devries chellie - the journey to clinical indication...perform dressing changes on short peripheral...
TRANSCRIPT
3/28/2018
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The Journey to Protected Clinical Indication:
Every Line Matters
Michelle DeVries, BS, MPH, CICSenior Infection Preventionist
Methodist Hospitals
Gary, IN
Michelle DeVries is a paid consultant of Ethicon US, LLC.
This presentation reflects the opinion of Michelle DeVries.The materials presented do not necessarily represent the
opinion of Ethicon US, LLC.
This promotional educational activity is brought to you by Ethicon US, LLC.
For complete indications, contraindications, warnings, precautions, and adverse reactions, please reference full package inserts.
Objectives
Identify emerging evidence, standards and guidelines impacting PIV insertion, care and maintenance practices
Explore practices and technologies in PIV management and risk reduction
Discuss strategies for moving to protected, clinically indicated management of PIVs
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Clinical process gives way to outcomes and efficiency over time as the model becomes more Pay for Performance
CMS’ Affordable Care Act
Value Based Purchasing TimelineFY 2019Value Based Purchasing Domains*
Efficiency
Safety: CAUTI / CLABSI / SSI/C. Diff/MRSA
Safety: AHRQ PSI‐90
Outcome: Mortality
Patient Experience of Care
Clinical Process of Care
http://www.qualityreportingcenter.com/wp‐content/uploads/2017/02/VBP_FY2019_DomainWeighting_QRG_02162017_FINAL.508.cr_.pdf
70%
45%
20%
10%5%
30%
30%
30%
25%25%
25% 25%
25%
30%40%
25%25% 25%
20% 25% 25%
20% 25% 25% 25% 25%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2013 2014 2015 2016 2017 2018 2019
Maki DG et al., Mayo Clinic Proc 2006;81:1159‐1171.
Emerging EvidenceAuthor/ Year
Title Key Findings
Kovacs/ 2016
Hospital‐acquired Staphylococcus aureus primary BSI: A comparison of events that do and do not meet the central line–associated bloodstream infection definition
122 episodes of primary SA HABSIs:• 78 (64%) were CLABSIs (38 MRSA+)• 44 (36%) were non‐CLABSI*s (19 MRSA+)
Complicated SA HABSI was significantly more common in the non‐CLABSI group (15.9% [n = 7] vs 0% [n = 0], P ≤ .001)
Reasonable next steps include a critical look at routine peripheral IV care, particularly in hospital transfers, and attention to best practices to prevent these types of non–device‐related infections.
Austin/ 2016
Peripheral Intravenous Catheter Placement Is an Underrecognized Source of Staphylococcus aureus Bloodstream Infection
• 2‐year, 445 cases of SAB, 34 (7.6%) of which were due to thrombophlebitis at a PIV site
• Of the 34 PIV cases, 21 were caused by MSSA and 13 by MRSA.
• The PIV and non‐PIV groups did not differ significantly in comorbidities, complications, or sequelae
• “PIV infections as a preventable source of S. aureus bloodstream infection remain a major concern”
Guembe/ 2017
Nationwide Study on Peripheral Venous Catheter Associated–Bloodstream Infections in Internal Medicine Departments
• 70 episodes of PVC‐BSI (1.64 PVC 45 BSI episodes/1,000 IMD admissions)
• Staphylococcus aureus was the most frequently isolated microorganism (41.7%).
• “Our findings support the need for educational and interventional preventive measures both in IMDs and in emergency departments to reduce the rate of PVC‐BSI and associated comorbidities and costs”
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What is Clinically Indicated Replacement?
1. https://www.health.qld.gov.au/healthpact/docs/briefs/WP156.pdf2. Infusion Therapy Standards of Practice, Journal of Infusion Nursing. 2016. V39 (1S)
“Routine” Replacement1
• Removal and reinsertion at scheduled intervals
• 48, 72, 96 hours
• Based on clock, not on patient condition
Clinically Indicated2
• Removal if the PIV based on assessment findings, i.e. when the PIV:• Is no longer included in the plan of
care
• Has not been used for 24 hours or more
• Exhibits signs or symptoms of complications
• Reinsertion if warranted by patient condition/medical plan of care
Guidelines and Standards
CDC 2011O'Grady, N.P., et al. Guidelines for the
Prevention of Intravascular Catheter‐Related
Infections. AJIC 2011
There is no need to replace peripheral catheters more frequently than every 72‐96 hours to reduce risk of infection and phlebitis in adults.
Replace peripheral catheters in children only when clinically indicated.
Remove peripheral venous catheters if the patient develops signs of phlebitis
SHEA 2014Marschall, J., et al.
