You should complete this section if a majority of CLABSIs occur within six days of line insertion
If CLABSIs at your facility occur equally within 6 days of line insertion and  ≥ 7 days of line insertion, you should also select Step 2B: Care and Maintenance. If CLABSIs at your facility occur mainly ≥ 7 days of line insertion, you can skip "Step 2A: Insertion" and begin working on Step 2B: Care and Maintenance.
Perform and audit compliance with a checklist for proper insertion​
Element
Key Institutional Partners
  • Hand hygiene before insertion
Vascular Access Team, Abstractor, QI Department
  • Gloves, Gowns, Drapes, Maximal Sterile Barriers
Vascular Access Team, Abstractor, QI Department
  • Make MAGIC app available to providers/inserters  
Vascular Access Team, Abstractor, QI Department
  • 2-4% Chlorhexidine Gluconate (CHG) with alcohol for skin antisepsis
Vascular Access Team, Abstractor, QI Department
  • Use of ultrasound for vein mapping/insertion
Vascular Access Team, Abstractor, QI Department
  • Secure line with sutureless securement device
Vascular Access Team, Abstractor, QI Department
  • Competencies for insertion for all inserters
    • Audit should include at least 20% of all insertions
Vascular Access Team, Abstractor, QI Department
Resources/Tools
Assessment/Decision Tools
Articles/References
National/International References:
CDC-Guidelines for the Prevention of Intravascular Catheter-Related Infections (2011) The SIP Protocol- A GAVeCeLT bundle for the safe implantation of PICCs
Articles:
Stone PW, et al. State of infection prevention in US hospitals enrolled in NHSN. American  Journal of Infection Control 2014
  • Gap in compliance with evidence-based infection control policies for CLABSI prevention related to insertion and catheter site selection in ICUs
Raad II, et al. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infection Control & Hospital Epidemiology 1994 
  • Maximal sterile barrier precautions during the insertion of non-tunneled catheters reduce the risk of catheter infection
Hu KK, et al. Using maximal sterile barriers to prevent central venous catheter-related infection: a systematic evidence-based review. American  Journal of Infection Control 2004 
  • Studies suggest maximal sterile barriers may reduce infectious complications; however, further research is needed to support this conclusion. Current literature is limited
Chaiyakunapruk N, et al. Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: a meta-analysis. Annals of Internal Medicine 2002 
  • Incidence of bloodstream infections is significantly reduced in patients with central vascular lines who receive chlorhexidine gluconate versus povidone-iodine for insertion-site skin disinfection
Validation Survey
DVT Step 2 Validation - Appropriate Device Choice and Insertion.
  • This document includes all of the validation questions associated with this content area to help with collaboration on responses for your hospital. Responses to the validation questions should be entered in to the linked document and recorded to monitor progress. 
Appropriate device choice and insertion: only use a CVC if necessary
Element
Key Institutional Partners
  • Evaluate who is determining appropriateness/number of lumens 
    • Consider if another clinician type should be involved (i.e. Vascular Access Teams)
    • Ensure those identified as most appropriate to determine appropriateness/number of lumens are educated on appropriate device choice/insertion
Hospital Leadership, Vascular Team, QI Department
  • Make MAGIC app available to providers 
Hospital Leadership, Providers, IR,  Vascular Access Team, IT
  • Consider integrating use of the MAGIC app into your policy so that providers cannot order a PICC line unless it is first deemed appropriate through the app 
Hospital Leadership, Providers, IR,  Vascular Access Team, IT
  • Design electronic order sets that map to MAGIC criteria 
Hospital Leadership, Providers, IR,  Vascular Access Team, IT
  • Only use a CVC if necessary 
Providers, IR, Vascular Access Team
  • Place the minimum number of lumens 
Providers, IR, Vascular Access Team
​Resources/Tools
Articles/References
Assessment/Decision Tools:
Example Inpatient PICC Order set Criteria  
Tier 1 Resources and Tools 
Presentations: National Guidelines: Articles:
Chopra V, et al. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC). Annals of Internal Medicine 2015
