Bridging the gap: introduction of an antimicrobial peripherally inserted central catheter (PICC) in response to high PICC central line-associated bloodstream infection incidence*
To reduce the incidence of central line-associated bloodstream infection (CLABSI) in peripherally inserted central catheters (PICC) through the introduction of an antimicrobial (AM) catheter as recommended in evidence-based guidelines and standards.
Quality improvement project comparing incidence of infections pre-implementation and postimplementation of the new catheter.
A 582-bed community teaching hospital in Northwest Indiana.
Pre-implementation analysis of surveillance data indicated that 50% of CLABSIs occurred inpatients with PICCs in situ. A gap analysis was performed to review institutional practices against evidence-based recommendations. The use of an AM catheter was supported in each of the documents consulted. After introduction of the new device, performance was measured in a prospective manner using standardized Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) surveillance protocols for CLABSI and internal data sources for other measures.
After 30 months of data collection, the PICC CLABSI incidence reduced from a baseline rate of 1.83/1000 PICC days to 0.162/1000 PICC days (91.15% reduction, P=0.0002).
Combined with continued compliance with basic prevention strategies (ie use of a central line insertion checklist/insertion bundle) and optimization of device selection and lumen justification, the introduction of an antimicrobial/antithrombogenic (AM/AT) PICC was associated with a significant reduction in CLABSI.
Central venous catheters represent lifesaving devices for patients with critical vascular access needs. Peripherally inserted central catheters(PICCs)are a common choice for patients requiring longer courses of therapy, particularly with infusates such as vasopressors, parenteral nutrition, and pH considerations. PICCs are often placed by specially trained nursing (or respiratory therapist) teams at the patient's bedside, using tip navigation technology that can eliminate the need for chest X-ray confirmation before use in many organizations.
In 2016, as part of the organization's annual infection control risk assessment, a gap analysis was performed regarding central line-associated bloodstream infection (CLABSI) reduction activities. Fifty percent of CLABSIs occurred in patients with PICCs, which continued through the next year before implementation of the new device. The guidelines and standards reviewed were all aligned in favor of antimicrobial (AM) device use when CLABSI rates remain elevated despite adherence to central line insertion bundle and other prevention strategies, as shown in Table 1.1,2,3,4 A recent published systematic review and meta-analysis also supports reduction in CLABSI incidence with the use of AM devices.5 Previous studies have reviewed performance in acute care as well as long-term acute care settings, although not all have demonstrated decrease in infections.6,7,8 In our gap analysis, the only other items beyond AM catheters that were noted as significantly discrepant from the reviewed recommendations were the team's overreliance on triple- and double-lumen catheters (single-lumen devices were not used at the time) and the absence of a trained observer for up to 50% of PICC placements. The nurse-led vascular access team (VAT) presented a proposal through Shared Governance to pilot and ultimately adopt an AM/antithrombogenic (AT) catheter (Arrowg+ard Blue Advance™ PICC). Additionally, lumen justification criteria were introduced into order sets, and the team added single-lumen devices to their available stock.
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