CLABSI/ Infection Control

Question 1

Chain of Infection:

Answer 1

Microorganism (causative agent)
Reservoir
Portal of exit
Mode of transmission
Portal of entry
Susceptible host

Question 2

Microorganism (causative agent)

Answer 2

A causative agent for infection is any microbe that can produce disease.

Question 3

Reservoir

Answer 3

The reservoir is the environment or object in or on which a microbe survives and, in some cases, multiplies.
Inanimate objects, human beings, and other animals can serve as reservoirs, providing essential requirements for the microbe to survive at specific stages in its life cycle.

Question 4

Portal of exit

Answer 4

The portal of exit is the path by which an infectious agent leaves its reservoir. Usually, it’s the site where the organism grows. In human reservoirs, common exit portals include the respiratory, GI, and GU tracts; skin and mucous membranes; and placenta (in transplacental disease transmission from mother to fetus). Bodily secretions, such as blood, sputum, and emesis, can also serve as exit portals.

Question 5

Mode of transmission

Answer 5

• The mode of transmission is the means by which the infectious agent passes from the portal of exit in the reservoir to the susceptible host. The five modes of transmission are contact, airborne, droplet, common vehicle, and vector-borne. The transmission mode varies with the specific microbe. Some organisms use more than one mode.
• Direct Transmission: is through direct transfer from one person to another. This can be through biting, touching, kissing, or sexual intercourse. Sneezing, coughing, spitting, singing, or talking can also transfer microorganisms from one person to another if the person is close to the host and the organism is transferable by droplet spray into the mucous membranes of the mouth, nose, eye, or conjunctiva.
• Indirect transmission: can be either vehicle or vector-borne. A vehicle is anything that serves as a way to transfer a microorganism from the host to the susceptible person Inanimate objects (fomites) such as toys, soiled clothes, eating utensils, handkerchiefs, surgical instruments or dressings, and stethoscopes can serve as vehicles for indi- rect transmission. Vector-borne transmission is when an animal or insect transports the infectious agent.
  Airborne transmission: can include drop- lets or dust. Evaporated droplets and dust particles containing the infectious agent can remain in the air for long periods. Clostridium difficile and Mycobacterium tuberculosis are examples of microorganisms that can become airborne.

Question 6

Portal of entry

Answer 6

The portal of entry is the path by which an infectious agent invades a susceptible host. It’s usually the same as the portal of exit.

Question 7

Susceptible host

Answer 7

Transmission of infection requires a susceptible host. The human body has many defense mechanisms to keep pathogens from entering and multiplying. When these mechanisms function normally, infection doesn’t occur. In a weakened host, an infectious agent is more likely to invade the body and launch infection.

Question 8

Standard precautions

Answer 8

• guidelines that were established to break the chain of infection and reduce the risk of pathogen transmission in hospitals.
• Standard precautions apply to blood and body fluids, secretions and excretions (except sweat), nonintact skin, and mucous membranes.
• Hand hygiene is the number one weapon in preventing the spread of microorganisms

Question 9

Contact precautions

Answer 9

• used in addition to standard precautions when caring for patients with known or suspected diseases that are spread by direct or indirect contact.
• Contact precautions include gloving and gowning when in contact with the patient, objects, and surfaces within the patient’s environment.

Question 10

Droplet precautions

Answer 10

• require the use of a surgical mask in addition to standard pre- cautions when you’re within 3 ft (6 ft for smallpox) of a patient known to have or suspected of having a disease spread by droplets.
• These include influenza, pertussis, and meningococcal disease.

Question 11

Airborne precautions

Answer 11

• used in addition to standard precautions when in contact with patients with known or suspected diseases spread by fine particles transmitted by air currents
  such as tuberculosis, measles, and severe acute respiratory syndrome.
• You must wear a National Institute for Occupational Safety and Health certified, fit-tested N-95 respirator
• Healthcare personnel must be fit tested according to organizational policy or at least every 2 years to be sure you’re using the correct size.
• If eye protection is needed, wear goggles or a face shield during all contact with the patient, not just if you predict splashes or sprays.

Question 12

What is CLABSI?

Answer 12

A serious infection that occurs when microbes enter the bloodstream through a central line.

Question 13

What is a central line?

