Guidelines for preventing healthcare-associated infections in primary and community care

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Guidelines for preventing healthcare-associated infections in primary and community care Section 5 of 5 sections; each section is in an individual file Full guideline; section 5; draft for consultation,
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Guidelines for preventing healthcare-associated infections in primary and community care Section 5 of 5 sections; each section is in an individual file Full guideline; section 5; draft for consultation, February 2003 Page 1 of 49 SECTION 5 Guidelines for preventing healthcare-associated infections in caring for patients with central venous catheters in primary and community care Introduction Patients in the community with chronic health conditions may require long-term central vascular access as a necessary component of their treatment. Shorter-term central vascular access may also occasionally be needed, e.g., for completion of intravenous antimicrobial therapy. Bloodstream infections (BSI) related to the use of central venous catheters (CVCs) are associated with substantially increased costs, morbidity and mortality. Although the use of CVCs accounts for the vast majority of hospital-acquired BSI, the rates of catheter-related BSI (CRBSI) in patients in community and primary healthcare settings in England are unknown. Expert review of evidence These guidelines are primarily based upon an expert review of evidence-based guidelines for preventing intravascular device-related infections developed at the Centers for Disease Control and Prevention (CDC) in the United States of America by the Healthcare Infection Control Practices Advisory Committee (HICPAC). (1,2) Using a validated guideline appraisal instrument developed by the AGREE collaboration, (3) three experienced appraisers independently reviewed these guidelines, taking into consideration supplementary information provided by HICPAC at our request (see CVC Appendix 1). We concluded that the development processes were valid and that the guidelines were: evidence-based; categorised to the strength of the evidence examined; reflective of current concepts of best practice; and acknowledged as the most authoritative reference guidelines currently available. They were subsequently recommended as the principal source of evidence for developing the guidance below. Systematic review process After this appraisal, we systematically searched, retrieved and appraised additional supporting evidence published since the HICPAC guidelines were developed (CVC Appendix 2). This search was confined to elements of infection prevention where expert members of the Guideline Development Group indicated new developments or changes in technology had occurred, or where pertinent new experimental trials or systematic reviews had been published. The following systematic review questions were used: Should the catheter insertion site be protected by a dressing and, if so, which type of dressing should be used and how frequently should it be changed? Full guideline; section 5; draft for consultation, February 2003 Page 2 of 49 Which antiseptic/disinfectant was best for: preparation of the skin site (cutaneous antisepsis) prior to central venous catheter insertion; cleansing of the entry site once the catheter was in place (if any such evidence exists that routine cleansing prevents infections); cleaning the catheter hub and/or injection ports prior to accessing the system? Should the catheter be routinely flushed before or after accessing. If so, which solution, e.g., heparin or normal saline, should be used.? Would low-dose systemic anticoagulation reduce the risk of bloodstream infections? Was the maintenance of a closed system, e.g., Vygon Bionector 2 Connection Accessory, practicable, effective in reducing infection complications, and costeffective? Did stopcocks and three-way taps increase the risk of catheter colonisation and/or bloodstream infections? Did the use of inline filters (in-line filtration of microbes/endotoxins) prevent bloodstream infections? How frequently should the intravenous catheter administration set be changed? In setting up the search the following MeSH terms were used: Infection control; cross infection; universal precautions; equipment contamination; disease transmission; bacteremia; chlorhexidine; povidone-iodine; anticoagulants; sepsis; central venous catheterisation; indwelling catheters; parenteral nutrition. In addition the following free text terms were used: PICC; TPN; catheter hub; catheter port; dressings; flushing solutions. These databases were searched from 1998: Medline, Cumulated Index of Nursing and Allied Health Literature (CINAHL), Embase, The Cochrane Library, National Electronic Library for Health, The NHS Centre for Reviews and Dissemination (CRD), The National Research Register, The Web of Science, The Institute of Health Technology, Health CD Database, Health Management Information, Consortium Database. Search