Critically evaluate the influences on infection control and prevention practices relating to the care of invasive devices (choose either Intra-venous or Urinary Catheters). You need to consider: The pathogenesis of the most likely micro-organism involved and how infections may occur. All infection prevention and control measures that are involved in managing and preventing these infections. The organisational issues underpinning infection prevention and control.
Healthcare-associated infections from invasive medical devices are linked to high morbidity, mortality, and costs worldwide. Especially in central line–associated bloodstream infection (CLABSI) or catheter-related bloodstream infection (CRBSI) and catheter-associated urinary tract infection which have been shown to pose the greatest threat to patient safety. It was because intravascular catheters and urinary catheters are the 2 most commonly used in hospital.
CLABSI is a bloodstream infection related to the presence of central venous catheters which is third most frequent nosocomial infections in the world. It is around 12% of all nosocomial infection in Europe and around 250,000 cases of CLBSIs each year in U.S. However, it is a major cause of mortality with around 12%-25% and morbidity associated with prolonged length hospital stay with around 7-21 days longer and financial resources expended with increase cost around USD$3,700-USD$29,000. It is a major burden on worldwide hospitals. However, CLABSIs are potentially preventable through the use of evidence-based practices.
According the past studies done in the industrialized Western countries, it showed that assures to essential infection control practices has noticeable to reduce in the incidence of CLABSI in patients. The goal of an effective prevention program should be the elimination of CLABSI from all patient-care areas. The goal of the measures is to reduce the rate to as low as feasible given the specific patient population being served, the universal presence of microorganisms in the human environment, and the limitations of current strategies and technologies. Consequently, in this assignment, I will show how to prevent and control CLABSIs. Pathogenesis and risk factors of CLABSIs
Pathogenesis can define how the diseases develop. Infection is the invasion of the body by microorganisms which may results in changing the status of health. Understanding the process of pathogenesis can help us to deals with the diseases more effectively.
Central venous catheters (CVCs) are intravascular access devices which place in great vessels such as internal jugular vein which place on neck, subclavian vein which place on chest, axillary vein which place on arm and femoral vein which place on groin. CVCs for the care of hospitalized and critically ill patients which can monitor the fluid level and rapidly deliver large amounts of fluid or blood. Also it can provide reliable venous access for clinical activities such as blood sampling, infusion of medications or chemotherapy and hemodynamic measurement. However, it can cause of CLABSIs and are frequently implicated in life-threatening illnesses.
The infections which associate with the CVCs include catheter-related bloodstream infection (CRBSI) and central line–associated bloodstream infection (CLABSI). However, the teams we always confusing because they are often used interchangeably even though the meanings differ. Like the other nosocomial infection, CLABSIs or CRBSIs are interacting with the factors of microorganisms in hospital environment, compromised host and chain of transmission. According to Barbara & Rabih (2004); Wilson (2006) & U.S. Department of Health and Human Services (2013), CLABSIs can induce by the contamination of CVCs which disseminate the microorganisms into bloodstream.
The microorganisms can contaminate to the device through various routes. They are including invasion of the skin insertion site that migration of skin organisms at the insertion site into the cutaneous catheter tract and along the surface of the catheter with colonization of the catheter tip; direct contamination of the catheter or catheter hub by contact with hands or contaminated fluids or devices; haematogenous spread from a other site of infection; or contamination of infusate. The first and second sources of infection are most common and very important we need to know. Firstly, the skin site and the catheter hub may contaminate by the patient’s endogenous skin flora and by exogenous flora which on health care workers’ hands.
The organisms may infect blood stream through the skin insertion site or migrate along the external surface of the catheter and migrate along the internal lumen of the catheter via the hub. The most common organisms found in CLABSIs are including coagulase-negative staphylococci, staphylococcus aureus, enterococci and Candida. Furthermore, the other important pathogenic determinants of CLABSI are the material of which the device is made, the host factors consisting of protein adhesions such as fibrin and fibronectin which form a sheath around the catheter and the intrinsic virulence factors of the infecting organism, including the extracellular polymeric substance (EPS) produced by the adherent organisms. Catheters made of surface irregularities materials are especially vulnerable to microbial colonization and subsequent infection.
