Prevention Strategy 4: Choice of site / 预防策略 4 ：选择穿刺部位

The risk of catheter-related infection is lower with which insertion site? / 哪个部位导管相关性感

染的风险小些？

A. Internal Jugular Vein / 颈内静脉 B. Subclavian Vein / 锁骨下静脉

Prevention: What Site is Best? / 预防策略：那个部位最好？• RCT of femoral (n=145) and subclavian (n=144) lines in the ICU 在 ICU 进行的穿刺部位比较的随机对照研究 : 股静脉 (145 例 ) 和锁骨下静脉 (144 例 )• Outcomes/ 结果

– Mechanical complications / 机械性并发症 : 17.3% vs 18.8% (p 值无差异 ) – Infectious complications (colonization and BSI combined) in femoral grp:

19.8% vs 4.5% (p < .001) 感染（含细菌定植和血流感染在内）股静脉组 :19.8% vs 4.5% (p < .001)

– Thrombotic complications in femoral grp: 21.5% vs. 1.9% (p < .001); complete thrombosis 6% vs 0% 血栓并发症股静脉组： 21.5% vs. 1.9% (p < .001); 完全栓塞 6% vs 0%

JAMA; 2001,286:700-7

Prospective, Randomized, Multicenter Study of 750 Femoral vs Jugular Hemodialysis CVCs

750 例中心静脉导管血液透析穿刺部位股静脉与颈内静脉的前瞻性，随机，多中心研究

Parienti et al JAMA 2008

Femoral/ 股静脉 Jugular/ 颈内静脉CVC CVC

CRBSI/1000 catheter days 1.5 2.3 (p=0.4)

Cath coloniz/1000 cath d 41 36 (p=0.3)

Cath coloniz/1000 cath d 51 25 in pts with BMI >28/ 体重指数 >28 (HR 0.4[0.23-.69])

Cath coloniz/1000 cath d 24 45 in pts with BMI <24/ / 体重指数 <24 (HR 2.1 [1.1 – 3.9])

Subclavian Site for CVCs / 锁骨下静脉 CVC

• In adult patients, a subclavian site is preferred for infection control purposes / 成年患者锁骨下静脉是预防感染的首选部位

Þ although other factors (e.g. the potential for mechanical complications, risk for subclavian vein stenosis, obesity or hypoxemia, use of ultrasound guidance) may dictate site insertion 虽然其他因素（潜在的机械性并发症，锁骨下静脉狭窄风险，肥胖或血氧不足，使用超声引导等）可能会影响穿刺

Prospective, Randomized, Multicenter Study of Femoral vs Subclavian CVC Insertion / 股静脉穿刺锁骨下静脉穿刺部位的前瞻性，随机，多学科比较

†Femoral insertion independent risk for thrombosis (OR 14.4)股静脉独立危险因素Merrer et al JAMA 2001

Femoral SubclavianCVC† CVC

Cath. Colonization （定植） 14.2% 2.2% (p≤0.01)

CR Sepsis （脓毒血症） 4.4% 1.5%

CR thrombosis （血栓） 6% 0%

Prevention: What site is best? / 预防：那个部位最好？• Based on these and other studies, many experts recommend the

preferred order of line placement is SC IJ F / 基于上述研究，许多专家推荐穿刺部位的选用顺序为锁骨下静脉颈内静脉股静脉• Other factors to consider in site choice / 部位选择的其他考虑因素

– Anatomic deformity 解剖畸形改变– Coagulopathy 凝血异常– Operator experience 操作者经验

• Caveat--Hemodialysis catheters, JAMA article shows that femoral>IJ especially in highest BMI patients (JAMA 2008:299;2413-22) 警告—血透导管， JAMA 文章显示股静脉 > 颈内特别是身体指数高（肥胖）的患者

Finding the site using ultrasound / 使用超声引导

Pooled RRfor mechanical

complications with bedside US机械性并发症的相对危险度

Randolph AG et al. Crit Care Med 1996:24;2053-8

Tips About Execution执行要点

CourtesyTrish Perl, MD

Line Cart Contents/CVC 穿刺车内容物

“Stop the Line” (Toyota)“ 中止插管” ( 恰与丰田的口号一致 - 自动化生产线 )

• If a defect or break in recommended practices is noted during the procedure, nurse or physician observer is present during insertion and empowered to “stop the line” immediately if checklist not followed (i.e., breach in aseptic technique observed) / 操作中，如果操作规程中的要求出现中断或缺失，当值护士或医生可要求立即中止插管（如明显违反无菌原则等）

