DRAFT for review cycle 8/21/17 BEST PRACTICE GUIDELINE FOR THE INSERTION AND CARE OF CENTRAL VENOUS ACCESS IN CRITICALLY ILL Target Audience: Physicians and nurses providing care to patients in MultiCare ICUs, including IV teams Scope/Patient Population: This guideline applies to adult patients in the MultiCare Health System (MHS) critical care units. Rationale: Central venous catheters remain as one of the most common interventions in hospitalized patients, particularly in ICU settings. Central lines are associated with an increased incidence of preventable complications, including central line-associated bloodstream infection (CLABSI). CLABSIs continue to be one of the most deadly and costly hospital-associated infection in the US. Many cases of central line-associated infections are largely preventable and the incidence and prevalence of CLABSIs can be dramatically reduced by systematic adherence to best practices and minimizing the use of central lines (strict criteria for use and removal as soon as possible). The current guideline summarizes evidence based interventions and expert consensus to assist clinicians in following standard practices in the insertion and care of central venous access and in the prevention of central line-associated bloodstream infections. Objective To provide standardized work that ensures compliance to best practices related to central line insertions and care and to summarize evidence based interventions and expert consensus to assist clinicians in the prevention of central line-associated bloodstream infections. I. Definitions a. Central venous line: An intravenous catheter whose tip terminates in the lower segment of the superior vena cava or near the Cavo atrial junction. For lower body insertion sites, the tip should be located in the inferior vena cava above the level of the diaphragm. Page 1 of 15
b. Short term central venous access: These are central lines that penetrate the vein shortly after the puncture site at the skin; hence they lack a subcutaneous tunnel and/or cuff. Because of their propensity to allow microorganism entry from the skin into the bloodstream, they should not be maintained in place for extended periods of time. Examples include: triple lumen central venous catheters (CVCs), Cordis introducers (also known as introducer sheaths) and non-tunneled hemodialysis catheters. c. Long term central venous access: These central lines have a longer subcutaneous tract created during insertion and may sometimes be completely buried under the skin. These may also have structures known as cuffs to reduce the risk of penetration of microorganisms from the skin into the bloodstream. Examples include: Port-a-caths, Groshong catheters, tunneled hemodialysis catheters and peripherally inserted central catheters (PICCs). II. Standardized Process for Central Line Insertion, Maintenance and Daily Care, and Removal The following guideline describes the recommended process to ensure appropriateness of central venous access indications, standardized insertion and maintenance practices and to facilitate elimination of central line related complications in Adult Intensive Care Units and recognizes three main bundles of preventive measures. Clear documentation and auditing for consistent presence of the elements of each bundle by clinical team with removal of any central line that has at least one component missing is recognized as the mainstay of CLABSI and other complications prevention. 1. Central line insertion bundle The insertion bundle has 8 components that should be documented by the assisting RN in the patient care flow sheet. The clinical team must ensure during multidisciplinary rounds that every element on the insertion bundle has been completed. a. Optimal site selection The subclavian site remains the most appropriate choice in patients without coagulopathy, thoracic deformities or preexisting skin integrity disruption. Procedural competence of clinicians performing subclavian insertions is necessary to decrease the risk of mechanical complications (i.e. pneumothorax). Page 2 of 15
Lower extremity catheters should be replaced as soon as possible. Internal jugular site infection rates are higher than subclavian sites as the integrity of the sterile dressing is difficult to maintain. In some literature reports the internal jugular site infection rate may approach those seen with the femoral site. b. Hand hygiene prior to donning sterile attire The clinician should use soap and water or an alcohol based hand sanitizer immediately before donning sterile attire. c. Use of mask by all staff present during insertion d. Use of mask, hair cover, sterile gown and sterile gloves by the inserting clinician e. Use of mask, hair cover, isolation gown and gloves by the inserting assistant f. Skin antisepsis with chlorhexidine unless patient allergic unless clinically contraindicated. g. Use of ultrasound guidance when clinically indicated, to minimize the number of cannulation attempts and mechanical complications h. Maximal barrier precautions, a full size drape should cover the patient from head to toe during the entirety of the insertion procedure. i. Occlusive dressing, applied in a sterile fashion immediately after securing the newly place central line. 2. Maintenance and daily care bundle a. Hand hygiene Should be performed before and after handling any part of the line or its dressing and between glove changes. b. Inspection and palpation through the dressing to discern tenderness, erythema or frank purulent discharge. c. Replace the dressing if the dressing becomes damp, loosened or visibly soiled and every 2 days for gauze dressing and every 7 days for transparent dressing. Page 3 of 15