Answer 13

• A type of catheter that is placed in a large vein
• Allows multiple IV fluid infusions, blood draws, monitoring of pressures
• Stays in place longer than peripheral
• Delivers a greater volume of fluid
• Easier to draw blood

Question 14

Signs and Symptoms of patients with CLABSI

Answer 14

• Pain
• Redness, swelling or warmth around central line site
• Pus or bad smell around central line site
• Fever
• Chills

Question 15

Non-tunneled CVC’s
- Entry site
- Duration of use
- Advantages
- disadvantages

Answer 15

• Entry site: percutaneously inserted into central veins: internal jugular, subclavian, or femoral vein
• Duration of use: short term (usually less than three weeks)
• Advantages: percutaneous insertion
• disadvantages:
  — requires local anesthesia
  — Inserted in the operating room
  — Dressing required over site
  — *Risk of infection
  Comments:
• Account for the majority of central line associated bloodstream infections (CLABSI’s)

Question 16

Tunneled CVC’s
- Entry site
- Duration of use
- disadvantages

Answer 16

• Entry site: implanted into internal jugular, subclavian, or femoral vein
• Duration of use: long-term (weeks to months)
• disadvantages:
  — Requires surgical insertion
  — Requires local or general anesthesia
  — Increased cost
  Comments:
• Lower rate of infection then non-tunneled CVC’s
• Dacron cuff inhibits migration of organisms into catheter tract when ingrown

Question 17

Implantable ports
- Entry site
- Duration of use
- Advantages
- disadvantages

Answer 17

• Entry site: inserted in the subclavian or internal jugular vein. Tunnel beneath the skin; subcutaneous port access with a noncoring needle
• Duration of use: long term
• Advantages:
  — Improved body image (low visibility of port)
  — Patient comfort
  — Local catheter site care and dressing not needed when in use
• disadvantages:
  — Require surgical insertion and removal
  — Required general anesthesia
  — Increased cost
• Lowest risk of CLABSI

Question 18

Peripherally inserted central catheter (PICC):
- Entry site
- Duration of use
- Advantages
- disadvantages

Answer 18

• Entry site: inserted percutaneously into basilic, brachial, or cephalic vein, and enters the superior vena cava
• Duration of use: usually short to intermediate
• Advantages: insertion, usually at the bedside by a specially trained registered nurse
• disadvantages: can be difficult to position in central vein

Question 19

Collaborative Practice Interventions to Prevent CLABSI

Answer 19

Bundle: implementation of specific evidence-based bundle interventions that when used together improve patient outcomes

Question 20

*What are the five key elements of the central line bundle?

Answer 20

• Hand hygiene
• Maximal sterile barrier precautions during line insertion
• Chlorhexidine skin anti-sepsis
• Optimal catheter site selection with avoidance of femoral vein for central venous access in adult patients
• Daily review of line necessity, with prompt removal of unnecessary lines

Question 21

Who should use hand hygiene and when should hand hygiene be performed in the care of a patient with a central line?

Answer 21

• all clinicians who provide care to patients should adhere to good hand, hygiene, practices, particularly:
  — Before and after palpating the catheter insertion site
  — With all dressing changes to intravascular catheter access site
  — When hands are visibly soiled or contamination of hands is suspected
  — Before downing, and after removing gloves

Question 22

What changes can be made to improve hand hygiene?

Answer 22

• Implement central line procedure checklist that requires clinicians to perform hand hygiene as essential step in care
• Post signage stating the importance of hand hygiene
• Have soap and alcohol-based hand sanitizers promptly placed to facilitate hand hygiene practices
• Model hand hygiene practices
• Provide patient and family education and engage family in hand hygiene practices during visitation

Question 23

What are maximal sterile barrier precautions?

Answer 23

• these are implemented during central line insertion:
• For the primary provider, strict compliance with wearing a cap, mask, sterile gown, and sterile gloves
  — The cap should Cover all hair, mask should cover the nose and mouth tightly
  — The nurse should also wear a cap and a mask
• For the patient, covering the patient from head to toe with a sterile, drape, with a small opening for the site of insertion
• If a full-size drape is not available, two drapes may be applied to cover the patient, or the operating room may be consulted to determine how to procure, full-size sterile drapes, because these are routinely used in surgical settings

Question 24

Which antiseptic should be used to prepare the patient’s skin for central line insertion?

Answer 24

• Chlorhexidine skin antisepsis has been proven to provide better skin antis sepsis than other antiseptic agents, such as Povidode- iodine solutions

Question 25

How long should it be scrubbed?

Answer 25

An alcohol chlorhexidine antiseptic should be applied using a back and forth friction scrub for at least 30 seconds

Question 26

How do you dry it?

Answer 26

An anti-septic solution should be allowed time to dry completely before the insertion site is punctured/accessed (approximately two minutes)

Question 27

What should you not do?

Answer 27

this should not be wiped or blotted

Question 28

What nursing interventions are essential to reduce the risk of infection?

