Advice for Evaluating Vascular Access Products

Infection Control Today invited manufacturers to share their perspectives.

ICT:  What are the most critical aspects of vascular access-related infection prevention and why?

Access Scientific LLC: You may be surprised to learn that the major determinant of in-patient vascular access device (VAD)-related infection is the kind of device selected. As Makis meta-analysis demonstrated, the highest infection rates occur with central lines, CVCs and PICCs (1.1-3.5/1000 catheter-days); the lowest infection rates occur with upper arm midline catheters (0-0.2/1000 catheter-days).  Peripheral IVs have an intermediate risk of infection (0.07-0.5/1000 catheter days).(1)  Recent reports have re-confirmed Makis findings.(2) Why is this true?  The easy part of the answer relates to upper-arm midlines: Cutaneous bacterial colonization is substantially less in that part of the body than in the neck and hand. At least in part, this explains why midlines are superior to CVCs and hand/forearm IVs, with respect to infection. But PICCs are inserted in the same location, so why do they have higher infection rates?  We know that thrombosis is a prime contributing factor to PICC infection: Unlike midlines, where thrombosis risk ranges from 1.9 percent to 3.3 percent,(3-4) PICC associated thrombosis ranges from 8.5 percent to 60 percent.(4-6)  Of course, other factors like administration of TPN and frequent interruptions of the closed system for meds also contribute. Bottom line: All VADs have their proper place. But the data encourage clinicians to select the safest VAD for the task at hand. Remember:  Upper arm midlines infect less frequently than PIVs, which in turn infect less frequently than CVCs/PICCs.

References
1. Maki DG, Kluger DM, Crnich CJ.  The Risk of Bloodstream Infection in Adults with Different Intravascular Devices: A Systematic Review of 200 Published Prospective Studies.  Mayo Clin Proc 2006; 81(9):1159-1171.
2. Chopra V, Flanders S, Saint S. The Problem with Peripherally Inserted Central Catheters. JAMA 2012;(308)15:1527-1528.
3. Warrington WG, Penoyer DA, Kamps T, et al.  Outcomes of Using a Modified Seldinger Technique for Long Term Intravenous Therapy in Hospitalized Patients with Difficult Venous Access. JAVA 2012; (17)1;24-31.
4. Anderson NR, Midline Catheters: The Middle Ground of Intravenous Therapy Administration.  J Infusion Nursing 2004; 27(5):313-321.
5. Thiagarajan RR, Bratton SL, Gettmann T, et al.  Efficacy of Peripherally Inserted Central Venous Catheters Placed in Noncentral Veins.  Arch of Pediatr Adolesc Med 1998; 152:436-439.
6. Bonizzoli, M, Batacchi, S, Cianchi, G et al.  Peripherally inserted central venous catheters and central venous catheters related thrombosis in post-critical patients.  Intensive Care Med 2011;(37):284-289.
7. Castro, S, Allison, R. Use of a Midline (Extended Dwell Catheter) Device Improves Patient Safety and Saves Costs Compared to PICCs. Poster presented at 2012 Association for Vascular Access Annual Scientific Meeting.
8. Bird, D. The Power of Choice: Midline Catheter Improves Patient Safety and Comfort While Increasing Vascular Access Revenue and Productivity. Poster presented at 2012 Association for Vascular Access Annual Scientific Meeting.
9. Caparas, J. Staff Education/Training Aids Implementation of Advanced Midline Catheter. Poster presented at 2013 Infusion Nurses Society Annual Convention and Industrial Exhibition.
10. Baliad, P, Peterson, S. Midline Catheter Reduced Infiltrations for Coronary Artery Bypass Graft Patients. Poster presented at 2013 Infusion Nurses Society Annual Convention and Industrial Exhibition.

