We're going to continue with Insertion-Related Prevention.
So I think I first talked about one of the pieces of evidence of washing your hands.
So now we're going to things that are just specific to how do we prevent
inserted insertion-related central line-associated bloodstream infections.
There is a lot of evidence out there,
so one of the things that we wanted to support and this is one of
those meta analysis that I talked about and this is am turned out to be level 1A.
So it was supported when we put all of these studies together.
And what we see is that we have definitely
a 50% reduction in colonization at the site and Chlorhexidine has
turned out to be one of the best things
for decontaminating the skin whether it be for surgical reasons,
or for central line-associated bloodstream infections.
In fact, we say because of this is a procedure,
you should pretend this is just like any other surgical procedure.
And how you see that is if you look at the squares,
the squares are to the left of the vertical line meaning
that they either had a reduction or that there was limited change.
But collectively, we saw that Chlorhexidine was
definitely going to limit our ability to colonize and to have an infection.
The second piece that was related directly to
central line insertion was the choice of the Prep which was the Chlorhexidine.
And with the Chlorhexidine,
not only did we have to call some of
the senior executives within the organizations in order to get them
to buy this because it meant difference
supply change and some changes to how they did things,
but we had to explain why.
We also had to explain how to use this.
So Chlorhexidine had to be placed and it was a
little bit different than what we were used to so
instead of betadine going from inner to outer,
we were looking at Chlorhexidine which
was a vigorous scrubbing back and forth for 30 seconds,
so in two minutes for the groin.
So if you had a femoral and you would do that,
and depending on where you read at least one minute to dry.
What we encourage people to do was to use
their organizational representative from
the Chlorhexidine who provided the Chlorhexidine to
come and do demonstrations for the staff because it really was different for some of
the providers that have been placing dressings and using betadine for all of those years,
have been very different on how we did it.
The next one, if you had a Chlorhexidine allergy was Tincture of Iodine,
one minute to dry and Tincture of
Iodine was also for infants less than two months of age.
And then lastly, a last result Povidone Iodine,
two minutes to dry and also for people that
couldn't tolerate either the iodine were the Chlorhexidine,
and there were some patients that we saw that did develop
Chlorhexidine allergies but it was very minimal over time.
And level 1B.
So there were a couple of big studies and they
are identified in the lower left hand quarter.
And really what maximal barrier precautions says is that
we have to take great strides in order to protect our patients from bacteria.
So not only do they have a full barrier drape,
and we're covered appropriately but it showed
a 2-3 fold reduction depending on which study you
looked at in the CLABSI that we were looking at.
So maximal barrier precautions for the provider meant sterile gowns,
sterile gloves, hat mask, etc.,
and for anybody else in the room,
it meant that we covered the patients head from top to bottom with
a large sterile drape and the drape should be
long enough that it covered from the top to the bottom to the side to the side.
So it should have been hanging over the side rails.
We got a lot of push back on this.
People have been doing it the way they've been doing it for many years.
We found a lot of
different drapes being used and that was one of the things that we decided to do
was to keep the checklists that we later developed to see
how many people were not following the full barrier drape component.
And then, for anybody else in the room non-sterile cap and
mask and that was all for barrier precautions were.
This is what your patient should look like when you're using
a full barrier drape as you see it goes above the patient's head,
all the way to the bottom behind the bottom of the bed
and it covers both edges of the mattress all the way down to the side.
The only part exposed is that part that
you're working on and I can't really see that well.
But it looks like this is looks like it's going to be a
subclavian and this is how the foliage barrier drape was to be utilized.
Choice of site. There was
a really large study that showed the femoral site should be avoided at all costs.
And really what we had was
a significant increase if we didn't use the subclavian site,
we had an increase in thrombolitic events but we also
had like 19% compared to 3% in infection rate.
So really it was pretty significant.
There were no studies looking at femoral site versus IJ.
There were some providers that were uncomfortable with
the subclavian site because of the potential for pneumothorax.
What we ended up saying was that if you
followed the checklist and you use the IJ or subclavian,
as long as you avoided the femoral site, that was okay.
What we later deemed to be a little bit more
appropriate was that if you were thinking about long-term placement
of a percutaneous central line that may be an IJ wasn't a good place for
a male patient where they had beard growth every day because
it made it very hard for the dressing to stay on.
