DeVries Chellie - The Journey to Clinical Indication...Perform dressing changes on short peripheral catheters if the dressing becomes damp, loosened, and/or visibly soiled and at least

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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


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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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.



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)




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)



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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


2Year Post Implementation

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DeVries, M. and Methodist Hospital Infection Control Department, 2017 PIV Study findings


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


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


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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)


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?


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%)


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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


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

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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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Documents

DeVries Chellie - The Journey to Clinical Indication...Perform dressing changes on short peripheral catheters if the dressing becomes damp, loosened, and/or visibly soiled and at least