Infection Control Today

AUG 2018

ICT delivers to infection preventionists & their colleagues in the operating room, sterile processing/central sterile, environmental services & materials management, timely & relevant news, trends & information impacting the profession & the industry

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Page 24 of 32

24 ICT August 2018 By Michelle DeVries, MPH, CIC, VA-BC D espite increasing studies and interest in under- standing complication rates for all vascular access devices, many infection prevention programs still limit their scope to only CLABSI surveillance within the constraints of National Healthcare Safety Network (NHSN) protocols. By broadening our focus, we have an opportunity to improve the care and outcomes of devices that impact almost every patient who entrusts us with their inpatient care (as well as our outpatient infusion clinics and home healthcare patients). Last year, Mermel heightened awareness of the role that PIVs may place in serious infections when he estimated that a third of catheter related Staphylococcus aureus (S. aureus) infections may be coming from peripheral IVs (Mermel, 2017). This echoes the sentiment shared by Jim Davis and the Pennsylvania Patient Safety Authority. Pennsylvania requires reporting of all hospital acquired infections, so has a much more robust data set than most. In reviewing the bacteremias without central lines and comparing it with the S. aureus isolates they estimate that the leading cause of S. aureus bacteremias in hospitalized, acute care adults in the state may be the peripheral catheter (Davis, 2014). Kovacs similarly found that 36 percent of primary S. aureus bacteremias over a four-year period occurred in patients without central lines (Kovacs, Fatica, Butler, Gordon and Fraser, 2016). The SHEA Compendium also acknowledged that peripheral devices (both venous and arterial) carry with them a risk of infection, independent of central venous catheters, yet most programs are not actively monitoring (Marschall, et al., 2014). The 2016 Infusion Therapy Standards of Practice call for us to perform surveillance on these devices regularly (Gorski L, 2016). Including all devices allows us to begin to offer comparisons on risk that allow us understand performance beyond what we have may have traditionally included in our programs (Alexandrou, et al., 2018) (Mushtaq et al., 2018). Exploring Risk (and Risk Reduction) Beyond Central Lines How do we begin to address these fndings and recommendations in our own organizations? As a starting point, ensuring that a standardized protocol is used will help allow us to begin creating a systematic process by which we can eventually compare and trend our performance as we do with central lines. For 20 years I have followed the NHSN (formerly NNIS) protocols. At their core they are laboratory-confrmed bloodstream infections (LCBI) defnitions. We frequently think of them at CLABSI defnitions, but the core defnition is not specifc to CLABSI. The actual document title is "Bloodstream Infection Event (Central Line-Associated Bloodstream Infection and Non-central Line Associated Bloodstream Infection)." In fact, during the last two years of NHSN annual training, they suggest identifying whether LCBI has been met, then whether it is primary or secondary and then as the fnal step whether it was related to a central line. Our team has followed that strategy for years, at the end capturing all devices in place leading up to the infection and "attributing" it to the line(s) present the day of or day before infection criteria are met as long as there has been access for more than two calendar days. When more than one device is present and paired cultures or other conclusive data is not available, we err by attributing (for surveillance purposes only, not clinical treatment decisions) to the line with the higher published rate of infection (i.e., CVC > PIV > midline). We share infection data not only on our central lines, but from short peripheral catheters and midlines as well. We acknowledge it is an imprecise defnition, but wholly support the value of standardization. Further drill down on infections for contributing factors is conducted through an Apparent Cause Analysis facilitated by one of our infection preventionists (who is also a DNP, ACNS-BC, CIC, VA-BC and former nursing professor) who engages from line staff to recall and share memories of care and perhaps lapses in the days prior to the infection. As a starting point, ensuring that a standardized protocol is used will help allow us to begin creating a systematic process by which we can eventually compare and trend our performance as we do with central lines. Ò cover story

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