CLA-BSI

CLA-BSI: Update,Clinicians name and credentialsClinicians role (PBA, CS)Bard Access Systems,1,Central Line Infections中心静脉感染,Definition CLA-BSI vs. CR-BSI CLA-BSI vs. CRBSI定义Reported rates 报道的例数Cost of an infection 感染的花费CDC 2011 2011CDC指南,2,Terminology:术语CR-BSI (catheter related bloodstream infection)导管相关性血流感染CLA-BSI (Central line associated bloodstream infection)中心静脉导管相关性血流感染CA-BSI (Catheter associated bloodstream infection)导管相关性血流感染,Staph AureusSkin金黄色葡萄球菌皮肤,Staph EpidermisSkin表皮葡萄球菌皮肤,CandidaYeast念珠菌,Definitions定义,3,Definition of a Central Line中心静脉导管定义,Vascular access device that terminates close to the heart or one of the great vessels 终止于接近心脏或大血管的血管 通路设备Aorta大动脉Superior Vena Cava上腔静脉Inferior Vena Cava下腔静脉Brachiocephalic头臂静脉Subclavian锁骨下Internal Jugular颈内Femoral股External Iliac髂外Umbilical Artery脐动脉Umbilical Vein请静脉,Reporting guidelines指南报道Inpatient bloodstream infections associated with a catheter住院患者导管相关性血流感染All hospital units not just ICU并非在ICU，而是医院的所有科室Medicare is no longer providing reimbursement for hospital acquired infections as a result of a catheter由导管引起的感染，医保不予以支付,NHSN - 2006,4,CLA-BSI: Definition (CDC)CDC指南CLA-BSI的定义,Central line associated bloodstream infection 中心静脉导管相关性血流感染Used for surveillance and reporting to the CDC用于监控及向CDC报告Not related to an infection at another site并非由其他位置引起感染Central line within 48 hour period before BSI or at time of culture 中心静脉导管48小时内血流感染或血培养Pathogen from peripheral blood culture外周血培养病原体Pathogen not skin contaminant (1 culture)无皮肤污染物（1套血培养）Pathogen skin contaminant (2 cultures)皮肤污染物（2套血培养）,Source: Vital Signs: Central Line-Associated Blood Stream Infections - United States, 2001, 2008, and 2009, Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention, March 4 (/mmwr/preview/mmwrhtml/mm6008a4.htm),5,CR-BSI,Catheter related bloodstream infection 导管相关性血流感染Clinical definition used when diagnosing and treating patients临床定义用于诊断和治疗患者时Requires specific laboratory testing需要特殊的实验室检查Identifies the catheter as the source of the BSI将导管定义为血流感染的来源,CDC Intravascular Guidelines 2011,6,Diagnosis: CR-BSICR-BSI定义,Catheter culture导管培养Semiquantitative roll plate does not rule out intraluminal colonization 半定量不排除导管内定植Quantitative of catheter segment (vortex, sonication, centrifugation) 导管定量（涡流、超声处理、离心）CR-BSI (= 1,000 cfu) or (= 15 cfu count)Paired blood cultures Quantitative Peripheral and via CVC血培养定量配对-外周和中心静脉导管Draw before starting antibiotics使用抗生素之前 (2) cultures within 15 min of each other15分钟内完成培养Culture all lumens CVC (CVC 5 fold higher)培养每一个管腔-中心静脉导管Paired blood cultures Qualitative = 5:1 ratio of CVC to percutaneous患者血培养定量= 5:1CVC与外周相比Time to positivity CVC positive =2 hours before percutaneous CVC血培养阳性= 比外周早2小时Single blood culture CVC CVC单独血培养Quantitative CVC = 100 cfu/ml CVC定量= 100cfu/ml,Ryder “Catheter related infections: Its all about biofilms” Topics in Advanced Practice E-journal Medscape 2005 (8/18/2005),7,“CLA-BSI surveillance definition may overestimate the true incidence of CR-BSI.”CLA-BSI的监控可能高估CR-BSI的真实发病率,CDC Intravascular Guidelines 2011,8,Catheter InfectionsIncidence导管相关性感染的发病率,9,Blood stream Infection (14% HAIs) - #3血流感染Third most common hospital acquired infection (HAI)3个最常见的院内感染#1 Urinary Tract Infection (UTI) (34% HAIs)尿路感染#2 Surgical Site Infections (SI) (17% HAIs)手术部位感染#4 