Preventing vascular catheter-associated infection : the next steps

Tapei July 2013

Professor Didier Pittet, MD, MS,

Infection Control Program

&

WHO Collaborating Center for Patient Safety

University of Geneva Hospitals, Switzerland

Lead Advisor, 1st Global Patient Safety Challenge,

World Health Organization (WHO) Patient Safety

1. Pathogenesis

2. Epidemiology

3. Technology

4. Best practices in CLABSI-reduction

5. Implementation of guidelines & recommendations

6. Summary

1. Pathogenesis

2. Epidemiology

3. Technology

4. Best practices in CLABSI-reduction

5. Implementation of guidelines & recommendations

6. Summary

Sources of intravascular catheter infection

Skin Vein

Intraluminal from tubes and hubs

Haematogenous from distant sites

Extraluminal from the Skin

Mermel. Ann Intern Med 2000;132:391

Focus of infection prevention

Skin Vein

Insertion site

Focus of infection prevention

Skin Vein

Insertion site

Hubs

Tubes

Catheters

Schachter. Nature Biotechnology 2005;21:361

A. Attachment

D. Maximal thickness

B. Irreversible attachment, aggregation and formation of extracellular matrix

E. Detachment of planktonic bacteria

C. Maturation

Co-factors: - Fibrinogen1, Fibronectin2

- Calcium3, Magnesium3, Iron3,4

- Production of extracellular matrix5,6

- 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

Biofilm formation

Central venous catheter (CVC) 2.7/1000 catheter-days

Peripherally inserted central catheter (PICC) 2.1/1000 catheter-days

Tunnelled CVCs 1.6/1000 catheter-days

Peripheral catheters 0.5/1000 catheter-days

Implantable port systems 0.1/1000 catheter-days

Maki. Mayo Clin Proc 2006;81:1159

Risk for CRBSI Catheter-related bloodstream infections

Risk for CRBSI

1. Pathogenesis

2. Epidemiology

3. Technology

4. Best practices in CLABSI-reduction

5. Implementation of guidelines & recommendations

6. Summary

HELICS/ECDC – ICU-data

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

Rosenthal. Am J Infect Control 2012;40:396

International Nosocomial Control Consortium - ICU

Pooled mean CLABSI rate

Type of ICU ICU’s, n Patients, n

6.8/1’000 catheter-days

Zingg. J Hosp Infect 2009;73:41

Non-ICU wards

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:

Marschall. Infect Control Hosp Epidemiol 2007;28:905

Non-ICU wards

ICU vs. non-ICU

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

ICU Non-ICU

CVC-utilization, % 29.5 4.6

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

Catheter-days, % 40 60

CVC: Central venous catheter

Zingg. J Hosp Infect 2011;77:304

Number of „indications“

Use central venous lines Types of „indications“

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

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

1. Pathogenesis

2. Epidemiology

3. Technology

4. Best practices in CLABSI-reduction

5. Implementation of guidelines & recommendations

6. Summary

Ramritu. Am J Infect Control 2008;36:104

Catheter colonization CRBSI1

___________________ __________________

Coating nCVC RR (95% CI) nCVC RR (95% CI) ___________________________________________________________________ CHG/silver-sulfadiazine 2841 0.59 (0.50-0.71) 3016 0.31 (0.06-1.54) (external) CHG/silver-sulfadiazine 1070 0.44 (0.23-0.85) 1070 0.70 (0.30-1.62) (external/internal) Silver, platinum, carbon 720 0.76 (0.57-1.01) 970 0.54 (0.16-1.85) Minocycline/rifampicin 1063 0.40 (0.23-0.67) 840 0.39 (0.17-0.92) Chlorhexidine alone 254 1.11 (0.80-1.55) 254 2.37 (0.63-8.96) Cefazolin 518 0.59 (0.04-7.72) NA Vancomycin 176 0.77 (0.63-0.93) NA

Ruschulte. Ann Hematol 2008;88:267

Control Sponge n/1’000 CVC-days n/1’000 CVC-days

7.2 3.8 p=0.02 Dwell-times: 15.8 (controls), 16.6 (sponge) - 601 patients; Triple-lumen Ag/CHG-coated catheters for ≥ 5 days - Chemotherapy for haematological malignancies

Chlorhexidine-impregnated sponge

Control Sponge n/1’000 CVC-days n/1’000 CVC-days

1.3 0.4 p=0.004 Dwell-times: 6 (controls), 6 (sponge)

Timsit. JAMA 2009;301:1231

Chlorhexidine-impregnated sponge

1. Pathogenesis

2. Epidemiology

3. Technology

4. Best practices in CLABSI-reduction

5. Implementation of guidelines & recommendations

6. Summary

Multimodal intervention:

- Education/Training

- Standardized processes

- Maximal sterile barrier precautions

- Chlorhexidine

- Hand hygiene

- Catheter care

- etc.

