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Objectives Understand the impact and causes of infection associated with vascular access Identify signs and symptoms of infection in vascular access Explain procedures involved with safe insertion, maintenance and removal of intravascular devices to reduce the risks of infection
The Impact of Healthcare Associated Infection (HCAI) 9% of hospital inpatients at any one time will acquire an infection during their stay 1 There are at least 100,000 HAI a year 1 5,000 deaths a year 2 Financial impact 1. Auditor General (2000) the management and control of Hospital Acquired Infection in Acute NHS in England. 2. DOH CMO (England) (2002) Getting ahead of the curve
Preventing HCAI National Audit Office Suggests that 10-15% of HCAI can be prevented Good application of Infection Control policies and principles National Audit Office 2000
The extent of the problem Incidence of blood stream infections 0-15% (Elliott 1993) Central catheters responsible for 31% hospital bacteraemias, peripheral lines 7% (PHLS 2000) Paediatrics: 3-11 / 1000 catheter days (Seguin et al. 1994)
The extent of the problem (2) Up to 80% of hospitalised patients will receive some form of I.V. therapy (Wilkinson 1996) Nystrom et al. (1983) studied 10,616 surgical patients. 63% had an I.V. device 10.34% thrombophlebitis
General Principles of Infection Control Remove the source of infection Block routes of spread Enhance the patient s resistance to infection
Risk Factors for Infections Patient Factors External Factors
Vascular Access Associated Infections Local infection Local inflammation Discharge around line Erythema Pain/discomfort Systemic infection Fever Rigors when line is in use Tachycardia Metastatic infection
Common pathogens in bacteraemia Coagulase Negative Staphylococci (CNS) 30-40% Staphylococcus aureus 5-10%. Enterococcus 4-6%. Pseudomonas aeruginosa 2-6%. Candida 2-5%; Enterbacter 1-4%; Acinetobacter 1-2%; Serratia <1% Centres for disease Control and Prevention (2002) Guidelines for the Prevention of Intravascular catheter related Infections. Morbidity and Mortality weekly report. Vol. 51/ No. RR-10.
Routes of Infection Endogenous Infection arising from patient s own organisms Exogenous Infection originating from organism outside of the patient s body including environment, equipment & staff hands
Sources of Exogenous Infection Intrinsic contamination occurs prior to the use of the equipment manufacturing problem, poor storage Extrinsic contamination occurs at any point during the insertion, use or removal of the device Poor hand hygiene, poor aseptic technique
Extraluminal, intraluminal & haematogenous routes Extraluminal Organisms access the vein via outside of catheter Intraluminal Organisms access the vein via lumen of catheter Haematogenous Organisms from other sites transferred by blood flow to catheter
SKIN COLONISATION HAEMATOGENOUS SEEDING
Guidelines epic National Evidence Guidelines for Infection Control NICE Infection Control prevention of HCAI in primary and community care ICNA Guidelines for Preventing Intravascular Catheter- Related Infections
Other national resources Winning Ways Savings Lives
Professional Issues Provide service in best interest to patient / client Policies based on national standards and guidelines Necessary skills and competence Provide care in partnership Patient / carer information Evaluate Report Practice, clinical outcomes Adverse outcomes, limitations
Principles of PIVA Assessment of need Line choice Insertion site choice Insertion technique Site care Line management Asepsis Hand hygiene
Assessment of need Does the patient need I.V. access Alternative administration of therapy What treatment is to be administered Influence catheter type
Line choice Peripheral line (PVC) Ported vs. unported Peripherally Inserted Central Catheter (PICC) Other alternative e.g. vascuports Paediatric: Umbilical catheters
Line choice (2) Central line (CVC) Single lumen unless multiple ports essential Use tunnelled catheter or implantable port for long term devices (more than 30 days) Consider antimicrobial impregnated CVC for high risk adult patients who require short-term treatment (less than 10 days)
Insertion site choice (adult) Assess risks for infection against risk of mechanical complications Use subclavian line as a preference unless medically contraindicated Consider using PICC as alternative to subclavian or jugular access PVC site choice where least mechanical irritation
Insertion site choice (paediatric) Assess risks for infection against risk of mechanical complications Most CVCs will be jugular or femoral (subclavian occasionally) Consider using PICC as alternative to subclavian or jugular access PVC site choice where least mechanical irritation
Insertion technique PVC Aseptic technique Standard precautions utilised 70% Isopropyl Alcohol skin preparation
Insertion technique CVC Full aseptic technique Full body drape with access to insertion site only Full surgical attire by operator and assistant (epic 2001) Alcoholic chlorhexidine skin preparation (alcoholic poviodine-iodine solution for patients with history of chlorhexidine sensitivity) Allow the antiseptic to dry before inserting catheter
Site care Intact sterile, transparent, semi-permeable polyurethane dressing CVC dressing changed every 7 days or sooner if it becomes wet, loose or soiled Before accessing the system disinfect external surfaces of the catheter hub and connection ports with alcoholic chlorhexidine gluconate or povidone-iodine unless contraindicated by manufacturer
Site care (2) Insertion sites should be checked at least daily for signs of inflammation and document using VIP score
Line management Lines should be handled as little as possible Injection ports should be disinfected with alcohol wipes Replace all tubing when vascular device is changed Change tubing, stopcocks etc no more frequently than every 72-96 hours (unless clinically indicated) Replace tubing from blood transfusion within 24 hours of initiation and on completion Replace tubing following infusion of lipids within 24 hours of initiation
Asepsis Asepsis is defined as the method by which microbial contamination is prevented during invasive procedures or of breaches in the skin s integrity Aseptic techniques are methods that have been developed to ensure that only uncontaminated objects / fluids make contact with sterile / susceptible sites Full compliance with aseptic technique is essential for handling any line
Aseptic technique Compliance with aseptic technique must be used to insert all central lines Skin should be disinfected before inserting any catheter Alcoholic chlorhexidine gluconate (alcoholic povidone-iodine in sensitivity) for CVC and PICC Alcohol wipe for PVC Allow preparation to dry before insertion Use sterile gloves for CVC manipulation (based on risk assessment) Hands must be decontaminated prior to any line manipulation / intervention
Hand hygiene Hand hygiene is the principle factor to reduce risks of introducing micro-organisms Hands must be washed / decontaminated before and after any manipulation / intervention associated with the line Administering drugs, changing infusions, inserting lines, changing dressings Hands must be washed after removing gloves
Hand hygiene (2) Soap and water Wet hands Wash using Ayliffe 6 step technique Rinse Dry thoroughly To remove physical dirt / organic matter Alcohol based hand rubs Physically clean hands In absence of appropriate hand washing facilities Hand care
Hand hygiene (3)
Patient information Patients / carers should be trained how to look after a long term line Reducing risks of infection Identifying signs and symptoms of infection How to report concerns
Infection prevented? Surveillance Site infection surveillance (incidence, rates) Bloodstream infection associated with vascular devices Mandatory bacteraemia reporting Root-cause analysis
Infection prevented? (2) Audit Practices, local and organisational Insertion, management, documentation Department of Health, ICNA audit tool Saving Lives High impact intervention No. 1 & 2 PIVA audit tools
Infection prevention and control is everybody s responsibility every day!
Any Questions? Thank you for listening!