This association has led to emphasis on preventing catheter-related thrombus as an additional mechanism for reducing CLABSIs. Consequently, the pathogenesis of infections of CVC devices is a multifaceted interaction. For the bacterial factors such as staphylococcus aureus which is to bind to host tissue ligands with direct contact. Also for the device factors such as the surface properties of the device material, all play a role. The factor that probably carries the most weight in terms of whether an intravascular device infection arises is the virulence properties of the colonizing organisms. However, the factors that we as health care providers may influence the most are the properties of the device itself. Risk factors
Risk factors can separate into 3 categories which include patient-related risk factors, device-related risk factors, and risk factors pertaining to catheter insertion and care. According to Goede & Coopersmith (2009), patient-related risk factors such as immunosuppression or extremes of age are not generally subject to modification. Furthermore, patient located in ICU setting have a higher infection rate than those in the general ward in-patient or out-patient setting. It may be explained by differing disease processes, severity of illness, and potentially duration of CVC placement can affect the infection rate of CLABSIs. Device-related risk factors such as length of CVC duration, type of catheter such as number of lumens, the location of the catheter, number of use per day.
According to Yeung, May & Hughes (cited in Barbara & Rabih, 2004), the trials have suggested that multi-lumen catheters are associated with a higher risk of infection than single-lumen catheters because more ports may increase the frequency of catheter using. Another factor that needs to consider is the catheter placement that affects the risk of infection is the insertion site. Comparing with the femoral, jugular and subclavian sites for venous catheterization found a higher rate of infectious and thrombotic complications at the femoral site and lower infectious complications at the subclavian site. Risk factors pertaining to catheter insertion and care such as emergent during placement, manipulated catheter, etc. Well-planned, prospective trials provide strong evidence for the use of maximal sterile barriers during catheter insertion instead of place catheter in emergency situation.
Comparing with the standard insertion techniques which include sterile gloves and small drape and maximal sterile barriers which include mask, sterile gloves, gown, large drape for placement of CVC, the rate of catheter-related septicaemia was higher in the standard barriers group than maximal sterile barriers group. Furthermore, catheters should be manipulated as little as possible to lower the infection rate. For example, haemodialysis catheters should be used only for haemodialysis. Audit and surveillance
On the other hand, conduce the surveillance is to identify the epidemiology of diseases. It targets on the frequency of specific nosocomial infection which device-related typically such as CLABSIs. It collect and analysis of laboratory data systematically that can detect the trends of nosocomial infection to find out the risk factors of infections . Process audit is designed to monitor adherence to easily measurable, important control steps. For example, the healthcare workers need to follow the guideline of hand hygiene, based on the frequency with which hand hygiene is performed when clearly indicated, monitor it by the hospital infection control practitioner to ensure healthcare workers are aware and follow the guideline of hand hygiene practices to improve the prevention of nosocomial infection .
Infection prevention and control measures Once the risk factors were identified, we can design the prevention and control measurement to modify the risk factors which break the chain of infection. Preventing CLABSIs requires a multi-strategy ranging from educational to technologic interventions. We need to pay attention must to prevention before a CVC is placed, when it is placed and every day a catheter remains in place. Standard infection control precaution
At the beginning, standard infection control precaution that needs to perform routinely to all patients to minimize the transmission of microorganisms between patients and healthcare workers. According to Wilson (2006), firstly, the proper hand washing with soap or alcohol handrubs to remove the microorganisms from the hands. However, there is evidence that healthcare worker with long finger nails are more chance to have gram negative pathogens and transmit to patient (Moolenaar et al., 2000, cited in Wilson, 2006). Thus, long finger nails may affect the efficiency of hand washing process. Secondly, the protective clotting which includes gloves, mask, permeable gowns, plastic aprons, face shields and eye protection. They may selected depends on the risk of exposure to microorganisms during take care of patients. The most common use of protection clotting is gloves and mask. Gloves should wear in any activity which handling the body fluid to prevent the contamination of hands.
