Current Methods for Preventing CLABSIs
Many experts agree that the most effective way to prevent CLABSIs is to create “bundles” that prevent contamination at every critical point along the catheter placement/maintenance timeline. A bundle is a set of best practices for achieving a desired care outcome. The most widely accepted bundles for preventing CLABSIs combine behaviors and technologies that support or enhance those behaviors that achieve the best outcomes. The current Central Line Bundle (see www.IHI.org) includes:
Chlorhexidine skin prepping
Selection of best device site
Daily review of device necessity
Thorough skin antisepsis prior to insertion reduces bacteria at the insertion site, which is why it is part of standard CLABSI prevention protocols. Nevertheless, some bacteria will inevitably survive and enter the bloodstream with the catheter increasing risks for extraluminal infection (Ryder, 2005).
Peripherally inserted central catheters (PICCs), as opposed to other vascular access devices, are associated with fewer infections than central lines placed in the jugular or subclavian insertion sites. The lower infection rates are probably due to the fact that the resident skin bacteria counts are 1,000-fold fewer on the average patient’s arm, which tends to be dry, as opposed to the upper chest, neck and groin which are warm, moist, and dark (Macklin, 2007).
Intraluminal biofilm can form when microorganisms inhabit an improperly disinfected access portal or connection site giving them access to the catheter’s flow system. It is important that key parts of the catheter administration set be disinfected. There is concern now in the vascular access community that needless mechanical valve devices (NMVDs) may be problematic in this regard (SHEA guidelines, 2008). A study published in 2007 shows a significant increase in CLABSI rates when a hospital switched from needleless split-septum devices (NSSDs) to NMVDs (Salgado, 2007). This increase occurred despite the fact that nursing staff attended multiple educational sessions about the proper use and disinfection of NMVDs. This was not an isolated report. Three abstracts from national scientific meetings and one article in a peer-reviewed journal describe similar increases (Salgado, 2007). Other anecdotal reports concern a variety of NMVDs from different makers. In addition, a Veterans Administration medical center found increased bloodstream infection rates after implementing luer-activated mechanical valves (NMVDs) and positive displacement needle-free intravascular connector valves (NMVDs) (Salgado, 2007).
NMVDs originally came into wide use because, as a needleless device, they protected nursing staff from potential sharps injuries while providing easy connection with only a syringe. They were considered an advance over NSSDs, which were associated with frequent occlusions, backflow issues, and in some reports, increased bloodstream infections. NMVDs do appear to reduce occlusions and backflow but perhaps at the expense of a higher infection rate. Many of those studying NMVD use believe the increased CLABSIs occur because the multi-part devices are difficult to disinfect (Salgado, 2007).