Prevention of Central Venous Catheter Infections Using Chlorhexidine “Scrub the Hub”

Campaign in Pediatric Transplant PatientsJohn Mason, BSN, RN, Pediatric Vascular Access Specialist, Evel Michel, BSN, RN, Pediatric Transplant Surgical Unit,

Jennifer Garcia, MD, Pediatric GastroenterologyJackson Health System/ Holtz Children’s Hospital, Miami, Florida

INTRODUCTION

Sepsis is the leading cause of morbidity and mortality in post-

transplant recipients. In addition to an immunosuppressed state

and other risk factors, the presence of central venous catheters

(CVC’s) significantly increases the risk of bacteremia. CVC’s

are essential for providing alimentation and for vascular

access. Infection control by frequent surveillance and

prevention techniques can positively influence patient

outcomes and minimize the financial impact on a healthcare

system.

OVERVIEW

PEDIATRIC TRANSPLANT SURGICAL UNIT (PTSU)

9-bed Multi organ transplant unit.

Age: Newborn to 21 years of age.

Patient Population:

Heart Transplant

Kidney Transplant

Kidney / Pancreas Transplant

Liver Transplant

Intestinal Transplant

Multi-visceral Transplant

PROBLEM

2007- Central vascular catheter bloodstream infection

(CVC-BSI) rates were 22 infections per 1000 line days.

No published benchmark specific for a pediatric

transplant population.

70% of PTSU patients had a CVC.

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Primary CVC-Associated BSI Rate 2007 Internal Benchmark 2008 Internal Benchmark

METHODS

PROPOSED STUDY

Nonrandomized, prospective study including all patients

admitted to PTSU with a CVC regardless of admitting

diagnosis.

2008 Internal benchmark established

11 infections per 1000 line days.

A campaign, “Scrub the Hub”, was launched in

August of 2008.

Establishment of a steering committee to develop

protocols. Team members included:

Unit Practice Council (UPC)

Nurse Educator

Nurse Manager

Transplant physicians

Peripherally inserted central catheter (PICC)

Coordinator.

August 2008 “Scrub the Hub” technique and Two-

person assisted dressing change were instituted.

SCRUB THE HUB

When a CVC is accessed, the injection port in

cleaned using a friction scrub for 15 seconds with a

2% chlorhexidine solution.

TWO-PERSON TECHNIQUE

Utilized for any patient who is not capable of

remaining still for a dressing change

1st person holds baby to help maintain sterility

2nd person performs procedure

Dressing change was performed by champions

every Wednesday

Surveillance Definition and Criteria:

Rate Calculation:

Number of CVC Bloodstream Infections (CVC-BSI) divided by

the number of central line days multiplied by 1000 (CVC-BSI /

Central line days X 1000)

Positive blood culture results are analyzed.

Community acquired and Healthcare associated cases are

differentiated

RESULTS

ChloraPrep® FREPP 1.75 ml cutaneous solution

2% Chlorhexidine Gluconate w/v and 70% Isopropyl Alcohol

REFERENCES:

CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, MMR, August 9,

2005/51(RR 10); 1-26 Cost-Effective Infection Success Story: A Case Presentation, Retrieved from

http://www.cdc.gov/mmwr/preview/mmwr/html/rr511a1.htm

Dorothy, M., Lynn, J., Elizabeth, H., Micheal, J., Joanne, L., Kathy, S., Zahr, H., ... Denise, G. (12/22/05).

Central venous catheter-associated blood stream infections in intensive care units and in recipients

of haematopoetic stem cell transplants. Canadian Nosocomial Infection Surveillance Program.

Retrieved from www.phac-aspc.gc.ca/nois-sinp/projects/pdf/vc_protocol_e.pdf

Kaler, W. & Chinn, R. (2007). Successful disinfection of needleless access ports: A matter of time and

friction. Journal of the Association for Vascular Access (3)12. 140-142. DOI: 10.2309/java.12-3-9

CONCLUSION

The “Scrub the Hub” campaign is a simple yet successful

technique that can be implemented to prevent CVC infections.

Although chlorhexidine swabs are more expensive than alcohol

swabs, the cost of one line infection would likely cover the

difference for several months’ worth of chlorhexidine swabs.

LESSONS LEARNED

Best Practice supports the time and friction cleaning and the use of CHG to decrease CVC BSI.

Multidisciplinary sharing throughout HCH and Jackson Health System decreases CVC-BSI events and improves quality of care provided to patients.

FINANCIAL IMPACT

The 2009 NHSN reported that the 50% percentile is 2.5

BSI per 1000 days .

A pooled mean of 3 episodes per 1,000 CVC line

days.

Attributable cost=$34-$56,000 per infection

Attributable mortality 12-25% per infectionNOTE: Attributable costs not specific to Pediatric Transplant Unit.

PTSU is not an ICU.

Estimated

Cost for 2008

Estimated

Cost for 2009

Estimated

Cost $avings

$714,000-

$1.76 million

$370,000-

$616,000

$340, 000-

$560,000

Prior to implementation of the “Scrub the Hub” campaign

in August 2008:

Post implementation of “Scrub the Hub” campaign:

Quarterly CVC BSI rates ranged from 6.3 to 22

BSI/1000 catheter days with a mean of 14.5.

CVC BSI rate plummeted to 3.6 BSI /1000

catheter days with a mean of 3.5.