<p> Central Vascular Catheter (CVCs) Cause and Effect Chart – to reduce Catheter Related – Blood Stream Infections Version 2008-2</p><p>Preventing infection: insertion site sepsis, infusate contamination and catheter-related blood stream infections (CR-BSI) A literature search was performed and the identified papers underwent a rapid review. From this review, key points of information for optimal central vascular catheter care have been summarised below. A formal scientific critique was not performed on the identified papers and therefore there may be limitations to this process. Central vascular catheters are the leading cause of device-related bacteraemias [1]. The risk increases however with duration of line use, the more CVC manipulations required and the greater the number of infusions – particularly blood transfusions or infusions made up in house. The presence of other pre- existing sites of infection will also increase the risk [2-5]. Organisms causing CR-BSI: The majority of microorganisms that cause CR-BSIs are Gram-positive organisms: coagulase negative staphylococci and Staphylococcus aureus (MRSA and MSSA). These organisms originate from the patient’s skin at the insertion site, hub contamination with skin organisms or from the hands of HCWs. Gram-negative organisms causing CR-BSI originate from the patient, the hands of HCWs or infusate contamination where asepsis has not been practiced during the preparation of drugs [4-7]. (Skin organisms can remain viable in dry conditions for months). The entry of microorganisms can be at any manipulation point, i.e. hub/connection, or insertion site. Organisms gaining entry are frequently skin organisms from the HCW or the patient. Organisms from a distal site of infection can travel via the blood and infect the CVC. Once organisms enter the catheter they form biofilm on the surface of the catheter, multiply and eventually break off causing the patient to have the classic signs of a blood stream infection: pyrexia, rigors etc [2, 3, 8, 9]. Successful Strategies to minimise the risk of CR-BSIs include:  A commitment to excellence in the care of CVCs by all who care for patients with CVCs.  Only trained competent HCWs performing CVC procedures  Only using CVCs when it is essential to do so and removing the CVC as soon as practical.  Using checklists to remind HCWs of the correct process and reducing the risk of lapses at crucial steps  Using aseptic non-touch technique; chlorhexidine gluconate 2% antiseptic; sterile dressings; decontamination of hubs; using manufacturers’ instructions.  Optimising system performance by using aids such as insertion check lists, CR-BSI surveillance and use of Bundles; Then using the data generated to analyse performance and adjust and improve systems, performance and outcome [10-13] . Version 2008 1 Risk Factors & Aetiology EQUIPMENT ENVIRONMENT</p><p>Having a central vascular catheter is the Store equipment needed for CVC insertion / The environment must be safe for patients. key risk factor for CR-BSI. The risk maintenance in a safe, ready to access trolley or The ward manager and lead clinician should foster and increases however with duration of line use, cupboard where it will be free from splash or dust encourage excellence in care, reliability and patient the more CVC manipulations required and the exposure. Rotate stock to minimise wastage. safety from the entire team by continuously striving to greater the number of infusions. Use single use sterile antiseptics. Organisms+ can enter at any manipulation improve and optimise systems using measurement and point, i.e. hub/connection or insertion site. All equipment must be checked pre usage to ensure feedback of performance, e.g. use of CVC bundle. Organisms gaining entry are frequently skin it is within its expiry date and packaging is free organisms from the HCW or the patient. from damage (tears, splash or staining). Any area where IV drugs are Poor drug preparation can result in infusate prepared must be clean and free contamination – causing a direct BSI. HCWs must have access to (and comply with) from clutter. If asepsis cannot be Minimising CR- Organisms from a distal site of infection can policies/procedures on hand hygiene and CVC care maintained the area must not be BSI from non- insertion & maintenance; including checklists. used for IV drug preparation. travel via the blood and infect the CVC. tunnelled CVCs  Perform hand hygiene before & after all procedures.  