IV Therapy - Preventing Central Line Associated Complications

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IV Therapy - Preventing Central Line Associated Complications

Course Description

Accreditation Information: KLA Education Services LLC is accredited by the State of California Board of Registered Nursing, Provider # CEP16145.

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Course Objectives

Upon completion of this course, the course participant will be able to:

  • Implement a catheter checklist into standard practice.
  • Identify 3 factors leading to a higher risk of Central Line Associated Blood Stream Infection.
  • Identify 3 evidenced based methods of preventing Central Line Associated Blood Stream Infections.


Course Content

Introduction

Blood Stream infections are one the most serious and widespread health care acquired infections. In the United States, there are over 200,000 reported cases of Central Line Associated Blood Stream Infections annually8. These health care acquired infections increase the hospital length of stay, add significant costs to health care systems, and have a high rate of patient morbidity and mortality. The majority of these complications are entirely preventable10.

It was traditionally believed that the Intensive Care Unit (ICU) populations should be the primary focus point for Central Line Associated Blood Stream Infection reduction efforts. However, due to the rapidly growing frequency of Non-ICU Central Line administrations hospitals across the world are finding that the majority of patients with Central Lines are outside of the ICU8. This helps accentuate the need for hospital wide prevention efforts that are being measured and monitored hospital wide, rather than departmentally targeted7.

In January of 2014, the Joint Commission announced that reducing the rate of Central Line Associated Blood Steam infections was a key patient safety goal7. They helped identify several key components necessary for successful reduction initiatives:

  • Educate staff, licensed practitioners, patients, and family about central line-associated bloodstream infections and the importance of prevention.
  • Implement evidenced based policies and procedures aimed at preventing Central Line Associated Blood Stream Infections.
  • Conduct periodic risk assessments for central line-associated blood stream infections, monitor compliance with evidence-based practices, and evaluate the effectiveness of prevention efforts7.
  • Provide central-line associated bloodstream infection rate data and prevention outcome measures to key stakeholders, including leaders, licensed independent practitioners, nursing staff, and other clinicians7.

Educating Key Players

The education of risk factors, best practices, and prevention practices will help make the reduction of Central Line Associated Blood Stream Infections a priority topic for health care providers. Successful systems often educate upon hire, annually thereafter, and as soon as central line administration becomes a part of someone’s job description and duties7.

Several basic educational practices include:

Educational programs should include the indications for catheter use, appropriate sterilization, insertion, and maintenance, the risk of Central Line Associated Blood Stream Infections, and general infection prevention strategies5.
The health care system should ensure that all parties involved in the administration or maintenance of a Central Venous Catheter have passed an educational program (as determined by the health care system) certifying them to safely perform the procedure.
All practitioners should be routinely evaluated and measured in regards to preventative practices.
Patients and the patient’s families should be educated on the risks of blood stream infections and the correct maintenance and cleaning practices5. This is extremely important in situations where the patient is being discharged with a catheter.
The majority of hospitals create easy to follow brochures and pamphlets (in applicable languages) to help the health care team educate the patient and patient’s family.

Patient Risk Factors

Listed below is a list of the most common factors that can increase a patient’s likelihood to develop a Blood stream infection. Patient Risk factors of Central Line Associated Blood Stream Infections:
Femoral Catheterization
Prolonged hospitalization prior to Catheterization
Prolonged duration of Catheterization
Repeated Access of Catheterization
Catheters applied during an emergency situation
Heavy microbial colonization at the insertion site
Heavy microbial colonization of the catheter site
Internal jugular catheterization
Neutropenia
Prematurity (Birth at an early gestational age)
Total parenteral nutrition
Sub-standard care of the catheter (excessive manipulation of the catheter or an inefficient nurse-to-patient ratio)

Implementing Prevention Policies and Procedures

Aside from education, one of the most basic and highly recommended practices is the usage of a Catheter Checklist in order to ensure adherence to infection prevention practices4. Two key resources are the “On the CUSP” educational resources and the Agency for Health Care Research and Quality (AHRQ). The checklist listed here is a copy of the “Central Line Insertion Care Team Checklist” produced by the Agency for Health Care Research and Quality; it could be edited to fit a specific health care team’s needs3:

Central Line Insertion Care Team Checklist

Patient Name __________________
Hx # ________________
Unit _________________
Date/Time ____________

A minimum of 5 supervised successful procedures in both the chest and femoral sites is required (10 total). If a physician successfully performs the 5 supervised lines in one site, they are independent for that site only. A total of 3 supervised re-wires is required prior to performing a rewire independently.

