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INFECTION PREVENTION AND CONTROL MANUAL 3.1 Indwelling Vascular Devices CENTRAL VENOUS INFUSION AND PERIPHERAL INFUSION GUIDELINES RATIONALE The agency will promulgate procedures aimed at the prevention of vascular device- related infections. DEFINITIONS INTRAVASCULAR DEVICES INCLUDE THE FOLLOWING: Short Peripheral Venous Catheters, usually inserted into the veins of the forearm or hand. Because of their short-term nature they are rarely associated with Blood Stream Infections (BSI), but are frequently associated with a non-infective phlebitis. Midline Catheters, inserted via antecubital fossa into basilic/cephalic vein. Associated with lower rates of phlebitis than peripheral venous catheters, and lower rates of infection and cost than central venous catheters. Non-tunnelled Central Venous Catheters inserted into the internal jugular vein have shown a higher rate of infection than those inserted into the subclavian vein. Multi-lumen CVCs show a greater rate of infection than single lumen catheters. Peripherally Inserted Central Venous Catheters may have lower infection rates than those inserted into the subclavian area. Tunnelled Central Venous Catheters surgically implanted for long-term access eg; Hickmans, may have lower rates of infection. RISK MANAGEMENT Strict adherence to aseptic technique and hand washing remains the cornerstone of prevention of IV catheter – related infections. RICPRAC Infection Prevention & Control Manual, 3rd Edition 2008 Page 1 of 11 EVIDENCE- BASED GUIDELINES SELECTION OF CATHETER TYPE Use a single-lumen catheter unless multiple ports are essential for patient management. If TPN is being administered, use one central venous catheter or lumen exclusively for that purpose. Use a tunnelled catheter or an implantable vascular access device for patients in whom long-term vascular access is anticipated. Consider the use of an antimicrobial impregnated central venous catheter for adult patients who require short term (< 10 days) central venous catheterisation and who are at high risk of catheter-related blood stream infection. SELECTION OF CATHETER INSERTION SITE In selecting an appropriate insertion site, assess the risks of infection against the risks of mechanical complications. Unless medically contraindicated, use the subclavian site in preference to the jugular or femoral sites for non-tunnelled catheter placement. Consider the use of peripherally inserted catheters as an alternative to subclavian or jugular vein catheterisation. OPTIMUM ASEPTIC TECHNIQUE DURING CATHETER INSERTION Use optimum aseptic technique, including sterile gown, gloves, and a large sterile drape for insertion. Wearing of surgical mask by operator and patient has also been recommended. CUTANEOUS ANTISEPSIS Clean the skin with a single patient use application of an alcoholic chlorhexidine gluconate skin preparation (preferably 2% chlorhexidine gluconate in 70% isopropyl alcohol) prior to catheter insertion. Use an alcoholic povidone-iodine solution for patients with a history of chlorhexidine sensitivity. Allow the antiseptic to dry before inserting the catheter. Do not apply organic solvents, eg; acetone, ether, to the skin prior to catheter insertion. Do not routinely apply antimicrobial ointment to the catheter placement site prior to insertion. CATHETER AND CATHETER SITE CARE Before accessing the system, disinfect the external surfaces of the catheter hub and connection ports with a single use sachet of aqueous solution of chlorhexidine gluconate or povidone-iodiness, contraindicated by the manufacturer’s recommendations. Use transparent dressing to cover the catheter site. RICPRAC Infection Prevention & Control Manual, 3rd Edition 2008 Page 2 of 11 Do not apply antimicrobial ointment to CVC insertion sites as part of routine catheter site care. Routinely flush indwelling CVCs with an anticoagulant unless otherwise advised by the manufacturer. REPLACEMENT STRATEGIES Do not routinely replace non-tunnelled CVCs as a method to prevent catheterrelated infections. Use wire-assisted catheter exchange to replace a malfunctioning catheter, or to exchange an existing catheter if there is no evidence of infection at the catheter site or proven catheter-related blood stream infection. If catheter-related infection is suspected, but there is no evidence of infection at the catheter site, remove the existing catheter and insert a new one over a wire guide; if tests