Strategies to Prevent Central Line–Associated Bloodstream Infections in Acute Care Hospitals: 2014
Update. ICHE
Peripheral artery catheters and peripheral venous catheters are not included in most surveillance systems, although they are associated with risk of bloodstream infection independent of CVCs
APIC 2016APIC Implementation
Guide: Guide to Preventing Central‐Line Associated Bloodstream Infections.
2015
Repeated (PIV) sites may be required for lengthy courses… thus increasing costs
Superficial phlebitis results in pain, and lack of (PIV) sites can delay treatment and prolong hospitalization.
Venipuncture has been documented to produce nerve damage, such as complex regional pain syndrome
Additionally, the vesicant nature of medications can result in necrotic ulcers requiring surgical debridement.
ONS 2017Access Device Standards of Practice for Oncology
Nursing, ONS 2017
Emerging data suggests that the rate of catheter‐related bloodstream infections from peripheral catheters may be higher than once thought
Guidelines and Standards
INS Standards of Practice 2016
Consider monitoring bloodstream infection rates for peripheral catheters, or vascular catheter associated infections (peripheral) regularly
Use the venous site most likely to last the full length of the prescribed therapy
Make no more than 2 attempts at short peripheral intravenous access per clinician, and limit total attempts to no more than 4
Use a new pair of disposable, nonsterile gloves in conjunction with a “no‐touch” technique for peripheral IV insertion, meaning that the insertion site is not palpated after skin antisepsis
Infusion Therapy Standards of Practice, Journal of Infusion Nursing. 2016, V39 (1S)
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Guidelines and Standards
INS Standards of Practice 2016
Consider increased attention to aseptic technique, including strict attention to skin antisepsis and the use of sterile gloves, when placing short peripheral catheters… contamination of nonsterile gloves is documented
Consider the use of maximal sterile barrier precautions with midline catheter insertion
For peripheral catheters, consider two options for catheter stabilization: (1) in integrated stabilization feature on the catheter hub combined with a bordered polyurethane securement dressing or (2) a standard round hub peripheral catheter in combination with an adhesive ESD.
Infusion Therapy Standards of Practice, Journal of Infusion Nursing. 2016, V39 (1S)
INS Standards of Practice 2016
Perform dressing changes on short peripheral catheters if the dressing becomes damp, loosened, and/or visibly soiled and at least every 5‐7 days.
Remove the short peripheral catheter if it is no longer included in the plan of care or has not been used for 24 hours or more (V)
Notify the LIP about signs and symptoms of suspected catheter related infection and discuss the need for obtaining cultures (e.g. drainage, blood culture) before removing a peripheral catheter
Remove short peripheral and midline catheters in pediatric and adult patients when clinically indicated based on findings from site assessment and or clinical signs and symptoms of systemic complications (e.g.. Bloodstream infection)
Guidelines and Standards
Infusion Therapy Standards of Practice, Journal of Infusion Nursing. 2016, V39 (1S)
INS Standards of Practice 2016
Signs and symptoms of complications with or without infusion through the catheter include but are not limited to the presence of (I)
1. Any level of pain and or tenderness with or without palpation
2. Changes in color: erythema or blanching
3. Changes in skin temperature: hot or cold
4. Edema
5. Induration
6. Leakage of fluid or purulent drainage from the puncture site
7. Other types of dysfunction (e.g., resistance when flushing, absence of the blood return)
Guidelines and Standards
Infusion Therapy Standards of Practice, Journal of Infusion Nursing. 2016, V39 (1S)
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Moving to Protected Clinical Indication
Fewer Invasive Procedures
Improved Patient
Experience
Reduced Material Costs
Vein Preservation
Increased Nursing Efficiency
Fewer Breaches in
Skin
Regardless of dwell time, risks are still associated with PIVs
PIVs are the
MOST FREQUENT INVASIVE PROCEDURE1
1. ZinggW. et al., Int J Antimicrob Agents 2009;34 Suppl4:S38‐42.2. Kokotis K. Cost containment and infusion services. J Infusion Nurs. 2005; 28(3S):S22‐S323. Barton AJ, Danek G, Johns P, Coons M. Improving patient outcomes through CQI: vascular access planning. J Nurs
Care Qual. 1998; 13(2):77‐85.4. Vizcarra, C. Recommendations for Improving Safety Practices with Short Peripheral Catheters (SPC) Think Safety, Insert Safely. INS
Safety Practice Survey. 2013
60% of first attempts to insert are
unsuccessful2
27% of patients
endure 3 or more
attempts2,3
57% of RNs report that they were not taught how to insert PIVs during
nursing school4
Methodist Hospitals, NW Indiana
Background
674 beds
Previous standard of care for PIVs
Routine replacement every 72‐96h
Transparent film and tape dressings
Basic PIV policy not reflective of recent guideline updates
13 years of PIV related LC‐BSI data
Fall 2013 infection cluster
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Building the Case forProtected Clinical Indication
Fewer
Invasive
Procedures
Benefits of Longer Dwell Increased nursing
efficiency
Starting the Journey
All interested parties
Nursing, IR, Anesthesia, Pharmacy…
Applicability
All inpatients vs. select populations
All clinical units vs. select locations
Timeline
Policies, materials, education…
Support systems
Creating a Bundle
Policy, Practice and Materials
2011 CDC Guidelines and INS Standards of Practice
Insertion, care and maintenance
Dwell time & removal guidelines*
Best Practices and Process Improvements
“No touch” after prep or use sterile gloves
Quality materials
Proven technologies
Replacement when clinically indicated
1. Resar R, Pronovost P, Haraden C, Simmonds T, et al. Using a bundle approach to improve ventilator care processes and reduce ventilator‐associated pneumonia. Joint Commission Journal on Quality and Patient Safety. 2005;31(5):243‐248.*Consult device Instructions for use when determining maximum length of time between dressing changes
A bundle is a structured way of improving the processes of care and patient outcomes: a small, straightforward set of evidence‐based practices — generally three to five — that,
when performed collectively and reliably, have been proven to improve patient outcomes.1
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The Right Stuff?
