Central venous catheters (CVCs) are becoming increasingly popular in outpatient and inpatient settings to provide long-term venous access. Their benefit is undeniable, but there are consequences and they can be startling. CVCs disrupt skin integrity and therefore leave the epidermis susceptible to fungus and bacteria. Infection may spread to the bloodstream and create organ dysfunction or death.
Nosocomial bloodstream infections prolong hospitalization by a mean of seven days and cost between $3,700 and $29,000 per case.¹
When a patient has a catheter, he or she is at constant risk for catheter-related bloodstream infection (CR-BSI). Factors at play are the catheter type, the frequency of access or manipulation, and the patient’s clinical status.²
CVCs are associated with a greater quantity and seriousness of infection than short peripheral catheters, partly because patients who need CVCs are often sicker, and their catheters are likely to be accessed more often.²
Approximately 90 percent of CR-BSIs occur with CVCs.¹
There is a “tremendous” amount of work being done to decrease CVCs in intensive care units, but there should be more focus on at-risk populations, says Trish Perl, MD, MSc, professor of medicine, pathology and epidemiology at Johns Hopkins Medical University, and an epidemiologist at Johns Hopkins medical institutions in Baltimore. The vulnerable populations she speaks of include dialysis patients, patients with long-term central lines, or who are undergoing chemotherapy. “In some of these groups the bundle may need to be changed and adapted to the risk factors that these patient populations are affected by,” Perl says.
Why Catheters are Dangerous
Forty-eight percent of ICU patients have CVCs, and that adds up to a whopping 15 million CVC days per year in ICUs.¹ Approximately 5.3 central line infections occur per 1,000 catheter days in ICUs, and deaths range from 14,000 to 28,000 per year.¹
How do infectious organisms use catheters to invade the body? When the catheter is inserted, it breaks the skin and this creates a convenient path for organisms to enter the patient’s bloodstream. Skin antisepsis with proper technique can’t eliminate all organisms in the lower layers of the epidermis, and that means the catheter has access to these organisms as it passes through the skin.²
The danger doesn’t stop there. Medication administration, flushing, and tubing or cap changes require catheter manipulation and can introduce microorganisms to the lumen. Hub manipulation is the most common source of infection in long-term catheters but can also spur CR-BSI in short-term catheters.²
Reducing catheter-related infections is vital, but doing so requires staff members to implement changes. Employees meet these changes with any mix of hope or doubt. Attitude depends on the institution and the people, and whether they think there is even a problem to correct, Perl says. “So you see a myriad of attitudes and these attitudes depend on the safety climate, the leadership and the engagement of leadership and the clinical/medical perception of the problem,” she adds. “Finally, I think that the amount of personal accountability organizations place on healthcare workers affects their perception of the problem and their willingness to participate in solutions.”
The Institute for Healthcare Improvement (IHI)’s 100,000 Lives Campaign seeks to prevent catheter-related bloodstream infections by implementing components of care called the “central line bundle.” The central line bundle is a group of evidence-based interventions that are more effective together than alone. The bundle has five components:
Maximal barrier precautions
Chlorhexidine skin antisepsis
Optimal catheter site selection, with the subclavian vein as the preferred site for non-tunneled catheters
Daily review of line necessity, with prompt removal of unnecessary lines
1. Hand Hygiene
According to the IHI, caregivers tending central lines should wash their hands thoroughly before and after palpating catheter insertion sites; before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter; when hands are obviously soiled; before and after invasive procedures; between patients; before donning gloves and after removing them, and after using the restroom.
To improve hand hygiene facility wide, it is wise to include hand hygiene as part of a central line placement checklist. Staffs should keep soap or alcohol-based dispensers in convenient areas, and should make certain that personal protective equipment is located near hand sanitation equipment. IHI also advises staffs to post hand hygiene signs for education purposes, and to foster an environment where reminding each other about hand hygiene is encouraged.
