TO HELP REDUCE catheter-related bloodstream infections (CRBSIs), I helped to design and implement a central line bundle for our ICU in 2005. This grew out of our facility's involvement in the 100,000 Lives Campaign, a nationwide effort by the Institute for Healthcare Improvement (IHI) and its partner organizations to reduce preventable deaths in hospitals.
As defined by the IHI, a bundle is a collection of interventions that, when delivered as a group, improve outcomes. Our goal in developing a central line bundle was to develop a set of practices that, when followed consistently and reliably, would reduce our CRBSI rate.
To develop the central line bundle, our peripherally inserted central catheter (PICC) team took ownership for all central lines in the ICUs. In doing so, we changed practices throughout our facility for inserting and managing all central venous catheters (CVCs). Today, 90% to 95% of CVCs at Sutter Roseville Medical Center (SRMC) are PICCs inserted by a specially trained PICC team.
By implementing a central line bundle, we've eliminated CRBSIs in more than 5,000 PICC lines. This article describes the bundle, the practices that support it, and the results we've achieved.
The scope of the problem
Roughly 250,000 CVC-related bloodstream infections occur in the United States each year, with an attributable mortality of 12% to 25% per infection.1 These infections occur far more frequently with CVCs than with other I.V. catheters, so the bundle at our facility was a first line of defense against these infections.
While improving patient care was our top priority, the bundle was also a defense against CRBSI-related expenses. Beginning this month, the Centers for Medicare and Medicaid Services (CMS) will end payments for certain health care-associated infections, including vascular catheter-associated infections that can be prevented with ordinary precautions. Most private insurers will probably follow suit. Each CRBSI costs an average of $25,000 to treat.1 These infections can increase hospital length of stay by an average of 7 days, according to the IHI.2 Each infection can potentially represent a substantial financial loss to the facility involved.
An initiative by many states to publicize infection rates is also motivating hospitals to find new ways to prevent infections. Hospital administrators anticipate that many health care consumers will consider infection rates when choosing a hospital for treatment.
A tall order
Although a significant proportion of CRBSIs is preventable according to the Association for Vascular Access, eliminating them is no simple task. The bacteria that cause them live on hospital walls, floors, and bed rails. Some 60% of CRBSIs originate from the patient's own skin.3
Proper skin prep at the time of catheter insertion kills most but not all of these microorganisms. The survivors can multiply rapidly, often restoring the bacteria colony to substantial levels within a few days. Any bundle aimed at preventing CRBSI must take this factor into account.
Doing our homework
To develop our bundle, we began by collecting data and searching for evidence of best practices. We looked at the CDC and IHI recommendations and the impact these would have on the extraluminal catheter tract and the intraluminal fluid pathway. We reviewed our policies and procedures and correlated them with our review of the literature.
We also reviewed all of the products we were currently using and new products on the market. We evaluated these products from several perspectives: What did the research and literature say about their effectiveness? What did they cost? For the bedside nurse, were they user-friendly?
Our goal was to decrease our CRBSI rate to zero. Previously developed protocols such as the IHI central line bundle have been effective in reducing but not eliminating CRBSI. By combining evidence-based practices and current technology, we hoped to leave no cracks where bacteria could enter.
Components of the bundle
We believe that every component of the bundle is crucial and should be used with every CVC insertion. Here's a review of the seven bundle components:
1. Maximum barrier precautions. The first step in our bundle was implementing a maximum barrier kit. In investigating our practice, we learned that while members of the PICC team were diligent in following maximum barrier precautions, physicians and critical care nurses were struggling to comply. The kit, made available to everyone, includes a full-size sterile drape to cover the patient's entire body, a sterile towel, and a disk infused with chlorhexidine gluconate (CHG). It also includes alcohol swabs, CHG applicators, a sterile gown, a cap, and a mask. Our administration supported nurses who intervened and stopped procedures when staff members weren't using full barrier precautions.
2. Ultrasound-guided PICC placement. We trained our PICC team to transition from inserting PICCs using the traditional or modified Seldinger method and antecubital placement, to using ultrasound guidance and upper arm basilic vein of choice. Our review of the literature demonstrated that the basilic vein in the upper arm correlates with lower skin bacteria counts compared with those of the subclavian and jugular insertion sites.4 Our experience also showed that home-care patients with PICCs had fewer complications when the PICCs were placed in the basilic vein of the upper arm rather than the antecubital fossa.
3. Antimicrobial intervention and revision of CVC dressing kit. The literature shows that cleaning the skin with isopropyl alcohol then disinfecting with a solution of CHG attacks bacteria colonization and reduces infection risk, so we instituted this practice.5After this step, we place a protective disk infused with CHG around the catheter at the insertion site. This protective disk releases CHG for 7 days, reducing bacteria recolonization. We eliminated the gauze pressure dressing because gauze has no antimicrobial benefits and recolonization occurs within the gauze itself. Finally, the PICC nurse adds a catheter stabilization device, which also prevents migration, and then covers the site with a transparent occlusive dressing.
4. Neutral fluid connector system. The system eliminates blood refluxes in the line and supports our saline-only flushing policy. The system's smooth septum also supports our septum disinfection practice.
5. Septum disinfection. The connector hub can become contaminated if it lies on the patient's skin or gown or if it's not cleaned before it's accessed. It can also become contaminated if the clinician doesn't perform hand hygiene. The literature showed that disinfecting the catheter septum is critical for decreasing CRBSI.
6. Catheter flushing. We revised our flushing protocol to ensure effective cleaning of the intraluminal pathway. To support the nurses in following this policy, we developed a colorful grid that details the type of catheter, the flush volume required before and after medication administration, and the flush volume required for blood specimen withdrawal. Every medication cart carries a copy of the grid.
7. Daily catheter monitoring. Daily monitoring enables the team to intervene at an early stage if problems occur. To assist in this process, we developed a data collection tool that addressed the patient, unit, type of venous access, insertion site, and complications. This information lets the team intervene early when trends are identified that aren't optimal for our patients.
Even the most well-thought-through bundle is effective only with 100% compliance. The PICC nursing team has full responsibility for these catheters from the time of insertion until patient discharge. By taking full responsibility, the PICC team makes sure that the bundle is followed closely with every patient who has a CVC.
A perfect record
We're proud of what we've achieved with the sepsis bundle initiative. Our zero CRBSI rate occurred during a period when the number of PICC placements at the facility had risen dramatically. In the year before we implemented the bundle, the PICC team placed 767 PICCs, with 11 CRBSIs resulting. During 2006, the first year our bundle was implemented, placements increased 103% to 1,558, yet we had no CRBSIs. In 2007, we placed 2,278 PICCs, a 68% increase over the previous year, and have maintained our perfect record. To date, we've placed more than 5,000 PICCs without a single CRBSI.
Our success against these dangerous infections has been extremely gratifying. The commitment, passion, and diligence of the Sutter Roseville PICC team has made this success possible.