Infection control and prevention - Essay Example

of the of the Concerned Nursing 27 March Infection Control and Prevention Introduction Insertion of central venous catheters (CVCs) has become commonplace in the peri-operative and intensive care setting. Over the years, they have played a reliable role in patient care for haemodynamic management, patent intravenous access in patients suffering from chronic illnesses and administration of parenteral nutrition and other chemotherapeutic agents. The three sites that are utilized for central venous catheter insertion are internal jugular, subclavian and femoral. Although, like any other medical intervention, these catheters have their own share of complications, it is the risk of infection, which has the most serious clinical and economic repercussions for the patient, physician and health care facility with high morbidity and mortality (Saint, Savel & Matthay 2002, Rello, Ochagavia & Sabanes 2000, Collignon 1994, Heiselman 1994). One survey determined that central lines are associated with more than 40% of blood stream infections in England. Thus, it is imperative that strict infection control measures are enforced during the care of CVCs. Risk of infection in peri-operative setting would depend upon whether the CVC is kept in situ for a long time or it is removed post surgery. Otherwise, rest of the discussion about CRBSI is applicable to ICU as well as peri-operative setting. Definition and diagnosis of CRBSI Catheter related blood stream infection (CRBSI) is a type of hospital acquired infection which is clinically defined as fungemia or bacteremia in a patient with CVC in situ, as shown by positive blood culture from a peripheral vein, along with clinical signs of infection, but no other apparent source for positive blood culture. Standard guidelines for catheter and blood culture are in place to establish a microbiological diagnosis of CRBSI (IDSA 2012). Briefly, the diagnosis of Catheter related blood stream infection (CRBSI) requires that semiquantitative (roll plate) culture of the catheter tip grows > 15 colony forming units (CFU’s) or quantitative broth culture of catheter grows more than 100 CFU’s. Also, similar organisms should grow in the blood sample drawn percutaneously and the catheter tip, or, blood sample from a peripheral vein and sample drawn from the catheter hub (IDSA 2012)) Risk of CRBSI in perioperative and ICU setting Many factors have been investigated for the role that they are likely to play in the development of these infections. The factors which have been most commonly scrutinized for their role in causation of CRBSI are: Selection of the type of catheter: single lumen catheters have a lower incidence of CRBSI than multiple lumen, antimicrobial impregnated catheters preferred in centres with high rates of CRBSI or prolonged requirement of CVC (reference no.23), role of peripherally inserted central catheters (PICCs) the site of CVC insertion: Subclavian most preferred, femoral least preferred hand hygiene: technique should be accurately followed aseptic precautions and skin preparation followed during insertion: use of gloves and barrier precautions, skin preparation with chlorhexidine in alcoholic solution nature and material of the dressing applied over the insertion site antibiotic ointment systemic antibiotic prophylaxis antimicrobial flush and lock solutions anticoagulant flush replacement of CVCs Replacement of IV administration sets handling of the CVC port by nursing and other health care staff USG guidance at the time of insertion Various studies and clinical trials support or contradict these factors. Also, there are evidence based practices and interventions based on these related factors and derived from the existing knowledge about infection control, which, when diligently followed in ICUs and other health care settings, have demonstrated a decrease in the rate of development of CRBSI (National Institute for Clinical Excellence 2003, Healthcare Infection Control Practices Advisory Committee 2011). Pathogenesis of Catheter Related Infections Following mechanisms have been proposed for catheter related blood stream infections: 1) Colonization from insertion site either at the time of insertion or later: Bio film is present outside the catheter lumen. 2) Colonization from inside the injection port: Bio film is present inside the catheter lumen 3) Administration of solution already contaminated with pathogens Post-colonization, bacteria disseminate into the blood stream and cause CRBSI (Safdar & Mahi 2004, McGree & Gould 2003). Thus, it becomes easy to define our approach in dealing with such infections once the pathogenesis is clear. Current practices target both extraluminal and intraluminal mechanisms of infection. The most commonly implicated bacteria in CRBSI are coagulase-negative staphylococci (CONS), Staphylococcus aureus, enterococci, and the most common fungus is Candida spp (Wisplinghaff et al 2004). Almost one fifth of these infections are caused by gram negative bacilli (Gaynes & Edwards 2005). Standard Principles for Prevention of Hospital Acquired Infections Certain standard recommendations are foundations of our existing infection control knowledge and they should be a part of every infection control policy and all guidelines. These are the precautions of 1) hand hygiene and decontamination, 2) use of personal protection and 3) sharp disposal (National Institute for Clinical Excellence 2003). Hand decontamination regimen should be followed before and after every contact with the patient, with an alcohol based disinfectant, which is rubbed on hands till dry. Visibly soiled hands should be washed with soap and water. While applying soap or hand rub, it should thoroughly cover all the surfaces especially, fingertips, webspaces and thumbs. Hands must be vigorously cleaned and rubbed together for at least 10-15 seconds. Fingernails should be kept trimmed and jewellery should be removed (National Institute