reveal catheter-related infection, the newly inserted catheter should be removed and, if still required, a new catheter inserted at a different site. Do not use wire assisted catheter exchange for patients with catheter-related infection. If continued vascular access is required, remove the implicated catheter, and replace it with another catheter at a different insertion site. Replace all tubing when the vascular device is replaced. Replace intravenous tubing and stopcocks no more frequently than at 72 hour intervals, unless clinically indicated. Replace intravenous tubing used to administer blood, blood products, or lipid emulsions at the end of the infusion or within 24 hours of initiating the infusion. PERIPHERAL VENOUS CATHETERS Evaluate the catheter site at each shift. Replace all peripheral cannula inserted under emergency conditions within 24 hours of insertion Remove peripheral venous catheters if the patient develops signs of phlebitis, infection or malfunctioning catheter. In adults replace short peripheral venous catheters at least 72 – 96 hours. PAEDIATRIC PATIENTS Leave peripheral venous catheters in place until IV therapy is completed unless a complication (eg phlebitis or infiltration) occurs. CVC’S, INCLUDING PICC’S Routine catheter replacement at scheduled intervals has not reduced the incidence of catheter related blood stream infections. Routine replacement is not necessary for catheters that are functioning and have no evidence of causing local or systemic complications. Daily assessment of the need for continuing central access, and prompt removal of unnecessary access is an important aspect of infection prevention RICPRAC Infection Prevention & Control Manual, 3rd Edition 2008 Page 3 of 11 ANTIBIOTIC PROPHYLAXIS Do not administer systemic antimicrobials routinely before insertion or during the use of a central venous catheter to prevent catheter colonisation or bloodstream infection. REFERENCES: Farr, B.M. Nosocomial Infections related to use of intravascular devices inserted for shortterm vascular access. Chapter 11 in Hospital Epidemiology and Infection Control, second edition C. Glen Mayhall 1999 Lippincott, Williams and Wilkins. Guidelines for the prevention of intravascular catheter related infection. Centres for Disease Control.USA August 9 2002 Horvath R and Collignon P. Controlling intravascular catheter infections. Australian Prescriber 2003(26):2:41-43 Infection Control Guidelines for the Prevention of Transmission of Infectious Diseases in the Healthcare Setting. Australian Government Department of Health and Ageing, 2004. Pearson ML: Guidelines for Prevention of Intravascular Device-related Infection. HICPAC. Infection Control and Hosp. Epidemiology. 1996; 17(7) 438-473. Pratt RJ, Pellowe CM, WilsonJA, Loveday HP, et al. National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hos.Infect(2007)65S, S1-S64 Raad I. Hanna H., Nosocomial infections related to use of intravascular devices inserted for long-term vascular access. Chapter 12 in Hospital Epidemiology and Infection Control, second edition C. Glen Mayhall 1999 Lippincott, Williams and Wilkins. Management of peripheral intravascular devices. Clinical Update. The Joanna Briggs Institute for Evidence Based Nursing and Midwifery 2008, Adelaide. Australian Nurses Journal. Sept. 08 Vol.16 Number 3. RICPRAC Infection Prevention & Control Manual, 3rd Edition 2008 Page 4 of 11 INFECTION PREVENTION AND CONTROL MANUAL 3.2 Indwelling Urinary Catheter RATIONALE The agency will use evidence-based procedures for the management of urethral catheters and urinary drainage systems. DEFINITIONS Urethral catheters provide drainage of the urinary bladder when this is absolutely necessary. A sterile, closed to air, drainage system provides some protection against infection ascending into the bladder, and allows drainage of urine. RISK MANAGEMENT The presence of a urethral catheter presents several possible infection risks to the client. Firstly, the presence of a foreign body within the urethra creates a bio-film between the urethral mucosa and the catheter, in which micro-organisms can grow, and cause ascending infection. Secondly, micro-organisms may ascend up the lumen of the catheter, in air bubbles and due to back pressure. Micro-organisms introduced at the time of catheterisation also contribute to infection potential. Duration of catheterisation is strongly associated with the risk of infection, the longer the catheter is in place, the higher the incidence of urinary tract infection. 