2. Maximal Barrier Precautions
One key to decreasing central line infection risk is to apply maximal barrier precautions when preparing for line insertion. The operator who is placing the central line and everyone assisting him or her should wear a cap, mask, sterile gown and gloves.¹
“The cap should cover all hair and the mask should cover the nose and mouth tightly,” IHI suggests. “These precautions are the same as for any other surgical procedure that carries a risk of infection. For the patient, applying maximal barrier precautions means covering the patient from head to toe with a sterile drape, with a small opening for the site of insertion. Include maximal barrier precautions as part of your checklist for central line placement.”
The equipment should be well-stocked in a cart specifically for central line placements.
3. Chlorhexidine Skin Antisepsis
Chlorhexidine skin antisepsis has been proven to provide better skin antisepsis than other antiseptic agents such as povidone-iodine solutions, IHI researchers claim.
For most kits the technique is to:¹
prepare skin with antiseptic/detergent chlorhexidine 2 percent in 70 percent isopropyl alcohol.
pinch wings on the chlorhexidine applicator to break open the ampule; hold the applicator down to allow the solution to saturate the pad.
press the sponge against the skin and apply chlorhexidine solution using a back-and-forth friction scrub for at least 30 seconds. Do not wipe or blot.
allow antiseptic solution to dry completely before puncturing.
IHI recommends including chlorhexidine antisepsis as part of your checklist for central line placement, and putting chorhexidine antisepsis kits in carts or grab bags specifically for central line equipment.
4. Optimal catheter site selection
“Percutaneously inserted catheters are the most commonly-used central catheters,” IHI researchers say. “Several risk factors have been identified, however, that are associated with bloodstream infections. These include the site of placement. Whenever possible, and not contraindicated, the subclavian line site should be preferred over the jugular and femoral sites for non-tunneled catheters in adult patients.”
It is necessary to assess daily whether the central line is still necessary. It is common for central lines to stay in place simply because the caregiver has not considered taking them out. This is a critical misstep, as it’s clear that infection risks increase the longer a line remains. Daily review should be part of multidisciplinary rounds.¹ Record the time and date of line placement and make this information accessible to staff so they can draw upon it when making decisions.
Barriers to Bundling
Bundling is a simple idea overall, but many factors thwart it. According to Perl, one main barrier to proper bundling is that some employees may not know why bundling is important. Logistics are also vital. “Do you have the equipment you need, does the equipment work, does the institution make it easy for you to perform the correct behaviors?” Perl suggests asking. Staff also may not support bundling if they do not receive reinforcing factors such as outcome measures, Perl adds.
All bundling goals should be time-specific and measurable and should define which patient population will be affected.¹
Effective central line bundle programs cannot be implemented instantly. An efficacious program includes careful planning and implementation, observation, modifications, and readjustment.
According to IHI, some barriers to effective implementation may include fear of change. “All change is difficult,” IHI researchers write. “The antidote to fear is knowledge about the deficiencies of the present process and optimism about the potential benefits of a new process.”
Another culprit is communication breakdown, and inadequate buy-in from physicians and staff. They may be wondering if bundling is just another flavor of the week. To engage staff, share the good results of improvement measures, and make baseline data on CR-BSI rates accessible.¹ “If the run charts suggest a large decrease in CR-BSIs compared to baseline, issues surrounding ‘buy-in’ tend to fade,” the researchers continue.
Another roadblock to CR-BSI reduction is improper nurse-to-patient staffing ratios. A direct relationship between understaffing and high CR-BSI rates has been shown.²
Forming a Team
IHI leaders recommend a multidisciplinary, heterogeneous team-approach to patient care. They say the value of bringing diverse personnel together is that people from several levels (nurses, therapists, physicians) share a stake in the outcome. This can lead to greater camaraderie, and therefore, better communication and synergy.