• Empowerment still an issue in many locations (Culture of Safety) / 医疗场所授权仍是一个有待解决的问题（安全文化）

Prevention Strategy 5: Other Considerations预防策略 5 ：其他要素

After Insertion/ 穿刺后• Perform surveillance for CLABSI using NHSN

definitions / 依照 NHSN 的定义监测 CLABSI– Focus first on ICUs / 重点关注 ICU

– Risk of CLABSI per CVC day as high in pts outside ICUs but surveillance more resource-intensive / CLABSI 风险 ICU 并非最高，但监测资源较集中在 ICU

– Hospital-wide inpatient CLABSI surveillance now required per TJC NPSG / 目前住院患者的 CLABSI 监测要求符合美国病人安全目标

• Assess need for line daily basis --- during multidisciplinary rounds / 根据每日需要保留导管—多学科查房

• Use the daily review sheet to prompt discussion of line removal. / 借助每日核查表，迅速判断是否拔管

• Avoid routine replacement of central lines, even over guidewires. /避免常规更换 CVC ，即使通过导丝

Implementation: Daily Review of Line Necessity / 执行：每日检查导管保留的必要性

Fact: Catheters and other invasive devices are the # 1 exogenous cause of hospital-acquired infections. / 事实 : 导管和其它侵入装置是造成院内感染的首要外因之一Actions:

use catheters only when essential /只有当必要时才使用导管use the correct catheter/ 使用正确的导管use proper insertion & catheter-care protocols /正确的置入 & 导管照护流程remove catheters when not essential 拔除不必要的导管

Take Home Points ： Get the catheters out不需要的时候就拔除导管

After Insertion/ 穿刺后Disinfect catheter hubs, needleless connectors, and injection ports before accessing / 在连接输液前，消毒导管接头，无针接头和注入座

Adjuvant Strategies/辅助策略• CHG impregnated transparent dressings

/ 含有 CHG 的透明敷料• Impregnated caps for end of ports

/ 含有消毒剂的保护帽

Stopcock Contamination三通接头污染• Microbial contamination rate of needleless connectors

in cardiothoracic patients undergoing surgery: /胸外科手术患者中，无针连结接头细菌污染率– Internal surfaces of 20/200 (10%) of three-way

stopcock Luers with standard caps were contaminated vs. 1/193 (0.5) Y-type extension set Luers with needleless connectors (P< 0.0001) 三通带标准接头的内表面被污染 20/200 （ 10％） vs. Y型延长管带无针连接器 1/193 （ 0.5 ）（ P <0.000 ）

O’Grady NP et al. MMWR. 2002;51:1-29: Casey AL et al. J Hosp Infect. 2007;65:212-218.

Pathogenesis of Catheter-Related Infections / 导管相关感染的发生机理

• Recently inserted catheters (< 1 week) are commonly colonized by skin microorganism along external surface 置入导管 <1周感染，多为皮肤上的微生物附着于导管外表面

• When duration of placement > 1 week intraluminal spread from hub may be dominant mechanism of colonization 置入导管 >1周感染，可能是接头腔内感染所致

• Catheter hubs and sampling ports should be disinfected prior to sampling. /取样前必须消毒导管接头及取样口

• Antiseptic containing hub (iodinated ETOH) decreased CR-BSI rates (RR=0.2; CI 0.1-0.7). / 含消毒剂的螺旋帽（含碘醇剂）减少 CR-BSI 发生率

• Providone iodine saturated sponge casing for hub reduced catheter infections from 24% to 0% (p=0.02). 用完全浸透碘伏的海棉刷消毒接头降低导管相关感染由 24%至 0% (p=0.02).

Segura M et al. Ann Surg 1996 223; 363-9, Halpin et al. Nutrition 1991;7:33-4.

Preventing Catheter Hub Contamination/ 预防接头污染

• “Scrub the Hub”: Perform alcohol hub decontamination before each access /“摩擦接头”每一次连接前，用酒精消毒

• All insertion sites contaminated with skin organisms - most common organisms that infect CVC lines / 穿刺部位皮肤上的污染物是影响 CVC 最常见的微生物

• CHG or 70% alcohol is effective /CHG 或 70% 的酒精是最有效的 • Technique is critical – Scrub 10-15 seconds, allow to dry /技术是最关键的—摩擦 10-15秒，充分干燥• Buddy system to encourage best practice/配套的系统，鼓励最佳实践

Other Considerations: “Scrub the Hub”其他要点：

Seconds Count!时间是关键！

No Scrub – then after 15 Second Alcohol Scrub无摩擦—至 15 秒酒精摩擦后的效果比对Courtesy U Mich PICU