Results: 4650 articles were located. They were initially sifted to determine if they related to infections associated with central venous catheters, were written in English, were primary research or were a systematic review or a meta-analysis, and appeared to inform one or more of the review questions. Following this first sift, 153 full text articles were retrieved. Using the same criteria as in the first sift, retrieved full-text articles were then re-sifted to select those for critical appraisal. A total of 18 full text articles were independently critically appraised by two appraisers. Consensus and grading was achieved through discussion. Following critical appraisal, 11 were accepted into the study (7 were rejected). Evidence tables for accepted and rejected studies were generated and used to create evidence summary reports (see CVC Appendix 3). The summary reports along with Full guideline; section 5; draft for consultation, February 2003 Page 3 of 49 the primary evidence from the Expert Review of the HICPAC Guidelines, were used as the basis for guideline writing. Previously, a similar process had informed the development of national guidelines for preventing CRBSI in hospitals associated with the insertion and maintenance of CVCs commissioned by the Department of Health (England) and published in (4) It is expected that patients in primary and community care settings would have a CVC inserted or replaced in hospital where these guidelines apply. Consequently, recommendations for the selection of the best type of catheter and insertion site and the optimum aseptic technique required during CVC placement are not included in guidance for community and primary healthcare personnel as these issues are addressed in the above guidelines for acute care facilities. However, it is good practice for hospital and relevant community nursing staff to discuss in advance the selection of the most appropriate type of catheter in relation to the available skills and resources in the community to care for patients with different types of central vascular access devices. Following our reviews, guidelines were drafted which described 28 recommendations within the below 4 intervention categories: Education of patients, their carers and healthcare personnel; General asepsis; Catheter site care; Standard principles for catheter management; These guidelines apply to caring for all adults and children in the community with CVCs which are being used for the administration of fluids, medications, blood components and/or total parenteral nutrition (TPN). They are to be used in addition to the guidance on Standard Principles for preventing healthcare-associated infections (HAI). Although these recommendations describe general principles of best practice that apply to all patients in the community using long-term central vascular access devices, they do not specifically address the more technical recommendations needed for the management of haemodialysis patients who will generally have their CVCs managed in dialysis centres. Because these recommendations describe broad general statements of best practice, they need to be adapted and incorporated into local practice guidelines. References 1. Centers for Disease Control and Prevention. Guidelines for the prevention of intravascular-catheter-related infections. MMWR 2002;51(No. RR-10):1-29. Available from: 2. Centers for Disease Control and Prevention. Erratum Appendix B. MMWR 2002;51(32):711. Available from: 3. The Agree Collaboration. Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument. June 2001, St Georges Hospital Medical School, London. Available from: 4. Pratt RJ, Pellowe C, Loveday HP, Robinson N, Smith GW, and the epic guideline development team; Barrett S, Davey P, Harper P, Loveday C, McDougall C, Mulhall A, Full guideline; section 5; draft for consultation, February 2003 Page 4 of 49 Privett S, Smales C, Taylor L, Weller B, and Wilcox M. The epic project: Developing national evidence-based guidelines for preventing healthcare associated infections. Phase 1: Guidelines for preventing hospital-acquired infections. Journal of Hospital Infection 2001a January 47(Supplement):S1-S82. Available from: Full guideline; section 5; draft for consultation, February 2003 Page 5 of 49 Intervention 1 Education of patients, their carers and healthcare personnel To improve patient outcomes and reduce healthcare costs, it is essential that everyone involved in caring for patients with CVCs is educated about infection prevention. Healthcare personnel, patients and their carers need to be confident and proficient in infection prevention practices and to be equally aware of the signs and symptoms of clinical infection and how to access expert help when difficulties arise. Wellorganised educational programmes that enable healthcare personnel to provide, monitor, and evaluate care and to continually increase their competence are critical to the success of any strategy designed to reduce the risk of infection. Evidence reviewed by HICPAC consistently demonstrated