Efficacy and Durability
Is the dressing going to hold?
Is a stabilization dressing or device needed?
Does the policy reflect what to do when the dressing is loose
(ie; avoidance of tape reinforcements )
Protection from bacterial re‐colonization
A proven BSI reduction strategy
A multi‐faceted approach
Materials Implemented
Intraluminal protection
PIV with integrated extension tubing and a stabilization platform
Neutral needle‐free I.V. connector
Use an alcohol‐impregnated disinfection cap
Extraluminal protection
Sterile gloves
Updated transparent dressing
Dressing with built‐in catheter securement
Protective disk with chlorhexidine gluconate [CHG]
DeVries, M. Valentine, M. Bloodstream infections from peripheral lines: An underrated risk. American Nurse Today. Jan 2016 Vol. 11 No. 1
Education and skill building
All clinicians, all units
Targeted product in‐services
“IV Basics” classes
Device, site & gauge selection
Strict adherence to site prep protocol
Application and dry time
“No Touch” or sterile gloves for palpation after prep
Application of protective CHG disk, securement device & dressings
Meticulous hub hygiene
Bolstering Best Practices
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The Origin of Microorganisms Causing CRBSI1
Safdar N, Maki DG. The pathogenesis of catheter‐related bloodstream infection with nuncuffed short‐term central venous catheters. Int Care Med. 2004; 30:62‐67.
What are you doing for the PIVs that are staying in longer then 72 hours to reduce skin colonization?
A product exists that can help reduce the skin flora if you are leaving your catheters in for longer periods of time (up to 7 days at a time)
Protected Clinical Indication
Cleared Indication.
Highest Level of Evidence/ Multiple Studies
Repeatable, reliable results
National Guideline Recommendations
Evidence you should ask for
Role of Site Visualization
CVC Site Assessment and Care
“The sensitivity of local inflammation for diagnosis of CVC‐related BSI was dismal (0‐3%)”1
“In general, site appearance cannot be relied on to identify catheter colonization or CVC‐related BSI.”1
“Monitor the catheter sites visually when changing the dressing or by palpation through an intact dressing …if patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or bloodstream infection, the dressing should be removed to allow thorough examination of the site.”2
PIV Site Assessment and CareINS 2016 Standards for identification of PIV Complications3
Visual Assessment
Infiltration
Redness >1 cm from insertion site
Phlebitis
Non‐intact or saturated dressing
Palpation
Warmth
Palpable cord beyond the IV catheter tip
Subjective Patient Information
Tenderness, pain or discomfort
Numbness or tingling
1. Safdar N, Maki DG. Inflammation at the insertion site is not predictive of catheter‐related bloodstream infection with short‐term, noncuffed central venous catheters. Crit Care Med 2002; 30:2632–5.
2. http://www.cdc.gov/hicpac/pdf/guidelines/bsi‐guidelines‐2011.pdf3. Infusion Therapy Standards of Practice, Journal of Infusion Nursing. 2016, V39 (1S)
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Post‐ Implementation
On‐going Clinician Assistance
Internal
External/vendor
Surveillance1,2,3
What will be monitored?
Frequency?
Who is responsible?
How will the data be used?