d. Document breaches in the occlusive dressing and notify the responsible clinical team e. Friction scrub for 15 seconds, allowing the hub to dry before accessing or connecting f. Consistent use of Dual caps on all ports g. Consistent use of a properly placed antimicrobial disc 3. Removal bundle The clinical team should review the indications for insertion and continued use of a central line at insertion and during daily multidisciplinary rounds. Generally accepted indications for central line need include: Administration of vasoactive (pressor and inotrope) drips Long term IV need (PICC or tunneled lines preferred) Administration of hypertonic solutions including TPN Administration of IV medications during cardiac arrest All central lines should be removed promptly when the indication for its use has resolved. III. Procedure Effective implementation of this guideline relies on diligent communication among the members of the clinical team. All central lines in the intensive care unit setting should have the appropriate bundles completed by the RN staff at the time of insertion when applicable and every shift thereafter. A daily review of any bundle compliance breaches should be completed during multidisciplinary rounds. All lines with a breach should be addressed or removed no later than 24 hours after documentation of the bundle breach. IV. Special Considerations A midline catheter or PICC should be preferred over a short peripheral catheter when duration of IV therapy will exceed six days. Page 4 of 15
CVs, PICCs and HD catheters should follow the dwell time guidelines and appendices in the MHS Intravenous Access Guidelines. Guide wire exchanges should not be routinely used for exchanging non-tunneled catheters Blood draws from central lines should be minimized as much as possible. TPN should not be administered through femoral lines and avoided through internal jugular lines. A subclavian line or peripherally inserted central catheter is the preferred line to deliver total parenteral nutrition. Short term vasoactive infusion: Vasopressors administration can be accomplished through peripheral IVs after ensuring the following: o Vein diameter > 4mm measured by ultrasonography o Position of IV access to be documented in the vein with ultrasonography before starting the infusion of vasoactive medication o Upper extremity only, contralateral to blood pressure cuff o Intravenous line size 20gauge or 18 gauge o No hand, wrist or antecubital fossa PIV access position o Blood return from the PIV access prior to vasoactive administration o Assessment of PIV access function every 2 hours as per nursing protocol o Immediate interruption and treatment if extravasation occurs o 72 hours maximum duration of IV access use o The standard concentrations of vasoactive medication for use via PIV access are: norepinephrine 4 mg/250 ml or 8 mg/250 ml normal saline, dopamine 400 mg or 800 mg/250 ml D5W, and phenylephrine 40 mg/250 ml or 80 mg/250 ml mg/500 ml normal saline. Rapid infusion of volume should be performed through large bore peripheral lines or cordis/introducer sheath lines. Triple lumen catheters and PICCs are inferior to the former in allowing for rapid large volume infusion. The maximal flow rates of different lines are as follow: o 7-French Cordis introducer: 333 ml/minute o Standard 16-gauge IV: 220 ml/min Page 5 of 15
o Standard 18-gauge IV: 105 ml/min o Procedural 18-gauge angiocath: 85 ml/min o Standard 20-gauge IV: 60 ml/min o Distal lumen, triple lumen catheter: 52 ml/min o Lateral lumens, triple lumen catheter: 26 ml/min Algorithm: At insertion Daily Care Daily Rounds Review Ensure and document Optimal site selection Hand hygiene prior to donning sterile attire Use of mask by all staff present during insertion Use of mask, hair cover, sterile gown and sterile gloves by the inserting clinician Use of mask, hair cover, isolation gown and gloves by the inserting assistant Skin antisepsis with chlorhexidine unless patient allergic. Use of ultrasound guidance when clinically indicated Maximal barrier precautions (large sterile drape on operative site) Occlusive dressing before breaking sterile technique. Remove line within 24 hours if ANY item not met Evidence: Ensure and Document Hand hygiene Redness, induration or discharge Replace loose dressings Document breaches in the occlusive dressing and notify the responsible clinical team 15 second friction scrub before accessing the line Proper use of dual caps Properly placed antimicrobial disc Remove line within 24 hours if ALL of the above not met Review Accepted Indications for Continuation of Central Vein Access Administration of vasoactive (pressor and inotrope) drips Administration of hypertonic solutions including TPN Administration of IV medications during cardiac arrest Long term IV need Remove line if ANY of the above are not met 1. US Centers for Disease Control. Guidelines for the Prevention of Intravascular Catheter Related Infections. 2011 Page 6 of 15
