annual Conference & Exposition

20 PUSH FOR IMPROVEMENT ENT Centers for Medicare & Medicaid Services (CMS) Guideline Changes and Impact on Hospitals: 2005 Deficit Reduction Act s Hospital- Acquired Conditions (HACs) and Present On Admission ion (POA) Program 30-day readmissions yield penalties, providers need to improve continuum of care 2014 NHIA Annual Conference & Exposition 19

21 CMS Never Event and Public Reporting Central Line Associated Bloodstream Infections 2011 CMS Requirements Association for Professionals in Infection Control and Epidemiology, Inc. 3/31/10. Standards of Evidence-Based and Best Practice Infusion Nurses s Society INS Association ion for Vascular Access AVA Centers for Disease Control and Prevention - CDC Society for Healthcare Epidemiology of America - SHEA Manufacturer s acturer s Recommendations NHIA Annual Conference & Exposition

22 Guidelines for Peripheral and CVCs CDC 2011 SHEA 2008 (CVCs only) INS 2011 Needleless s Connectors or Add-On/ Administration Sets Site and Dressing Changes Split septum valve No more frequently Peripheral catheters: preferred over than 96-hours intervals, hours mechanical valve but at least every 7 days Do not routinely use No longer than 96 Non-tunneled CVCs, positive pressure hours change transparent needleless connectors ors dressings every 5-7 days Needleless connectors c shall be Luer-lock design Change with site rotation: up to 96 hours dependent on infusate When clinically indicated d Needleless s Technology Ryder Science 2014 NHIA Annual Conference & Exposition 21

23 Needleless Technology No ISO standard on fluid displacement Negative displacement: Upon syringe disconnection, blood refluxes into catheter er tip Action: clamp BEFORE syringe disconnection Positive displacement: Upon syringe disconnection, small amount of fluid pushes out end of catheter tip Action: clamp AFTER syringe disconnection Neutral displacement: Designed to minimize blood reflux into catheter tip upon syringe disconnection Action: clamp BEFORE syringe disconnection Anti-reflux technology: ogy: Prevents blood reflux from occurring in IV therapy due to mechanical and physiological factors Action: NO dependency on clamping sequence, reflux protection is automatic Clamping does NOT stop all blood reflux potentials NHIA Annual Conference & Exposition

24 Blood Reflux and Thrombosis How much reflux is too much? Blood Reflux associated with needleless connector into catheters between L Total Incidence of Occlusion 15 L = 2.94% 30 L = 24.71% Impact of blood reflux on the incidence of catheter occlusions A controlled experimental trial. Hunter M. VonBriesen T, Faintuch S. 37 th National Canadian Vascular Access Association Conference, 2012 Positive Needleless Connectors SHEA Do not routinely use positive-pressure needleless connectors with mechanical valves Risk Benefits Education FDA Alert Initiated post market surveillance and supports SHEA s recommendations CDC Split septum valve may be preferred over some mechanical valves 2014 NHIA Annual Conference & Exposition 23

25 Are you doing what it takes to decrease the occurrence of blood reflux? EXAMINE YOUR PRACTICE Clinical Practice: Policy and Protocol Policy must reflect facility-specific flush protocol: Proper flush-clamp sequence according to connector being used Proper r flush solution, technique, frequency of flush, and volume of flush Treat partial and complete occlusion in central catheters PROMPTLY NHIA Annual Conference & Exposition

26 Clinical Practice: Needleless Connectors Negative Fluid Displacement Needleless Connector Flush Clamp Remove Syringe Positive Fluid Displacement Needleless Connector Flush Remove Syringe Clamp Clinical Practice: Data Number of PIV catheters placed Number of PIV catheter days Mean, median and average dwell time Complications: Phlebitis Infiltration and extravasation Infection Air embolism Catheter embolism Thrombosis and occlusion 2014 NHIA Annual Conference & Exposition 25

27 2014 NHIA Annual Conference & Exposition 26 SUMMING IT UP Strategies to Prevent Blood Reflux Standards of best practice Education Data collection continuous quality improvement Select new devices based on outcome evidence Investigate new technology to reduce: Biofilm formation, blood reflux, catheter occlusion and accidental needle stick SUM MING IT SUM UP Education Standards of be Strategies to Prevent Blood practice andards of best Reflux Strategies to Prevent Blood Strategies to Prevent Blood idental ne Biofilm format ne Investigate new devic Select Data collection c Education stick dle Biofilm formation, blood reflux, cat to reduc new technology vices based on outcome ion continuous qualit lusion and atheter occ duce: evidence ome improvement inuous quality accidental ne stick edle