In addition, it can reduce the risk of injury (Palmer & Rickett, 1992, cited in Wilson 2006). However, it needs to discard after each procedure to prevent the transmission of diseases. Masks can protect the patients which prevent the contamination of microorganisms which expelled from the respiratory tract of healthcare workers or protecting the healthcare workers which caring the patients with infectious diseases to minimize the transmission of diseases. Furthermore, strict aseptic technique, safe handling the sharps and clinical waste, disinfect the reusable equipment and dealing with spills of blood or body fluid are also important in standard infection control precaution which can break the chain of transmission and thereby prevent the infectious diseases. Precaution during CVC insertion
Before CVC insertion, a systems-based intervention featuring a catheter kit which contained a large sterile drape and maximal sterile barrier precautions which include a cap, mask, sterile gown, gloves, and a sterile full-body drape are recommended when inserting CVCs that evidence to reduce CLABSIs I mention before. Furthermore, proper skin antisepsis before a procedure is an effective route of preventing infection days later. The use of 2% chlorhexidine has been shown to result in decreased nearly 50 % in the subsequent risk of CLABSI compared 10% povidone iodine. Choose the site of CVCs insertion were important in reduce CLABSIs.
Therefore subclavian vein is recommended for CVCs insertion. Furthermore, Single lumen catheter is recommend rather than multi lumen of catheter to reduce the risk that I mention before . However, if aseptic technique cannot be ensured during insertion of CVCs, for example, catheters inserted during a medical emergency, replace the catheter as soon as possible. CVCs care after insertion
Following the insertion of a CVC, several practices may decrease the risk of developing CLABSI. Chlorhexidine dressing is recommended in reducing the microorganisms at CVC sites. However, there are no significant differences of risk of CRBSIs which comparing gauze and tape to transparent dressings. Therefore, we can choose the dressing materials case by case. Disinfect hubs, needleless connectors and injection ports prior to CVC before and after use to reduce the contamination of the catheter hub due to non-sterile access technique that is a recognized path for developing CLABSI. Disinfect the catheter hub with an appropriate antiseptic specifically recommended by the device manufacturer or swabbing the membranous septum of a CVC with 70% alcohol have been shown to reduce both risk of catheter contamination and incidence of CLABSI.
Furthermore, change the needleless components at least as frequently as the administration set and change needleless connectors no more frequently than every 72 hours or according to manufacturers’ recommendations for the purpose of reducing infection rates . On the other hand, always maintain close infusion system is benefit to reduce the risk of CRBSIs. Also replace tubing used to administer blood, blood products or fat emulsions such as parenteral nutrition within 24 hours of initiating the infusion because they are the nutrition rich substance may increase the risk of CLABSIs. Lastly, remove nonessential CVCs because each day with a CVC increases the risk of developing CLABSI. Prompt removal of CVCs that are no longer warranted is thus an important practice to reduce CLABSI.
Although there are a lot of guideline and recommendation can follow by healthcare workers, but the infection rate still high may related to knowledge deficiency of healthcare workers is the main reason of lack of compliancy of following the guideline. Therefore, educational programs that can show the appropriate indications for CVC placement and programs that review proper procedures for catheter insertion and maintenance have both been shown to reduce the incidence of CLABSI in various settings. Furthermore, reporting and monitoring for infections is an important element of CLABSI prevention. Therefore education and training regarding how to implement and assess infection control measures and periodic reassessment of this knowledge has also been shown to reduce CLABSI. Consequently, educational initiatives thus represent an important area of opportunity for institutions and health systems interested in controlling CLABSI .
Organizational issues underpinning in CLABSIs prevention
Successful of CLABSI reduction efforts using bundles has led to a renewed appreciation of organizational complexities such as local culture, clinical care team engagement that influence the implementation of evidence-based practices in health care settings. In a study, using data collected as part of a multi-centre study that answer why certain hospitals were more likely to succeed in CLABSI reduction efforts than others. Thus, closely examined quality improvement efforts and the implementation of recommended practices to prevent CLABSI and compare the experiences among hospitals to better understand certain hospitals were more successful with practice implementation when taking into consideration specific aspects of the organizational context. Furthermore, by use of externally-facilitated initiatives such as infection prevention measures, technology-based solutions or a quality collaborative may provide the motivation and sometimes resources which needed for implementation needed to implement CLABSI prevention measures and overcome these major obstacles. Those interventions can issues underpinning in CLABSIs prevention and control.
