Exploring Approaches 'Beyond the Bundle' to Help Decrease Vascular Access Device-Associated Infections

By Chellie DeVries

It has been more than 10 years since The New England Journal of Medicine published the Keystone project’s ground breaking work on reducing ICU CLABSIs using a central line insertion bundle. Since that time, this has become the absolute standard throughout healthcare settings in the United States. When it comes to completing the central line insertions checklist, many of us only accept “yes” and “yes with prompting” as possible responses. Our accrediting agencies expect this as a standard of practice. 

With CMS/NHSN mandated reporting now in its seventh year, there are reports of tremendous improvements in reported central line-associated bloodstream infection (CLABSI) incidence as this and other evidence-based standards are more fully adopted. Hospitals are analyzing their data and examining contributing factors to determine where improvements are most needed. What happens when opportunities for improvement persist and bundle compliance (both insertion and maintenance) is consistently high?  It may be time to look beyond those bundles to examine additional approaches that may be beneficial.

For so long now we have (rightly) stressed the importance of maximum sterile barrier precautions for insertion of central lines and daily re-view of line necessity to get them out promptly, yet many units continue to have central line utilization in excess of reported means. How much progress could be made by also looking more critically at device selection and early vascular assessment as part of a prevention strategy?  MAG-IC gives us the framework for assessing the hierarchy of device options before using a central line for difficult access or peripherally compatible infusates. How much further could we get if we slowed the progress to central lines or got them out even a day or two sooner while still ensuring reliable access? It is true that many of our patients truly require a central line, but when we go through the motion of “daily review of line necessity” are we truly asking whether the patient still needs the device they have?  There is a difference between needing vascular access and needing a central line. 

At my organization, we are tackling this in a number of different ways – starting now in the emergency room. We have completed the first year of our midline program at the hospital (managed by our PICC team) with over 3500 midline days and tracked our outcomes closely. For our primary, power injectable line we are now at nearly 3,000 midline days with zero BSIs. Based on those successes and feedback from our medical staff leaders that there remains an opportunity for addressing lines placed in the emergency room we are now in the early phases of training interested ER nurses in ultrasound skills to allow them to assist with preventing unnecessary central line insertions (and subsequent excess central line days) by giving them (after completing competencies) the ability to place a high flow, power injectable midline if it is appropriate for the patient’s vascular access needs.  Those lines will be monitored for outcomes and the impact they may contribute to the organization’s central line utilization ratios.   

As we reviewed our 2016 CLABSIs there was considerable discussion about the CLABSIs that were occurring in our critical care step down units; although they are not included in state or federal reporting they represent a considerable source of morbidity (and potential mortality) for our patients and central line days exceeds what are seen in our intensive care units (ICUs). Recent conversations, supported by our ICU medical director will help drive staff to more carefully consider whether central lines can be reduced or replaced with midlines for patients with continuing need for therapy as they leave the ICU with medications not contraindicated for peripheral infusion. Review the available evidence to see which devices may be able to most safely help you achieve your goals, by keeping a patient focused prevention strategy.

When you look beyond your bundles what else do you see?  What other trends bear further investigation?  A review of our bloodstream infections (CLABSI and peripheral line related) for 2016 showed that 25 percent had documentation of problems with the dressing based on chart review documenting reinforced dressings or premature dressing changes.  Concordant review of charts with direct observation suggested that the dressing disruption rate was even more significant. Knowing that repeated dressing changes has significant impact on CLABSI incidence, solving this problem became a priority. Several different strategies were used, starting with re-education on appropriate use of our dressings. When that was insufficient we created an intervention bundle that included a dressing in conjunction with a gum mastic based medical adhesive. Combining a securement dressing with these adhesive allowed us, in our pilot, to achieve 93 percent fully adherent dressings (without any tape reinforcement or lifted edges) and zero disrupted dressings.   

We are in the process of expanding the study across multiple other devices in our organization to find the bundle that works best for us.  By studying this in the careful manner we did, we have the potential to decrease excess dressing changes and the related BSI risks but also save nursing time through allowing our dressings to remain in place and intact, while protecting our investment in protective strategies like CHG sponge dressing and advanced securement dressings.   

I am fortunate to get to talk with colleagues in vascular access and infection control across the country on a weekly basis. I hear the struggles they are facing with the implications of Value-Based Purchasing and most recently the impact that rebaselining had on many facilities’ standardized infection ratios (SIRs). I hear the pressure that Infection Prevention and Vascular Access teams are under to improve their CLABSI numbers. I am frightened by some of what has been shared with me.  I have heard programs be actively encouraged to NOT try to decrease central line days – because leaving them high helps to make rates or SIRs look better. Rather than focusing on decreasing the risk by ensuring optimal compliance with prevention strategies, this leaves our patients at unacceptable risk by potentially leaving in a device that is not actually necessary for care.   
I am equally concerned with hospitals who are suggesting that central lines should not be used… since then there could be no CLABSIs.  That is a disturbing proposition in terms of vessel health – our veins are meant to last us a lifetime and must be treated with careful consideration of what is infused into devices and how those devices are placed and maintained. On the flip side, I have heard of hospitals who look at their rates and because they are “OK” they are not pushing further to improve outcomes or improve compliance with the process measures that drive those outcomes.  If we continue to have patients with potentially fatal infections, how can we allow ourselves to become complacent?

Please partner with your vascular access teams or whomever has primary responsibility for those considerations in your hospital. Share the data you have from NHSN and any process measures you follow for all vascular access devices; ask them to share the measurables they track for their productivity.    Learn together how you can collaborate to help make your hospital the safest possible place they can be for our patients.  In September, I am teaching a “Power Hour” at the National Association for Vascular Access conference focusing on NHSN surveillance and how to leverage that data for vascular access teams. That came about because so many of these professionals have indicated they do not have strong, open relationship with their infection preventionists. Please reach out and collaborate – you truly will not find better allies in the organization for achieving our mutual goals.

Chellie DeVries has been involved in infection control and hospital epidemiology with a passion for vascular access considerations for more than 20 years. She was a reviewer for the 2016 Infusion Therapy Standards of Practice, wrote the Infection Prevention and Control Chapter for the forthcoming new edition of Infusion Nursing: An Evidence Based Approach and the chapter on Vascular Access Device Associated Infections for the International Federation of Infection Control text book.. She volunteers as an advisor for AVA's Patient Advocacy Committee and a member of their PIV task force and serves as a director-at-large with the Vascular Access Certification Corporation (VACC).

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