Use of Maximal Sterile Barrier Precautions for PICC line ...

Use of Maximal Sterile Barrier
Precautions for PICC line
insertion.

Deborah Bolton
Clinical Nurse Specialist IV Therapy
RGN, PGCHSE, Ma Nursing Studies and Education
Brighton and Sussex University NHS Hospitals Trust

The origins of maximal sterile
barrier precautions

A Central Venous Access Device
(CVAD) is………………

…………a catheter whose tip
terminates in a central
vessel.



A PICC is a CVAD.

Use of maximal sterile barrier
precautions 2010.



PICC placement at the bedside in
BSUH NHS Hospitals Trust.

Healthcare Act 2006

– Code of Practice for Prevention and Control of Healthcare Associated Infections.

„Effective prevention of HCAIs
has to be embedded into every
day practice and applied
consistently by everyone‟

British Committee of Standards in
Haematology 2006

„Whatever the environment, maximum
sterile barrier conditions (mask, cap,
sterile gloves, gown and large drape) have
been shown to lower the risk of acquiring
catheter-related infections‟

Saving Lives 2007 DOH

„Gowns, gloves and drapes as indicated
should be used for insertion of invasive
devices.‟

EPIC 2

„Using maximal sterile barrier precautions during
CVC placement will significantly reduce the risk
of infection.‟

CVC 15:
Use of maximal sterile barrier precautions,
including sterile gown, sterile gloves and a large
sterile drape, for the insertion of central venous
catheters

Review of 13 articles

CDC guidelines 2010

Maximal barrier precautions (e.g. Cap, mask, sterile gown,
sterile gloves, large sterile drape) during the insertion of CVCs
substantially reduces the incidence of CRBSI compared to
standard precautions……….
………….the use of maximal barrier precautions are probably
applicable to PICCs

(O‟Grady, P. et al 2010. Guidelines for the prevention of
Intravascular Catheter-related infections.)

290 articles reviewed US.

Clinical Excellence Commission
2010

The Proceduralist and Assistant/Supervisor
should use maximum sterile barriers, meaning
mask, hat (head and hair cover) and eye
protection, sterile gown and gloves.

Other staff involved in central line insertion who
do not enter the sterile field should wear a mask,
hat and eye protection and perform hand
hygiene appropriately.

Sterile drapes should fully cover the patient and
their bed (unless this is impractical)

Royal College of Nursing 2010

To prevent possible infection of staff, face masks,
caps and eye protection should be worn when
there is a risk that the procedure could cause
hazardous substances or body fluids to splash
into the face, eyes or mouth.

The wearing of a sterile gown should be part of
maximal barrier precautions during central
venous access device insertion.

Mermel et al 1991

 The Risk to Reward ratio

 The odds ratio for an infection was 2.2
times greater without maximal barrier
precautions

Raad et al 1994

 176 insertions using MSBPs
 167 using sterile gloves and small drape

(control)

 Findings - 6.3 times more likely to get an
infection when maximal barrier precautions are
not used

 Conclusion – Use of MSBPs reduces the risk of
CR-BSI

IHI- 100,000 Lives Campaign 2001

 “Some is not a number. Soon is not a
time”

 The time is now for 100% compliance to
the Care Bundle approach to CVC
insertion.

 Updated in 2006 to „Protecting 5 million
lives from harm‟

Kent et al 2004

 Using maximal barrier precautions lowered the
cost of CVC insertion from $621 to $369
(calculated by looking at total direct medical
costs, incidence of CR-BSI, catheter colonisation
and death.)

 Decrease in colonisation from 5.3% to 2.9%
 Decrease in CR-BSI 5.3% to 2.8%
 Decrease in death 0.8% to 0.4%

Other supporting literature

 Hu et al 2004 – a systematic review using 22
references

 Young, Commiskey and Wilson 2006

Results if you google CVC insertion.
 10 articles on page 1
 9 support the use of Maximal Sterile Barrier

Precautions for CVC insertion

Challenging current practice
Ishikawa et al 2010

 424 patient study
 CVC insertion for 212 used MSBPs
 212 used Standard Sterile Precautions (????)

 Results very similar for both groups and were
inconclusive due to small size of sample.

 Concluded need further larger randomised
control trial.

They can‟t all be wrong!

Local evidence

In BSUH we have 13 nurse
PICC placers

We place 1200 PICC per year
We use MSBP every time



The results speak for themselves

BSUH NHS Hospitals Trust
 1 PICC line infection (CR BSI)

recorded since 2000

Change and
over complication of guidelines
leads to confusion in clinical practice

Challenging practice should be
encouraged, but why change if

current practice works?

Change for change‟s sake can
be disastrous



Thank you for listening