Management of Catheters Infectious Diseases Working Party/Nurses Group

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1 Management of Catheters Infectious Diseases Working Party/Nurses Group Arno Mank RN PhD, Amsterdam (NL) London 09/04/2012

2 Content Background Management of CVC Types of CVC Care aspect of CVC General comments Preliminary survey results Guidelines 2

3 Guidelines and Protocols Both: Documents which support decision-making and their handlings Guideline: What should be done Protocol: How should it be done Standards for infusion therapy, RCN Guidelines for the prevention of intravascular Catheter Related Infections Infusion Nursing Standards of Practice 3

4 Criteria: Where what and how Where are you infusing into? Diagnosis/Treatment Medical condition Peripheral vascular integrity Compliance to therapy How long are infusing? Duration of therapy Length of overall therapy Number/frequency of infusions What are you infusing? Chemotherapy Multiple (incompatible) drugs Antibiotics Hydration Blood and blood products 4

5 Types i.v. lines/ Duration of use PAC Over 6 Weeks Tunnelled CVC 3 Weeks till 6 Months PICC 3 Weeks till 6 Months Non tunnelled CVC 7 Days till 6 Months Peripheral access 3 Days till 7 Days 5

6 Where Vena Jugularis interna Vena Subclavia Vena Femoralis Vena Brachialis 6

7 Patient perspective? What kind of CVC Education Aesthetic Daily life/function In- outpatient treatment 7

8 Guideline How long most it kept in? Most important risk factor for infection Not necessary then remove Limit the number of lumen 8

9 Common practice? Skin disinfection, with what and how Gloves for dressing change: sterile or not? Frequency of dressing change: every P. days? Flushing with: Saline, Heparine solution, other? Needleless connector when and how to use it? Yes, which one, why? No, why? 9

10 Desinfection of the skin 10

11 Chlorhexidine compare Povidone-iodine Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: a meta-analysis. Chaiyakunapruk N, Veenstra DL, Lipsky BA, Saint S. Ann Intern Med Jun 4;136(11):

12 Skin disinfection Old recommendation Disinfect clean skin with an appropriate antiseptic. A chlorhexidine-based preparation with >2% is preferred. Alternatively, tincture of iodine, an iodophor, or 70% alcohol could be used. New recommendation Disinfect clean skin with an appropriate antiseptic. A chlorhexidine-based preparation with >0.5% is preferred. Alternatively, tincture of iodine, an iodophor, or 70% alcohol could be used. 12

13 Hand washing Cleaning: Wash and Dry Willingness? It is so easy and so much evidence, but.. 13

14 Hand hygiene and aseptic technique N=41 Yes No by washing hands with conventional soap and water 38 3 by alcohol-based hand rubs 39 1 before and after inserting CVCs 36 5 before and after dressing an intravascular catheter 36 5 Use aseptic technique for the insertion of intravascular catheters 40 1 Use aseptic technique for the care of intravascular catheters Sterile gloves should be worn for the insertion of CVCs Wear clean gloves when changing the dressing on CVCs

15 Guideline: Gloves Sterile Gloves or No-touch technique Use the no touch method for dressing change and flushing protocol Gloves for dressing change: sterile or not Use either clean or sterile gloves when changing the dressing of intravascular catheters (CDC, 2011, category 1C) Security? 15

16 Limit manipulating Opening catheter Medication Drawing Blood Changing of the system Every 72 hour More often with blood products and nutrition Flushing Use of Needless connector 16

17 Flushing Flushing with: Saline, Heparine solution, other? Normal saline between incompatible drugs Frequency depending on: Valved or open ended catheter Use of correct needless connector Lock solution differ Volume at least 2 times volume of the lumen 17

18 Needleless connector Connect to CVC hub Manny different types Positive displacement Negative displacement Non displacement Neutral Disinfection before use 18

19 Needleless connector N=41 Yes No Use of needleless connector in your hospital Use connector to access IV tubing 19 2 Change connector as frequently as the administration set 16 5 Change connector no more frequently than every 72 hours

20 Dressing regime External contamination Do we need dressing? Gauze or transparent bandage? 20

21 Type Catheter site dressing regimens Gauze Transparant (semipermeable) transparant with chlorhexidine sponge 21

22 Catheter site dressing regimens (N=42) no dressing 5 35 sterile gauze dressing to cover the catheter site semipermeable dressing to cover the catheter site Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled Replace dressings used on short-term CVC sites every 2 days for gauze dressings Replace dressings used on short-term CVC sites at least every 7 days for transparent dressings Yes No

23 How often is the CVC dressing changed? every day every 2nd day once in 3 days once in 4 days once in 5 days once a week 23

24 Guideline Dressing change Transparent dressing should be changed every 5-7 days Replace dressing if dressing become damp, loosened or is visible soiled Gauze dressing should be changed every 2 days Well-healed tunnelled CVAD consideration may be give to no dressing Infusion Nursing Standards of Practice,

25 Chlorhexidine sponge old new missing Use a chlorhexidine sponge dressing in adult patients with short-term catheters to reduce the incidence of infection catheterrelated infection. Chambers ST, et al. Reduction of exitsite infections of tunnelled intravascular catheters among neutropenic patients by sustained release chlorhexidine dressings : results from a prospective randomized controlled trial. The Journal of hospital infection, 2005, 61(1), 53 25

26 Replacement of CVC Yes Routinely replace CVCs to prevent catheter-related infections 3 38 Remove CVCs on the basis of fever alone 2 39 Use a guide wire exchange to replace a malfunctioning nontunneled catheter if no evidence of infection is present In patients not receiving blood, blood products or fat emulsions, replace administration sets that are continuously used, including secondary sets and add-on devices, no more frequently than at 96-hour intervals, but at least every 7 days. No

27 CVC/IV team Specialisation Supervision Bundle of interventions 27

28 Don t go for low, go for zero < 5% CR-BSI is often accepted bundle of interventions Sophie Harnage, JAVA,

29 Thank you 29

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