Answer 28

• Maintaining sterile technique when changing the central line dressing
• Always performing hand hygiene before manipulating or accessing the line ports
• Wearing clean gloves before accessing the line port
• Performing a 15 to 30 second “ hub scrub” using chlorhexidine or alcohol and friction in a twisting motion on the access hub (reduces biofilm on the hub that may contain pathogens)
• Using chlorhexidine containing dressings in patients older than two months
• Consider using antiseptic containing port protectors to cover connectors

Question 29

When should central lines be discontinued?

Answer 29

• Assessment, for removal of central lines should be included as part of the nurses daily goal sheets
• The time and date of central line placement should be recorded and evaluated by staff to aid in decision-making
• The need for central line access should be reviewed as part of multidisciplinary rounds
• During these rounds, the “ line day” should be stated to remind everyone how long the central line has been in place (e.g., “ today is line day 6”)
• An appropriate timeframe for regular review of the necessity for a central line should be identified, such as weekly, when central lines are placed for long-term use (e.g., chemotherapy, extended antibiotic administration)

Question 30

PICC CATHETER

Answer 30

• PICC stands for Peripherally Inserted Central Catheter = “peripherally inserted central venous catheter”. It is a central venous access that is introduced into the upper arm via a peripheral vein and the tip of the catheter is positioned in the superior vena cava ( superior vena cava)/Right atrium or at the cavoatrial junction . PICCs are mainly used in medium-term intravenous therapy (1 to 6 months). This makes them an excellent alternative to other central venous catheter systems, e.g. Portacath or Broviac catheter.

Question 31

Advantages of a PICC:

Answer 31

• PICCs are a safe and easy alternative to other central venous catheters such as Ports and broviac catheters (small bore central venous catheters), since they can also be placed on an outpatient basis by an experienced interventional specialist (e.g. doctor who has experience with image guided central venous access placement). The benefits of this type of catheter is the relative ease of placement which can be performed at bedside as compared with a port which needs to be placed in the operating room given that a skin incision and pocket has to be made to allow for the port to be implanted under the skin. Additionally infusion through a PICC is simple as is subsequent removal of the catheter which can also be done at bedside.
  — Catheter can be placed at bedside for Inpatients or outpatients
  — Patients can go home with PICC lines in place and have the option for outpatient infusion therapy.
  — PICCs are especially favored in patients who have previously suffered a port infection
  — Catheter can be left in place for medium to long terms
  — New devices can confirm catheter tip position as appropriate even when the PICC is placed at bedside (port and many other catheters require xrays to confirm tip location)
  — Easy removal of the catheter, which is also possible on an outpatient basis

Question 32

MIDLINE CATHETER

Answer 32

The midline catheter is a vascular access that is also introduced on the upper arm – but has a maximum length of approximately 25 cm. The tip of the catheter lies in a peripheral vein before getting to the level of the chest. A midline catheter is a safe alternative to IV and can remain in place longer than conventional IV (recommended for treatments 5-28 days) but are generally reserved for patients who cannot get a conventional PICC or in whom treatment requires IV access for greater than 5 days where non-caustic medication is administered. When more caustic medication such as some antibiotics and chemotherapy is to be administered a PICC is preferred because the central position of the catheter tip allows for mixing of the medication with the high blood flow near the catheter tip.

Question 33

Advantages of a midline:

Answer 33

• For patients requiring infusion therapy of more than six days, a midline catheter is a safe alternative to an indwelling tunneled small bore central venous catheter. Midline catheters do not have to be changed regularly, and can be left on the patient for several weeks unlike peripheral IVs. This eliminates the need to repeatedly puncture the patient’s arm for IVs. Additionally, the infusion therapy can be carried out at home. Having said the benefits we generally prefer PICC lines be placed especially for those patients receiving medication which can irritate/be caustic to venous walls. The reason for this is that PICCs unlike Midline catheters have tips that terminate near the heart and allow medication to be mixed in with the high blood flow near the heart. In contrast to PICCs midline catheters tip terminates in the axilla (arm pit region) where infusion of some medications can irritate vein walls.
  — Much like PICCs midline catheters can be placed at bedside for Inpatients or outpatients
  — Midlines are generally reserved for those patients whom infusion duration exceeds six days.
  — Outpatient infusion therapy and thus shortened hospital stay
  — No x-ray is needed during placement of the midline (much like the PICC) however catheter tip does generally need to be confirmed with a post procedural xray given that devices to localize catheter tip without x ray are not widely available as they are with PICCs.
  — No repeated puncture of the patient as you may need with IVs