for Clinical Excellence 2003, Pellowe et al 2004). Protective equipment must be used by the health care personnel for all invasive procedures and when there is risk of contamination by any of the patient’s secretions. These include disposable gloves, disposable plastic aprons, face masks, eye protection gear etc. Gloves must be discarded after single use and must be changed for different procedures or treatments in the same patient and between 2 patients. Same holds true for other protective equipment (National Institute for Clinical Excellence 2003). Also, hands must be decontaminated after the gloves are removed. Needles and sharps should be minimally handled and discarded in to special containers (National Institute for Clinical Excellence 2003). Thus, all the above mentioned standard principles, along with maintenance of hospital hygiene are applicable in care of patients with central venous catheters. Simple adherence to these basic principles has shown significant reduction in infectious outbreaks in health facilities all over the world. Its only when we neglect to follow basic procedures, infections spread because of cross contamination. Prevention of Infection in Patients with CVCs: Nursing Care Infection control practices specifically targeting patients with CVCs deal with 1) education of the patient and health care staff, 2) maintenance of asepsis, 3)care of catheter site and 4) other principles (National Institute for Clinical Excellence 2003). Education and training of the health care personnel involved in the insertion and care of CVCs should be done in implementation of infection control measures (Healthcare Infection Control Practices Advisory Committee 2011). This training should be periodically assessed and reinforced (Healthcare Infection Control Practice Advisory Committee 2011). Also, if a patient is being discharged to home with a CVC in situ, the patient and his attendants should be taught these principles. Asepsis can be maintained by hand hygiene and use of sterile gloves while accessing CVC. Catheter insertion site is cared for by applying transparent sterile dressing. If the site is wet because of bleeding or oozing, a gauze dressing can be done. It should be replaced by transparent dressing as soon as the wound is dry. This transparent dressing should be changed every 7 days or sooner, if it becomes wet or loosened (National Institute for Clinical Excellence 2003, Healthcare Infection Control Practices Advisory Committee 2011). During dressing change, cleaning with chlorhexidine in alcoholic solution is recommended (National Institute for Clinical Excellence 2003). However, recent guidelines do not recommend application of antibiotic ointments at the insertion site (Healthcare Infection Control Practices Advisory Committee 2011). Cleaning of the injection port or hub with chlorhexidine or alcohol before and after it is handled should be done. There is no role of systemic antibiotic prophylaxis, in-line filters or antibiotic lock solution to routinely prevent infection (National Institute for Clinical Excellence 2003). On the other hand, CDC guidelines allow prophylactic antimicrobial lock solution in patients with recurrent CRBSI (National Institute for Clinical Excellence 2003). Parenteral nutrition should be administered through a dedicated port (National Institute for Clinical Excellence 2003). However, in some guidelines, this is an unresolved issue (Healthcare Infection Control Practices Advisory Committee 2011). Sterile normal saline solution should be used to flush the lumen; anticoagulants are not routinely recommended (National Institute for Clinical Excellence 2003). Subclavian site has shown the minimal risk of infection, whereas femoral line should be avoided for non tunnelled catheters (Healthcare Infection Control Practices Advisory Committee 2011, Jones, McDougall & Wilcox 2007). CVC should have minimal possible number of ports required for the management of the patient (Healthcare Infection Control Practices Advisory Committee 2011, Jones, McDougall & Wilcox 2007). If the catheter was not inserted aseptically, it should be replaced as soon as possible (Healthcare Infection Control Practices Advisory Committee 2011). Replacement of central venous catheters Routine replacement of CVC based only on time period is not recommended for prevention of infection. Also, for non tunnelled catheters, exchange over guidewire is not recommended to prevent infection or remove the source of infection. Only for CVCs being replaced for non-infectious reasons, guidewire exchanges are allowed, and in that case, new gloves should be used for new catheter (Healthcare Infection Control Practices Advisory Committee 2011). CVC Bundle A set of interventions which are individually proven to decrease the rate of CRBSI, demonstrate superior results when collectively applied. This set of high impact interventions is termed as ‘Central Venous Catheter Care Bundle’. Meticulous application of this bundle has led to reduction in the incidence of CRBSI in adult and paediatric ICU’s (Pronovost, Needham & Berenholtz 2006, Bhutta, Gilliam & Honeycatt 2007). These interventions are further grouped as pre insertion (during insertion) and post insertion (ongoing care) interventions. Insertion: The issues addressed by this set of interventions concern the following: 1) Type of CVC 2) Site of insertion of CVC 3) Barrier precautions 4) Skin preparation 5) Hand hygiene 6) Dressing 7) Safe disposal of sharps 8) Documentation These above mentioned interventions, if strictly followed for every patient, significantly reduce the risk of CRBSI. Succinctly, single lumen and antimicrobial impregnated catheters should be preferred unless indicated otherwise. Catheters coated with antiseptic (chlorhexidine/silver sulfadiazine) agents or impregnated with antibiotics (minocycline/rifampin) have demonstrated lower CRBSI rates as compared to conventional catheters, with antibiotics proving superior in this regard to