At Sutter Roseville Medical Center (SRMC) in Roseville, CA, our PICC team has been able to accomplish something that is rare in healthcare. We implemented a central line bundle of our own creation in January 2006, and to this day, we have not had any catheter-related bloodstream infections.

Of course, we didn't begin our project to set the healthcare world on its ear. We were simply trying to improve care for our patients. The previous year, our facility reported 11 occurrences of CRBSI, and we knew we could do better.

Our goal was a bundle, or group of evidence-based practices, that would minimize the risk of infection at every step of the insertion and site care continuum. We didn't really invent anything—we simply did our homework, reviewing the literature for practices and product technologies with proven effectiveness against CRBSI. We examined best practices at well-regarded facilities and met with product representatives so we could view demonstrations that interested us.

Ultimately, we identified practices and products to address the problem comprehensively, and we assumed full responsibility for central lines. Thanks to the bundle and an early assessment program—where we advocate for a central line within the first 24 – 48 hours, should the diagnosis warrant it—our IV team was redirected into a more advanced vascular access team that consistently placed the most appropriate line for each patient.

Since we implemented the new bundle and the assessment program, our PICC volume has really started to climb; it's up 195%. At the same time, we eliminated our CRBSIs—an added plus.

We had no idea we could achieve a zero CRBSI rate. The fact that we accomplished our goal—joining the growing ranks of other facilities that are achieving similar results—suggests that hospitals nationwide can create a predictably strong defense against CRBSI by applying best practices with best products and relentless attention to detail.

Why it matters

CRBSIs are some of the most significant of all hospital-acquired infections (HAIs), both clinically and financially. About 250,000 central venous catheter–related BSIs occur every year. They are among the most dangerous HAIs, with an attributable mortality rate of 12 – 25%.

CRBSIs impose substantial costs on the healthcare system, both in terms of actual dollars and increased length of stay. Each infection costs $34,000 to $56,000 to treat, and extends length of stay an average of seven days, according to the Institute for Healthcare Improvement (IHI). Hospitals are paying closer attention to these figures because the Centers for Medicare and Medicaid Services (CMS) recently ruled that in October 2008, it will cease reimbursement for certain preventable infections, including CRBSI. Most private insurers are expected to follow the lead of CMS, leaving hospitals with even stronger financial and clinical incentives to reduce the incidence of these infections.

A preference for PICCs

Fortunate timing paved the way for our bundle project. Our PICC team would not have been able to take responsibility for almost 95% of central lines at our institution if new PICC technology hadn't appeared on the scene at the right time.

In 2006, PICC catheters became available that allowed for power injection for CECT scans and hemodynamic monitoring. This made PICCs a viable alternative to centrally inserted central catheters for our critical care patients and meant the PICC team could insert most lines.

This was good news all the way around. Patients benefited because PICC lines have fewer complications than centrally inserted central catheters. Physicians benefited from patients receiving the appropriate line more quickly, resulting in therapeutic interventions being delivered in a more timely manner. The PICC team benefited, as we managed all PICC lines from admission to discharge and could identify complications sooner.

Under the early assessment program for each patient in the hospital, PICC nurses educated staff at the bedside on candidates for PICC catheters. For example, PICC lines are appropriate for patients with limited venous access who require short-term aggressive treatment or those with certain diagnoses, like severe cellulitis or an osteomyelitis, who need antibiotics for four to six weeks. Also, if the pH of the medication (e.g., vancomycin, chemotherapy drugs, or total parenteral nutrition) is not between 5 and 9, a standard of practice recommended by the Infusion Nurses Society, then we advocate for a central line. Otherwise, a peripheral IV is appropriate. The right catheter for the right patient, with the right diagnosis, at the right time remains at the core of this project.

Bundle components

Our bundle consists of seven components that, when used consistently, have been successful. We begin with maximum barrier precautions. The nurse and the patient are fully covered and all protective measures are taken. Since the upper arm has the lowest incidence of bacterial skin contamination of any central line access point, it is the vein of choice when placing the PICC.

We also use 100% ultrasound-guided PICC insertion. All PICC nurses are trained in the ultrasound guided insertion.