  • Criteria for the use of PICCs was developed, adopting the RAND/UCLA Appropriateness Method. After a review of 665 scenarios, 43% of PICCs were flagged as inappropriate. Applying these criteria as a guide can help decrease the likelihood of an inappropriate catheter, improve care, and inform quality improvement efforts
Xiong Z, et al. Interventions to reduce unnecessary central venous catheter use to prevent central line-associated blood stream infections in adults:  A systematic review. Infection Control & Hospital Epidemiology 2018
  • Interventions aimed at improving CVC appropriateness and prompt device removal significantly reduce CLABSI rates. CLABSI reduction interventions should include focus on CVC appropriateness and device assessment/removal
Ratz D, et al. Limiting the Number of PICC Lumens to Improve Outcomes and Reduce Cost: A Simulation Study. Infection Control & Hospital Epidemiology 2016
  • Every 5% increase in single-lumen PICC use would prevent 0.5 PICC-related central line-associated bloodstream infections and 0.5 PICC-related deep vein thrombosis events, while saving $23,500
Swaminathan L, et al. Improving PICC use and outcomes in hospitalized patients:  An interrupted time series study using MAGIC criteria. BMJ Quality & Safety 2018
  • A multi-modal intervention based on MAGIC resulted in a modest decrease in inappropriate PICC use
Bozaan D, et al. Less lumens-less risk:  A pilot intervention to increase the use of single-lumen peripherally inserted central catheters. Journal of Hospital Medicine 2019
  • An intervention involving setting PICC default orders to single-lumen devices, establishing criteria of when multi-lumen PICCs are appropriate, and provider, nursing, and pharmacy education resulted in significant decrease in inappropriate PICC use as well as an overall increase in single lumen PICC use 
Lam PW, et al. Impact of defaulting to single-lumen peripherally inserted central catheters on patient outcomes:  An interrupted time series study. Clinical Infectious Diseases 2018
  • Defaulting non-ICU PICC orders to single-lumen devices resulted in a sustained decrease in PICC-associated complications
Validation Survey
CLABSI Step 2 Validation - Appropriate Device Choice and Insertion. 
  • ​This document includes all of the validation questions associated with this content area to help with collaboration on responses for your hospital. Responses to the validation questions should be entered in to the linked document and recorded to monitor progress. 
Avoid PICCs in patients at a high risk of CLABSI
Element
Key Institutional Partners
  • Provide education on the Michigan PICC CLABSI (MPC) Score to Providers and/or PICC Inserters at your facility
Providers, IR, Vascular Access Team
  • Use the MPC Score to determine risk of CLABSI prior to selecting a PICC 
Providers, IR, Vascular Access Team
  • If a patient is at high risk of CLABSI, consider advanced approaches (i.e. Chlorhexidine gluconate impregnated catheters) to device insertion or use another device
Providers, IR, Vascular Access Team
​Resources/Tools
Articles/References
​Herc E, et al.  Model to Predict Central-Line-Associated Bloodstream Infection Among Patients With Peripherally Inserted Central Catheters: The MPC Score. Infection Control & Hospital Epidemiology 2017 Chopra V, et al. The risk of bloodstream infection associated with peripherally inserted central catheters compared with central venous catheters in adults:  A systematic review and meta-analysis. Infection Control and Hospital Epidemiology 2013
  • Risk for CLABSI may be similar for hospitalized patients with PICCs vs CVCs
Chopra V, et al. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC). Annals of Internal Medicine 2015
  • Criteria for the use of PICCs was developed, adopting the RAND/UCLA Appropriateness Method. After a review of 665 scenarios, 43% of PICCs were flagged as inappropriate. Applying these criteria as a guide can help decrease the likelihood of an inappropriate catheter, improve care, and inform quality improvement efforts
Micic D, et al. Choosing the right central venous catheter for parenteral nutrition. The American Journal of Gastroenterology 2018
  • Review of appropriate venous access device selection for patients requiring total parenteral nutrition (TPN)
Validation Survey
CLABSI Step 2 Validation - Avoid PICCs in Patients at High Risk of CLABSI/Michigan PICC CLABSI Score. 
