Device related infections and prevention

 Laurl at ONS 

Welcome to the ONS Hot Topic Chats! Today’s expert is Mikaela Olsen, who will be talking with us about Device-Related Infections and prevention. Also with us today is Brenda Shelton. Welcome Mikaela and Brenda!

 olsenmi 

Hi everyone! We are now open for questions.

 brenda 

How about if I start with something that came up at another chat- when we suspect a line infection, when should the line be pulled?

 olsenmi 

This is a complicated question and the answer varies in the literature and from institution to institution. Generally if a patient presents with severe hypotension, fevers and other signs of sepsis with a central line we consider a line infection and immediately obtain cultures and begin antibiotics. If a gram negative infection is suspected then we attempt to remove the line immediately.

 brenda 

Should you use a potentially infected line or leave it capped?

 olsenmi 

When a patient presents with signs of sepsis and complains of rigors and chills when flushing the line we strongly suspect the catheter.

 olsenmi 

Some patients will not improve until the line is removed. This is often organism specific. Gram positive infections we usually treat through if the patient is stable.

 akowens 

We typically draw blood cultures both from the port and peripherally. Is this the standard?

 olsenmi 

What do you all do at your workplace?

 steph199 

That's what the Docs order at my facility.

 olsenmi 

Yes, it is recommended that you get peripheral cultures.

 akowens 

If there are no local signs of infection around the port, would you still pull it?

 kkaiser 

We have a lot of implanted lines in oncology and our Infectious Disease (ID) docs suggest drawing only from the line. For the rest of the house we draw peripherally.

 olsenmi 

Micro lab needs peripheral cultures to assist with time to positivity and the amount of bacteria in the blood vs. catheter.

 akowens 

That makes sense.

 brenda 

Is Candida in the line also an indication to pull it?

 olsenmi 

Pulling a port is a difficult decision. We would only consider pulling the port if the patient is unstable and not improving and the port is the suspect. Once the preliminary culture results are back we may then decide to pull it based on the organism. Gram negative or Candida infections are difficult to clear through central lines and may require it to be dc'd.

 olsenmi 

We have worked for the past year with our microbiology director to ensure that our blood culture policy is evidenced based. There are national microbiology guidelines which we have adopted.

 brenda 

Does anyone have experience or feedback about silver, heparin or chlorhexadine impregnated lines for high risk patients?

 olsenmi 

I can post the reference to these guidelines in the transcript.

 olsenmi 

Do any of you use central line bundles when lines are placed?

 steph199 

What's a central line bundle?

 kkaiser 

We use the bundle in our ICUs and the roving PICC team. Working on getting IR and OR to use the bundle. Regarding BSI (blood stream infection), what are you monitoring (e.g., who counts line days, who keeps track of the lines, and what type of data is reported by Infection Control Practitioners)?

 olsenmi 

Bundles: When central lines are placed at the bedside a central line bundle is recommended to ensure that maximum sterile barrier is used. A central line bundle has a large sterile drape, sterile gloves, bonnets, gowns, etc. This helps ensure that the inserter is compliant with infection control precautions.

 steph199 

Yes we do "bundle" just not using that terminology.......thanks.

 olsenmi 

At my institution the infection control department tracks line infections in all ICU's. With the new national patient safety goals that have been released we are preparing to monitor blood stream infections (BSIs) in all patients with central lines by April of 2010.

 brenda 

Our bundle also includes a checklist that has all the essential steps including time out, and empowers the nurse to stop if sterile technique is broken- then just get another bundle and start again.

 olsenmi 

Line days are challenging to keep track of. We are currently looking into our new computer documentation systems to help us keep track of accurate line days.

 steph199 

We also the tracking and on the 5th day the Infection control nurse gets involved to track the line and its need to be there.

 olsenmi 

The most common line at my institution is the power picc and we have 3 picc teams. Adult oncology, adult, and peds. The individual picc teams monitor their lines and maintain data.

 olsenmi 

Yes, having someone look at whether the line is still needed is an important issue.

 steph199 

We track line days with on a daily sheet, and now, on insertion, a sheet is sent to the Nurse manager (NM). Nothing done on the computer at this time.

 olsenmi 

That is great! Half the battle is knowing the line days.

 olsenmi 

What kind of dressings are you all using on your central lines and do you cover them during showering?

 kkaiser 

In Oncology, we use a transparent dressing and after the shower change it.

 olsenmi 

Did you know that at least one half of all cases of nosocomial infections are related to devices?

 steph199 

We use the biopatch, and just last week, a new tracking process and new dressing has been introduced......Haven't seen it yet.

 olsenmi 

I see, each dressing has unique aspects. I would make sure that you get information from the manufacturer as to whether they consider the dressing waterproof, water resistant or none of the above. You may not have to change the actual dressing daily. We currently use a plastic cover (approved for use with showering over wounds or catheters) and a waterproof dressing.

