New IV Guidelines: What's Most Critical to Know

January 1, 2003

New IV Guidelines: What's Most Critical to Know

New IV Guidelines: What's Most Critical to Know

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

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 newguidelines for preventing IV-related infections. With IV catheter use on therise, harder-to-treat pathogens making their way into patient bloodstreams andthe substantial cost of treating catheter-related bloodstream infections (CRBSI),these new guidelines serve as a reminder that we can never become complacentabout IV infection control.

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

Additionally, the type of pathogens causing CRBSI has changed -- for theworse. The three most common pathogens causing CRBSI are coagulase negativestaphylococcus, Enterococcus, and Staphylococcus aureus, all of which arecommonly resistant to multiple antibiotics and therefore are more difficult totreat.

The cost per infection attributable to central venous catheters (CVCs) isestimated at $34,508 to $56,000.3-4 The annual cost of caring forpatients 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 guidelinesthat take into account new evidence related to antiseptics, devices, dressingsand replacement of devices. The most significant changes affecting healthcareprofessionals, administrators and patients capable of assisting in the care oftheir 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 ofCVCs because maximum precautions substantially reduce the incidence of CRBSI.6-7This guideline definitely sends the message that we need to think of CVCinsertion as an procedure requiring stringent asepsis, which may require abehavior change for many physicians including anesthesiologists who often failto utilize optimal aseptic technique when inserting vascular catheters in theoperating room .

Chlorhexidine is the preferred skin antiseptic

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

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

Routine CVD replacement discouraged

Catheter replacement at scheduled time intervals was thought to reduceinfections, but two trials showed no CRBSI rate reduction in patients undergoingcatheter replacement every seven days compared with patients whose catheterswere replaced as needed.10-11 The CDC now recommends leaving CVCcatheters in as long as necessary.

Tubing and dressing change intervals extended

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

Recommended materials

Catheters coated or impregnated with antimicrobial or antiseptic agents havebeen found to decrease the risk for CRBSI.12 Recognizing theadditional cost of impregnated catheters, the CDC recommends switching toimpregnated catheters only if other strategies for reducing CRBSI do not achieveyour institution's set goals. The guidelines include very specific strategiesthat should be tried first. The comprehensive strategies should include thefollowing components: educating persons who insert and maintain catheters, useof maximum sterile barrier precautions and 2 percent chlorhexidine preparationfor skin antisepsis during CVC insertion.

Although the CDC guidelines didn't find any clinical difference in infectionprevention between transparent and gauze dressing, they do recognize transparentdressings' other advantages. These include allowing for continuous visualinspection of the catheter site, permitting patients to bathe and shower withoutsaturating the dressing, and requiring less frequent changes than standard gauzeand tape -- saving healthcare personnel time.

Specialized IV teams

The CDC guidelines avoid recommending that healthcare facilities institutespecialized IV teams; however, several studies cited in the guidelines haveshown that specialized teams reduce the incidence of CRBSI and associated costs.13-15For now, the guidelines focus on staff education and training, as well asadequate 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 anevidence-based blueprint for reducing catheter-related infections and reducingthe high costs associated with CRBSIs. For the full CDC report, see"Guidelines for the Prevention of Intravascular Catheter-RelatedInfections" 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 theUniversity of Wisconsin Hospital and Clinics. She was a HICPAC member from 1991to 1998 and was on the task force that developed the draft of the 2002 IVguideline. Laura Rutledge, RN, MN, CRNI, is a member of 3M's technical serviceteam.

TEST QUESTIONS: TRUE OR FALSETF
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