Healthcare-Associated Infections _ ______________________________________________________________
PRACTICAL STEPS IN FOLLOWING GUIDELINES TO PREVENT INTRAVASCULAR DEVICE-RELATED BLOODSTREAM INFECTIONS
Hand Hygiene Include hand hygiene as part of the checklist for placement of central lines. Keep soap/alcohol-based hand hygiene dispensers prominently placed, and make universal precautions equipment, such as gloves, available only near hand sanitation equipment. Post reminder signs at the entry and exits to patient rooms. Initiate a campaign using posters including photos of celebrated hospital physicians/employees recommending hand hygiene. Create an environment in which reminding each other about hand hygiene is encouraged. Maximal Barrier Precautions Include maximal barrier precautions as part of the checklist for placement of central lines. Keep equipment stocked in a cart for central line placement to avoid the difficulty of finding necessary equipment to institute maximal barrier precautions. If a full-size drape is not available, apply two drapes to cover the patient or consult with the operating room staff to determine how to obtain full-size sterile drapes, as they are used routinely in surgical settings. Chlorhexidine Skin Antisepsis Include chlorhexidine antisepsis as part of the checklist for placement of central lines. Include chlorhexidine antisepsis kits in carts or grab bags storing central line equipment. (Many prepared central line kits include povidone-iodine kits, and these must be avoided.) Ensure that the solution dries completely before attempting to insert the central line. Selection of Optimal Insertion Site Include optimal site selection as part of the checklist for placement of central lines, with room to note appropriate
contraindications (e.g., bleeding risks). Daily Review of Need for Central Line
Include daily review of the need for the central line as part of multidisciplinary rounds. Include assessment for removal of central lines as part of daily goal sheets. Record time and date of line placement for record-keeping purposes and evaluation by staff to aid in decision making. Source: [265] Table 15
Adherence to appropriate postinsertion care has been the focus of some studies. In one study, there were breaches in postinsertion care in 45% of cases [266]. The primary breaches were non-intact dressing (158 breaches per 1,000 catheter-days) and incorrectly placed caps and taps (156 breaches per 1,000 catheter-days) [266]. The rate of intravascular device-related bloodstream infection during the study period was 5.5 per 1,000 catheter-days [266]. In another study, nursing staff used a postinsertion care bundle that consisted of the following: daily inspection of the insertion site; site care if the dressing was wet, soiled, or had not been changed for 7 days; documenta- tion of ongoing need for the catheter; proper application of a chlorhexidine gluconate-impregnated sponge at the insertion site; appropriate hand hygiene before handling the intravenous system; and application of an alcohol scrub to the infusion hub for 15 seconds before each entry [267]. Adherence to this bundle led to a significant decrease in intravascular device- related bloodstream infections, from 5.7 per 1,000 catheter- days to 1.1 per 1,000 catheter-days [267]. The availability of policies regarding prevention strategies is also lacking. Although 80% of 25 ICUs (10 hospitals) had written policies for insertion of central venous catheters, only 28% had a policy requiring maximal sterile barrier precautions, and 36% and 60% of the units required hand hygiene before accessing a central venous catheter or treating the exit site, respectively [264]. A formal educational program on catheter
insertion was in place at 52% of the units [264]. Education, in the form of self-study modules with pretest and post-test, along with didactic lectures and integration of evidence-based guidelines have been associated with increases in adherence to recommended practices and decreases in bloodstream infec- tions [268]. One systematic review included 27 interventional studies of central line insertion or maintenance or both in adult ICU settings with documentation of central line-associ- ated bloodstream infection incidence per 1,000 catheter days [269]. Statistical significance was found in 26 of the 27 studies in terms of infection reduction, despite large variations in the length or type of educational intervention. The authors suggest that providing continuing education on infection prevention measures may improve post-insertion outcomes [269]. A systematic review demonstrated moderate strength of evi- dence for audit and feedback and provider reminder systems, along with base strategies [1]. CLOSTRIDIOIDES DIFFICILE INFECTIONS C. difficile is the most common cause of infectious diarrhea among adults in healthcare settings [35]. Colonization with the inactive spore is much more prevalent in the healthcare setting than in the community. Studies show that the rate of asymptomatic colonization is approximately 2% to 3% in the community, 3% to 26% among adult inpatients in acute care
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