Attracting and retaining an excellent team requires education, finding visible, credible champions within the facility, and recruiting people who want to be part of the project, not people who have to be forced.¹
“The team needs encouragement and commitment from an authority in the intensive care unit,” IHI leaders say. “Identifying a champion increases a team’s motivation to succeed. When measures are not improving fast enough, the champion readdresses the problems with staff and helps to keep everybody on track toward the aims and goals.”
Eventually, the program is established and becomes the norm, but that doesn’t mean the team members or patients are out of the woods yet.
“At some point ... changes in the field or other changes in the ICU will require revisiting the processes that have been developed,” IHI leaders continue. “Identifying a ‘process owner,’ a figure who is responsible for the functioning of the process now and in the future, helps to maintain the long-term integrity of the effort.”
In 2001 through 2005, the Pittsburgh Regional Healthcare Initiative invited the Centers for Disease Control (CDC) to ICUs in southwestern Pennsylvania to provide technical assistance for a hospital-based intervention to prevent central line-associated infections. During the intervention, infection rates among ICU patients declined 68 percent, from 4.31 to 1.36 per 1,000 central line days.³ The results suggest that a coordinated, multi-institutional infection-control initiative is a worthwhile approach, according to authors of, “Reduction in central line-associated bloodstream infections among patients in intensive care units.”
The intervention included 32 hospitals from 10 counties.
The median size of the hospitals involved was 215 beds. Among the participating hospitals, 66 ICUs contributed data. Forty eight percent were medical/surgical, 11 percent cardiothoracic, 14 percent coronary, 9 percent surgical, 6 percent neurosurgical, 5 percent trauma, 3 percent medical, 3 percent burn, and 3 percent pediatric.³
The promoted prevention practices were hardly a space-age creation; they have been included in the Healthcare Infection Control Practices Advisory Committee recommendations since 1996.³ Sometimes, however, older, more simple techniques are the best. “The results described in this report suggest that adhering to these evidence-based preventive practices can prevent BSIs,” the report authors write. “Nonetheless, previous reports suggest that adherence to these practices remains low.”
A study conducted at Banner Desert Hospital, in Mesa Ariz., sought to decrease CVC infections in the adult medical/surgical ICU by using literature from the CDC and IHI, and benchmarks from the National Institute of Health Services.4
Project leaders gathered initial data about the nature of central line infections with the help of a central line audit tool, which included aspects such as patient symptoms, cultures and culture sites, and the date the central line was placed.4 The central line audit tool was used to track the number and nature of infections after the central line bundle and safety checklists were instituted, writes Jeanette Meyer, MSN, RN, CCRN, CCNS, PCCN, in her paper, “Decreasing central line infections with evidence-based practice.”
The result was that in seven consecutive months after the practice change, no CVC infections were noted. The recommendation from Meyer’s paper is to continue using the central line bundle and safety checklists.
“Examine each specific infection that occurs in detail to attempt to determine causative factors,” Meyer writes. “Create specific criteria for evaluating line necessity and use this criteria in determining whether to maintain or discontinue central lines.”
Some research supports bundling, but the process should not be mandatory at every hospital, Perl says.
“It would be a shame to force reporting of something that is not supported by the literature,” Perl says. “While I think the bundle is important, these data are lacking. Also, we need to make sure people know that the bundle in itself will not prevent all CA-BSI—there are other reasons patients get these and we cannot forget these other important components of infection prevention programs.”ICT
1. Institute for Healthcare Improvement: Getting Started Kit: Prevent Central Line Infections, How-to Guide. www.ihi.org/ihi.
2. Hadaway LC. Best-practice interventions: keeping central line infection at bay. Nursing2006. April 2006
3. Centers for Disease Control and Prevention. Reduction in Central Line-Associated Bloodstream Infections Among Patients in Intensive Care Units: Pennsylvania, April 2001-March 2005. Oct. 2007.
4. Meyer JM. Decreasing central line infections with evidence-based practice. Academic Center for Evidence-Based Practice.