New IV Guidelines: What's Most Critical to Know

January 1, 2003

New IV Guidelines: What's Most Critical to Know

By Rita McCormick, RN, CIC and Laura Rutledge, RN, MN, CRNI

OBJECTIVES:

1. To understand why new IV guidelines from the CDC are necessary.

2. To explore maximum barrier precautions for CVC insertion.

3. To explain the recommended frequency of replacement for CVCs.

The Centers for Disease Control and Prevention (CDC) recently published new
guidelines for preventing IV-related infections. With IV catheter use on the
rise, harder-to-treat pathogens making their way into patient bloodstreams and
the substantial cost of treating catheter-related bloodstream infections (CRBSI),
these new guidelines serve as a reminder that we can never become complacent
about IV infection control.

Since publication of the 1996 CDC IV guidelines, catheter use has increased
significantly, especially by patients at home. As with any medical device that
has widespread use, there is a tendency to handle catheters with a casual
attitude. While the number of bloodstream infections (BSIs) associated with
catheters hasn't increased since 1996, we're still seeing approximately 80,000
CRBSIs each year in the United States associated with central venous catheters (CVCs).1

Additionally, the type of pathogens causing CRBSI has changed -- for the
worse. The three most common pathogens causing CRBSI are coagulase negative
staphylococcus, Enterococcus, and Staphylococcus aureus, all of which are
commonly resistant to multiple antibiotics and therefore are more difficult to
treat.

The cost per infection attributable to central venous catheters (CVCs) is
estimated at $34,508 to $56,000.3-4 The annual cost of caring for
patients with CVC-associated infections ranges from $296 million to $2.3 billion5
-- a hefty toll on America's already-strained healthcare system.

To improve patient outcomes and reduce costs, the CDC issued new guidelines
that take into account new evidence related to antiseptics, devices, dressings
and replacement of devices. The most significant changes affecting healthcare
professionals, administrators and patients capable of assisting in the care of
their catheters are:

Maximum barrier precautions for CVC insertion

The CDC now recommends maximum sterile barrier precautions (cap, mask,
sterile gown, sterile gloves and large sterile drape) during the insertion of
CVCs because maximum precautions substantially reduce the incidence of CRBSI.6-7
This guideline definitely sends the message that we need to think of CVC
insertion as an procedure requiring stringent asepsis, which may require a
behavior change for many physicians including anesthesiologists who often fail
to utilize optimal aseptic technique when inserting vascular catheters in the
operating room .

Chlorhexidine is the preferred skin antiseptic

To date, povidone iodine has been the most widely used antiseptic for
cleaning insertion sites prior to insertion as well as maintenance of the IV
catheter, however research data indicates that 2 percent aqueous chlorhexidine
gluconate significantly lowered BSI rates compared with 10 percent povidone
iodine or 70 alcohol alcohol.8 It's important to note that the amount
of CHG needs to be high enough. A 0.5 percent tincture is not more effective
than povidone iodine, according to one study.9 Although it has been
known for some time that the persistence of chlorhexidine gluconate is greater
than that of povidone iodine, until recently a chlorhexidine skin antiseptic was
not available for such purposes in the United States.

This change shouldn't be a problem for most healthcare practitioners. It's
simply a matter of switching from a brown to a clear antiseptic.

Routine CVD replacement discouraged

Catheter replacement at scheduled time intervals was thought to reduce
infections, but two trials showed no CRBSI rate reduction in patients undergoing
catheter replacement every seven days compared with patients whose catheters
were replaced as needed.10-11 The CDC now recommends leaving CVC
catheters in as long as necessary.

Tubing and dressing change intervals extended

Replacement of CVC administration sets remains at 72 hours. For dressing
change intervals, the guidelines recommend replacing CVC dressings every seven
days if using transparent dressing or two days if using gauze.

Recommended materials

Catheters coated or impregnated with antimicrobial or antiseptic agents have
been found to decrease the risk for CRBSI.12 Recognizing the
additional cost of impregnated catheters, the CDC recommends switching to
impregnated catheters only if other strategies for reducing CRBSI do not achieve
your institution's set goals. The guidelines include very specific strategies
that should be tried first. The comprehensive strategies should include the
following components: educating persons who insert and maintain catheters, use
of maximum sterile barrier precautions and 2 percent chlorhexidine preparation
for skin antisepsis during CVC insertion.

Although the CDC guidelines didn't find any clinical difference in infection
prevention between transparent and gauze dressing, they do recognize transparent
dressings' other advantages. These include allowing for continuous visual
inspection of the catheter site, permitting patients to bathe and shower without
saturating the dressing, and requiring less frequent changes than standard gauze
and tape -- saving healthcare personnel time.

Specialized IV teams

The CDC guidelines avoid recommending that healthcare facilities institute
specialized IV teams; however, several studies cited in the guidelines have
shown that specialized teams reduce the incidence of CRBSI and associated costs.13-15
For now, the guidelines focus on staff education and training, as well as
adequate nursing staff levels in intensive care units.

Summary

The updated CDC IV guideline, which takes into account new research findings,
as well as improvements in medical devices and supplies, provides an
evidence-based blueprint for reducing catheter-related infections and reducing
the high costs associated with CRBSIs. For the full CDC report, see
"Guidelines for the Prevention of Intravascular Catheter-Related
Infections" on the CDC Web site at http://www.cdc.gov/ncidod/hip/iv/iv.htm/.

Rita McCormick, RN, CIC, is an infection control practitioner at the
University of Wisconsin Hospital and Clinics. She was a HICPAC member from 1991
to 1998 and was on the task force that developed the draft of the 2002 IV
guideline. Laura Rutledge, RN, MN, CRNI, is a member of 3M's technical service
team.

TEST QUESTIONS: TRUE OR FALSE T F
1. Increased catheter use, harder-to-treat pathogens making their way
into patient bloodstreams and the cost of treating catheter-related
bloodstream infections (CRBSIs) remind healthcare workers not to become
complacent about IV infection control.
   
2. While the number of bloodstream infections associated with catheters
hasn't increased since 1996, approximately 80,000 CRBSIs occur each year
in the United States associated with central venous catheters (CVCs).
   
3. The three most common pathogens causing CRBSI are coagulase negative
staphylococcus, MRSA and Staphylococcus aureus.
   
4. The cost per infection attributable to central venous catheters is
estimated at $34,508 to $56,000.
   
5. The CDC does not recommend maximum sterile barrier precautions (cap,
mask, sterile gown, sterile gloves and large sterile drape) during the
insertion of CVCs.
   
6. Chlorhexidine gluconate is now recommended as the preferred skin
disinfectant for insertion and maintenance of IV devices.
   
7. For arterial peripheral tubing, the new CDC guidelines recommend
extending the replacement interval from 72 hours to 96 hours, unless
infection is suspected.
   
8. Catheters coated or impregnated with antimicrobial or antiseptic
agents have not been found to decrease the risk for CRBSI.
   
9. According to several studies cited in the guidelines, specialized IV
teams have shown unequivocal effectiveness in reducing the incidence of
CRBSI and associated cost.
   
10. Since publication of the 1996 CDC IV guidelines, catheter use has
decreased significantly.
   

ANSWERS

1. T

2. T

3. F

4. T

5. F

6. T

7. T

8. F

9. T

10. F