Ventilator Associated Pneumonia(VAP)(13% HAIs)呼吸机相关性肺炎,US Department of Health and Human ServicesHHS Action Plan to Prevent Health-care Associated Infections page 7,10,ICU central-line infections drop dramatically nationwideICU中心静脉感染全国范围内下降,In 2009 alone, an estimated 25,000 fewer CLABSIs occurred in U.S. ICUs than in 2001, a 58% reduction. This represents up to 6,000 lives saved and $414 million in potential excess health-care costs in 2009 and approximately $1.8 billion in cumulative excess health-care costs since 2001.仅在2009年，约少于25 000例CLABSIs发生在美国的ICU，比2001年降低了58。这代表6000条生命被挽救，2009年节约了$4.14亿的潜在过度医疗费用，2001年以来节约了约1.8$十亿的超额医疗保健费用。,Source: Vital Signs: Central Line-Associated Blood Stream Infections - United States, 2001, 2008, and 2009, Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention, March 4 (/mmwr/preview/mmwrhtml/mm6008a4.htm),11,CDC Report CDC报道,Estimated there were 23,000 central-line infections among inpatients outside the ICU (2009) 2009年，在ICU外的住院患者约有23,ooo条中心静脉导管Estimated there were 37,000 bloodstream infections among hemodialysis outpatients (2008)2008年，血透门诊患者约有37,000例血流感染,Source: Vital Signs: Central Line-Associated Blood Stream Infections - United States, 2001, 2008, and 2009, Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention, March 4 (/mmwr/preview/mmwrhtml/mm6008a4.htm),12,CDC Rates CLA-BSI CLA-BSI发生率,Source: Vital Signs: Central Line-Associated Blood Stream Infections - United States, 2001, 2008, and 2009, Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention, March 4 (/mmwr/preview/mmwrhtml/mm6008a4.htm),13,The reduction in CLABSI incidence in 2009 compared with 2001 was greatest for Staphylococcus aureus CLABSIs (73% reduction; rate ration RR =0.27; 95% confidence interval CI =0.2380.294)与2001年相比，2009年CLABSI发病率下降率最大的是由金黄色葡萄球菌引起的CLABSIs（减少73;,“S. aureus more commonly inhabits the skin and thus might be a more common cause of insertion-related infections”金黄色葡萄球菌通常寄居在皮肤上，因此可能是植入相关性感染更常见的原因,Source: Vital Signs: Central Line-Associated Blood Stream Infections - United States, 2001, 2008, and 2009, Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention, March 4 (/mmwr/preview/mmwrhtml/mm6008a4.htm,14,Variables Affecting Evaluation of Infection Rates变量影响感染率评价,Adding all VAD rates together 将所有VAD发生率加在一起Difficult to analyze rates 很难分析发生率Difficult to determine performance improvement measures 很难确定改进的行为Difficult to distinguish where problems lie 很难分辨问题的所在Separate by:Service/placer服务/植入者Type of VAD VAD种类Insertion site 植入位置Unit 科室Compare rates to National Healthcare Safety Network national database与国家医疗保健安全网数据库做比较,15,Goal Rate CLA-BSI目标CLA-BSI 零容忍,ZERO,16,Cost of HAI HAI成本,Published Cost发布时间成本Operational Cost运营成本,HAI Health Care Associated Infection,17,Patient Payer Mix HAIs (2006),57%Medicare,17%,11%,14%,Source: APIC Briefing by MedMinded Inc.,18,Not Reimbursed (CMS)医保不覆盖（CMS）,Serious preventable event严重的可预防事件object left in during surgery手术中残留物品blood incompatibility血液不相容air embolism空气栓塞Catheter associated urinary tract infection导管相关性尿路感染Pressure ulcers压力性溃疡Vascular access associated infection血管通路相关性感染Surgical site infections 手术部位感染(i.e. mediastinitis after CABG)Injury hospital acquired 医院获得性伤害fractures, dislocations, intracranial injury, crushing injury, burn, etc.