  • ​This document includes all of the validation questions associated with this content area to help with collaboration on responses for your hospital. Responses to the validation questions should be entered in to the linked document and recorded to monitor progress. ​
Assessment of catheter to vein ratio
Element
Key Institutional Partners
  • Use Catheter to Vein (CVR) App or Tool
    • CVR is associated with PICC related UE DVT. Thrombosis in the catheter or around the vein increases risk of infection
Provider, IR, Vascular Team, Hospital Leadership
  • Document CVR measurement in the chart 
Provider, IR, Vascular Team
  • Audit of CVR documentation
Vascular Team, Abstractor, QI Department
​Resources/Tools
Decision tools:
Articles/References
​Thornburg CD, et al. Association between thrombosis and bloodstream infection in neonates with peripherally inserted catheters. Thrombosis Research 2008
  • There was a positive association between thrombosis and bloodstream infection in infants who did not have lines removed for infection. Further research must be done to understand the pathophysiology between these two complications
Spencer T, et al. Reducing catheter-related thrombosis using a risk reduction tool centered on catheter to vessel ratio. Journal of Thrombosis and Thrombolysis 2017
  • Increasing the understanding and utilization of CVRs will lead to a safer, more consistent approach to device placement, with potential thrombosis reduction strategies
Timsit JF, et al. Central vein catheter-related thrombosis in intensive care patients:  Incidence, risk factors, and relationship with catheter-related sepsis. Chest  1998
    • Catheter-related venous thrombosis is associated with higher rates of septicemia and catheter-related sepsis
Validation Survey
CLABSI Step 2 Validation - Assessment of Catheter to Vein Ratio. ​
  • This document includes all of the validation questions associated with this content area to help with collaboration on responses for your hospital. Responses to the validation questions should be entered in to the linked document and recorded to monitor progress.

Step 2B: Care and Maintenance

You should complete this section if a majority of CLABSIs occur ≥ 7 days of line insertion
Mandatory steps:  dressing, flushing, cap hygiene, patient education
Optional steps:  hand hygiene, nurse to patient ratios
  • In several portions of this Step, you will be asked to conduct a review for a four-month period.  You should use the same four-month period in all instances. Please refer to the Care and Maintenance Audit and Rounding Form as you move through this Step. This audit form includes the content you need for the various modules within this step and filling it out for all content will be helpful in later steps.
  • If CLABSIs at your facility occur equally within 6 days of line insertion and ≥ 7 days of line insertion, you should have also selected Step 2A: Insertion. If CLABSIs at your facility occur mainly within 6 days of line insertion, you can skip step 2B: Care and Maintenance, and begin work on Step 3. Please contact the Coordinating Center if this pertains to your hospital.
Dressing
Element
Key Institutional Partners
  • Perform Dressing audits to examine whether site is clean, dry, intact and dressing is adherent to and covering entire site
Abstractor, QI Department
  • Ensure competencies of nursing staff are up-to-date for dressing care and maintenance 
Abstractor, QI Department, Nursing Leadership
  • Consider use of advanced dressings (e.g., Sorbaview, Securacath) if dislodgement or migration are concerns 
Provider, IR, Vascular Team, Hospital Leadership/Nursing Leadership
Resources/Tools ​Example Education Fliers from Intermountain Healthcare:
Articles/References
​National Guidelines: Articles:
Page, J et al. Reducing oncology unit central line-associated bloodstream infections:  Initial results of a simulation-based educational intervention. Journal of Oncology Practice 2016
  • A targeted educational intervention for central-line care on an Oncology unit proved to decrease CLABSIs and increase competence in care of central-lines. A simulated central-line care model was used for the purpose of this testing
Validation Survey
CLABSI Step 2 Validation - Care and Maintenance - Dressing. 
  • This document includes all of the validation questions associated with this content area to help with collaboration on responses for your hospital. Responses to the validation questions should be entered in to the linked document and recorded to monitor progress.
