Increasing the Use of Midlines in Place of Central Lines: Pros and Cons

Ruth Carrico PhD APRN FNP-C CIC Associate Professor

University of Louisville School of Medicine

Objectives

• Review some of the basic points about bloodstream infection and intravascular devices

• Address the controversy surrounding Midline v. Central Venous Catheters as a CLABSI prevention strategy

Objectives • Review some of the basic points about

bloodstream infection and intravascular devices

• Address the controversy surrounding Midline v. Central Venous Catheters as a CLABSI prevention strategy

3

1 = 60%

2 = 12%

3 = <1%

Unk = 28%

Safdar N, Maki DG. The pathogenesis of catheter-related bloodstream infection with noncuffed short-term central venous catheters. Int Care Med. 2004;30:62-67.

Skin organisms Endogenous Skin flora Extrinsic HCW hands or Contaminated disinfectant

Contaminated catheter hub Endogenous Skin flora Extrinsic HCW hands

Contaminated Infusate Extrinsic Fluid or Medication Intrinsic Manufacturer

Hematogenous from distant infection

Skin Vein

Fibrin sheath, thrombus

Femoral Vein Last choice

Subclavian Vein First Choice

Internal Jugular Second choice

Traditional Sites for Central Venous Catheter

CVL Insertion Bundle Component: Maximum Sterile Barrier Precautions

Hat and mask

Persons within 6 feet also wear head cover and mask

Sterile gown

Sterile gloves

CVL Insertion Bundle Component: Skin Preparation

• Gross debris or dirt should be removed

– with an alcohol pad, prior to using the skin preparation

– by washing with soap and water, prior to using the skin preparation

• Clean with friction for minimum of 30 seconds

• Allow preparation to completely dry, before procedure for best results.

• DO NOT REMOVE skin preparation after the procedure is completed.

Central Line- Associated

Bloodstream Infection

Poor/ImproperTechnique

Line Colonization/Contamination

Number ofCatheters and/or

Lumens

AntibioticUsage

ContaminatedSupplies

EducationStaffing

Acuity/TimeSite Selection

Lack of hand hygiene

Line inserted without

using sterile technique

Dressing not changed on time

Dressing not occlusive or lacking correct use

of chlorhexidine sponge

Line accessed withoutclean technique including adequate

disinfection of access site

Poor technique when obtaining blood cultures

More lumens on line than needed

Line not needed but not removed

More than one

central venous catheter

Inadequate gown, mask, gloves or hair

covering during insertion

Appropriate skin disinfectant not

used or not allowed to dry prior to

line insertion

Line manipulation or adjustment

Multiple attempts

Breaks in sterile technique

Inadequateuse of maximum draping prior

to insertion

Treatment basedon false positive/contaminatedblood cultures

Blood cultures drawn through

line and results

questionable

Antibiotic use outside hospital

guidelines

Blood leftIn line/end cap

Line from ED/field not changed

Blood at insertion site not

removed

Vascular end caps not

changed or changed too frequently

Blood left in end caps

IV tubing hanging without covered end

IVF and components not changed

according to policy

Dressing changes done without appropriate

supplies

Improper technique when using ultrasound devices

during line insertion

Reuse of single-use items

Inexperienced clinicians

Resident unfamiliar with policy

Nurses do not know dressing change

due; no dates on dressing

Policies not written or not current

Supplemental staff unaware of

policy/lack training

Policy unavailable to medical staff

Medical staff not supportive of policies

Internaljugular or femoral site used

Insertion site near

tracheostomy

Nurses too busy to change

dressingMD inserts

line alone-too busy to get

nurse assistance

Supplemental nursing staff

Inexperienced nursing staff

Other opportunity for dressing

Contamination

Midline v. PICC

Line inserted via undesirable

site (i.e., femoral) not changed

Lack of data to demonstrate outcomes/adherence

High patient volume/acuity

Poor environmental conditions

Use of multi-dose vials without attention to

safe injection practices

Use of contaminated supplies(e.g., dropped or used multiple

times during procedure

Kits do not contain all needed items

Line remains inbut no longer

needed

Investigating Practices to Prevent CLABSI (Do we have problems with….)

Ruth Carrico PhD APRN FNP-C CIC University of Louisville School of Medicine, Division of Infectious Diseases ruth.carrico@louisville.edu Rev 08/16

5 Rights of Intravascular Devices

Every patient has the RIGHT to best practice care 1. Right device for that individual patient 2. Right route of the device based on the intended

use of the device 3. Right device for the medication to be

administered 4. Right device for the dose of medication to be

given 5. Right timing for the device

1. Right Device for That Individual Patient

• Early assessment – Before central access device is placed – Vessel health – Anticipatory care – Short term versus long term use – Risks associated with the device(s)

2. Right Route of the Device Based Upon the Intended Use of the Device

• What is the intended use of the device – Short term versus long term – Anticipated difficulty with device insertion – Risk for adverse events associated with a long

term v. short term device – Existing skill of those caring for the device – Existing skill of those choosing the type of device – Existing skill of those inserting the device

Why Do These Patient Develop BSI?