Antimicrobial-Coated or Impregnated Catheters抗菌涂层或含抗菌素的导管• Catheters impregnated with chlorhexidine and silver sulfadiazine or with

minocycline and rifampin can decrease risk of CR-BSI 导管含 CHG、磺胺嘧啶银盐或二甲胺四环素和利福平可降低 CR-BSI 风险• All studies done in adult patients with triple-lumen, non-cuffed catheters in

place < 30 d 全部的研究，在成人三腔导管，没有保护套，导管留置 <30天以内Þ A single randomized compared CVCs impregnated with minocycline/rifampin

(both internal and external) were associated with lower rates of CR-BSI than with first generation chlorhexidine-sliver impregnated catheters 一项随机比对含有二甲胺四环素 /利福平的 CVC （内外两面） CR-BSI 发生率较含有一代 CHG银的导管低

Þ (Darouiche R et al NEJM 1999;340:1-8)

Minocycline-Rifampin-Impregnated vs 1st Generation CHG-Silver Sulfadiazine- Impregnated CVCs含二甲胺四环素 -利福平 vs 含 1st CHG-磺胺嘧啶银盐 CVC

M-R CHSSDurationcatheterization 6 d 7 d/残留时间CRBSI 0.3% 3. 4% (RR 0.1, CI 0-0.6)

Darouiche et al, NEMJ 1999

CHG-Silver Sulfadiazine-Impregnated Catheters/CHG 或磺胺嘧啶银盐涂层导管

1st Generation: Summary CA-BSI incidence prospective, RCT of catheterization < 11 days: RR 0.4 (CI 0.2-0.8)

第一代：前瞻性 CA-BSI 发生率，随机对照研究 < 11 天2nd Generation: Summary CA-BSI from 3 published,

prospective, RCT: RR 0.46 (0.2-1.2), p=0.08第二代： 3 个研究结果对比，前瞻性预测，随机对照 : RR 0.46 (0.2-1.2), p=0.08Rupp et al; Bruin-Buisson et al; Ostendorf et al; Maki et al 1997; van Heerden et al 1996; Hannan et al 1996;Bach et al 1996; Collin 1999; George et al 1997, Pemberton et al, 1996, Ramsay et al 1994

Recommendations on Use of Antimicrobial or Antiseptic-impregnated CVCs in Adults (1B)成人使用含有抗菌素的 CVC 导管的建议

1 Catheter expected to stay > 5 days and 导管预计留置 >5天，并且 2 CVC rate of infection is high despite adherence to

comprehensive strategy to reduce rates of infection (e.g. education, maximal sterile barrier, 2% chlorhexidine) 尽管执行了减低感染发生率的策略， CVC 的感染率仍是很高的（如：培训、最大无菌屏障、 2%CHG ）

Þ Issues of limited studies, cost and emergence of resistant organisms 有限的研究，成本和耐药性的出现

Special Approaches: Daily CHG Bathing特殊方法：每日 CHG擦拭• Bathe ICU patients with a chlorhexidine (CHG) preparation on a

daily basis /ICU 患者每日用 CHG擦拭– Several studies found routine bathing of ICU patients reduces the risks of

CLABSI, as well as acquisition of MRSA and VRE infections (one recent SICU study did not observe such benefit)

几项研究显示 ICU 患者常规擦浴降低 CLABSI 风险，同时也减少了MRSA 和万古霉素抗药性肠球菌感染（最近的一个外科重症监护病房的研究并没有观察到这样的好处）• Single-use bottles of aqueous CHG added to a basin of water or use 2% CHG

bathing cloths

一次性的瓶装 CHG加入盆中稀释或用含 2%CHG 的擦浴棉• CHG not approved for children <2 months of age

CHG 不建议用于 <2月的婴儿

Use of Professional IV Teams/ 成立专业的静疗团队

• After professional, dedicated IV team introduced / 引入专业的、专职的静疗团队• CR-BSI were reduced 35% (1.1 to 0.7 BSI/1000 pt days) CR-BSI减少 35% • S. aureus BSI reduced 51% (P<0.01) /金黄色葡萄球菌 BSI 的减少 51％ (P<0.01)• Team cost $253,000 /团队成本 $253,000 • Cost per infection saved $14,000 / 每一例感染成本节约

$14,000

Meier et al. Am J Infect Control 1998; 26:388.