2. Institute for Healthcare Improvement. How-to guide: Prevent Central Line- Associated Bloodstream Infections (CLABSI). 2012 3. Pronovost PJ, Watson SR et al. Sustaining Reductions in Central Line-Associated Bloodstream Infections in Michigan Intensive Care Units: A 10-Year Analysis. Am J Med Qual. 2016 May;31(3):197-202. 4. Deshpande KS, Hatem C, Ulrich HL, et al. The incidence of infectious complications of central venous catheters at the subclavian, internal jugular, and femoral sites in an intensive care unit population. Crit. Care Med. 2005;33:13 5. Mermel LA, McCormick RD, Springman SR, Maki DG. The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters: a prospective study utilizing molecular subtyping. Am J Med. Sep 16 1991;91(3B):197S- 205S. 6. McCarthy MC, Shives JK, Robison RJ, Broadie TA. Prospective evaluation of single and triple lumen catheters in total parenteral nutrition. J Parenter Enteral Nutr. 1987 May-Jun;11(3):259-262. 7. Nolan ME, Yadav H et al. Complication rates among peripherally inserted central venous catheters and centrally inserted central catheters in the medical intensive care unit. J Crit Care 2016 Feb;31(1):238-42. 8. Wilson TJ, Stetler WR et al. Comparison of catheter-related large vein thrombosis in centrally inserted versus peripherally inserted central venous lines in the neurological intensive care unit. 2013 Jul;115(7):879-82. Clin Neurol Neurosurg. 9. Goetz AM, Wagener MM, Miller JM, Muder RR. Risk of infection due to central venous catheters: effect of site of placement and catheter type. Infect Control Hosp Epidemiol. 1998;19:842-845. 10. Parienti JJ, Thirion M, Mégarbane B, et al. Femoral versus jugular central catheterization in patients requiring renal replacement therapy: A randomized controlled study. JAMA. 2008;299:2413-2422. Page 7 of 15
11. Richet H, Hubert B, Nitemberg G, et al. Prospective multicenter study of vascular-catheter-related complications and risk factors for positive central-catheter cultures in intensive care unit patients. J Clin Microbiol. 1990;28:2520. 12. Collignon P, Soni N, Pearson I, et al. Sepsis associated with central vein catheters in critically ill patients. Intensive Care Med. 1988;14:227. 13. Merrer J, Jonghe BD, Golliot F, et al. Complications of femoral and subclavian venous catheterization in critically ill patients. A randomized controlled trial. JAMA. 2001;286:700. 14. Parienti JJ, Mongardon N, et al. Intravascular Complications of Central Venous Catheterization by Insertion Site. N Engl J Med. 2015 Sep 24;373(13):1220-9. 15. McCarthy MC, Shives JK, Robison RJ, Broadie TA. Prospective evaluation of single and triple lumen catheters in total parenteral nutrition. J Parenter Enteral Nutr. 1987 May-Jun;11(3):259-262 16. Gavin NC, Webster J et al. Frequency of dressing changes for central venous access devices on catheter-related infections. Cochrane Database Syst Rev. 2016 Feb 1;2:CD009213 17. O Brien J, Paquet F et al. Insertion of PICCs with minimum number of lumens reduces complications and costs. J Am Coll Radiol. 2013 Nov;10(11):864-8 18. Cooper K, Frampton G et al. Are educational interventions to prevent catheter-related bloodstream infections in intensive care unit cost-effective? J Hosp Infect. 2014 Jan;86(1):47-52. 19. Cardenas-Garcia J, Schaub KF et al. Safety of Peripheral Intravenous Administration of Vasoactive Medication. Journal of Hospital Medicine. 2015; 00: 1-5 Page 8 of 15
20. Journal of Infusion Nursing: Infusion Therapy Standards of Practice. 2016 Jan/Feb; 39(1S): S46-S47. List of Implementation Items and Patient Education: Standardized documentation tools yearly review with Information Technology o Procedure Documentation (Appendix A) o Central Line Continued Use Documentation Compliance (Appendix B) Nursing education module annually Physician education module annually Patient education not applicable Metrics Plan: Quarterly review of the following: 1. Decrease of device days in ICU patients central line days by x% by xx date 2. Decrease x% of CLABSI incidence by x date 3. Decrease x% of CLABSI standardized infection ratio in all adult ICU by x date 4. Measure discontinuation rate due to breaches from standardized protocol by x date 5. Measure location and type of Central Line-percentage of total by x date PDCA Plan: Every two-year review by the Critical Care Collaborative (Central Line Work Group) unless new evidence identified by the group at large. Point of Contact: Medical Director Critical Care Unit, MultiCare Good Samaritan Hospital Approval by: Collaborative (Critical Care) MHS/Other Committee MCC/Collaborative Leadership Original Date: Revision Dates: Reviewed with no Changes Dates: Date of Approval: X/XX X/XX; X/XX X/XX; X/XX 08/2017 08/2017; X/XX X/XX; X/XX Distribution: MultiCare Connected Care + MultiCare Health System Page 9 of 15
I. APPENDIX A Page 10 of 15
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II. APPENDIX B Page 15 of 15