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The Oct. 1, 2008 deadline for the Centers for Medicare and Medicaid Services (CMS) to end payment on hospital-acquired conditions which they deem “reasonably preventable” is now behind us. Catheter-related bloodstream infection (CRBSI) is one of eight conditions CMS has identified for non-payment.1 Bloodstream infections are the third leading cause of hospital-acquired infections (HAIs). Each year in the United States, central venous catheters cause an estimated 300,000 catheter-related bloodstream infections and, as a result, up to 75,000 deaths. CRBSIs amount to an estimated $2.3 billion in avoidable healthcare costs annually.2 Have you implemented evidence-based practices to reduce the occurrence of CRBSI and minimize your facility’s exposure to unreimbursed expenses?
The Centers for Disease Control and Prevention (CDC) has released evidence-based guidelines with specific recommendations to reduce the incidence of CRBSIs. Simple interventions such as adopting evidence based practices and implementing innovative technology to facilitate clinician adherence to these practices can assist your facility in minimizing infection rates. The following basic steps, which are part of the 2002 CDC Recommendations, Infusion Nursing Society (INS) 2006 Standards of Practice and Association of Vascular Access (AVA) “SAVE That Line” campaign, can significantly reduce the likelihood of microbial contamination of vascular access devices, and contribute to reduced risk of infection and improved patient outcomes:
Scrupulous hand hygiene
• CDC Category 1A, meaning strongly supported by well-designed studies.
• 2002 CDC Guidelines recommend use of an alcohol-based hand rub for routinely decontaminating hands.
Aseptic technique during catheter insertion and care
• CDC Category 1A.
• One study found a six-fold higher rate of catheter-related septicemia when minimal barriers were used instead of maximum sterile barriers.3
Disinfection of access port
• CDC Guidelines recommend wiping the access port with an appropriate antiseptic.
• INS recommends cleansing access ports with an approved antiseptic solution.
Ensuring patency of the vascular access device
• INS Flushing Standards state that vascular access devices shall be flushed at established intervals to promote and maintain patency and prevent the mixing of incompatible medications and solutions.
• INS recommends that positive fluid displacement within the catheter lumen should be maintained to prevent reflux of blood.
Best practices and innovative technologies such as swabable positive displacement connectors have resulted in rate reductions.
The needleless access device you choose does make a difference. Often overlooked is the importance of evaluating needleless connectors as a component of your infection prevention strategy. The most important function of a connector in addition to providing access is to effectively seal the line when not in use, preventing inadvertent leaking from the catheter and contamination of the catheter from an outside source. Research suggests that keeping the line patent (open) and clean (clear of occlusions and bacteria) will assist in the prevention of CRBSI.4 Facilities that have implemented swabable needleless access devices with anti reflux features have been extremely effective in reducing CRBSI rates. Does the connector you use allow evidence-based practices to work? As a part of line maintenance, nurses are taught to swab vigorously prior to access, flush to clear the line, and use a manual positive pressure flush technique while clamping to prevent reflux. These practices, which have been used for decades, are intended to keep the catheter patent (open) and clean (free of occlusions and bacteria). The problem is sometimes the devices we use do not allow our line maintenance practices to work. Several facilities have added a new tool, a clear positive displacement connector to their CRBSI prevention program. With this tool, evidence-based practices designed to maintain lines are rendered almost instinctive for the clinician. The application of this technology to evidence-based practices is outlined in the following section.
CDC guidelines recommend wiping the access port with an appropriate antiseptic. Unfortunately, research has shown that even after proper swabbing, some needleless access ports remain contaminated and conventional disinfection will not reliably prevent entry of microorganisms.5 Healthcare workers may not adequately clean the intricate surface details, leading to fluid path contamination. “If ports are not disinfected, the contamination is infused into the valve and patient.”4
The flat, smooth access port of the positive displacement connector allows for optimum disinfection prior to access. The intricate surface details of other connectors can retain bacteria even after best-practice disinfection attempts.
