Cvl bundle presentation

1. Central Venous Lines and Central Venous Lines and
Blood Stream Infections Blood Stream Infections
Breaking out the Bundles Breaking out the Bundles
Elizabeth Gilger, RN, CCRN Elizabeth Gilger, RN, CCRN
Medical University of South Carolina Medical University of South Carolina

2. Infection Control Infection Control
Did you know? Did you know?
Approximately 90% of catheter related Approximately 90% of catheter related
blood stream infections (BSI) occur with blood stream infections (BSI) occur with
central venous catheters (CVC) central venous catheters (CVC)
Between 500 and 4,000 patients die Between 500 and 4,000 patients die
annually from BSI annually from BSI
Institute for Healthcare Improvement, 2007

3. Infection Control Infection Control
Did you know? Did you know?
Mortality of ventilated patients who Mortality of ventilated patients who
develop VAP is 46 % develop VAP is 46 %
$40,000 is the estimated cost $40,000 is the estimated cost
accumulated due to VAP accumulated due to VAP
Institute for Healthcare Improvement, 2007

4. Blood Stream Infections Blood Stream Infections
””
Disruption of the integrity of the skin Disruption of the integrity of the skin
creates an avenue for infection creates an avenue for infection
””
Infection spreads to the bloodstream Infection spreads to the bloodstream
leading to Hemodynamic changes and leading to Hemodynamic changes and
organ dysfunction and potentially may lead organ dysfunction and potentially may lead
to death to death

5. Institute for Healthcare Institute for Healthcare
Improvement (IHI) Improvement (IHI)
Developed in 1991 to improve health care Developed in 1991 to improve health care
worldwide worldwide
Developed improvement measures based on Developed improvement measures based on
research. Many of these measures had been research. Many of these measures had been
previously recommended by CDC in their previously recommended by CDC in their
guidelines for the prevention of CVL related guidelines for the prevention of CVL related
bloodstream infections. bloodstream infections.
Incorporated bundles into the healthcare culture Incorporated bundles into the healthcare culture
to ensure standardized practice to ensure standardized practice

6. What is a bundle??? What is a bundle???
Bundles are groupings of best Bundles are groupings of best
practices with respect to a practices with respect to a
disease process that disease process that
individually improve care, but individually improve care, but
when applied together result in when applied together result in
substantially greater substantially greater
improvement. improvement.
Institute for Healthcare Improvement, 2007

7. Central Line Bundle Central Line Bundle
Hand Hygiene Hand Hygiene Maximal Barrier Precautions Upon Maximal Barrier Precautions Upon
Insertion Insertion
Chlorhexidine Skin Antisepsis Chlorhexidine Skin Antisepsis Optimal Catheter Site Selection, with Optimal Catheter Site Selection, with
Subclavian Vein as the Preferred Site for Subclavian Vein as the Preferred Site for
NonNon--Tunneled Catheters Tunneled Catheters
Daily Review of Line Necessity with Daily Review of Line Necessity with
Prompt Removal of Unnecessary Lines Prompt Removal of Unnecessary Lines

8. Think Outside the Bundle Think Outside the Bundle
CVL Assessment CVL Assessment –– Each shift, assess for patency, site condition Each shift, assess for patency, site condition
and dressing patency and dressing patency
–– If the CVL was placed in a true clinical If the CVL was placed in a true clinical
emergency, the line is to be changed after 24 emergency, the line is to be changed after 24
hours hours

9. Think Outside the Bundle Think Outside the Bundle
CVL Care CVL Care
–– Change transparent dressings every 7 days, Change transparent dressings every 7 days,
those you cannot visualize the site i.e. gauze those you cannot visualize the site i.e. gauze
dressing, change every 24 hours dressing, change every 24 hours
–– Change tubing and caps every 72 hours Change tubing and caps every 72 hours
–– Cleanse caps prior to tubing change, IVP Cleanse caps prior to tubing change, IVP
medication or flushing with alcohol swab. Use medication or flushing with alcohol swab. Use
friction! friction!

10. Insertion Insertion
Site selection Site selection--recommended site in adults is the recommended site in adults is the
subclavian site. For pediatrics subclavian site. For pediatrics --no data. no data.
Full barrier precautions should be used Full barrier precautions should be used --MDs MDs
should use gown, hat, gloves and mask. If you should use gown, hat, gloves and mask. If you
are in and out of the room, wear a mask. If you are in and out of the room, wear a mask. If you
stand there the entire time, you should use full stand there the entire time, you should use full
barriers, too. barriers, too.
Antibiotic impregnated catheters recommended Antibiotic impregnated catheters recommended
for lines that are anticipated to remain 7 days or for lines that are anticipated to remain 7 days or
more. more.

