ESCMID Online Lecture Library. by author

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Multimodal approaches for catheter related bloodstream infections

Dr. Walter Zingg Dr. Walter Zingg

Service de Prévention et Contrôle de l’Infection, Genève

ESCMID – Postgraduate Technical Workshop – 26. February 2013

ESCMID Online Lecture Library © by author

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1. Pathogenesis 2. Epidemiology

3. Best practices in CLABSI-reduction

4. Implementation of guidelines & recommendations 5. Summary

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1. Pathogenesis

2. Epidemiology

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Sources of intravascular catheter infection

Intraluminal

from tubes and hubs

Skin

Vein

Haematogenous

from distant sites

Extraluminal

from the Skin

Mermel. Ann Intern Med 2000;132:391

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A. Attachment D. Maximal thickness B. Irreversible attachment, aggregation and formation of extracellular matrix C. Maturation

Schachter. Nature Biotechnology 2005;21:361

D. Maximal thickness E. Detachment of

planktonic bacteria

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Co-factors:

- Fibrinogen1_{, Fibronectin}2

- Calcium3_{, Magnesium}3_{, Iron}3,4

- Production of extracellular matrix5,6

Biofilm formation

- Production of extracellular matrix - DNA7

- Stress8*

*subinhibitory concentrations of aminoglycoside on P.aeruginosa & E. coli

1. Mehall. Crit Care Med 2002;30:908 2. Vaudaux. J Infect Dis 1993;167:633

3. Banin. Appl Environ Microbiol 2006;72:2064 4. Rhodes. J Med Microbiol 2007;56:119

5. Falcieri. J Infect Dis 1987;155:524 6. Sheth. Lancet 1985; 2:1266

7. Qin. Microbiology 2007;153:2083 8. Hoffman. Nature 2005;436:1171

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Central venous catheter (CVC)

2.7/1000 catheter-days

Peripherally inserted central catheter (PICC)

Risk for CRBSI

Catheter-related bloodstream infections

Risk for CRBSI

Tunnelled CVCs

Peripheral catheters

Implantable port systems

Maki. Mayo Clin Proc 2006;81:1159

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1. Pathogenesis

2. Epidemiology

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HELICS/ECDC – ICU-data

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International Nosocomial Control Consortium - ICU

Pooled mean CLABSI rate

Type of ICU ICU’s, n Patients, n

422 ICUs from 36 countries in Latin America, Asia, Africa, and Europe

Rosenthal. Am J Infect Control 2012;40:396

6.8/1’000 catheter-days

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Non-ICU wards

Zingg. J Hosp Infect 2009;73:41

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Central Venous Catheter (CVC) Utilization and Catheter-Associated

Bloodstream Infection (CA-BSI) Rates for 4 General Medicine Wards at a Teaching Hospital in St. Louis, Missouri:

Non-ICU wards

Marschall. Infect Control Hosp Epidemiol 2007;28:905

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ICU vs. non-ICU

ICU Non-ICU

CVC-utilization, % 29.5 4.6

CVC dwell-time, median (IQR) 4 (2-7) 8 (3-14)

Zingg. J Hosp Infect 2009;73:41 Zingg. J Hosp Infect 2011;77:304

CVC dwell-time, median (IQR) 4 (2-7) 8 (3-14)

Catheter-days, % 40 60

CVC: Central venous catheter

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Number of „indications“

Use central venous lines

Types of „indications“

ICU; median dwell-time: 4 (2-7) ICU; median dwell-time: 4 (2-7)

Zingg. J Hosp Infect 2011;77:304

Non-ICU; median dwell-time: 8 (3-14) Non-ICU; median dwell-time: 8 (3-14)

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Multimodal intervention:

- Education/Training

- Standardized processes

- Maximal sterile barrier precautions - Chlorhexidine

- Hand hygiene - Catheter care

- etc.

Eggimann. Lancet 2000;355:1864

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Initiative from the ICU

Contact infection control Detailed protocol

based on literature

Teaching on the ward Bedside teaching

CVC-insertion Surveillance

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Initiative from the ICU Key personnel

Key personnel Written Protocols

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Eggimann et al.

Eggimann. Lancet 2000;355:1864

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Bundle:

- Hand hygiene - Hand hygiene

- Maximal sterile barrier precautions*

- Skin antisepsis with Chlorhexidine

- Avoiding femoral access

- Removing catheter when not needed anymore

*Mask, cap, sterile gown, large sterile drape, sterile gloves

- Targeting catheter-insertion

Pronovost. New Engl J Med 2006;355:2725

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Med ia n /1 ’0 0 0 ca th e ter -d a y s Mean/1’000 catheter-days: 7.7 Mean/1’000 cathter-days: 1.3

Pronovost. New Engl J Med 2006;355:2725

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Pronovost et al.

Sustainability?

Data from 90 out of 103 participating ICUs

Baseline Implementation 0-3 16-18 34-36

Pronovost. BMJ 2010;340:c309

CLABSI1 _7.7 _2.8 _2.3 _1.3 _1.1

1_{Central line-associated bloodstream infections; mean incidence densities} (events per 1000 device-days)

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Pronovost et al.