50% of patients become infected by day 15 of catheterisation and almost 100% by one month. EVIDENCE-BASED GUIDELINES Only use indwelling urethral catheters after considering alternative methods of management. The device should not be left indwelling unless absolutely necessary. Choice of catheter material will depend on clinical experience, patient assessment and anticipated duration of catheterisation. Select the smallest gauge catheter that will allow free urinary outflow. A catheter with a 10 ml balloon should be used. Urological patients may require larger gauge sizes and balloons. Catheterisation is an aseptic procedure. Ensure that staff are trained and competent to perform urethral catheterisation. Clean the urethral meatus prior to catheter insertion. Use an appropriate sterile lubricant from a single dose container to minimise urethral trauma and infection. RICPRAC Infection Prevention & Control Manual, 3rd Edition 2008 Page 5 of 11 Connect indwelling urethral catheters to a closed urinary drainage system. Ensure that the connection between the catheter and the urinary drainage is not broken, except for good clinical reasons. Obtain urine samples from a sample port, or aseptic needle aspiration. If there is no balloon on the catheter (to hold it in place) the catheter should be stabilised against movement. Position urinary drainage bags below the level of the bladder on a stand that prevents contact with the floor. Where such drainage cannot be maintained, eg., during moving and handling, clamp the urinary drainage bag tube and remove clamp as soon as the bag can be maintained below the level of the bladder. Empty the urinary drainage bag frequently enough to maintain urine flow and prevent reflux, but avoid unnecessary emptying as this constitutes disruptions of the closed system. Use a separate and clean container for each patient, and avoid contact between the urinary drainage tap and container. Do not add antiseptic or antimicrobial solutions into urinary drainage bags. Do not change catheters unnecessarily or as part of routine practise. Routine personal hygiene is all that is needed to maintain meatal hygiene. Bladder irrigation, instillation and washout do not prevent infection. INDICATIONS FOR USE Indwelling urinary catheters should be inserted only when essential for the management of the patient, and left in place only for as short a time as possible. The main indications are: to relieve urinary tract obstruction to permit bladder drainage in patients with neurogenic bladder dysfunction or retention during urological investigations and procedures to assist healing following surgery/trauma to the genitourinary tract to measure urinary output accurately as part of critical fluid balance estimation RICPRAC Infection Prevention & Control Manual, 3rd Edition 2008 Page 6 of 11 CATHETER INSERTION Staff responsible for insertion or management of indwelling urinary catheters must understand the risks of infection and the rationale of procedures designed to prevent infection and be trained in the correct techniques of aseptic catheter insertion and management. HOSPITAL POLICY Male catheterisation must be performed by medical staff or a suitably trained Registered Nurse Female catheterisation can be performed by either a nursing or medical staff. PREPARATION OF THE OPERATOR Antiseptic hand hygiene, sterile gloves and gown should be used when inserting an indwelling urinary catheter. This will prevent exogenous contamination and provide a barrier to avoid exposure of staff to the patient’s urine. HANDWASHING An antiseptic hand wash solution should be used and the hands dried with a clean paper towel. SITE PREPARATION The perineal area should be cleaned using mild soap and water prior to catheterisation. If additional cleansing is required at the time of the procedure use 0.9% saline to cleanse labia minora and urethral meatus using downward strokes. A single use sachet of sterile lubricant or lignocaine jelly is used to minimise friction/pain on insertion. ASEPTIC TECHNIQUE Catheterisation should be performed using an aseptic technique and sterile equipment to minimise entry of microorganisms to the bladder during the procedure. Discard catheter if it is accidentally contaminated during the procedure. Contamination includes any contact with the perineal area other than the urethral meatus. The catheter must be connected to the drainage bag maintaining