Bard Access Systems: The most critical element of preventing CLABSI is administrative support and empowerment.  One can implement a checklist, MSB precautions, review of line necessity, handwashing and disinfecting catheter hubs and needleless systems, but without the backing of administrations leadership these programs may not be effective. For example, in the placement of a central venous access device (CVAD) a checklist is a great tool to identify breaks in sterile techniques. However, if the overseer to the checklist is intimidated to stop the medical professional in the placement of a CVAD when sterile technique is broken, then the checklist becomes another piece of paper and the real change in patient safety has not occurred. Empowerment from administration has to be provided to implement the recommended steps at all levels in the organization. When a CLABSI does occur, a root cause analysis based on organism, type of device, dwell time, current safety practices must be undertaken to develop a corrective action plan to prevent future CLABSI events. Ownership of CLABSI is a house wide responsibility but prevention empowerment starts at the top levels of an organization.

CareFusion: Invasive procedures, such as vascular access, hemodynamic monitoring, blood cultures, drainage tubes and surgical intervention procedures break the skins barrier. Cutaneous antisepsis is vital in infection control. Antiseptics are agents that destroy or inhibit the growth and development of microorganisms in or on living tissue. Unlike antibiotics that act selectively on a specific target, antiseptics have multiple targets and a broader spectrum of activity, which include bacteria, fungi, viruses, protozoa, and even prions. There are several antiseptic categories, including alcohols (ethanol), anilides (triclocarban), biguanides (chlorhexidine), bisphenols (triclosan), chlorine compounds, iodine compounds, silver compounds, peroxygens, and quaternary ammonium compounds. The most commonly used products in clinical practice today include povidone iodine, chlorhexidine, and alcohol. Antiseptics must be active against both resident and transient microorganisms and ideally reduce the number of bacteria by mechanical removal and chemical action. Healthcare antiseptic formulations have a variety of modes and mechanisms, speed of antimicrobial activity, and persistent or residual properties.

ICU Medical: The most critical aspects of vascular access-related infection prevention have been identified by various organizations and typically revolve around care bundles.  In general, these are groupings of best practices with respect to a disease process that individually improve care, but when applied together result in substantially greater improvement. The science supporting the bundle components is sufficiently established to be considered standard of care. For example, the IHI Central Line Bundle is a group of evidence-based interventions for patients with intravascular central catheters that, when implemented together, result in better outcomes than when implemented individually.

ICT:  What should clinicians and infection preventionists look for when evaluating and purchasing vascular access-related products?

Access Scientific LLC: There is only one right answer, and that is outcome data. All clinicians should beware of unsubstantiated claims and mere in vitro studies.  We know from the evidence that antimicrobial-coated CVC catheters and/or patch usage results in lower infection rates. Two brands of coated CVC catheters have substantial outcome data proving their efficacy. There are no coated midlines or PIVs. Therefore, clinicians are obliged to look for the evidence-based best in class. Midline outcome data is scarce. Only two brands have outcome data regarding infection: one from a single institution, the other from five separate institutions; both midlines demonstrated <1 percent infection rates. (3-4,7-10) As to PIVs, infection preventionists should abandon the no touch insertion technique. Anyone observing this practice will witness contamination of the insertion site, which undoubtedly accounts in part for Makis data showing a 2.5 times greater infection rate for PIVs than for midlines. (3-4,7-10) (see references from first question/response above)

Bard Access Systems: In selecting a vascular access product it is critical to evaluate if the product will impact the sterility and technique of the user.  For example, in the placement of a peripherally inserted central line (PICC) nurses at the bedside are tempted to use the ultrasound probe under the sterile drape during a procedure to determine if the PICC line has mal-positioned to the jugular. This break in sterility contaminates the ultrasound probe and sterile gloves from the contaminated neck of the patient. The key would be to investigate what change in procedure or product can be utilized in order to prevent this break in sterility, during the PICC line insertion. Infection preventionists may not be aware that this break in sterile technique occurs unless one actually observes PICC line placements at the bedside.