CLABSIs are the common nosocomial infection in healthcare setting that may lead to high morbidity, mortality, and costs. Well control the nosocomial infection is very important in healthcare setting. If all the nosocomial infection can well controlled, it can decrease the day of hospitalization, improve the health status and reduce the cost in the treatment of nosocomial infection. Thus, we can improve the healthcare services in the other areas.
Word count: 2760
Aviles, M. R. ed. (2010) Toolkit for Preventing Health Care-Associated Infections. Oakbrook Terrace: Joint Commission Resources. Barbara, T. & Rabih, D. (2004) Catheter-Associated Infections: Pathogenesis Affects Prevention. Archives of Internal Medicine, 164(8), pp. 842-850. Crosby, C. T. (2005) Catheter site dressings and infection control. Healthcare Purchasing News, 29(2), pp. 36-37. Eggimann, P., Sax, H. & Pittet, D. (2004) Catheter-related infections. Microbes and Infection, Volume 6, pp. 1033-1042. Fahy, B. & Sockrider, M. (2007) Central Venous Catheter. [Online] Available at: http://patients.thoracic.org/information-series/en/resources/central-venous-catheter.pdf [Accessed 20 July 2013].
Goede, M. R. & Coopersmith, C. M. (2009) Catheter-Related Bloodstream Infection. Surgical Clinics of North America, 89(2), pp. 463-474. Krein, S L; Damschroder, L J; Kowalski, C P; Forman, J; Hofer, T P; Saint, S (2010) The influence of organizational context on quality improvement and patient safety efforts in infection prevention: a multi-center qualitative study. Social Science and Medicine, 71(9), pp. 1692-1701. Marik, P. E., Flemmer, M. & Harrison, W. (2012) The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis.. Critical Care Medicine, 40(8), pp. 2479-2485. Mermel, L. A. (2007) Prevention of central venous catheter-related infections: what works other than impregnated or coated catheters?. The Journal of Hospital Infection,
65(2), pp. 30-33. O’Grady, N P; Alexander, M; Burns, L A; Dellinger, P; Garland, J; Heard , S O; Lipsett, P A; Masur, H; Mermel, L A; Pearson, M L; Raad, I I; Randolph, A; Rupp, M E; Saint, S. (2011) Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. [Online] Available at: http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf [Accessed 18 July 2013].
Rosenthal, V D; Maki, D G; Rodrigues, C; Alvarez-Moreno, C; Leblebicio, H; Sobreyra-Oropeza, M; Berba, R; Madani, N; Medeiros, E A; Cuellar, L E; Mitrev, Z; Duenas, L; Guanche-Garcell,, H; Mapp, T; Kanj, S S; Fernandez-Hidalgo, R. (2010) Impact of International Nosocomial Infection Control Consortium (INICC) Strategy on Central Line–Associated Bloodstream Infection Rates in the Intensive Care Units of 15 Developing Countries. Infection Control and Hospital Epidemiology, 31(12), pp. 1264-1272. Rupp, M E; Sholtz, L A; Jourdan, D R; Marion, N D; Tyner, L K; Fey, P D; Iwen, P C; Anderson, J R (2007) Outbreak of bloodstream infection temporally associated with the use of an intravascular needleless valve. CID, Volume 44, pp. 1408-1414. Tortora, G. J., Funke, B. R. ; Case, C. L. (2010) Microbiology: An introduction. 10th ed. San Francisco: Pearson Education. U.S. Department of Health and Human Services (2013) Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. [Online] Available at: http://www.ahrq.gov/research/findings/evidence-based-reports/ptsafetyII-full.pdf [Accessed 26 July 2013].
Weber, S. G. ; Salgado, C. (2013) Healthcare Associated Infections: A Case-based Approach to Diagnosis and Management. New York: Oxford University Press. Wilson, J. (2006) Infection Control in Clinical Practice. 3rd ed. Lodon: Elsevier.