In addition, we use several antimicrobial interventions in placing each line, including aggressive cleansing of the skin with alcohol and chlorhexidine (CHG) prior to PICC insertion, followed by the use of a protective disk with CHG placed directly on the insertion site. We eliminated the 24-hour gauze pressure dressing and instead placed the protective disk on the insertion site following line placement. Bacteria colonization that is suppressed by CHG antisepsis before insertion can re-establish itself in the several days afterward, because some bacteria will survive antisepsis and begin multiplying again. With its secretion of CHG for seven days, the protective disk attacks this re-colonization for the entire period between routine dressing changes. We applied a securement device that assisted with catheter stabilization as well. This resulted in less movement and less irritation and subsequently decreased the potential for complications.

Our technology review also supported the use of a neutral connector device. A neutral connector device provides a number of advantages. It eliminates reflux episodes, supports our saline-only flushing policy and septum disinfection protocol, and helps prevent the complication of occlusion.

Septum disinfection proved to be a critical component to our bundle and one that many would assume everyone does without instruction. However, our review of septum disinfection revealed a wide variation in practice, technique, and thoroughness in cleansing the catheter hub, and required time and attention to assure it was done correctly.

Another critical element was the catheter flushing protocol. Our facility uses saline-only flushing for all catheters except port-a-caths and dialysis catheters. We created a grid for all staff to follow on the correct way to flush lines, using the push-pause method. This grid assists staff in flushing each central line with the correct amount of saline at correct intervals and also establishes routine flushing times to maintain catheter flow and decrease occlusion.

The last line of defense is the PICC team itself, whose members are trained to care for inpatients in all units as well as individuals visiting the outpatient infusion center. Four to five nurses are available weekdays, with three PICC team members staffing weekends.

Team members insert the lines, which can take up to two hours from start to finish, including assessment, consent, prep, insertion, cleanup, charting, and radiology read. As of this January, we have a standardized protocol for initial interpretation of the chest X-ray by the PICC nurse, with radiologist confirmation within 24 hours. Two nurses may work as a team, with one inserting the line and the other setting up the PICC tray, drawing up the saline and lidocaine, and completing the paperwork, reducing the time considerably.

PICC team members also perform daily monitoring. Continuous monitoring decreases complications and increases compliance with the bundle. When staff members join our team, they must be dedicated to patients and have a desire to contribute to a skilled PICC team, including following protocols. When the right people do the right things, it's a powerful combination that drives success.

Sharing the message

As the number of months without CRBSIs mounted, we were thrilled to have found something that worked in our institution and to have protected our patients against potentially fatal infections. All patients deserve to come into a hospital and be free from infection, and that's where our team has made a huge difference.

Along the way, colleagues in vascular access encouraged us to share our experience, which has promoted camaraderie, strong teamwork, and respect for one another. Our PICC nurses have been empowered by the admiration they've gained from peers, physicians, and other members of the interdisciplinary team. Doctors and hospital administrators now have a whole new understanding and dialogue for this type of advanced vascular access team. They know who we are, what we do, and what we're capable of doing. This level of respect, in turn, has allowed us to advance, continuing successful insertions and the successful elimination of infections.

We close by encouraging each of you to share your clinical success stories with your peers in whatever forum you have available. As we all learn from each other, our patients will only benefit more.

Achieving best practices

Interested in implementing similar best practices for reducing CRBSIs at your institution? Follow these suggestions:

• Read professional journals and perform an evidence-based practice literature search. Look up IHI and CDC recommendations, as well as others found at www.guidelines.gov.
• Join specialty associations, such as the Infusion Nurses Society, Association for Vascular Access, or Association for Professionals in Infection Control & Epidemiology, Inc., and network with colleagues from across the country to gain additional recommendations and insights.
• Determine products to be included in the bundle and retain key speakers who can demonstrate usage and infection control properties.
• Include team members in decision-making processes, adjusting policy and developing new institutional protocols.
• Get management and staff buy-in through supporting evidence, such as increased volume and reduced instances of infection. Be able to show why you want to move in a certain direction and the expected positive outcomes for quality of care, patient safety, and overall satisfaction.
• Create an intensive one-to-one training program that includes a four- to six-week competency component with a goal of 25 – 50 ultrasound insertions before being allowed to practice independently.
• Implement aggressive education to disseminate information to hospital staff on new products, policies, and procedures (like flushing protocols).
• Use a simplified, user-friendly data collection tool that is compatible with your existing IT system and consistently track outcomes.
• Work closely with your manager, director, and chief nurse executive to ensure open positions on the PICC team are filled in a timely manner and necessary resources are obtained.
• Be prepared for increased public interest in your hospital's infection rates and protocols as media attention builds around preventable infections and CMS' revised reimbursement policies.

By the numbers