CLABSI Surveillance

CLABSI Surveillance / 监测• Core function of an Infection Prevention

program / 感染预防方案的核心功能– Establish base line rate – recognize increase in

disease activity /建立基准线率 - 识别增加的疾病活动• Provide actionable data for improvement

efforts / 为改进工作提供依据• Metric for public reporting – Proxy for quality

of care delivered /公示—提高护理质量改进

HABSI/ 医院获得性感染Empirical CLABSI

CLABSI 实验室证实的Probably Secondary - Indeterminate Source疑似继发感染 ---- 不确定来源

Translocation 置换Immunocompromised Host 宿主免疫系统受损At or near time of line insertion /接近或查管时

Secondary source suspected clinically / 可能来自临床的继发感染

SecondaryNHSN defined secondary site符合 NHSN诊断的继发感染

•Single Enterococcus considered a contaminant•Enterobacteriaceae, Enterococcus, Bacteroides, Candida in blood = Indeterminate•C. septicum or tertium, MAC, TB, Nocardia, Aspergillus, Fusarium, Cryptococcus

Not CLABSIs

Process Measures: CLABSICLABSI 过程控制

• Compliance with central line insertion checklist / 依从 CVC 穿刺核查表• Compliance with daily assessment regarding the need for continued central

line access /遵从每日评估需要保留的导管• Compliance with avoiding femoral insertion site /避免穿刺股静脉• Compliance with cleaning of catheter hubs and injection ports before they are

accessed /连接前，清洁导管接头和注入座– Look for documentation (hard to capture) 通过寻找文档（难以捕捉的）– Observe practice 观察实践

Objective / 目的• Reduce the number of hospital acquired

bloodstream infections through application of best practices for infection prevention to include: adherence to the central line bundle, optimal maintenance lines, adherence to hand hygiene and standard precautions /通过感染预防最佳实践，减少医院获得性血流感染的数量，包括：执行 CVC 穿刺集束，最优化的导管维护，执行手卫生和标准预防措施

Process Improvement Components/ 流程优化

– Bundle compliance dashboard / 集束依从性公示板– Monitoring bundle compliance 监测集束依从性– Electronic documentation of the bundle & procedure

checklist / 集束 & 流程核查表的电子记录– Identification and measurement of line use outside of the

ICUs /ICU以外 CVC 使用结果的鉴定和衡量– Selection of IC Champions at the local level /区域感控责任人的挑选– Expansion to the Regional Hospitals /区域院的推广

Bundle Audits / 集束核查– A bundle audit tool will be developed shortly

which will look at insertion practice in the ICUs. Would like to look at every patient, every unit, and every line for 1-2 weeks. 将制定一个简洁的集束核查工具，可以观察 1-2周在 ICU置管、每名患者，每个单元和每条导管

– Once we discover that we are fully compliant with utilizing the bundle then we can focus on other areas 一旦我们发现，我们已经完全遵从了集束，那我们还可以关注其他方面

Central Line Maintenance Audit ToolCVC 导管维护核查工具

– The data will be collected at the bedside via paper forms. These will be collected and taken to a central point for data display. The data will be moved from paper into a table displaying the results. /床旁的纸张记录表格将被收集并传送到数据中心汇总分析

– This audit should be used as a teaching moment with the unit. /这次核查应作为科室教学培训

Maintenance Audit/维护核查表HF CCU MICU NICU SICU CTICU Total

N 6 5 32 8 25 58 134

SC Site 17% 20% 22% 37% 56% 19% 28%

Intact Dressing

4/6 3/5 28/32 6/8 25/25 52/58 88%

Dressing Dated

2/6 3/5 31/32 6/8 23/25 31/58 72%

CHG patch Present

3/6 0 13/32 3/8 3/25 37/58 44%

Stat Lock* 0/6 1/5 9/32 1/8 3/25 6/58 15%

Microclave 6/6 2/5 10/32 7/8 15/25 25/58 49%

No Ports Open

6/6 4/5 31/32 8/8 25/25 55/58 96%

CHG Bath** 4/6 4/5 5/32 7/8 25/25 53/58 73%

CHG patch and Statlock*

0/6 0/5 5/32 0/8 1/25 4/58 7%

CLABSI Dashboards/ CLABSI公示板

CLABSI2009 - 2011

0

40

80

120

1q-09 2q-09 3q-09 4q-09 1q-10 2q-10 3q-10 4q-10 1q-11 2q-11

Quarter

N

ICUNon-ICU

Data Driving Improvement / 数字驱动着改进

…for the secret of the care of the Patient is in caring for the patient”如何照顾好患者？秘密就是关心他们。Francis W. Peabody, October 21, 1925

每个患者每时每刻没有例外没有借口患者不知道你的医疗知识有多少，但是他们能体会出你有多关心他们

每一个生命都值得世界级的护理