Are We There Yet? More Than Just Central Lines

By Michelle DeVries, MPH, CIC, VA-BC 

For 25 years, I have been in infection prevention and watched our field grow and shift into so much more than it was when I first started. My passion is at the intersection of hospital epidemiology, vascular access and patient safety. I have been fortunate, throughout my career, to create a program that allows me to explore the impact on our patients and strive to see those focuses align. I have studied, published, presented and mentored to ensure every patient who entrusts us with their care has all of their invasive vascular access devices treated with the respect they deserve – knowing that any line can truly be our patient’s life line. 

This year has already been a monumental step forward in raising awareness. International tennis phenomenon Andy Murray shared a photo of himself with his peripheral IV device post operatively and it raised a tremendous amount of questions. The Association for Vascular Access (AVA) came across this social media post and used it as a teaching tool – annotating the photo to point out aspects that may have been out of alignment with what we would expect to see in our hospitals (https://www.avainfo.org/general/custom.asp?page=AndyMurray). It was followed by a podcast with an international panel discussing the potential to do better with our peripheral vascular access devices around the globe. This sparked a spirited conversation about differences in practice, assessing competency and ensuring programs have plans for measuring performance on all vascular access devices.

Ramzy Nasrallah, CEO of the Association for Vascular Access (AVA) and AVA Foundation, explains it this way: “When we annotated the Andy Murray Instagram photo, where he had what appeared to be two PIVCs in the same vein covered by non-occlusive dressings on a hairy arm that should have been clipped, the overwhelming defense from anesthesiologists was, 'But we always do it this way.' And the overwhelming reply from nurses involved in the care and maintenance of those devices was, 'Yes, we know.'"

That is not the only “big news." Every year, ECRI Institute publishes a Top 10 Patient Safety Concerns list (https://www.ecri.org/top-10-patient-safety-concerns). As a patient safety organization, it reviews the available data and consults with a broad group of experts when formulating the list. It is a document that can start conversations within our leadership teams and help increase focus on risk reduction opportunities that may not be receiving the necessary level of attention. 

For 2019, one of the items that made the list is bloodstream infections from peripherally inserted IV lines. They are not referring to PICCs (peripherally inserted central catheters) with that statement, they are talking about the ubiquitous short peripheral catheters that almost every patient receives as part of their care. My organization has proactively followed these infections as well as monitored process measures (dressing integrity, CHG sponge usage, administration set management, alcohol impregnated caps, site selection, etc. as well as hand hygiene and overall device utilization) for years, but we will still be using this publication to reinforce all the efforts to continually improve outcomes with every invasive device used for patient care. If you have not already seen the executive summary, it can be a great tool for expanding conversations with patient safety and the executive team.

For surveillance, many programs have not yet expanded their scope to include outcome (or process) data beyond central line associated bloodstream infections (CLABSI). Surveillance for peripheral devices has been part of the INS standards for years but has not yet become a standard component of infection prevention team efforts.1 There is significant optimism that may soon change. Earlier this year, the Centers for Disease Control and Prevention (CDC) issued a call for comments on a proposal to potentially expand National Healthcare Safety Network (NHSN) surveillance protocols to include all hospital onset bacteremia (https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-01915.pdf). 

CLABSI would be a subset of that data collection but would no longer be the only category of bloodstream infection monitored. The comment period is now closed but if successful, the protocol changes may be implemented as early as January 2020. Continued publications have been released discussing performance of peripheral, midline and central line complications including infections along with a variety of strategies to mitigate those risks.2-4 

What next steps are you taking to be ready to lead on this topic? In our role as infection preventionists and hospital epidemiologists, we have the opportunity to lead the development of robust patient-safety programs. Expanding the data collected, analyzed and formulated into meaningful reports can be a driver of change. Understanding the performance differences between every device placed by our teams and cared for by our staff can contribute to a better understanding about the implications of device choices and help continue to improve device selection algorithms as refined tools for patient safety. 

We have looked closely at bloodstream infections, but there is much more to device performance that we would benefit from understanding. The partnership between infection prevention and vascular access is a natural (and necessary one). Even with the current focus only on CLABSI and MRSA lab ID events for public reporting the collaboration between us leads to great breakthroughs for improved outcomes. Looking at device utilization ratios along the vascular access team inserters, ER inserters and interventional radiologists, hospitalists and whomever else is placing central lines is so much more powerful than merely looking at a statistic. What is driving selection of a certain device type, or insertion style? Are their barriers to optimal site selection related to access to appropriate ultrasound competencies or device availability? Has an assessment been done for compliance not only with use of ultrasound guidance recommendations, but also on how those transducers, cords and devices are disinfected between patients? 

