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Draft revised Australian Guidelines for the Prevention and Control of Infection in Healthcare submission

ID: 
31
Personal Details
This submission reflects the views of
Organisation Name: 
Australian Vascular Access Society
Specific Questions
1. Introduction: 

Nil comment

2. Basics of infection prevention and control: 

Text describing Patient Centred Care and Involving Patients in Care are laudable. However, barriers to accepting and truly incorporating this into healthcare exist. Healthcare staff can be defensive if challenged about their hand hygiene or other practices. This is particularly distressing for patients with Chronic Disorders and Chronic care needs who normally manage (successfully) their care at home. A cultural shift is required for healthcare staff and providers to truly recognize the merit and value of patient centred care. In addition to campaigns with existing staff, education about consumer involvment and patient centred care needs to form part of Undergraduate curriculums (for all disciplines), including exposure to Consumer Groups and representatives. Some areas use experiential learning through role play for health care staff to truly understand what it is like to be patient.

3. Standard and transmission-based precautions: 

In 3.1.3 To assist further with management of sharps guidelines reiterate use of needleless devices (e.g. connectors on intravenous administration and extension sets; manufacturer prepared prefilled flush syringes; vacutainers for blood sample collection). These negate the need for needles (sharps) and reduce the risk of needlestick injury and associated infection risk.

In 3.4.2 

Device Selection - There is no mention of the potential role for extended dwell Peripheral or Midline IV catheters which may provide a suitable alternative to central devices. Midlines can safely dwell for up to 29 days.

See below reference points from INS; CDC; Anderson; Gorski & Czaplewski:

 

Infusion Therapy Standards of Practice 2016 Lisa Gorski, Lynn Hadaway, Mary E. Hagle, Mary McGoldrick, Marsha Orr, Darcy Doellman, S56

 

II. Midline Catheters: A. Choose a midline catheter as follows: 1. Consider infusate characteristics in conjunction with anticipated duration of treatment (eg, 1-4 weeks). 1-3,5

 

1. Perucca, R. Peripheral venous access devices. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing: An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:456-479.

 

2. Hagle ME, Mikell M. Peripheral venous access. In: Weinstein SM, Hagle ME, eds. Plumer’s Principles and Practice of Infusion Therapy. 9th ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins; 2014:303-334.

 

3. Alexander M, Gorski L, Corrigan A, Bullock M, Dickenson A, Earhart A. Technical and clinical application. In: Alexander M, Corrigan M, Gorski L, Phillips L, eds. Core Curriculum for Infusion Nursing. 4th ed. Philadelphia, PA: Wolters Kluwer/ Lippincott Williams & Wilkins; 2014:1-85.

 

5. O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. http:// www.cdc.gov/hicpac/BSI/BSI-guidelines-2011.html. Published April 2011.

 

Anderson (2005) suggests that the MC should be used for a patient requiring treatment for at least 5 days but no more than 28 days. Anderson, N. R. (2005). When to use a midline catheter. Nursing200535(4), 68.

 

Gorski & Czaplewski (2004) propose a maximum dwell time of between 1-6 weeks but suggest 2-4 weeks in principle is optimalGorski, L. A., & Czaplewski, L. M. (2004). Peripherally inserted

central catheters and midline catheters for the homecare nurse. Journal of Infusion Nursing27(6), 399-409.

 

CDC guidelines CID 2011:52 (1 May) d e5 Replacement of Peripheral and Midline Catheters. 4. Replace midline catheters only when there is a specific indication. Category II

Insertion - Initial and ongoing training required to ensure all health care staff are competent inserters. Significant, high quality (level I & II) evidence demonstrating that Ultrasound guided location and insertion can improve first insertion success and reduce complications for both peripheral and central devices

https://www.bmj.com/content/327/7411/361

http://emj.bmj.com/content/30/7/521.short

https://www.nature.com/articles/pr201674

https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1460-9592.2012.03830.xFurther, a Systematic Review has demonstrated the value of dedicated, multidisciplinary Vascular Access Teams in the reduction of complications including infection http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD011429/full

Approximately 1 in 2 patients in Australia (including pediatrics) experience >1 attempt at IV insertion. Some experience >5! We know that multiple attempts at IV insertion are associated with patient discomfort/pain, infection and complications risk and increased of failure

https://www.ncbi.nlm.nih.gov/pubmed/29073316

https://www.ncbi.nlm.nih.gov/pubmed/24334800

The NHMRC and the ACSQHC should make trained vascular access staff/teams with ready access to ultrasound the benchmark for vascular access insertion practice. There are a number of tools (yet to be validated) aimed at assessing difficult intravenous access patients and fast-tracking them to trained staff/teams where possible

https://www.ncbi.nlm.nih.gov/pubmed/26163026

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5693534/

...but given the acuity and characteristics of contemporary patient cohort (i.e. rate of obesity and number of comorbidities) nearly all patients require assessment and appropriate referral for IV access.