1. Marschall, et. al. Strategies to Prevent Central Line–Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update. ICHE, Vol. 35, No. 7 (July 2014), pp. 753‐771
2. Short Peripheral Catheter (SPC) Checklist: Think Safety, Insert Safely. Infusion Nurses Society, 20143. Infusion Therapy Standards of Practice, Journal of Infusion Nursing. 2016, V39 (1S)
Methodist Hospitals:
1Year Post Implementation
37%Reduction in House‐wide LC‐BSIs
19% Reduction in PIV related
BSIs
48%Reduction in PIV Kit usage
68% Fewer
CLABSIs (compared to NHSN
prediction)
Reduced IV “sticks”
Positive patient feedback
Positive staff feedback
Devries, M. et al. Protected Clinical Indication of Peripheral Intravenous Lines: Successful Implementation. JAVA 2016. V21, N2, 89‐92
37%Reduction in House‐wide LC‐BSIs
sustained
25% Reduction in PIV related
BSIs
6% further reduction
75%Reduction in CLABSIs
(68% Fewer CLABSIs compared to NHSN
prediction)
sustained
DeVries, M. – Oral Abstract, AVA 2016, Orlando, FL
1st Place Oral
Abstract AVA 2016
Methodist Hospitals:
2Year Post Implementation
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DeVries, M. and Methodist Hospital Infection Control Department, 2017 PIV Study findings
Methodist Hospitals:
3Year Post Implementation (Preliminary)
Sustained original decrease in PIV
observed in year 3
PIV performance remained strong despite
institutional opportunities with CLABSI
What did we learn about the infections?
Of those (9) that took place 5 days or more after insertion:
Based on definition:
2 were field starts (policy violation)
1 was likely secondary to a POA UTI, but did not meet CDC definition (surveillance definition)
1 had a POA BSI with the same organism on admission but still positive after 16 days so have to count again (surveillance definition)
16
9
0
2
4
6
8
10
12
14
16
18
Less than 5 days 5 days or more
Number of in
fections
Insertion to Infection
DeVries, M. – Oral Abstract, AVA 2016, Orlando, FL
What did we learn about the infections?
The remaining 5 (20%):
1 started with alcohol and no CHG sponge dressing placed (policy violation, year one)
1 with dressing disruption/change at day 5 (hospital wide focus –AC start from ER)
1 (day 14) had no documented dressing change (policy violation, year one)
2 with no documented problems
DeVries, M. – Oral Abstract, AVA 2016, Orlando, FL
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Emergency Room starts
10/25 (40%) were initiated in the Emergency Department
2 more were field starts (EMS)
Of those hospital based, 43.5% were started in the ER
This is a similar ratio to the percent of PIVs overall that are placed in
the ER in our hospital
Suggesting this may be largely attributed to volume as much as differences
in practice
Provides opportunity for enhanced focus for this group to see the biggest
impact per inserter
Average from insertion to infection similar between ER and
inpatient starts (once one high outlier of 14 days is removed)
3.6 vs. 4.2 days (not significant)
DeVries, M. – Oral Abstract, AVA 2016, Orlando, FL
Failed IVs
5/25 (20%) had 5 or more PIVs prior to the bloodstream infection
4/5 (80%) of these took place prior to Day
Do we need to expand our definitions/awareness of “attempts” to include serial failed IVs?
Early identification and referral to expert team?
DeVries, M. – Oral Abstract, AVA 2016, Orlando, FL
What Have We Learned So Far?
Average dwell time 4.36 days
Range 1‐21 days
35% lasted over 5 days
20% lasted 7 or more days
1/3 were removed within 1st 48 hours
23% due to patient discharge
21% due to infiltration
17% due to removal by patient
Infiltration rates highest at days 2 & 3 (24%, 22%)
Rates of infiltration drop after 3rd day mark (15‐11%)
DeVries, M. – Oral Abstract, AVA 2016, Orlando, FL
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Can you measure the impact on patient experience?
We hypothesized that overall satisfaction could be improved by improving the overall experience with IVs.
One year after introducing our protected clinical indication bundle we experienced
Increase of 23 percentile ranking improvement with top box
24 percentile ranking improvement with courtesy of person starting IV.
This suggests an quantifiable association worth further study.
PRESS GANEY
Top Box:
Overall patient satisfaction
Tests and Treatment:
Courtesy of the person starting IV
DeVries, M. – Oral Abstract, AVA 2016, Orlando, FL
What about midlines?
In an effort to reduce CLABSI incidence many hospitals are looking increasingly to midline catheters as part of their solution.
Midlines are considered peripheral catheters per INS standards1 and CDC definitions regarding tip termination.
How are you protecting your patients with these lines?
Insertion? INS says consider maximum sterile barriers.
Protection? These lines may dwell for up to 29 days
How are you measuring success?
Decrease in central line days?
Decrease in CLABSI?
Material costs and time savings?
Incidence of Midline associated bloodstream infection?
1. Infusion Therapy Standards of Practice, Journal of Infusion Nursing. 2016, V39 (1S)2. Chopra, V. et.al. MAGIC study Ann Intern Med. 2015;163:S1‐S39. doi:10.7326/M15‐0744
Resources
3/28/2018
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To make a large impact, make a small change to the most frequently performed invasive procedure in your
institution.
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