asepsis. RICPRAC Infection Prevention & Control Manual, 3rd Edition 2008 Page 7 of 11 SELECTION OF CATHETER The smallest catheter compatible with adequate function should be selected to minimise urethral trauma. The anticipated length of time the catheter is likely to remain in situ, the reason for catheterisation, and the patient’s tolerance to catheter material should be considered. A catheter that is too large may produce urethral irritation, leading to urethritis and possibly to the development of urethral strictures. Pressure on blood vessels may produce tissue necrosis. SECURING THE CATHETER Indwelling catheters should be secured to the thigh after insertion in such a manner as to prevent unnecessary tension on the catheter within the urethra and urethral tract. The catheter tubing and drainage bag should be positioned at all times to promote drainage and prevent reflux of urine from the bag to the bladder. Suitable drainage bag carriers should be used to hang the drainage bag on the bed or, for ambulatory patient, to allow it to be carried. Drainage systems must not be placed onto the floor. DOCUMENTATION The following data should be documented in the patients’ medical records: date, time and reason for insertion type and size catheter volume of the balloon re-catheterisation if necessary MAINTENANCE OF CLOSED DRAINAGE A closed drainage system should be maintained with as few disconnections as possible. Interruption of the catheter and drainage system should be kept to a minimum and done using strict aseptic technique. Hands should be washed before and after any manipulation of the catheter system. Avoid disconnection of the catheter and drainage system by irrigating only when absolutely necessary and collecting specimens from the designated collection port. If breaks in aseptic technique, disconnection or leakage occur, replace the system after disinfecting the catheter-tubing junction with alcoholic chlorhexidine or aqueous povidone iodine. RICPRAC Infection Prevention & Control Manual, 3rd Edition 2008 Page 8 of 11 REPLACEMENT OF CATHETERS Do not change catheters arbitrarily. The catheter may need to be removed or replaced only if problems such as obstruction, malfunction or contamination are present. The catheter should be checked at least daily. If re-catheterisation is necessary, replace the entire system using aseptic technique. Long-term catheters can remain in place for up to 3 months. REPLACEMENT OF CATHETER DRAINAGE BAG Replace drainage bags, including leg bags at weekly intervals. Using strict aseptic technique to minimise the risk of infection. Overnight bags can be attached directly to the leg bag for overnight drainage. Each morning the over night bag should be disconnected, emptied and washed with warm soapy water. It should then be allowed to dry in a clean area. Drainage bags should always be replaced when a new catheter is inserted. EMPTYING OF THE CATHETER DRAINAGE BAG Catheter bag emptying can be a major cross infection hazard if the procedure is not exercised with extreme care. The drainage bag port can be a potential source of infection. Wash hands before and after drainage bag emptying. The wearing of non-sterile gloves is recommended. Eye protection is recommended. The urine should be emptied into a collecting receptacle and care should be taken to prevent the drainage port from coming into contact with the collecting receptacle. Heat disinfected or disposable collecting receptacles should be used. BLADDER IRRIGATION Irrigation of the bladder and/or catheter should only be performed when essential for the management of the patient. The practice of bladder irrigation does not offset the potential for micro organisms to enter the catheter system during the procedure. The main indications are: to prevent clot formation in the patient who has had prostatic surgery and studies; to bathe the membranous lining of the bladder with prescribed drugs; to irrigate the bladder with a prescribed fluid to remove debris from the bladder . A sterile irrigant is used for all bladder irrigation. Irrigation is to be performed using strict aseptic technique. A three-way foley catheter should be used for continuous bladder irrigation RICPRAC Infection Prevention & Control Manual, 3rd Edition 2008 Page 9 of 11 PATIENT CARE AND MAINTENANCE OF DEVICES Increased intake of fluids should be encouraged (unless medically contraindicated) to facilitate the removal of micro-organisms and debris. Perineal/vulval washing