Prevention of Vascular Access Device-Associated Hospital Onset Bacteremia and Fungemia: A Review of Emerging Perspectives and Synthesis of Technical Aspects.

Significant events impacting healthcare over the last several years have been associated with escalating rates of healthcare-associated infections. This has resulted in increased efforts to reinstitute well-established and evidence-based infection prevention practices, particularly for central line associated bloodstream infections. However, implementation of prevention initiatives beyond central lines has not received the same level of acknowledgement and response as being a considerable risk to patients. This article, authored by infection prevention, infectious disease, and vascular access professionals, provides emerging perspectives and technical aspects associated with the complete lifecycle of a vascular access device. The intent is to provide insight and perspective into enhancing current IP practices in the acute care hospital setting. This will also help prepare hospitals for upcoming broader surveillance and intervention activities aimed at reducing Hospital Onset Bacteremia and Fungemia (HOB) associated with all types of vascular access devices.

An Implementation Framework for the Clinically Indicated Removal Policy for Peripheral Intravenous Catheters.

BACKGROUND: Equivalent clinical outcomes, lower costs, and fewer invasive procedures have resulted in revised recommendations for the removal of peripheral intravenous catheters (PIVCs) from the traditional 72- to 96-hourly removal to removal based upon clinical indication. PROBLEM: Uptake of this evidence-based innovation to health systems is often delayed, in part due to the lack of a guiding framework for successful implementation strategies to guide systems to transition to and sustain clinically indicated PIVC removal. APPROACH: We used the Consolidated Framework for Implementation Research (CFIR) to reflect on strategies likely important for the successful implementation of PIVC removal evidence into policy and practice. OUTCOMES: We discuss and provide a critique of salient strategies for successful implementation of clinically indicated PIVC removal with regard to intervention characteristics, the outer and inner settings, characteristics of individuals, and implementation processes. CONCLUSIONS: Successful implementation of clinically indicated PIVC removal can be achieved through planned and systematic processes within the CFIR framework.

Improving Vascular Access Dressing Integrity in the Acute Care Setting: A Quality Improvement Project.

PURPOSE: The purpose of this quality improvement project was to evaluate transparent vascular access dressings and the use of a liquid gum mastic adhesive on improving dressing integrity over peripheral intravenous (PIV) insertion sites without increasing medical adhesive-related skin injuries (MARSIs) such as tears. PARTICIPANTS AND SETTING: A multidisciplinary team consisting of specialists in infection prevention, vascular access, nursing professional development, materials management, and WOC nurses met to review current audit data and available products to trial on 2 intermediate care units in our 2 hospitals in Indiana with a combined average daily unit census of 35 patients. APPROACH: Four dressing protocols-including our existing dressing with education, and an updated dressing with education, and the updated and new dressing, both with education and the addition of a gum mastic adhesive agent-were sequentially implemented by nurses on the units, each over a 2-week period. The goal was for 80% of the dressings to remain with all 4 corners fully intact without reinforcement at day 7, or sooner if PIV was discontinued before day 7. Data were reported as frequencies for intact dressings and skin complications. OUTCOMES: Education combined with the original dressing and the updated dressing did not achieve the goal of 80% fully intact dressings in the samples evaluated. The addition of the adhesive agent to the updated and new dressings with education exceeded the 80% goal. In addition, there were zero exposed PIV insertion sites and no documented MARSI in any of the 4 protocols. IMPLICATIONS FOR PRACTICE: We continued to collect postproject data of 30,049 vascular access sites including central line catheters and observed the same effectiveness of incorporating a gum mastic adhesive on dressing integrity. This practice change has now become standard of care in our institution.

Bridging the gap: introduction of an antimicrobial peripherally inserted central catheter (PICC) in response to high PICC central line-associated bloodstream infection incidence.

OBJECTIVE: To reduce the incidence of central line-associated bloodstream infection (CLABSI) in peripherally inserted central catheters (PICC) through the introduction of an antimicrobial (AM) catheter as recommended in evidence-based guidelines and standards. DESIGN: Quality improvement project comparing incidence of infections pre-implementation and postimplementation of the new catheter. SETTING: A 582-bed community teaching hospital in Northwest Indiana. METHODS: Pre-implementation analysis of surveillance data indicated that 50% of CLABSIs occurred inpatients with PICCs in situ. A gap analysis was performed to review institutional practices against evidence-based recommendations. The use of an AM catheter was supported in each of the documents consulted. After introduction of the new device, performance was measured in a prospective manner using standardized Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) surveillance protocols for CLABSI and internal data sources for other measures. RESULTS: After 30 months of data collection, the PICC CLABSI incidence reduced from a baseline rate of 1.83/1000 PICC days to 0.162/1000 PICC days (91.15% reduction, P=0.0002). CONCLUSION: Combined with continued compliance with basic prevention strategies (ie use of a central line insertion checklist/insertion bundle) and optimization of device selection and lumen justification, the introduction of an antimicrobial/antithrombogenic (AM/AT) PICC was associated with a significant reduction in CLABSI.

