Infection Prevention & Control CVC Presentation – Link Staff - Wirral ...

Infection Prevention & Control
CVC Presentation – Link Staff
March 2010

Central Venous Catheters or
CVCs
• A central venous catheter (CVC) or central line is a catheter
placed into a large vein in the neck (internal jugular vein),
chest (subclavian vein) groin (femoral vein) or periphery
e.g. arm (PICC) with the tip located in the superior vena
cava of the heart.....
• Dependent on its use, the catheter can be mono, bi,
tri, quad or quin (1,2,3,4 or 5 !) luminal...........

Indications for Central Venous
Catheter Insertion.....
CVCs may be used for giving multiple
infusions, medication or chemotherapy,
haemodialysis, monitoring of central
venous pressure (CVP), frequent blood
sampling etc......

Associated Complications
• Pneumothorax
• Air Embolism
• Haemorrhage
• Arrhythmia
• Infection
Whilst essential in the majority of cases, all invasive devices
can potentially introduce bacteria into the (usually sterile)
circulatory system (or bloodstream) if not inserted or cared
for appropriately.......and may lead to bacteraemia

MRSA Bacteraemia
Of the 16 MRSA bacteraemias
identified in WUTH between
April 2009
and February 2010
4 have been
related to various types of
CVCs

2 renal patients
* internal jugular line (long-term; patient refused A-V fistula
formation)
* femoral line (emergency – unable to insert IJ at time – vessel
preservation)
1 haematology patient
* PICC line (inserted in x-ray department - noted as difficult
procedure )
1 coronary care patient
* femoral line (emergency insertion)

As CVC insertion may cause a number of complications, the
benefit expected from their use therefore needs to
outweigh the risk of those complications......
the most common of which is a central lineassociated
bloodstream infection (CA‐BSI) or
bacteraemia....

Causes of Catheter Related-
Blood Stream Infection (CR-BSI)
• CR‐BSI is generally caused either by skin
microorganisms at the insertion site that
contaminate the catheter during insertion and
migrate along the catheter track, or
• Microorganisms from the hands of healthcare
workers that contaminate and colonise the
catheter/hubs/ports during post‐insertion care or
interventions.....

EPIC 2 Recommendations
1. Education of healthcare workers and patients
2. Maximal sterile barrier (MSB) precautions during
catheter insertion
3. General asepsis
4. Cutaneous (skin) antisepsis
5. Selection of catheter type
6. Selection of catheter insertion site
7. Catheter and catheter site care
8. Catheter replacement strategies and
9. General principles for catheter management

Improving Patient Outcomes....
• To improve patient outcomes and reduce healthcare costs, it is
essential that everyone involved in caring for patients with a CVC is
educated about gold standard insertion and ongoing care
requirements...
• Current evidence consistently demonstrates that:
‣ the risk of infection declines following the standardisation of care
but
‣ increases when insertion and/or maintenance of CVCs is
undertaken by uneducated/inexperienced healthcare workers
Additional evidence demonstrates that informing/advising
healthcare workers to adhere to local evidence‐based CVC protocols
can decrease the risk to patients of CR‐BSI......and save a life ......

Associated Risks-Summary
Failure to control healthcare‐associated infections
(HCAIs) and hospital acquired infections (HAIs) can
have the following consequences:
• Complaints, litigation and adverse publicity
• Increased costs associated with treatment of avoidable
infections (approx £6,829 per patient ‐ NAO Report 2004)
• Increased morbidity and mortality amongst affected
patients.........
• Failure to achieve MRSA bacteraemia targets

WIVAG Initiative to Improve Central Venous
Catheter (CVC) Care
Trust-Wide
As part of a MONITOR directive to improve
central venous catheter (CVC) care
throughout the Trust, the Wirral
Intravenous Access Group (WIVAG) were
charged with leading a project to
comprehensively address this issue....