Eggimann. Lancet 2000;355:1864

Initiative from the ICU

Contact infection control

Detailed protocol based on literature

Teaching on the ward

Bedside teaching

CVC-insertion

Surveillance

Initiative from the ICU

Key personnel

Written Protocols

Eggimann et al.

Eggimann. Lancet 2000;355:1864

Bundle: - 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

Me

dia

n/1

’00

0

cath

ete

r-d

ays

Mean/1’000 catheter-days: 7.7

Mean/1’000 cathter-days: 1.3

Pronovost. New Engl J Med 2006;355:2725

Pronovost. BMJ 2010;340:c309

Pronovost et al.

Sustainability? Data from 90 out of 103 participating ICUs

Baseline Implementation 0-3 16-18 34-36

CLABSI1 7.7 2.8 2.3 1.3 1.1

1Central line-associated bloodstream infections; mean incidence densities

(events per 1000 device-days)

Pronovost. BMJ 2010;340:c309

Pronovost et al.

Variability

Ishikawa Y. Ann Surg 2010;251:620

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) - 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

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

Information/Invitation head nurses

Focus groups with

head and teaching nurses

Adjustment of the intervention

Ex-cathedra teaching

Bedside teaching

Baseline Intervention Incidence density 3.9 1.0 (n/1‘000 catheter-days) 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)

Zingg. Crit Care Med 2009;37:2167

Zingg et al. – Zurich

Zingg. Crit Care Med 2009;37:2167

Zingg et al. – Zurich

Multidisciplinary task force Anesthesiology, infection control, board of nursing

Physicians Nurses Education strategy,

training tools

Simulator training

workshops

Modular E-learning program

Zingg et al. – Geneva

Zingg. 52th ICAAC 2012; San Francisco

Implementation

Workshops for physicians

Training for nurses

Adoption by school of nursing

Surveillance

Physician training: tools

Nurse training: modular E-learning program

2007 2008 2009 2010 2011

Preparation Training Baseline

39

Comprehensive insertion kit

Line cart

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

Zingg. 52th ICAAC 2012; San Francisco

Simulator training

Half day training course

- Interactive theoretical lecture

- Simulation based practice on a

- Videotape review

41

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

www.carepractice.net

050

010

00

15

00

01

23

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16quarter

CRBSI/1000 catheter-days CRBSI/1000 catheter-days

Trained nurses (n) Trained physicians (n)

Results

980 nurses 294 nurses

146 physicians

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

Zingg. Curr Opin Infect Dis 2011;24:377

Multimodal or „bundle“ strategies in the prevention of catheter-related or catheter-associated bloodstream infections: publications 2009-2010

1. Pathogenesis

2. Epidemiology

3. Technology

4. Best practices in CLABSI-reduction

5. Implementation of guidelines & recommendations

6. Summary

Healthcare

worker Patient Patient care

Space Infrastructure

Medical devices Tools

Ventilation Lighting Noise

Ergonomics

Performance

Carayon. Qual Saf Health Care 2006;15: i50

Systems Engineering Initiative for Patient Safety

Process of Care

Adoption

Implementation

Re-Evaluation

Barrier Identification

Sustainability iterative process

Greenhalgh et al. 2004

“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 with them, modify them to fit particular tasks, and try to improve or redesign them – often through dialogue with other users.”

Implementation

Implementation

Damschroder. Implementation Sci 2009;4: 50

Zingg W. Submitted.

The “SIGHT”-project

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

1. Pathogenesis

2. Epidemiology

3. Technology

4. Best practices in CLABSI-reduction

5. Implementation of guidelines & recommendations

6. Summary

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

Summary

- 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

- 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

Summary

- 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 while respecting local barriers

Think implementation and practice!

Summary