antimicrobials. (Reference no.8)Although, the initial cost of these devices may be higher, they ultimately turn out to be more cost effective in patients requiring CVCs for a longer period (> 5 days) as CRBSI rates are related to in situ duration of the catheter (Hanna, Benjamin & Chutzinik 2004). Furthermore, subclavian and internal jugular insertion sites are preferred over femoral CVCs. However, previous studies have reported conflicting results, so far as the site with highest rate of infection is concerned (Deshpande et al 2005, Merrer, DeJonghe & Galliot 2001). Observation of sterile barrier precautions during insertion in the form of sterile gown, cap, mask, gloves and full body sterile drape should be done. Local disinfection is recommended with 2% chlorhexidine gluconate in 70% isopropyl alcohol for at least 30 seconds. Povidone iodine based disinfectants are to be used only if the patient is allergic to chlorhexidine (Maki, Ringer & Alvarado 1991). On the other hand, CDC guidelines treat the comparison of alcoholic preparations of chlorhexidine and alcoholic preparations of povidone-iodine as an unresolved issue (Healthcare Infection Control Practices Advisory Committee 2011). As with all hospital acquired infections, hand hygiene should be strictly adhered to. Hand washing according to the proper technique and rubbing of alcohol based disinfectants should be done before and after touching each patient. After completion of the procedure, the insertion site should be dressed with a sterile, transparent dressing so that the insertion site is clearly visible for any signs of infection. Insertion details including name of physician doing the procedure, date and location of the procedure are recorded. Post insertion interventions: This set of interventions is to be applied during the ongoing care of the catheters. 1) Hand hygiene 2) Daily inspection of insertion site 3) Dressing- 3 - 4) Catheter injection ports 5) Catheter access 6) Administration set replacement 7) Catheter replacement Hand hygiene is a part of ongoing care of any patient in general. It is to be performed before and after handling of the CVC. A daily record of the status of insertion site is to be kept. Any signs of infection such as redness, swelling, and discharge should prompt an immediate action. The transparent dressing should be dry and covering the site well, otherwise, it should be replaced. Before that, it should be cleaned with the same disinfectant recommended during insertion. Catheter ports should be closed when not in use, with caps or one way connectors. Ports and lines are to be handled aseptically. Before each use, ports are disinfected with 2% chlorhexidine gluconate in 70% isopropyl alcohol. Normal saline should be used for flushing the lumen. IV administration sets for each patient are to be replaced within 72 hours except administration sets used for parenteral nutrition which are replaced every day and blood products administration sets which are replaced immediately. Patients’ requirement for having a CVC is assessed daily and the catheter is removed as soon as its utility ceases. Similar to insertion details, the details of removal of a CVC are also recorded. Despite following the decontamination protocol of hubs and ports of the catheters, a recent study determined that microorganisms were present in the internal lumen of 55% connectors attached to the CVCs. Thus, even more effective regimens are required to prevent this colonisation (Casey et al 2012). Also, only stringent monitoring and regular assessment of hygiene and decontamination practices can bring down CRBSI rates (Pellowe et al 2004). Control of MRSA Meticillin resistant staphylococcus aureus is an important hospital acquired pathogen whose outbreaks have significant health and financial ramifications. Patients in intensive care unit are at a high risk of infection with MRSA. Preventive and control measures include adequate nursing staff to care for the patients. It has been seen that an increased workload doesn’t allow the nurse adequate time to follow infection control measures and this results in cross infection from one patient to other. Also, routine surveillance of high risk patients and health care staff and decolonisation of throat, nose and skin is recommended in conjunction with standard measures of infection control (Coia et al 2006). Conclusion Clinical experience and literature have shown ample evidence that CVC insertion is associated with a high risk of developing catheter related blood stream infection. For the purpose of infection control, time honoured practices exist which have universal applicability for any invasive or non invasive procedure or treatment. Strict compliance with hand washing, use of gloves, disinfectant application, daily dressings and no touch aseptic technique are some of them. Now, these time-honoured practices have been applied, tried and tested in various settings and they have emerged as evidence based practices, high impact interventions and bundles of care. They are still being evaluated continuously and till now, have proven their utility in reducing the risk and incidence of CRBSI. Although, some guidelines differ or are undecided about the role of a particular intervention and a high degree of evidence may not be available for some of them, our existing knowledge and fundamentals about infection control strategies should equip us to judge their effectiveness for ourselves. More importantly, as health care personnel, we should be committed to spare our patients the suffering and additional expense caused by CRBSI whose rates can be significantly decreased if we strictly adhere to the infection control practices discussed above. Reference List Bhutta, A, Gilliam, C & Honeycatt, M 2007, ‘Reduction of Bloodstream Infections Associated with Catheters in Paediatric Intensive Care Unit: Stepwise Approach’, British Medical Journal, Vol. 334, pp. 362-365. 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