28 DON T FORGET!! Hand hygiene is king! Site care and maintenance including a meticulous scrubbing the hub routine is essential Assessment for complications Catheter site dressing regimens per best practice Objectives Describe how blood reflux in vascular access catheters contributes to thrombotic catheter occlusions and bloodstream infections. ions. List two quality initiatives to prevent blood reflux complications. Identify two strategies for preventing complications created by blood reflux in the vascular access catheter NHIA Annual Conference & Exposition 27

29 QUESTIONS? NHIA Annual Conference & Exposition

30 References: Bagot, CN, Arya, R. Virchow and his triad: a question of attribution British Journal of Haematology. Oct2008, Vol. 143 Issue 2, p Baskin JL, Ching Hon P, Reiss U, et al. Management of Occlusion and Thrombosis Associated With Long Term Indwelling Central Venous Catheters. Lancet July 11; 373 (9684): 159. Crnich, CJ, Maki DG. The Promise of Novel Technology for the Prevention of Intravascular Device Related Bloodstream Infections. I Pathogenesis and Short Term Devices. CID 2002 Deficit Reduction Act of 2005, Public Law Feb.8, 2006, Retrieved 7/15/2013 at 109publ171/pdf/PLAW 109publ171.pdf FDA Memorandum, Dear Infection Control Professionals. Available at: ucm htm Accessed July1, 2013 Hadaway L. Technology of flushing vascular access devices. J Infus Nurs. 2006; Infusion Nursing Standards of Practice, Journal of Infusion Nursing, Volume 34, Number 1S ISSN Revised Jarvis W, Choosing the Best Design for Intravenous Needleless Connector to Prevent HA BSI. Infection Control Today. August 2010 Vol. 14 No 8 Macklin D, What s Physics Got to Do With It? J Vasc Access Devices. 1999;4(2): Marschall J, Mermel LA, Strategies to Prevent Central Line Associated Bloodstream Infections in Acute Care, Infection Control and Hospital Epidemiology, vol. 29, Supplement 1, October McKnight S Nurse s Guide to Understanding and Treating Thrombotic Occlusions of Central Venous Access Devices. Medsurg Nurs. 2004; 13: Morbidity and Mortality Weekly Report, Vital Signs: Central Line Associated Blood Stream Infections United States, March 1, 2011, Vol. 60 National Patient Safety Goals, Joint Commission, Accessed 5/10/2013 at: Jan2013_HAP.pdf O Grady NP, Alexander, M, Burns LA, et a. Guidelines for the Prevention of Intravascular Catheter Related Infection, Centers for Disease Control and Prevention, 2011 Poole S. Central Line Infection: Improving our Surveillance, Treatment and Prevention in the Home Setting. Infusion Mar/Apr Potera C, Biofilm Dispersing Agent Rejuvenates Older Antibiotics. Environmental Health Perspectives 2010; 118; A288 Premier Advisor Live Hospital value based purchasing program: What s in the new CMS proposed rule? 2011, Accessed 7/1/2013 at: Ryder M. Needleless Connectors minimizing the risk of bacterial transfer. Accessed 2/28/14 at: Sinno M, Alam M, Echocardiographically Detected Fibrinous Sheaths Associated with Central Venous Catheters. Echocardiography. Mar2012, Vol. 29 Issue 3, pe56 E59. Timsit JF, Misset B, CarletJ, Central Vein Catheter Related Thrombosis in Intensive Care Patients: Incidence, Risk Factors, and Relationship with Catheter Related Sepsis. Chest 1998; 114; Wallis M, McGrail M, Webster J. et. al. Risk factors for PIV catheter failure: a multivariate analysis of data from a randomized controlled trial. Infection Control & Hospital Epidemiology. Under review. Hunter M. VonBriesen T, Faintuch S. Impact of blood reflux on the incidence of catheter occlusions A controlled experimental trial. 37 th National Canadian Vascular Access Association Conference, NHIA Annual Conference & Exposition 29

31 NOTES: NHIA Annual Conference & Exposition

32 NOTES: 2014 NHIA Annual Conference & Exposition 31

33 Answers: 1. a. True 2. a. True 3. a. True 4. d. All of the above 5. b. False NHIA Annual Conference & Exposition

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