should be carried out regularly (twice daily), as well as after a bowel motion. Cleaning of the catheter and the insertion site should be carried out regularly (twice daily) to avoid encrustation. Closed drainage/collection systems should not be opened unless necessary. The ports should be aseptically swabbed with an antimicrobial solution and allowed to dry immediately before use in order to prevent the entry of micro-organisms into the line. The interruption of urine flow should be avoided, as should the interruption of routine irrigation of urinary catheters. Urine samples should be collected from the closed system with a syringe and needle (after cleaning the port), not by breaking the connection between the catheter and the drainage/collection system, and never from the drainage tap attached to the collection container itself. Before collecting urine samples or emptying the collection container, HCW’s should wash their hands and then put gloves on. They should wash their hands after removing the gloves. The collection container should neither be raised above the level of the urethra nor allowed to trail on the floor. If there is a risk of urinary reflux when the patient is being moved, the tubing should be clamped temporarily, then unclamped afterwards. CULTURE FOR SUSPECTED CATHETER-RELATED INFECTION Routine urine cultures are not required for patients with indwelling urinary catheters but should be performed if there is any clinical evidence of urinary tract infection. Catheterisation should never occur solely to obtain a urine specimen for culture because of the risk of introducing organisms. If the patient is already catheterised, this is a valid method of urine specimen collection. Collect the urine specimen before the commencement of antibiotic therapy and before, not after any irrigation procedure. The specimen must be accompanied with a request slip detailing type of specimen (eg. CSU, MSU) and accurate clinical notes to aid the laboratory with bacteriological examination and sensitivity patterns. COLLECTION OF CATHETER URINE SPECIMENS FOR CULTURE Specimens of urine from catheterised patients must be aseptically obtained using an aspiration technique to avoid contamination of the specimen. Specimens should never be obtained by disconnecting the catheter from the drainage system. A closed system must be maintained to avoid introducing pathogens. Specimens must never be collected from the drainage bag. Such specimens only indicate the microorganisms in the drainage bag and not in the urinary tract. RICPRAC Infection Prevention & Control Manual, 3rd Edition 2008 Page 10 of 11 METHOD OF COLLECTION Wash hands with antiseptic preparation. Clamp catheter tubing below sampling/aspiration port. Put on clean gloves –sterile gloves are not necessary. Disinfect port with 70% alcohol swab and allow 15 seconds to dry. Aspirate 5-10 mls urine. If a needle and syringe is used, transfer urine to sterile labelled container. Disinfect port with 70% alcohol swab to remove any urine. Remove clamp. Send specimen to the laboratory immediately, together with a completed request form noting this is a CSU. The urine specimen must reach the laboratory for culture within 2 hours of collection to avoid multiplication of possible contaminants. When delay is inevitable refrigerate the urine at 4oC to retard the degeneration of cells and multiplication of micro organisms. The urine will be suitable for culture for 24-48 hours if kept at 4°C. REFERENCES Burke, J.P. and Zavasky, D. Nosocomial Urinary Tract Infections in Hospital Epidemiology and Infection Control 2nd Edition by C. Glen Mayhall. Lippincott, Williams and Wilkins, Philadelphia 1999. Lee, G. and Bishop, P. Microbiology and Infection Control for Health Professionals. Prentice Hall, Australia 1997. Lewin, S. Urinary Tract Infections in Infectious Diseases – a Clinical Approach. Yung, McDonald, Spelman, Street and Johnson, Cherry Print, Australia 2001. Infection Control Guidelines for the Prevention of Transmission of Infectious Diseases in the Healthcare setting. Australian Government Department of Health and Ageing, 2004. Pratt RJ, Pellowe CM, Wilson JA, Loveday HP, et al. National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp.Infect(2007)65S, S1-S64 Wenzel RP. Prevention and control of nosocomial infections. 4th Edition Lippincott, Williams and Wilkins Philadelphia 2003, pp 298-311 RICPRAC Infection Prevention & Control Manual, 3rd Edition 2008 Page 11 of 11