that the risk for infection declines following the standardisation of aseptic care and increases when the maintenance of intravascular catheters is undertaken by inexperienced healthcare personnel. (1) IV Recommendations CVC1. Before discharge from hospital, patients and their carers should be taught any techniques they may be required to undertake in order to prevent infection and safely manage a central venous catheter. CVC2. Community healthcare personnel need to be trained and assessed as competent in using and consistently adhering to the infection prevention practices described in these guidelines in caring for a patient with a CVC. CVC3. Follow-up training and support of patients with CVCs and their carers needs to be available. D D D References 1. Centers for Disease Control and Prevention. Guidelines for the prevention of intravascular-catheter-related infections. MMWR 2002;51(No.RR-10):1-29. Available from: Full guideline; section 5; draft for consultation, February 2003 Page 6 of 49 Intervention 2 General Asepsis Good standards of hand hygiene and antiseptic technique can reduce the risk of infection Because the potential consequences of CRBSI are so serious, enhanced efforts are needed to reduce the risk of infection to the absolute minimum. For this reason, hand antisepsis and proper aseptic technique are required for changing catheter dressings and for accessing the system. (1,2) Hand antisepsis can be achieved by washing hands with an antimicrobial liquid soap and water or by using an alcohol-based hand rub. When hands are visibly dirty or contaminated with organic material, such as blood and other body fluids or excretions, they must first be washed with soap and water if alcohol-based hand rubs are going to be used to achieve hand antisepsis. In community and primary care settings, alcoholbased hand rubs are the most consistently accessible and appropriate agent to use for hand antisepsis. Appropriate aseptic technique does not necessarily require sterile gloves; a new pair of disposable nonsterile gloves can be used in conjunction with a no-touch technique, for example, in changing catheter site dressings. (1) The Standard Principles for Preventing HAI previously described in these guidelines gives additional advice on hand decontamination and the use of gloves and other protective equipment. Recommendations CVC4. An aseptic technique must be used for catheter site care and for accessing the system. Ib Ib IV B CVC5. Before accessing or dressing central vascular catheters, hands must be decontaminated either by washing with an antimicrobial liquid soap and water or by using an alcohol handrub. A CVC6. Hands that are visibly soiled or contaminated with dirt or organic material must be washed with soap and water before using an alcohol handrub. A CVC7. Following hand antisepsis, clean gloves and a no-touch technique or sterile gloves should be used when changing the insertion site dressing. D References 1. Centers for Disease Control and Prevention. Guidelines for the prevention of intravascular-catheter-related infections. MMWR 2002;51(No.RR-10):1-29. Available from: Full guideline; section 5; draft for consultation, February 2003 Page 7 of 49 2. Centers for Disease Control and Prevention. Guidelines for hand hygiene in health-care settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002;51(No.RR-16):1-45. Available from: Full guideline; section 5; draft for consultation, February 2003 Page 8 of 49 Intervention 3 Catheter Site Care Use the right dressing regimen to protect the catheter site Following CVC placement, one of two types of dressings is used to protect the catheter site; sterile gauze and tape or sterile transparent semipermeable polyurethane dressings. HICPAC reviewed the evidence up to the end of 1999 related to which type of dressing provided the greatest protection against infection and found little difference. (1) They concluded that the choice of dressing can be a matter of preference. If blood is oozing from the catheter insertion site, a gauze dressing might be preferred. Our systematic review did not identify any additional evidence which conflicted with HICPAC s conclusions. Ib Gauze dressings are not waterproof and require frequent changing in order to inspect the catheter site. They are rarely useful in patients with long-term CVC. Sterile transparent, semipermeable polyurethane dressings have become a popular means of dressing catheter insertion sites. These reliably anchor the CVC, permit continuous visual inspection of the catheter site, allow patients to bathe and shower without saturating the dressing, and require less frequent changes than do standard gauze and tape dressings, saving healthcare personnel time. Ib Recommendations CVC8. Preferably, a sterile, transparent, semipermeable polyurethane dressing should be used to cover the catheter site. CVC9. If a patient has profuse perspiration or if the insertion site is bleeding or oozing, a sterile gauze dressing is preferable to a transparent, semi-permeable dressing. Gauze dressings