Exploring Risk (and Risk Reduction) Beyond Central Lines

By Michelle DeVries, MPH, CIC, VA-BC

Despite increasing studies and interest in understanding complication rates for all vascular access devices, many infection prevention programs still limit their scope to only CLABSI surveillance within the constraints of National Healthcare Safety Network (NHSN) protocols. By broadening our focus, we have an opportunity to improve the care and outcomes of devices that impact almost every patient who entrusts us with their inpatient care (as well as our outpatient infusion clinics and home health care patients).

Last year, Mermel heightened awareness of the role that PIVs may place in serious infections when he estimated that a third of catheter related Staphylococcus aureus (S. aureus) infections may be coming from peripheral IVs (Mermel, 2017). This echoes the sentiment shared by Jim Davis and the Pennsylvania Patient Safety Authority. Pennsylvania requires reporting of all hospital acquired infections, so has a much more robust data set than most. In reviewing the bacteremias without central lines and comparing it with the S. aureus isolates they estimate that the leading cause of S. aureus bacteremias in hospitalized, acut- care adults in the state may be the peripheral catheter (Davis, 2014).

Kovacs similarly found that 36 percent of primary S. aureus bacteremias over a four-year period occurred in patients without central lines (Kovacs, Fatica, Butler, Gordon and Fraser, 2016). The SHEA Compendium also acknowledged that peripheral devices (both venous and arterial) carry with them a risk of infection, independent of central venous catheters, yet most programs are not actively monitoring (Marschall, et al., 2014). The 2016 Infusion Therapy Standards of Practice call for us to perform surveillance on these devices regularly (Gorski L, 2016). Including all devices allows us to begin to offer comparisons on risk that allow us understand performance beyond what we have may have traditionally included in our programs (Alexandrou, et al., 2018) (Mushtaq et al., 2018).

How do we begin to address these findings and recommendations in our own organizations? As a starting point, ensuring that a standardized protocol is used will help allow us to begin creating a systematic process by which we can eventually compare and trend our performance as we do with central lines. For 20 years I have followed the NHSN (formerly NNIS) protocols. At their core they are laboratory-confirmed bloodstream infections (LCBI) definitions. We frequently think of them at CLABSI definitions, but the core definition is not specific to CLABSI. The actual document title is “Bloodstream Infection Event (Central Line-Associated Bloodstream Infection and Non-central Line Associated Bloodstream Infection)."

In fact, during the last two years of NHSN annual training, they suggest identifying whether LCBI has been met, then whether it is primary or secondary and then as the final step whether it was related to a central line. Our team has followed that strategy for years, at the end capturing all devices in place leading up to the infection and “attributing” it to the line(s) present the day of or day before infection criteria are met as long as there has been access for more than two calendar days. When more than one device is present and paired cultures or other conclusive data is not available, we err by attributing (for surveillance purposes only, not clinical treatment decisions) to the line with the higher published rate of infection (i.e., CVC > PIV > midline). We share infection data not only on our central lines, but from short peripheral catheters and midlines as well. We acknowledge it is an imprecise definition, but wholly support the value of standardization. Further drill down on infections for contributing factors is conducted through an Apparent Cause Analysis facilitated by one of our infection preventionists (who is also a DNP, ACNS-BC, CIC, VA-BC and former nursing professor) who engages from line staff to recall and share memories of care and perhaps lapses in the days prior to the infection. During those discussions aspects of all lines present are included to give the broadest approach for reviewing possible opportunities for improvement. We engage staff to critically review the “why” behind the device choices and also include insertion staff and other involved departments to try to capture the fullest understanding.

Infection preventionists, and many of us with specialized training, function within the broader function of hospital epidemiology – looking at the distribution and determinants of disease (in our case complication) within our patient population. When it comes to understanding the risks of all of our devices, we look beyond just those that develop an infection, knowing that preventing precursors to infection (poor site selection, non-intact dressings, occluded catheters, etc.) can help impact the incidence. Collaborating with our vascular access team, we have also created sustainable methods for capturing non-infectious complications from these devices as well to help with more fully understanding device risk. We work together to review (and compare across device types) issues such as completion of therapy, percent of patients discharged with lines in place, infiltration, occlusion, phlebitis and other potentially preventable complications.