11. Policy 75 Policy 75--A A
Prior to placement of the line, someone, usually the RN, Prior to placement of the line, someone, usually the RN,
is designated to monitor the sterile field and practice. is designated to monitor the sterile field and practice.
This designee This designee must stop the procedure must stop the procedure if the if the
appropriate steps are not followed. appropriate steps are not followed.
If the patient is conscious , the designee will stop the If the patient is conscious , the designee will stop the
procedure by saying procedure by saying ““Break Scrub Break Scrub””: indicating to the : indicating to the
clinician that the bundle has not been followed and the clinician that the bundle has not been followed and the
procedure must be stopped. procedure must be stopped.
If the clinician does not stop the procedure, the RN is to If the clinician does not stop the procedure, the RN is to
notify the nurse manager. notify the nurse manager.
Find this checklist on the Clinician Find this checklist on the Clinician ’’s Order site at s Order site at
http:// http://www.musc.edu/cce/ORDFRMS www.musc.edu/cce/ORDFRMS//

13. CVL Insertion Carts and Supplies CVL Insertion Carts and Supplies To facilitate adherence to the bundle, carts To facilitate adherence to the bundle, carts
are being purchased for nursing units are being purchased for nursing units
These carts will hold necessary supplies These carts will hold necessary supplies Physicians have participated in the Physicians have participated in the
selection of drapes for the adult and selection of drapes for the adult and
pediatric populations. pediatric populations.
A variety of drapes are available in A variety of drapes are available in
different styles and sizes. different styles and sizes.

14. 3 rolls of tape 3 rolls of tape
2 boats 4 x 4s 2 boats 4 x 4s
6 OpSites 6 OpSites
4 Biopatch 4 Biopatch
6 Chlorapreps 6 Chlorapreps
6 10 ml syringes 6 10 ml syringes
2 transducer covers 2 transducer covers
4 packs KY 4 packs KY
4 vials 30 ml saline 4 vials 30 ml saline
4 vial adaptors 4 vial adaptors
6 injection ports 6 injection ports
3 sterile gowns 3 sterile gowns
Sterile Gloves: 2 of Sterile Gloves: 2 of
each 6.5, 7, each 6.5, 7,
7.5 and 8 7.5 and 8
Box of hats Box of hats
Box of masks Box of masks
2 Proxima Drapes 2 Proxima Drapes
2 Arrow Drapes 2 Arrow Drapes
2 triple lumens 2 triple lumens
2 quad lumens 2 quad lumens
1 Long Quinton 1 Long Quinton
1 Short Quinton 1 Short Quinton
2 Cordis 2 Cordis
1. After use, clean cart thoroughly with Cavicide.
2. For isolated patients, avoid taking cart inside the room.
3. Restock after each use from the Pyxis, charging supplies to the
patient.
4. Check daily to make sure lock is secure.
CVL Cart

15. http://www.learnovation.com/johnwise_samples.htm
You can’t be
too clean!!!And wash your hands!!!!!!!! And wash your hands!!!!!!!!

16. Question 1 Question 1
1. Which of the following personal 1. Which of the following personal
protective equipment are required to be protective equipment are required to be
worn by the physician for central venous worn by the physician for central venous
line insertion? line insertion? a)a)
Gloves and gown Gloves and gown
b)b)
Gloves, gown and mask Gloves, gown and mask
c)c)
Gloves, gown, mask, and hat Gloves, gown, mask, and hat
d)d)
None of the above None of the above

17. Question 2 Question 2
2. The preferred site for central venous line 2. The preferred site for central venous line
placement in adults is placement in adults is a)a)
Jugular vein Jugular vein
b)b)
Femoral vein Femoral vein
c)c)
Subclavian vein Subclavian vein
d)d)
All of the above are acceptable All of the above are acceptable

18. Question 3 Question 3
3. The Central Line Bundle includes all of 3. The Central Line Bundle includes all of
the following except: the following except: a)a)
Hand hygiene Hand hygiene
b)b)
Daily review of line necessity Daily review of line necessity
c)c)
Ensuring optimal site selection Ensuring optimal site selection
d)d)
Chlorhexidine skin Chlorhexidine skin antipsesis antipsesis
e)e)
Keeping the HOB elevated 30 degrees Keeping the HOB elevated 30 degrees

19. Question 4 Question 4
4. The RN or designee in the CVL 4. The RN or designee in the CVL
placement procedure has the authority to placement procedure has the authority to
stop the procedure if sterile technique is stop the procedure if sterile technique is
broken by saying: broken by saying: a)a)
““Time Out Time Out””
b)b)
““Break Scrub Break Scrub””
c)c)
““STOP! STOP!””
d)d)
The RN or designee cannot stop the The RN or designee cannot stop the
procedure procedure

20. CONSISTENCY IS BEST PRACTICE CONSISTENCY IS BEST PRACTICE