Variability

Pronovost. BMJ 2010;340:c309

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MSB-precautions: always effective?

A recent multicenter randomized controlled trial found that MSB was not effective for CRBSI prevention:

CRBSI/1000catheter- days

2.4/1000 vs. 1.9/1000 (RR: 1.2; CI 95%0.43–3.1; P=0.78)

Ishikawa Y. Ann Surg 2010;251:620

- The study was performed among surgical patients in general wards - Median catheter dwell-times in both groups were high (14 days)

For central lines of longer duration, catheter care may be equally important in CRBSI-prevention than optimal catheter insertion

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Interventions:

- Hand hygiene

- Catheter care

- Exit site dressing

- Manipulations on tubes, hubs, stop cocks (non-touch technique)

- Preparation of infusates using an aseptic technique

Zingg. Crit Care Med 2009;37:2167

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Information/Invitation head nurses

Focus groups with

head and teaching nurses Adjustment of

the intervention

Ex-cathedra teaching Bedside teaching

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Baseline Intervention

Incidence density 3.9 1.0

(n/1‘000 catheter-days)

± ±

Zingg et al. – Zurich

Time to infection 6.52 ±3.48 9.3 ±6.63

(mean ±SD)

Catheters 974 1015

Total catheter-days 6200 7279

Dwell-time, median days (IQR) 5 (3-8) 6 (3-9)

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Zingg et al. – Zurich

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Multidisciplinary task force

Anesthesiology, infection control, board of nursing

Education

Zingg et al. – Geneva

Physicians Nurses Education strategy, training tools Simulator training workshops Modular E-learning program

Zingg. 52th ICAAC 2012; San Francisco

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Implementation

Workshops for physicians

Physician training: tools

Nurse training: modular E-learning program

Preparation Baseline Training

Workshops for physicians

Training for nurses

Adoption by school of nursing

Surveillance

2007 2008 2009 2010 2011

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Comprehensive insertion kit

Line cart

Availability of and easy access to material and equipment and optimized ergonomics

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Zingg. 52th ICAAC 2012; San Francisco

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Simulator training

Half day training course

- Interactive theoretical lecture - Simulation based practice on a - Videotape review

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www.carepractice.net

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“Train the trainer“

Two workshops per clinical service: - Presentation of the E-learning tool - Simulated training sessions

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1 0 0 0 1 5 0 0 2 3 Results 980 nurses _{294 nurses} 0 5 0 0 0 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 quarter

CRBSI/1000 catheter-days CRBSI/1000 catheter-days Trained nurses (n) Trained physicians (n)

146 physicians

-8.2%; 95% CI -3.9-12.6%; P < 0.001

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Multimodal or „bundle“

strategies in the prevention of catheter-related or

Zingg. Curr Opin Infect Dis 2011;24:377

of catheter-related or catheter-associated

bloodstream infections: publications 2009-2010

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4. Implementation of guidelines & recommendations

5. Summary

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Performance

Healthcare

worker Patient care Patient

Space Infrastructure

Medical devices Tools

Ventilation

Lighting Noise

Ergonomics

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Systems Engineering Initiative for Patient Safety

Process of Care

Carayon. Qual Saf Health Care 2006;15: i50

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Adoption Implementation Re-Evaluation Barrier Identification Sustainability →iterative process

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“People are not passive recipients of innovations. They seek innovations, experiment with them, evaluate them, find (or fail to find) meaning in them, develop feelings (positive or

negative) about them, challenge them, worry about them, complain about them, “work around” them, gain experience

Implementation

Greenhalgh et al. 2004

complain about them, “work around” them, gain experience with them, modify them to fit particular tasks, and try to

improve or redesign them – often through dialogue with other users.”

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Implementation

Damschroder. Implementation Sci 2009;4: 50

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The “SIGHT”-project

Zingg W. Submitted.

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PROHIBIT

Six hospitals in Europe. Interviews with 65 individuals: 9% CEOs, 11% infection

control physicians; of note, 15% ICU front-line physicians; 17% ICU front-line nurses

Theme counts

Sax, Clack, Casillas, Touveneau, Da Liberdade, Pittet, Zingg

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4. Implementation of guidelines & recommendations

5. Summary

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CLABSI prevention has become a network of technology and practice change in an ever changing work environment and increasing public interest in

healthcare-Summary

increasing public interest in healthcare-associated infections

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- The recent literature suggests that most success in infection prevention does not come from a magical device, but

simply by complying with practice recommendations, which have been available for many years

Summary

- Hospitals are confronted with overwhelming evidence that practice change successfully reduces CLABSI rates

- Unfortunately, practice change is more difficult to

implement than the introduction of a new medical device

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- The question today is not ‘what to do’, but ‘how to do it’

- Hospitals are well advised to think how they can

implement practice change in their institutions

Summary

implement practice change in their institutions

while respecting local barriers

→ → →

→ Think implementation and practice!

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Multimodal approaches for catheter related bloodstream infections

Dr. Walter Zingg

Thank you

Dr. Walter Zingg

Service de Prévention et Contrôle de l’Infection, Genève

ESCMID – Postgraduate Technical Workshop – 26. February 2013