Only use a CVC if it is necessary to do so.  Use aseptic technique for all CVC administration  Use an insertion checklist to ensure procedure manipulations / procedures. HCWs must show commitment to excellence is performed correctly.  Prevent contamination of the insertion site by using  in care and prevention of complications by: Before insertion perform a surgical scrub sterile gloves during dressing changes.  Undertaking the CVC bundle weekly and technique.  Designate one port for TPN (if required).  assisting in CR-BSI surveillance. Use maximal barrier precautions:  Replace the dressing aseptically – using 2%  Discussing possible system changes with o Hat, sterile gown, sterile gloves, mask. chlorhexidine gluconate in alcohol for skin antisepsis -  colleagues to improve care /patient Use a sterile drape(s) to create a sterile field. when it has become damp loosened, soiled or after 7  safety. Use aseptic technique throughout procedure. days.   Presenting for duty with tidy hair, short, Select a CVC most appropriate to patient  Have a planned scheduled change of the clean nails (without false nails/varnish) management. administration set minimum 72 hrs, max 96 hours or  and performing hand hygiene frequently. Use 2% chlorhexidine gluconate in alcohol for 24 hours if lipid or blood transfusions are used. skin antisepsis pre insertion.  Decontaminate hubs aseptically with alcohol and  HCWs caring for a patient with a CVC Use single-use vials (not multi-use). change according to the manufacturer’s instructions.   Must undergo education and training and Do not use the femoral vein for insertion  Ensure the catheter material is compatible with the on an ongoing basis be deemed unless the subclavian or internal jugular routes antiseptic used during dressing change. competent in CVC care. are unavailable.  Monitor the patient’s temperature and pulse for signs   Adhere to local infection prevention Use a sterile IV film dressing or dry gauze. of a CR-BSI (sustained high temperature [>38 C]  policies. Commence a regimen of daily assessment for associated with line usage). HEALTHCARE WORKERS (HCWs) continuing line use – remove CVC ASAP.  Document all care – and report to medical staff any abnormal findings, e.g. pyrexia or inflammation. METHODS (Insertion) METHODS (Maintenance) References:</p><p>1. Coello, R., et al., Device-related sources of bacteraemia in English hospitals--opportunities for the prevention of hospital-acquired bacteraemia. J Hosp Infect, 2003. 53(1): p. 46-57. 2. Morales, M., et al., Biofilm: the microbial "bunker" for intravascular catheter-related infection. Support Care Cancer, 2004. 12(10): p. 701-7. 3. Pascual, A., Pathogenesis of catheter-related infections: lessons for new designs. Clin Microbiol Infect, 2002. 8(5): p. 256-64. 4. O'Grady, N.P., et al., Guidelines for the prevention of intravascular catheter-related infections. The Hospital Infection Control Practices Advisory Committee, Center for Disese Control and Prevention, US. Pediatrics, 2002. 110(5): p. e51. 5. Maki, D.G. and C.J. Crnich, Line sepsis in the ICU: prevention, diagnosis, and management. Semin Respir Crit Care Med, 2003. 24(1): p. 23-36. 6. Mermel, L.A., et al., Guidelines for the management of intravascular catheter-related infections. J Intraven Nurs, 2001. 24(3): p. 180-205. 7. Vonberg, R.P. and P. Gastmeier, Hospital-acquired infections related to contaminated substances. J Hosp Infect, 2007. 65(1): p. 15-23. 8. Crump, J.A. and P.J. Collignon, Intravascular catheter-associated infections. Eur J Clin Microbiol Infect Dis, 2000. 19(1): p. 1-8. 9. Raad, I., Intravascular-catheter-related infections. Lancet, 1998. 351(9106): p. 893-8. 10. O'Grady, N.P., et al., Patient safety and the science of prevention: the time for implementing the Guidelines for the prevention of intravascular catheter-related infections is now. Crit Care Med, 2003. 31(1): p. 291-2. 11. Pratt, R.J., et al., epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect, 2007. 65 Suppl 1: p. S1-64. 12. Berenholtz, S.M., et al., Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med, 2004. 32(10): p. 2014- 20. 13. Warren, D.K., et al., A multicenter intervention to prevent catheter-associated bloodstream infections. Infect Control Hosp Epidemiol, 2006. 27(7): p. 662-9.</p>