While our organizations are required to report outcomes measures (i.e., CLABSI, MRSA Lab-ID, and C. diff Lab-ID), it would behoove us to spend considerable efforts monitoring process measures in an effort to correct deficiencies before they lead to an infection, rather than waiting to conduct a huddle only after significant patient harm has occurred. Within our organization, we achieve this (with the support and guidance of the executive team) through multi-disciplinary process measures rounding. Rather than falling as a siloed activity for the infection prevention team (which is where its origins were within our facility), every inpatient unit is expected to round and document their findings within a shared spread sheet. A screen shot of one of the data entry sheets is shown below. A data dictionary is provided to staff in an effort to ensure consistency in how measures are evaluated. Last year the organization opted to add some of the process measures to the unit score card, in addition to standardized device utilization ratios and standardized infection ratios. Each unit can access the elements of performance on their own patients, plus the aggregate data is presented monthly to Infection Control Committee. Taking it even a step further, every month, the Infection Prevention team coordinates inclusive rounding when vendors (representatives, clinical specialists, engineers, leadership, etc.) are welcomed and round with the hospitals’ infection prevention team at the bedside to see how products are performing. The team is frequently joined by professional development and nursing leadership as well as members of the vascular access team. It provides front line staff with a chance to pose their questions to internal and external experts on every component of their care of central as well as peripheral lines and helps build collaboration on amongst providers of our bundle elements.

There is much remaining work to be done to feel as that we have done everything possible to make vascular access as safe as possible for all patients. Consideration of expanding infection surveillance as well as process measure analysis across all devices can help identify opportunities for further study. Partnering with our vascular access teams individually at our organization, but also through active involvement with local and national organizations such as the Association for Vascular Access (AVA) can help us go even further in creating a complication-free possibility for our patients.

Michelle DeVries is a member of the speaker’s bureau for Access Scientific, Becton Dickinson, Eloquest and Ethicon. She is a 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:

Alexandrou E, Ray-Barruel G, Carr PJ, Frost SA, Inwood S, Higgins N, et al. (2018). Use of Short Peripheral Intravenous Catheters: Characteristics, Management, and Outcomes Worldwide. Journal of Hospital Medicine, 13(5). doi:10.12788/jhm.3039

Davis J. (2014). Peripheral Vascular Catheter-Related Infection: Dwelling on Dwell Time. Pennsylvania Patient Safety Advisory, 11(1), 30-35.

Gorski LHL, Hagle ME, McGoldrick M, Orr M, Doellman D. (2016). Infusion therapy standards of practice. J Infus Nurs, 39 (suppl 1), S1-S159.

Kovacs CS, Fatica C, Butler R, Gordon SM and Fraser TG. (2016). Hospital-acquired Staphylococcus aureus primary bloodstream infection: A comparison of events that do and do not meet the central line-associated bloodstream infection definition. American Journal of Infection Control, 44(11), 1252-1255. doi:10.1016/j.ajic.2016.03.038

Marschall J, Mermel LA, Fakih M, Hadaway L, Kallen A, O’Grady NP, et al. (2014). Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update. Infection Control & Hospital Epidemiology, 35(S2), S89-S107. doi:10.1017/s0899823x00193870

Mermel LA. (2017). Short-term Peripheral Venous Catheter-Related Bloodstream Infections: A Systematic Review. Clin Infect Dis. 65(10), 1757-1762. doi:10.1093/cid/cix562

Mushtaq A, Navalkele B, Kaur M, Krishna A, Saleem A, Rana N, et al. (2018). Comparison of complications in midlines versus central venous catheters: Are midlines safer than central venous lines? Am J Infect Control. doi:10.1016/j.ajic.2018.01.006