CareFusion: There are specific characteristics to consider when selecting appropriate antiseptics for healthcare personnel handwashing, surgeons and operating room surgical scrub, and patient skin preparation prior to invasive procedures. The selection should consider the safety and efficacy, quality of the evidence, ease of implementing, availability of product, and health economic value. Cutaneous antiseptics should have the following properties: broad spectrum of activity against Gram-positive bacteria, Gram-negative bacteria and fungi;  rapid bactericidal and fungicidal activity; persistence or residual antimicrobial properties on the skin; maintain its activity in the presence of organic matter, including blood; be non-irritating or have low allergic and/or toxic responses; and no or minimal systemic absorption. Single unit dose application is also an important component. Clinicians should look for an application methodology that promotes aseptic technique and reduces the risk of direct hand to patient contact, which reduces the risk of cross contamination. If using a single unit dose applicator, choose an applicator that was designed for the specific procedure. 
 

ICU Medical: First and foremost, buyers should look for clinically proven vascular access products with a solid clinical data behind them.  If adding a new product, technology, or process to an existing bundle, ensure that only one variable is altered to ensure that the true impact of the new product/process is apparent.

Vascular Access Product Showcase

POWERWAND
The POWERWAND® is the only power-injectable, kink-resistant, high-flow (130-160ml/min) midline inserted using the accelerated Seldinger technique (AST).  The unique all-in-one POWERWAND design allows for atraumatic insertion, resulting in superior clinical outcomes. And, because it is blood-drawable, the POWERWAND offers patients the opportunity for a one-stick hospitalization. Clinically proven, the POWERWAND delivers safety and performance to patients and clinicians alike. (Now available in 4Fr and 5Fr, 8cm and 10cm.)
www.the-wand.com

One-Link Needle-Free IV Connector
The neutral displacement ONE-LINK connector is designed to help reduce the risk of thrombotic catheter occlusions compared to devices with higher reflux volumes.1 Less chance of reflux means simplified training and usage and more time to focus on your patients. Plus, ONE-LINK is a needle-free connector that can be used throughout your facility, from OR to ER and from neonatal to oncology. For safe and proper use of the One-Link devices, refer to the appropriate Instructions for Use.
Reference: 1. Data on file. Baxter Healthcare Corporation. Baxter and One-Link are trademarks of Baxter International Inc.
www.baxter.com

Neutron Needlefree Catheter Patency Device
The NeutronTM needle-free catheter patency device from ICU Medical is the first FDA-cleared device shown to significantly reduce blood reflux into the catheter. Reflux contributes to biofilm formation and catheter occlusion, and maintaining catheter patency and minimizing occlusions are important steps in your efforts to enhance patient safety and improve outcomes  Clinicians around the world count on ICU Medical to provide them with clinically-proven, cost-effective products, and innovative patient safety solutions. We help you reduce bloodstream infections and minimize occlusions with our clinically-proven needle-free infusion access devices, including the Neutron Catheter Patency Device, shown to reduce catheter occlusions by 50 percent. Maintaining catheter patency and minimizing occlusions are important steps in your efforts to enhance patient safety and improve outcomes.
www.icumedical.com or (800) 824-7890

Sherlock 3CG® Tip Confirmation System
The Sherlock 3CG® Tip Confirmation System (TCS) is Bards fully integrated magnetic tracking and ECG-based peripherally inserted central catheter (PICC) tip confirmation technology. Sherlock 3CG® TCS allows the clinician to visually navigate the catheter tip into the superior vena cava and then use ECG technology to confirm catheter placement in proximity to the cavoatrial junction. Final tip location is confirmed by the nurse at the bedside and infusion therapy can begin immediately without the need for a confirmatory chest X-ray. Additionally, a unique through-drape connection allows the clinician to maintain sterility throughout the procedure. Any alterations of cardiac rhythms that change the normal presentation of the P-wave limit the use of ECG tip confirmation technology. In these instances, confirm PICC tip location using an alternative method.
www.discoversherlock.com or  (800) 545-0890   

ChloraPrep® Skin Preparation Products
ChloraPrep® skin preparation products from CareFusion are rapid-acting, persistent and broad-spectrum antiseptics that reduce microorganisms on the skin that can cause infection. The Chlorhexidine Gluconate/Isopropyl Alcohol formulation acts fast on a broad spectrum of bacteria, and keeps fighting bacteria for at least 48 hours. The unique formulation and single-use applicator reduce microorganisms on the skin.
www.carefusion.com/chloraprep or (800) 523.0502, ext. 3576