• Site care • Access technique • Care of junction sites and access ports • Hand hygiene of personnel • Medication administration • Intrinsic patient factors

Some Prefilled Saline Syringes Are for Flushing ONLY • The saline flush syringes in the clear cellophane package is

ONLY for flushing – According to the manufacturer, DO NOT use for

medication dilution. • The inside of the barrel & the fluid pathway is all that is sterile on

these syringes. • When you push out saline, the outer side of the plunger

contaminates the inside of the barrel. • Then, when you draw back into the syringe, you are pulling the

plunger over areas that were just contaminated. • If you do this, you could be pushing pathogens into the patients’

bloodstreams.

• The saline flush syringes in the sterile peel pack may be used for medication dilution.

Disconnecting tubing Sterile end cap in place

Not recommended by manufacturer. Off-label use.

How do you know if the tubing tip is still sterile?

Indicates tip sterility maintained

B

C A

D

Traditional Central Venous Catheter Placement

Peripherally Inserted Central Catheter

Midline Catheter

Diameter of vessel for Midline

Diameter of vessel for PICC

3. Right Device for the Medication

• What medication are anticipated to be administered – Hydration using non-irritating fluids – Irritants or vesicants – Nutrition (10% dextrose or greater) – Length of time medication anticipated to be

needed – What if therapy fails and next line drugs needed – Lab draws?

4. Right Device for the Dose

• What are anticipated doses – Escalating therapy – Increased nutrition (10% dextrose or greater) – Increasing time intervals or continuous therapy – What if therapy fails and next line drugs needed – Lab draws?

5. Right Timing for the Device

• Changes in patient condition – Anticipated course of illness – Ability to identify alternatives for infusion therapy – Comorbidities – Other medications or combinations

Midlines v. Central Catheters

• Challenges – Prevent CLABSI (reporting) – Prevent adverse events (no reporting required)

• What is the real question?

– What drives decision regarding line selection – Will attention to care of the device and reduced

rates of complication/infection change the approach

How to Make a Patient-Centered Decision

• Existing data (not perception) – Outcome data – Process data

• Performance Improvement • Implementation Sciences

A Problem WHAT

How

Where

Who

When

Why

Plan-Do-Study-Act Enables Testing of Change in a Real World Setting

• Plan: – Identify existing processes that have

resulted in the current results – Design/redesign workflow to incorporate

desired changes; – Determine metrics to demonstrate

results – Identify tools to support the new design;

• Do: Implement the plan • Study: Look at the metrics; determine

results

• Act: Fix any “misses” in the process and repeat the process

Rapid Cycle Change

Repetition and continuous reach toward improvement

*Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance.

26

Process Map

Patient needs CVC

Is Kit available?

Yes Get Kit with checklist, go to

patient room

Yes Conduct patient

education

Breach of Safe

Insertion Practice?

RN MD select best practice insertion site

No Insertion of CVC

Breach of Safe Maint.?

Search for CVC supplies

No

Search for PPE supplies

Find instructions

(consult ICP)

Wrong supply/product

Yes

Use of femoral site

Failure to perform HH

No full barriers used

Contaminated sterile field

No "hub" care

Yes

Unsatisfactory products / equipment

Poor technique for dressing

changes

Using CVC for routine blood

draws

Failure to remove line

when no longer needed

Over guidewire changes

Failure to change

lines/caps

Patient develops

BSI?

No Patient with

no BSI

No

Problem Solving RCA

Yes

Lab Real Time

Learning System

This work cannot be done without process owners: front line staff!

Implementation of Improvements

• Applying quality improvement strategies • Measure results before and after • Use many of the same designs to study ability

to apply and sustain change • Evaluation of interventions is the most

important step • Do not substitute a care process that may be

less than ideal simply to prevent reporting of results associated with an ideal process

Resources • Masters, B., Hickish, T., & Uña Cidon, E. (2014). A midline

for oxaliplatin infusion: the myth of safety devices. BMJ Case Reports, 2014.

• Deutsch, G.G., Sathyanarayan, S.A., Singh, N. et al (2014). Ultrasound-guided placement of midline catheters in surgical intensive care unit: a cost-effective proposal for timely central line removal. J Surg Res. Sep;191(1):1-5.

• Nolan, M.E., Yadav, H., Cawcutt, K.A., et al (2016). Complication rates among peripherally inserted central venous catheters and centrally inserted central catheters in the medical intensive care unit. J Crit Care. Feb;31(1):238-42.