Keeping Patients Safer: Reviewing Predictors of Success and Failure of Short Peripheral Intravenous Catheters.

In 2014, a large urban community hospital adopted protected clinical indication practices as a quality improvement project. It then undertook a research study to examine bedside practices with short peripheral catheters, which included direct observation at the bedside once weekly for 6 months. A total of 4305 catheters were observed and remained in place for a total of 23 423 days. Fifty six percent of devices remained in place beyond 96 hours. The overall rate of peripheral bloodstream infection in patients enrolled in the study was 0.12/1000 peripheral intravenous days. Significant differences were noted based on which department placed the catheter, as well as which department cared for the patient during hospitalization. Patients admitted to step-down critical care units had the highest completion of therapy rates; however, those being cared for in medical/surgical units had the best outcomes. Devices placed in the emergency department had a higher successful dwell rate than those placed in critical care units. Twenty-gauge catheters were found to have the highest successful dwell rate, as well as insertion sites that were observed to be within normal limits during the weekly observation. Dressings that were noted to be clean, dry, and intact had a stronger association with completion of therapy than those that were not fully intact. Emphasis was placed on ensuring consistent practices with insertion, care, and maintenance, which contributed to more consistent outcomes between settings that insert, care for, and maintain devices. Nonmodifiable risk factors may remain.

Beyond Bean Counting: Gathering and Using Data to Drive Improvements.

Data collection of process and outcome measures for vascular access procedures and devices is recommended in all relevant guidelines and standards. A variety of strategies for achieving these objectives and how the findings can be aggregated and presented to improve patient care is discussed, along with a review of specific recommendations.

International recommendations for a vascular access minimum dataset: a Delphi consensus-building study.

BACKGROUND: Data regarding vascular access device use and outcomes are limited. In part, this gap reflects the absence of guidance on what variables should be collected to assess patient outcomes. We sought to derive international consensus on a vascular access minimum dataset. METHODS: A modified Delphi study with three rounds (two electronic surveys and a face-to-face consensus panel) was conducted involving international vascular access specialists. In Rounds 1 and 2, electronic surveys were distributed to healthcare professionals specialising in vascular access. Survey respondents were asked to rate the importance of variables, feasibility of data collection and acceptability of items, definitions and response options. In Round 3, a purposive expert panel met to review Round 1 and 2 ratings and reach consensus (defined as ≥70% agreement) on the final items to be included in a minimum dataset for vascular access devices. RESULTS: A total of 64 of 225 interdisciplinary healthcare professionals from 11 countries responded to Round 1 and 2 surveys (response rate of 34% and 29%, respectively). From the original 52 items, 50 items across five domains emerged from the Delphi procedure.Items related to demographic and clinical characteristics (n=5; eg, age), device characteristics (n=5; eg, device type), insertion (n=16; eg, indication), management (n=9; eg, dressing and securement), and complication and removal (n=15, eg, occlusion) were identified as requirements for a minimum dataset to track and evaluate vascular access device use and outcomes. CONCLUSION: We developed and internally validated a minimum dataset for vascular access device research. This study generated new knowledge to enable healthcare systems to collect relevant, useful and meaningful vascular access data. Use of this standardised approach can help benchmark clinical practice and target improvements worldwide.

Short Peripheral Catheter Performance Following Adoption of Clinical Indication Removal.

Two years following the adoption of clinical indication policies for short peripheral catheters (SPCs), a large community hospital undertook 2 extensive point prevalence reviews at 1-year intervals to study the overall outcomes associated with the SPCs. The findings were used to enhance documentation as well as staff awareness. A bundled approach was taken, focusing on insertion as well as care and maintenance needs. Consistent outcomes included at least 20% of catheters remaining functional more than 7 days and 35% more than 5 days.

Infection free midline catheter implementation at a community hospital (2 years).

BACKGROUND: To reduce excess central line use and provide an option for difficult venous access patients through the introduction of a midline catheter. METHODS: Design included prospective monitoring of the implementation of a quality improvement project. The setting was a 576 bed, urban, community, nonprofit, Magnet recognized, level 3 trauma center serving primarily adult patients. Midline and peripherally inserted central catheters were inserted by a specialty nursing team; care and maintenance of all devices were provided by front line staff. RESULTS: Zero midline catheter infections were observed in the 24 months after implementation of the fixed length, power injectable device. Completion of therapy was 80%, the most frequently encountered complication was device dislodgement. CONCLUSIONS: Adoption of a vascular access nurse led midline catheter program, coupled with device selection algorithms expanded the ability to select the right device for the patient, while decreasing excess central line usage without additional increased risks to the patient.