Some connectors have gaps around the plunger that can harbor bacteria.6 The positive displacement connector features a patented dual seal design with a tight friction seal at the access port. The clinical impact of this technology is illustrated in a recent study which compares microbial ingress of three devices including the positive displacement connector (device 3).7 The results are displayed in Table 2 (please refer to the print publication of the January issue of ICT)
INS recommends that positive fluid displacement within the catheter lumen be maintained to prevent reflux of blood and ensure line patency. Most needleless access devices create negative displacement upon disconnection causing blood to reflux into the catheter. A positive displacement needleless access device reduces blood reflux into the catheter and helps maintain line patency. This feature does not rely on a clinician’s ability to properly implement a flush/clamp “technique” to create positive pressure. Unlike negative and neutral displacement devices, there is no blood reflux into the catheter at disconnection. Positive displacement connectors like the MaxPlus are designed to sweep the catheter tip and push fluid out the tip at disconnect. This action reduces the likelihood of reflux thrombi and intraluminal occlusions. A recent study compared the displacement properties of several needleless access devices including the MaxPlus. Even devices described as “neutral” exhibit some degree of negative displacement and allow reflux in the catheter which can contribute to increased incidence of intra-luminal clot formation.
A positive displacement connector aids in maintaining patency by preventing reflux of blood into the catheter. Blood reflux can lead to occlusions which may serve as a rich culture medium for bacteria growth, increasing the risk of infection. Recent research comparing a positive displacement connector to a “neutral” connector for number of catheter occlusions over a seven-week period in virtually identical conditions illustrates improved clinical outcomes with a positive displacement connector.8
Another innovative tool which simplifies adherence to best practices and maintaining line patency is a clear housing, allowing complete visualization of the fluid path. A visible fluid path enhances compliance with proper flushing protocols and provides the clinician the ability to visually assess the effectiveness of their flush. Complete flushing of the IV line helps to prevent occlusions and bacteria growth, a major contributor to the development of complications such as infection.
William R. Jarvis, MD, in a 2006 presentation to the Puget Sound chapter of the Infusion Nurses Society on the prevention of catheter-related bloodstream infections, noted, “Opaque housing hides incomplete flushing of media-based fluids. During the course of normal manipulation of catheter, small amounts of bacteria and media-like fluids contaminate the valve. If these organisms proliferate, then they can be infused with subsequent manipulations.”
A study comparing infection rates before and after implementation of the MaxPlus Clear connector resulted in a five- fold decrease in CRBSI from 7.4/1,000 line days to 1.5/1,000 line days. Blood culture contamination decreased 60 percent. Cost savings were estimated to be more than $241,000 from these reductions in infection and contamination.4
A clear, positive displacement connector with a flat, smooth, sealed access port simplifies IV procedures and facilitates adherence to best practices, reducing conditions conducive to the development of infection. Standardizing to one needleless connector on all catheters will provide uniformity and enhance clinician compliance, eliminating different protocols and clamping sequences. By implementing a clear positive displacement connector as a part of a CRBSI prevention strategy, medical facilities can improve patient outcomes, reduce the potential for needlestick injuries and limit exposure to healthcare expenses that in the future may not be reimbursed through CMS. An effective option is the MaxPlus Clear, a positive displacement connector with an easily disinfected access port and a clear housing. Studies demonstrate the MaxPlus Clear increases the effectiveness of clinical best practices.
1. The Centers for Medicare and Medicaid Services In-Patient Prospective Payment System (IPPS) Fiscal Year (FY) 2009 Prospective Rule. Accessed at: http://www.cms.hhs.gov/HospitalAcqCond/06
2. CDC MMWR Recommendations and Reports. Guidelines for the Prevention of Intravascular Catheter-Related Infection. MMWR Recommendations and Reports. Aug. 9, 2002. Vol. 51, No. RR-10.
3. Raad et al. Prevention of central line venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infect Control Hosp Epidemiol. 1994; 15: 231-238.
4. Royer T. et. al. A five-fold decrease in intravascular catheter associated blood stream infections: Clearly beyond the central bundle. 2007 VHA MRSA Prevention Forum, Orlando, Fla.
5. Maki D. et al. Disinfection of needleless catheter connectors and access ports with alcohol may not prevent microbial entry: The promise of a novel antiseptic barrier cap. Infect Control and Hosp Epidem. Vol. 27. January 2006.
6. William Jarvis, MD speech at 2005 SHEA meeting.
7. Lange V. Needleless valves/connectors: Infection prevention poster. 2008 INS winner of the Clinical Innovations/Practices & Research Award.
8. Schotte A. Luer Activated Device (LAD) performance; comparing positive pressure, neutral and negative pressure devices clinically with follow up laboratory testing. Winner of the 2008 INS scientific poster contest for clinical research.