骨折、脱臼、颅内损伤、视神经损伤、烧伤等Hospitals will submit a POA (present on admit) with each secondary diagnosis or there will be no payment 医院根据辅助诊断或未支付凭证将提供一份POA, (Oct. 1, 2007),19,Medicare: Reimbursement医疗保险,20,Published Cost CLA-BSI/CR-BSI成本计算,$3,700 - $29,000 per episode (SHEA) $36,441 (estimated) per patient (HHS) 每位患者约$36,441 Average LOS 4.5 w/o HAI and 30.4 with CLA-BSI (APIC)Allegheny General HospitalCost of potentially harmful CR-BSI = $27,000 (average) per Pt. (2003)潜在的CR-BSI损害= $27,00040 infected patients in 2003 with CR-BSI 2003年CRBSI 40例Total cost of more than $1.5 million in 2003 for CR-BSI 2003年总花费超过150万美元,Warye “Target :zero hospital-acquired infections” Healthcare Financial Management” Jan 2009 86-91SHEA/IDSA Practice Recommendations (Oct 2008) vol 29 Infection Control and Hospital EpidemiologyUS Department of Health and Human Services HHS Action Plan to Prevent Health-care Associated Infections APIC Briefing by MedMinded Inc.,21,Strategies Reduce Infections减少感染的策略,Extraluminal 腔内Intraluminal 腔外,22,Routes of contamination污染途径,“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: this is the most common route of infection for short-term catheters” 在插入导管的部位，细菌沿着导管定植在表面，这是最常 见的短期导管感染途径“Direct contamination of the catheter, catheter hub by contact with hands or contaminated fluids or devices” 手接触导管直接污染或液体污染或设备污染“Less commonly, catheters might become hematogenously seeded from another focus of infection” 导管可能会随着另一个感染变为血行性感染，不常见“Rarely, infusate contamination may lead to CR-BSI” 输液污染导致的CR-BSI很少见,Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 () page 10,23,Intraluminal route腔内途径Extraluminal route腔外途径,24,Skin皮肤,Epidermis (top layer)表皮（最表面）5 layers of cells 5层细胞Dermis (thickest portion)真皮（最厚的部分）Elastin and collagen fibers弹性蛋白和胶原纤维Sebaceous ducts皮脂腺Sweat glands汗腺Hair follicles毛囊Microorganisms are found in all layers of the skin and not just on the surface 微生物在皮肤的所有层，并不只在表面Skin prep may leave 20% of flora 皮肤准备可能是菌群离开20%,Hadaway “Skin flora and infection” Journal of infusion Nursing Vol 26 No 1January/February 2003 pp 44-48,25,Skin皮肤,Temperature and moisture affect colonization 温度和湿度影响定植Axilla and Groin腋下和腹股沟Highest number and types of microbes微生物数量和种类最多Extremities / antecubital space四肢和肘窝Dry/cool and fewest number of microbes干燥/阴凉微生物数量少10 CFU per site (antecubital)每个部位10CFUNeck and Chest颈部和胸部1,000 10,000 CFU per site (neck/chest)每个部位1000-10000CFU,Ryder “Peripherally inserted central catheters” Nursing Clinics of North America Vol 28 No 4 Dec 1993 p 954Hadaway “Skin flora and infection” Journal of infusion Nursing Vol 26 No 1 January/February 2003 pp 44-48,26,Skin皮肤,Skin surface transient flora皮肤表面-瞬态菌群MRSA, Candida MRSA,念珠菌Resident flora within layers of skin/glands常驻菌群-皮肤腺体层内Coryneforms, Staphlococci, Acinetobacter, Micrococci, MalasseziaHead and thorax头部和胸部Staphylococcus epidermides dominant species表皮葡萄球菌-主导菌群Staphylococcus hominis arms and legs人型葡萄球菌-胳膊和腿Most common pathogen bloodstream infection is CNS (coagulase-negative staphylococci)最常见的致病菌血流感染是凝固酶阴性葡萄球菌Study preoperative skin C/S pectoral region before pacemaker研究起搏器术前皮肤的C / S胸部区域88% positive for bacterial growth and 85% were staphylococci88的阳性细菌生长和85的葡萄球菌,Hadaway “Skin flora and infection” Journal of infusion Nursing Vol 26 No 1 January/February 2003 pp 44-48,27,CDC Definition of Category RecommendationsCDCD类别的定义,Category IA. Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies. IA类。精心设计的实验、临床或流行病学，强烈建议执行Category IB. Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale; or an accepted practice (e.g., aseptic technique) supported by limited evidence. IB类。一些实验、临床或流行病学研究和强大的理论基础支持;或者所接受的做法（例如，无菌技术） 通过有限的证据支持，强烈建议执行Category IC. Required by state or federal regulations, rules, or standards. 类别IC。由州或联邦法规，规章或标准要求的。Category II. Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale. 第二类。由临床或流行病学研究或理论基础的支持，建议实施Unresolved issue. Represents an unresolved issue for which evidence is insufficient or no consensus regarding efficacy exists. 尚无定论，证据不足或根本没有一致意见存在,Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 (),28,Hand Hygiene手卫生,Perform hand hygiene procedures, either by washing hands with conventional soap and water or with alcohol-based hand rubs (ABHR). Hand hygiene should be performed before and after palpating catheter insertion sites as well as before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter. Palpation of the insertion site should not be performed after the application of antiseptic, unless aseptic technique is maintained ( Category IB )执行手卫生程序，无论是传统的肥皂水或使用酒精擦手，在进行导管植入前后、换管前、植入时、修复时或为导管更换辅料前都应该执行手卫生；除菌剂应用后不应该触碰穿刺点，除非无菌技术包含在内（IB类）,Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 (),29,Site Selection置管部位选择,“Use a subclavian site rather than a jugular or a femoral, in adult patients to minimize infection risk for nontunneled CVC placement” (category 1B strongly) 非隧道式CVC，比起颈内或腹股沟，选用锁骨下作为 成人患者的置管部位，可产生最少的感染风险Avoid using the femoral vein for central venous access in adult patients ( Category 1A ) 成人患者的中心静脉通路避免选用股静脉（IA类）,Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 (),30,Site Selection置管部位选择,Weigh the risks and benefits of placing a central venous device at a recommended site to reduce infectious complications against the risk for mechanical complications (e.g., pneumothorax, subclavian artery puncture, subclavian vein laceration, subclavian vein stenosis, hemothorax, thrombosis, air embolism, and catheter misplacement). Category IA 为了减少感染，在放置中心静脉装置时需要权衡风险与利益，以减少机械性并发症的风险（如气胸，锁骨下动脉穿刺，锁骨下静脉裂伤，锁骨下静脉狭窄，血胸，血栓，空气栓塞，导管移位）。 IA类,Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 (),31,Skin Preparation置管部位的准备,Prepare clean skin with a 0.5% chlorhexidine preparation with alcohol before central venous catheter and peripheral arterial catheter insertion and during dressing changes. If there is a contraindication to chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol can be used as alternatives. (Category IA)中心静脉及外周静脉置管前前、更换敷料时，准备大于0.5%的洗必泰。如果对于洗必泰、碘酒、碘伏有禁忌，用70乙醇替代。 （IA类）Antiseptics should be allowed to dry according to the manufacturers recommendation prior to placing the catheter. (Category IB ) 根据厂家的推荐，待抗菌剂干燥后再植入导管（IB类）,Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 (),32,Ultrasound Guidance超声引导,Use ultrasound guidance to place central venous catheters (if this technology is available) to reduce the number of cannulation attempts and mechanical complications. Ultrasound guidance should only be used by those fully trained in its technique. ( Category 1B ) 超声引导下置管，可以减少穿刺次数和机械性并发症。 