 Dressing - There is significant (level I ) evidence supporting the using of anti microbial dressings for central lines to reduce the risk of blood stream infection

http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD010367.pub2/full

Further, I believe a significant trial evaluating different dressing and securement devices/agents has been conducted and due for imminent publication that will provide level II evidence for recommendation for peripheral devices. 

http://bmjopen.bmj.com/content/5/9/e008689

securement-methods-for-peripheral-venous-catheters-to-prevent-failure--a-randomised-controlled-pilot-trial

http://bmjopen.bmj.com/content/6/6/e011197

Maintenance - Low level evidence supports the use of gentle, pulsatile flushing to reduce biofilm formation, fibrin build up, and potential mixing of incompatible medications. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4230174/

https://www.ncbi.nlm.nih.gov/pubmed/21748725

Similarly, low level evidence demonstrates the use of manufacturer prepared prefilled flush syringes and the reduction of blood stream infection

https://www.ncbi.nlm.nih.gov/pubmed/23498359

Rigorous trial evidence is urgently required to give clinicians and healthcare providers definitive guidance about IV flushing and locking to reduce complications specifically occlusion, thrombosis and infection.

The evidence and recommendations related to Needleless Connector and their decontamination is limited. A lab study has demonstrated the apparent reduced levels of bacterial ingress associated with positive displacement needless connectors. Interestingly their results showed no difference in level of ingress between 5 sec and 15 sec decontamination with 70% IPA in the study. (Reduced levels of bacterial ingress are possibly related to the design of the NC top and the minimal reflux allowed by positive displacement of NC). They discussed the potential value of adding CHG in to the decontamination solution and in fact referenced the UK’s epic3 guidelines recommend decontamination with CHG & IPA for 15 secs plus 15 secs drying time (also attached see p S47). N.B. There is a real risk of CHG toxicity if the drying time is not observed and CHG is inadvertently injected into the bloodstream through the NC.  Nonetheless, a number of clinical areas use this. Other lab studies have demonstrated that a 5 sec decontamination with CHG wipe is far superior to a 30 sec wipe with IPA. The Infusion Nursing Society recommend using 70% IPA for NC decontamination but state that timing is dependent of type of NC. THough importantly, Observational studies of IV practice show repeatedly that most nurses do not decontaminate actively for longer than 5 secs. One alternative to consider to overcome the issue of clinical adherence to NC decontamination is the use of passive decontamination through a IPA impregnated cap. We await clinical studies on all of the above, so for now lab studies are the best evidence we have. 

Rigorous trial research is urgently required to generate evidence to inform clinicians about needleless connector type and decontamination technique, timing and solution appropriate to NC types and patient cohort.

https://www.ncbi.nlm.nih.gov/pubmed/25545971

https://aricjournal.biomedcentral.com/articles/10.1186/s13756-018-0342-0

https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/alcohol-caps-or-alcohol-swabs-with-and-without-chlorhexidine-an-in-vitro-study-of-648-episodes-of-intravenous-device-needleless-connector-decontamination/47F98B64CA57AC311E0486EE6C1E6AE6

Removal/Replacement - Why are there two recommendations based on varied levels of evidence for PIVC replacement/removal? The recommendation should be based on the highest level of evidence available. Currently there exists level I and II evidence to support the removal/replacement of PIVCs as clinically indicated. It is confusing and inconsistent with EBP to give contradictory recommendation based on lower level of evidence (i.e. observational  cohort studies). The UK's EPIC 3, plus US INS guidelines recommend as clinically indicated. The use of clinically indicated demands adherence to previous recommended practice of at least daily patient and device assessment to determine its condition and requirement.

http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD007798.pub4/full

 

4. Organisational support: 

4.1.3 As mentioned before, the use and merit of dedicated, multidisciplinary vascular access specialist teams to guide insertion and management of IVDs is associated with reduced risk of complications, including infection, and improved outcomes for patients.

4.4 Ensure BSI surveillance and reporting in line with current CDC recommendations and uses common deonminator to enable fair and accurate comparisoni.e. rate/1000 catheter days

Page reviewed: 24 September, 2019