AVA offers a guidance document on Transducer Disinfection for Assessment and Insertion of Peripheral and Central Catheters which begins to tackle some of the questions that need to be asked (https://www.avainfo.org/general/custom.asp?page=UltrasoundDisinfect). It is another tool worth discussion at infection control committee meetings and further opening multi-disciplinary dialogue. Is your antimicrobial stewardship program looking at blood culture contamination? 

As infection preventionists, it may not have been at the top of your attention, but we have another real opportunity to raise awareness of something that is often accept with complacency. With less than 10 percent of blood cultures being positive, a 3 percent contamination rate would imply that these critical results are “wrong” nearly one-third of the time, yet this is often the threshold used when evaluating performance with this indicator. We would not accept those failure rates anywhere else in healthcare, and this one can trigger unnecessary further testing, admission and treatment. 
Many avenues have been explored for reducing this occurrence to the absolute lowest achievable with substantial improvements in antibiotic usage.5 Decreasing antibiotic exposure also has downstream benefits on outcomes of concern such as C. difficile.6 Now is the time to begin identifying how we can position our programs to be ready to respond to these calls to action. How can we be prepared with the evidence that what we are doing for every patient is aligned with best practice and excellent outcomes? If you are not already involved with your Vascular Access team deeply, invite them to join you at your next Association of Professionals in Infection Control and Epidemiology (APIC) chapter meeting. If you are not already a member of your local AVA network, get involved. 

Ramzy Nasrallah is a very vocal champion for high-level as well as grassroots collaboration. Not only do we have an infection preventionist on the AVA board of directors, he has clearly defined infection prevention as core to all vascular access. He sums it up beautifully by saying: “Vascular access is the gateway to healthcare delivery, and preserving that gateway - the patient’s bloodstream, the veins, the access -- is paramount to ensuring that the treatment is received properly. AVA’s multidisciplinary approach to vascular access unites infection prevention, the clinicians performing the insertion, care and maintenance - as well as the patient to ensure that the gateway stays open, free of infection and sustainable for the duration of treatment. If you’re not an AVA member or attending your local network meetings in working to align the vascular access continuum, then what are you waiting for?” 

If that does not sound like an open invitation to take your seat at the table, I am not sure what is. Our patients deserve nothing less. 

Michelle DeVries, MPH, CIC, VA-BC, is a member of the speaker’s bureau for Access Scientific, Becton Dickinson, Eloquest and Ethicon. She is a former director-at-large with the Vascular Access Certification Corporation, an adjunct research fellow with the Alliance for Vascular Access and Teaching and Research (Griffith University, Health Institute Queensland) and the senior infection control officer at Methodist Hospitals in Gary, Ind.

References:
1. Gorski L HL, Hagle ME, McGoldrick M, Orr M, Doellman D. Infusion therapy standards of practice. J Infus Nurs. 2016;39 (suppl 1):S1-S159. 
2. Marsh N, Webster J, Larson E, Cooke M, Mihala G, Rickard CM. Observational Study of Peripheral Intravenous Catheter Outcomes in Adult Hospitalized Patients: A Multivariable Analysis of Peripheral Intravenous Catheter Failure. J Hosp Med. 2018;13(2):83-89. 
3. Chopra V, Kaatz S, Swaminathan L, et al. Variation in use and outcomes related to midline catheters: results from a multicentre pilot study. BMJ Quality & Safety. 2019. 
4. Krein SL, Saint S, Trautner BW, et al. Patient-reported complications related to peripherally inserted central catheters: a multicentre prospective cohort study. BMJ Qual Saf. 2019. 
5. Garcia RA, Spitzer ED, Kranz B, Barnes S. A national survey of interventions and practices in the prevention of blood culture contamination and associated adverse health care events. American Journal of Infection Control. 2018;46(5):571-576. 
6. Kazakova SV, Baggs J, McDonald LC, et al. Association between Antibiotic Use and Hospital-Onset Clostridioidesdifficile Infection in U.S. Acute Care Hospitals, 2006-2012: an Ecologic Analysis. Clin Infect Dis. 2019.