超声引导下置管技术需要经过充分的培训后方能使用,Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 (),33,Maximal Sterile Barrier Precautions最大无菌屏障,“use MSB precautions including the use of a cap, mask, sterile gown, sterile gloves, and a sterile full body drape for the insertion of CVCs PICCs or guidewire exchange” (category 1B ) 植入CVC,PICC或更换导丝 时，使用最大无菌技术，包 括帽子、口罩、无菌手套、 全身覆盖无菌巾（IB类）,Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 (),34,Max Barrier最大屏障,What is not being done in this picture? 在这幅图片中什么没 有做？,35,Replacement of emergency CVAD紧急更换中心静脉装置,When adherence to aseptic technique cannot be ensured (i.e., catheters inserted during a medical emergency), replace the catheter as soon as possible, i.e., within 48 hours. Category IB 不能确保无菌技术被使用时（比如紧急导管植入） 48小时内更换导管（IB类）,Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 (),36,Peripheral arterial catheters外周动脉导管,1. In adults, use of the radial, brachial or dorsalis pedis sites is preferred over the femoral or axillary sites of insertion to reduce the risk of infection. Category IB 为了减少感染，成人使用桡动脉、肱动脉或足背动脉 穿刺优于股动脉、腋动脉2. In children, the brachial site should not be used. The radial, dorsalis pedis, and posterior tibial sites are preferred over the femoral or axillary sites of insertion . Category II 儿童不能使用肱动脉；桡动脉，足背动脉和胫后优于股 动脉和腋窝3. A minimum of a cap, mask, sterile gloves and a small sterile fenestrated drape should be used during peripheral arterial catheter insertion. Category IB 外周动脉导管植入时，至少要使用帽子，口罩，无菌手套和无菌孔巾4. During axillary or femoral artery catheter insertion, maximal sterile barriers precautions should be used. Category II 腋动脉或股动脉导管植入时，使用最大无菌屏障,Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 (),37,Chlorhexidine Impregnated Sponge洗必泰海绵,“Use a chlorhexidine impregnated sponge dressing for temporary short-term catheters in patients over 2 months of age if the CLA-BSI rate is not decreasing despite adherence to basic prevention measures; including education and training, appropriate use of chlorhexidine skin antisepsis and MSB (category 1B) 虽然遵守基本原则，但CLA-BSI几率没有下降， 大于2个月的患者， 使用洗必泰海绵敷料用于临时短期导管，还包括教育和培训，使用洗 必泰皮肤消毒剂和最大无菌屏障（IB类别）,Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 (),38,Antimicrobial/antiseptic impregnated catheters and cuffs带抗菌涂层的导管,“Use a chlorhexidine/silver sulfadiazine or minocycline/rifampin-impregnated CVC in patients whose catheter is expected to remain in place 5 days if after successful implementation of a comprehensive strategy to reduce rates of CLA-BSI, the CLA-BSI rate is not decreasing. The comprehensive strategy should include at least the following (3) components: (category 1A ) “如果成功实施了全面的无菌技术并没有减少CLA-BSI，预计导管使用大于5天，使用 洗必泰/磺胺嘧啶银或米诺环素/利福平浸渍CVC，。综合策略应至少包括以下（3） 内容Educating persons who insert and maintain catheters培训置管及维护者Use of maximal sterile barrier precautions使用最大无菌屏障0.5% chlorhexidine preparation with alcohol for skin antisepsis during CVC insertion 植入CVC时使用大于0.5%洗必泰皮肤消毒,Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 (),39,Prevention: Maximal Barrier Precautions (MSB)预防：最大无菌屏障注意事项,Standardized supply cart or kit that is all inclusive for the insertion of a CVC CVC植入时使用标准化置管包JCAHO (January 1, 2010) (M),JCAHO-Joint Commission on Accreditation of Healthcare Organizations National patient safety goals100K live Campaign Getting Started Kit: Prevent Central line Infections How to Guide 6/14/2006 /IHI/Programs/Campaign,40,Prevention CR-BSI/CLA-BSI