Flushing
Element
Key Institutional Partners
  • Catheters should be flushed with 10 cc NS every day if not in use
Provider, IR, Vascular Team, Hospital Leadership/Nursing Leadership
  • If catheter is in use, flush with 10 cc NS before and after each use
Provider, IR, Vascular Team, Hospital Leadership/Nursing Leadership
  • Heparin solutions on their own are not recommended for PICC maintenance
    • Note: Heparin use in conjunction with the SASH (saline, medication administration, saline, heparin) flushing technique appears to be beneficial
Provider, IR, Vascular Team, Hospital Leadership/Nursing Leadership
  • tPA preferred over other drugs to treat any problems related to occlusion, sluggish flow
Provider, IR, Vascular Team, Hospital Leadership/Nursing Leadership
Resources/Tools​ ​Example Education Fliers from Intermountain Healthcare:
Articles/References
​​Goossens, GA. Flushing and locking of venous catheters:  Available evidence and evidence deficit. Nursing Research and Practice 2015
  • A review of intravenous catheter flushing and locking describing techniques, sufficient volumes, and necessity. High risk associated with common flushing agents requires investigation of alternatives
Page, J et al. Reducing oncology unit central line-associated bloodstream infections:  Initial results of a simulation-based educational intervention. Journal of Oncology Practice 2016
  • A targeted educational intervention for central-line care on an Oncology unit proved to decrease CLABSIs and increase competence in care of central-lines. A simulated central-line care model was used for the purpose of this testing
Occlusion Management Guideline for Central Venous Access Devices (CVADs). Vascular Access:  Journal of the Canadian Vascular Access Association 2013 (Free)
Validation Survey
CLABSI Step 2 Validation - Care and Maintenance - Flushing. ​
  • This document includes all of the validation questions associated with this content area to help with collaboration on responses for your hospital. Responses to the validation questions should be entered in to the linked document and recorded to monitor progress.
Cap Hygiene
Element
Key Institutional Partners
  • Perform audits for caps with visible blood in septum 
Abstractor, QI Department
  • Neutral displacement or anti-reflux caps preferred over positive displacement caps 
Providers, IR, Vascular Team, Hospital Leadership/Nursing Leadership
  • Consider use of alcohol impregnated caps for PICCs, especially those placed in patients at high risk of CLABSI 
Provider, IR, Vascular Team, Hospital Leadership/Nursing Leadership
Resources/Tools​​
Articles/References
​Moureau NL, et al. Disinfection of needleless connector hubs:  Clinical evidence systematic review. Nursing Research and Practice 2015
  • Systematic review of the practices for needleless connector disinfection showing high risk of needless connector contamination and low disinfection practice compliance. The use of alcohol impregnated caps resulted in 48-68% decrease in infection
Kamboj M, et al. Use of disinfection cap to reduce central-line-associated bloodstream infection and blood culture contamination among hematology-oncology patients. Infection Control and Hospital Epidemiology 2015
  • Use of alcohol impregnated caps (passive disinfection) resulted in a 34% reduction of hospital acquired CLABSI rates, particularly among high risk patients, and 51-63% reduction in blood culture contamination
Validation Survey
CLABSI Step 2 Validation - Care and Maintenance - Cap Hygiene. ​​
  • This document includes all of the validation questions associated with this content area to help with collaboration on responses for your hospital. Responses to the validation questions should be entered in to the linked document and recorded to monitor progress.
Patient education regarding care and maintenance of PICC line
Element
Key Institutional Partners
  • Educate patients regarding precautions they need to take while the PICC line is in place, including no lifting heavy weights, no contact sports, avoid lifting the arm above your head, and monitor the catheter length on the skin
​Provider, IR, Vascular Team, Hospital Leadership/Nursing Leadership
  • Educate patients on PICC care
Provider, IR, Vascular Team, Hospital Leadership/Nursing Leadership
  • Evaluate when patients are being educated and ensure that education occurs at a minimum prior to/upon PICC insertion and upon discharge if the patient is being discharged with a PICC
Provider, IR, Vascular Team, Hospital Leadership/Nursing Leadership
Resources/Tools​​
Validation Survey
CLABSI Step 2 Validation - Care and Maintenance - Patient Education.  
  • This document includes all of the validation questions associated with this content area to help with collaboration on responses for your hospital. Responses to the validation questions should be entered in to the linked document and recorded to monitor progress.
Hand Hygiene
Element
Key Institutional Partners
  • Educate nurses and any other providers responsible for manipulation and care of the PICC line on the importance of hand hygiene prior to line manipulation and access
​Provider, IR, Vascular Team, Hospital Leadership/Nursing Leadership
  • Proper hand hygiene is required before and after palpating catheter insertion sites as well as before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter
Provider, IR, Vascular Team, Hospital Leadership/Nursing Leadership
Ensure nurse to patient ratios are adequate for patients with central lines (optional)​
Element
Key Institutional Partners
  • Evaluate nurse to patient ratios, and nursing hours per patient to ensure they are adequate for the care of patients with central lines
    • ICU
    • Non-ICU
Nursing Leadership
Articles/References​