 kkaiser 

We are using Biopatch for inpatients in temporary lines only.

 kkaiser 

Can you provide information off line about the plastic cover? kkaiser@umm.edu

 olsenmi 

Temporary lines, according to the literature, have the highest infection rates so it is important to use measures such as this to prevent infection.

 olsenmi 

Yes, I would be glad to give you information.

 kkaiser 

Are there specific rates for cancer centers so we can compare ourselves?

 olsenmi 

Hub contamination of central lines is a major area of concern. What do you all do to prevent hub contamination?

 steph199 

Change hub when changing the dressing; change the hub after each blood draw.

 kkaiser 

Are you talking about insertion site of port-a-cath, or the end cap of the line, when you say hub?

 olsenmi 

Benchmarking catheter related BSI (CRBSI) rates is also challenging. You are right; we need to benchmark against like populations. Additionally, the CDC definition of a CRBSI has been an area of discussion for our oncology physicians. We carefully review other risk factors such as mucositis, etc. prior to determining if the line is actually infected.

 olsenmi 

Do you mean the needleless valve?

 kkaiser 

End cap would be the needleless valve. Is that the hub you are referring to?

 kkaiser 

We change the needleless valve hub when we change the tubing.

 kkaiser 

We use alcohol to clean the needleless valve hub.

 olsenmi 

Needleless valves are very useful for nurses but you all are correct we must be diligent with changing them and cleaning them with alcohol and lots of friction.

 olsenmi 

Another important reference that I find helpful is the ESPEN guidelines on parenteral nutrition: central venous catheters. Do you all dedicate a line to IV nutrition? Central parenteral nutrition is a known risk factor for blood stream infections.

 kkaiser 

Yes, we dedicate a port for central parenteral nutrition.

 olsenmi 

The above guidelines are European and the following website includes the American Society for Parenteral and Enteral Nutrition. www.nutritioncare.org/

 olsenmi 

Re:dedicated line: Good, this is what is recommended. However, it can be challenging in oncology to do this, especially in hematology and bone marrow transplant (BMT) patients.

 brenda 

Can I take a turn in topic- I have heard controversy about changing Foley catheters- some say never, some say 2-3 three days into treating urinary track infections (UTIs)....

 olsenmi 

We do not routinely change the Foley but if we are treating a UTI we first try to remove the Foley and if the patient must have it then we change it out.

 brenda 

Another pearl- I just read that about 50% of pts with candiuria will acquire candidemia, so should treat Candida in urine aggressively.

 olsenmi 

Another interesting new device that we have recently begun to use is the vacutainer system with tubes (similar to blood tubes) for obtaining cultures out of a Foley catheter. This may help to decrease contaminants.

 brenda 

So... another interesting turn in practice here- no more xeroform gauze on chest tube dressings- apparently it increases infection risk? How about some of you?

 steph199 

Surgeon puts in the chest tube, dresses it (sterile technique of course) and nursing does not touch the dressing, any problems then surgeon is called and he makes daily rounds.

 brenda 

That is good if they are conscientious. We have stories of them "forgetting us" for days.

 kkaiser 

Where do your critically ill oncology patients go (to an oncology ICU, the MICU)?

 brenda 

We obtain an order for chest tube dressing changes, although the surgeon does usually change the first one. Some of them would like to use no dressing at all!!! We found a great clear IJ dressing than can be turned upside down to make a good chest tube dressing.

 steph199 

Small Hosp here.....they go to our ICU.........we're the med/oncology floor.

 brenda 

We have an integrated critical care model that has some units doing intermediate care and two units doing all critical care within the oncology center. We do transfer out pts who need intracranial pressure monitoring, intra-aortic balloon pump (IABP), Oscillator ventilator, transvenous pacing. We keep vents, pressors, PA cath, continuous renal replacement therapy (CRRT).

 brenda 

We are down to last 5 min. Any final questions of concerns you want us to address.

 kkaiser 

No. Thanks!

 brenda 

Any final pearls to impart Mikaela?

 Laurl - ONS 

Please don't forget to come to tomorrow's chat- the last in this series: Brenda and Amy will be here- fever, infection, evaluation and management.

 Laurl - ONS 

Thank you for attending today! Please be sure to tell your co-workers about tomorrow's final chat in this series. The transcripts from this series are posted under "Dates and Speakers" on the Hot Topic web pages. Today's transcript will be posted tomorrow.

 steph199 

Have a great day........thanks for the good info.

 olsenmi 

The number one cause of health-care associated BSIs is vascular access devices so scrub those hubs, change dressings according to the CDC guidelines, and when loose, soiled or when there is drainage!!!

 Laurl - ONS 

Have a great day!