should be changed when they become damp, loosened or soiled and the need for a gauze dressing should be assessed daily; a gauze dressing should be replaced by a transparent dressing as soon as possible. CVC10. Transparent dressings should be changed every 7 days or when they are no longer intact or moisture collects under the dressing. A D A CVC11. Dressings used on tunnelled or implanted CVC sites should be replaced every 7 days until the insertion site has healed unless there is an indication to change them sooner. A Full guideline; section 5; draft for consultation, February 2003 Page 9 of 49 Reference 1. Centers for Disease Control and Prevention. Guidelines for the Prevention of Intravascular-catheter-related Infections. MMWR 2002;51(No.RR-10):1-29.Available from: Use an appropriate antiseptic agent for disinfecting the catheter insertion site during dressing changes HICPAC described compelling evidence that aqueous chlorhexidine 2 percent was superior to either 10% povidone iodine or 70% alcohol in lowering CRBSI rates when used for skin antisepsis prior to CVC insertion. They made no recommendation for the use of any disinfectant agent for cleaning the insertion site during dressing changes. (1) A recent meta-analysis assessed studies that compared the risk for CRBSI following insertion-site skin care with either any type of chlorhexidine gluconate (CHG) solution vs. povodine iodine (PI) solution. (2) This analysis indicated that the use of CHG rather than PI can reduce the risk for CRBSI by approximately 49% (risk ratio, 0.51 [CI, 0.27 to 0.97]) in hospitalised patients who require short-term catheterisation, i.e., for every 1000 catheter sites disinfected with CHG rather than PI, 71 episodes of catheter colonization and 11 episodes of CRBSI would be prevented. In this analysis, several types of CHG solutions were used in the individual trials, including 0.5 percent or 1 percent CHG alcohol solution and 0.5 percent or 2 percent CHG aqueous solution. All of these solutions provided a concentration of CHG that is higher than the minimal inhibitory concentration (MIC) for most nosocomial bacteria and yeasts. Subset analysis of aqueous and non-aqueous solutions showed similar effect sizes, but only the subset analysis of the five studies that used alcoholic CHG solution produced a statistically significant reduction in CRBSI. Because few studies used CHG aqueous solution, the lack of a significant difference seen for this solution compared with PI solution may be a result of inadequate statistical power. Alcohol and other organic solvents and oil-based ointments and creams may damage some types of polyurethane and silicon CVC tubing. The manufacturer s recommendations for only using disinfectants that are compatible with specific catheter materials must be followed. Recommendations CVC12. Preferably, an alcoholic chlorhexidine gluconate solution should be used for cleaning the catheter site during dressing changes and allowed to air dry. An aqueous solution of chlorhexidine gluconate should be used if the manufacturer s recommendations prohibit the use of alcohol with their product. CVC13. Individual sachets of antiseptic solutions or individual packages of antiseptic impregnated swabs or wipes should be used to disinfect the dressing site. Ib Ia IV A D Full guideline; section 5; draft for consultation, February 2003 Page 10 of 49 CVC14. Healthcare personnel should ensure that catheter-site care is compatible with catheter materials (tubing, hubs, injection ports, luer connectors and extensions) and carefully check compatibility with the manufacturer s recommendations. D References 1. Centers for Disease Control and Prevention. Guidelines for the prevention of intravascular-catheter-related infections. MMWR 2002;51(No.RR-10):1-29. Available from: 2. Chaiyakunapruk N, Veenstra DL, Lipsky BA, Saint S. Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: A meta-analysis. Annals of Internal Medicine 4 June 2002;136(11): Available from: Full guideline; section 5; draft for consultation, February 2003 Page 11 of 49 Intervention 4 General Principles for Catheter Management Aseptic technique is important when accessing the system Following their review of the evidence, HICPAC stressed the importance of minimising the risk of introducing infection by using an appropriate antiseptic to decontaminate the access port before accessing the system with sterile devices. As most modern catheter hubs, luer connectors and other access ports are made from alcohol-resistant materials, the use of alcohol wipes, chlorhexidine gluconate or an iodophor for this purpose are recommended by HICPAC. However, they stress the importance of ensuring that any antiseptic agent used is chemically compatible with catheter hubs, ports and connectors. (1) III Recommendation CVC15. The injection port or catheter hub should be decontaminated with either alcohol or an alcoholic solution of chlorhexidine gluconate before and after it has been used to access the sy
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