A WIVAG sub-group was established and the
project focused on 3 main aspects:
1. Optimising aseptic technique in terms of
insertion and ongoing care
2. Improving documentation and ‘traceability’
3. Reviewing and revising Trust guidelines

In order to accomplish this, several new
‘tools’ have been introduced:
a. Customised CVC Insertion Pack
b. PCIS noting (to enable monitoring, support
and surveillance)
c. CVC Care Pathway/Guidelines (detailing
insertion, ongoing care and removal etc.)

Why use a CVC Insertion Tray?
Because it contains MSB equipment!
• EPIC 2 states that using MSB equipment has been found to:
‣ decrease transmission of microorganisms
‣ delay colonisation and
‣ reduce the rate of hospital acquired infections (HAIs)
• EPIC 2 evidence supports using MSB equipment during routine
insertion of a CVC to minimise the risk of infection.......
• Given the relatively low cost of the CVC insertion tray and the high
cost of bacteraemia, it is highly probable that this initiative will prove
to be a cost‐effective or even a cost‐saving intervention for the
Organisation whilst improving patient safety....

How our Link Staff Can Help (1)...
• Promote Cutaneous Antisepsis: micro‐organisms that colonise the skin
surrounding the CVC insertion site and catheter hubs are the cause of most
CR‐BSIs. Skin cleansing/antisepsis of the insertion site using 2%
chlorhexidine/70% alcohol is therefore one of the most important
measures for preventing bacteraemia . Chloraprep is included within the
new CVC pack.... Make sure Inserter allows this to dry as DRY TIME = KILL
TIME !
• Use HII No 1a ‐ on insertion !
• Ensure PCIS Entry (1): advise Inserter to enter details onto PCIS database;
daily mailerbot report is generated and alerts core group of staff – provides
tracking/assessment capability and ongoing support service for ward staff
• Ensure Ongoing Catheter and Catheter Site Care: safe maintenance of a
CVC and relevant care of the insertion site are essential components of a
comprehensive strategy for preventing CVC related bacteraemias...so.......

How our Link Staff Can Help (2).....
• Use CVC Care Pathway – includes CVC guidelines,
instructions for daily assessment, site monitoring
(RAID/VESS), care of exit site/dressing, hubs/ports etc.
Inserter completes page 1 and nursing staff complete
relevant sections each shift
• Use HII No 1b daily
• PCIS Entry (2) – when decision to remove CVC made by
medical staff, nursing staff responsible for removing
entry from PCIS system
• Exit Site Care – nursing staff discontinue CVC Care
Pathway only when exit site is fully healed

How to Access PCIS Central Line (CVC)
Documentation –Ward Based Staff
Medical staff
• Select patient
• Select ‘Master Guide’
• Select ‘Central Line’
• Central line insertion screen will
be displayed
Here you can select:
• Insertion/line/site information
• Removal
• Documented in error or
• Delete entry - flagged as ‘removed
in error’
• Follow on-screen instructions
Nursing Staff
• Select patient
• Select ‘Master Guide’
• Select ‘Central Line Removal’
or
• Delete entry - flagged as
‘removed in error’
• Follow on-screen instructions

What do you need to
remember ????
Your Ps and Qs !!!

Central Line (CVC) Placement Trays
WUTH Best Practice Guide to Insertion and
Ongoing Care
Know Your P’s and Q’s !
1. Pick up a Pack (and sign for it ‐ if obtained from CEL)
2. Pick up a Pathway – inserter enters details on page 1
3. PCIS entry – inserter enters details onto system (tracking)
4. Prevent Blood Stream Infections
5. Promote patient safety –RAID/VESS
6. Question CVC requirement daily
7. Quality assurance every time !

Information, Education and
Support.......
‣ Information, education and support with this
initiative is being provided by the Infection Control
Team and Divisional Surveillance Nurses in two
distinct stages; firstly within the critical care,
radiology and theatre areas and then trust‐wide (to
those areas where central lines are inserted and/or
utilised)......
‣ Further education and training will also be provided
by members of staff within the Clinical Skills Lab.....

Any Questions ???