And the more times the dressing had to be changed,
the increased frequency that we thought of the potential
for the central line associated bloodstream infection rearing its ugly head.
So avoid the femoral mind but also to think about
your patient and which is the best site for them.
The last thing, and certainly if you don't have a central line,
assess the need every day and if you don't need the central line,
you're certainly not going to have the risk for infection.
So this meant a change in culture for a lot of people.
A lot of people kept their central line until the patient was transferred out of the ICU.
What it did was have people look at how much volume the patient was getting.
Did they actually need it?
Could they switch over to a peripheral line?
Did they no longer need a percutaneous line?
Were there going to be on long-term antibiotics and if
so was the percutaneous line appropriate and if not
perhaps maybe a pick line that would be followed by
a specific pick team in order to maintain that line.
At the time the evidence showed that peripherally inserted central lines had
an actual reduction in central line-associated bloodstream infections.
Some of the things that we did in order to jog
our memories as I said numerous times to err is human.
Humans are fallible.
So one of the things that we developed was the central line checklists so
we have one foreign adult and we had a pediatric version.
And really, this was done to make sure that this was an interdisciplinary task.
So you had the provider whether it be a physician, a nurse practitioner,
or a PA placing the line and then you had the bedside nurse who was there
to not only hook up the line for you but they were there to fill out the form.
And they would check off yes that you were compliant or no that you needed reminded.
In the pediatric version,
it was a little bit different.
One of the things that we found across all pediatric units was
that more patients had their lines of access to draw blood.
Unlike, the physicians in adult ICUs,
they preferred to keep an art line and to draw blood,
and we didn't access the central line very much at all.
The other thing was is that you want to draw blood cultures from the central line.
So the checklists were both there to follow.
One of the things that came up while we were working on
the collaborative was what happens when you are in procedure areas?
So, this really had to do with interventional radiology.
It also had to do with emergency room.
So if they had the need to get a line in quickly,
were they still following the evidence?
So we had to go back and do
additional education for both the ER and interventional radiology to make sure
that they actually adhered to the CDC and
the evidence-based best practice standards that were set for in this program.
And we developed this tool for them in order to make sure that they were also compliant.
Because the issue here was is that
non-inpatient units so an interventional radiology unit,
an emergency room, an OR even are not accountable for their central line.
So they place the central line but they are not
attributed based on the CDC guidelines to that unit.
They are attributed to within 24 hours to the unit that they go to.
So we had a falsely elevated rates when lines
were placed elsewhere without following the evidence,
and this really helped to reduce that potential
for infection by including procedural areas.
The other thing that we thought was really important and this is
not probably an end or all for competency but,
one of the things that was very important was that we have adequate training.
So each one of our providers whether they be a nurse, a practitioner,
a physician, a PA,
they had to make sure that they had adequate training.
So the training included work on a module.
But then they also had to place five of the central lines in
each one of the different areas to be certified to place the central line.
Now our procedural list did not really feel that this was adequate
because there can be a lot of time that can go by and everybody has their preferences.
What we've found overall was that we needed to
include additional training for those providers that were not comfortable
with subclavians and that provider education had to continue throughout
the program so that people had an opportunity to
hone their skills and be comfortable with placement of all of the central lines.
And actually, hands-on work was so much more beneficial than just the training modules
whether it be Central Line insertion and the troop came out should
be true for the centralized maintenance that we looked at,
because rather than have the nurses just do the maintenance module,
it was so much better if we actually got to watch
them and see how they went ahead and change them.
The other thing that we brought with us from our project here at
Johns Hopkins was to make sure that we made
this as easy to follow the evidence as possible.
So we had the bundled kit where everything that was
in the kit that was needed for a central line was there,
or that we had a central line card that allowed the physician or
NP to pull up the cart and they would find that it was labeled,
every draw was labeled with what was in it and it was refilled at least twice a shift,
so that there was never missing something.
So there would be a place for culture bottles,
a place for the different types of central lines, sterile gloves,
everything that they could possibly need without having to run around to
make sure that they had everything which was very successful.
In fact, this was one of the first things that we looked at to
see did they have a bundled kit or
a central line cart when we did site
visits to make sure that they were ready to get started?
David Thompson DNSc, MS, RNAssociate Professor