Supervisor Role: 2nd-year resident and above (approved for line placement).

Assistant Role: RN, ClinTech, MD, NP, PA (responsible for completing checklist).

If there is a deviation in any of the critical steps, immediately notify the operator and stop the procedure until corrected. If a correction is required, make a check mark in the "Yes with reminder" column and note what correction was made in the comment space, if applicable. Uncorrected deviations and complications of line placement are to be reported. Contact the Attending if any item on the checklist is not adhered to or with any concerns. Please return completed form to the designated person in your area.

Before the procedure, did the operator:

Critical

Steps

Yes Yes with reminder Report Completed for procedure deviation? Comments:
Obtain informed consent?
Obtain supervision if needed
(see roles above)?
Perform a time-out/briefing? N/A [ ]
Confirm hand
washing/sanitizing
immediately prior?
Operator(s):cap, mask, sterile gown/gloves, eye
protection?
Supervisor: cap, mask, sterile gown /gloves, eye protection? N/A [ ]

Assistant: cap, mask, isolation gown, and gloves, eye protection (if at risk for
entering sterile field, use
sterile gown and gloves)?

Properly position to prevent
air embolism?
For Chest/EJ: Trendelenburg
(HOB < 0 degrees)
For Femoral: supine
Sterilize procedure site
(chlorhexidine)?
Allow site to dry?
Use sterile technique to
drape from head to toe?
Utilize local anesthetic
and/or sedation?


During the procedure, did the operator:

Critical Steps Yes Yes with Reminder Report Completed for Procedure Deviation? Comments
Maintain a sterile field?
Monitor that lumens were
not cut?
N/A [ ]
Clamp any ports not used during insertion (to avoid air embolism, clamp all but distal port)? N/A [ ]
Obtain qualified second
operator after 3 unsuccessful
sticks (except if emergent)?
N/A [ ]
Aspirate blood from each
lumen (to avoid air embolism and ensure intravascular placement)?
Transduce CVP or estimate CVP by fluid column (to avoid arterial placement)? N/A for fluoroscopy procedures [ ]

After the procedure, did the operator:

Critical Steps Yes Yes with Reminder Report Completed for Procedure Deviation Comments:
Clean blood from site using antiseptic agent
(chlorhexidine), apply sterile dressing
Verify placement by x-ray (tip in SVC/RA junction) N/A for
fluoroscopy
procedures [ ]

Operator: ________________________
Supervisor: _______________________
Assistant: ________________________

The above listed checklist is a proper starting point for implementing a Catheter Checklist in order to ensure that each necessary step happens each time. Checklists help provide standardized documentation and help ensure that each step happens each time3.

During the procedure, supporting staff should be empowered to stop the procedure at any time if a step has been missed or done incorrectly5. CVC insertion should also be supervised by a qualified member of the staff who has applicable experience.

At the Time of Insertion

Prior to performing a Catheter insertion or any sort of central line manipulation proper hand hygiene is absolutely necessary6.

  • Use an alcohol-based waterless product or antiseptic soap and water.
  • Use of gloves does not mean that hand hygiene can be skipped.
  • Hand hygiene should be practiced before any and all manipulations (drug administration, adjustments, bandage inspection, etc.)6
  • The administration site should be free of hair. Clipping rather than shaving is preferred9.

It is widely recommended that health care providers use a catheter cart or kit that has all of the necessary materials arranged on a sterile setting8. A cart or kit should be easily available in all areas where central venous catheters have been inserted.

When performing a CVC insertion, all of the necessary sterile barrier precautions must be followed by all of the staff participating6. These precautions include:

  • Mask
  • Cap (To cover hair and head)
  • Sterile Gown
  • Sterile Gloves
  • The patient should be covered with a large sterile body drape during the insertion.
  • All of these sterile protective measures must be followed when exchanging a catheter over a guide wire6.

The recommended antiseptic for the skin is an alcoholic Chlorhexidine solution (2% Chlorhexidine)2.

  • The Chlorhexidine solution must be allowed to dry before inserting the catheter2.
  • Pediatric patients younger than 2 months should use Povidone‐Iodine, especially low birth weight neonates. Chlorhexidine is not approved by the FDA for children younger than 2 months6.
  • If a patient has Chlorhexidine sensitivity and Chlorhexidine is contra-indicated a 5% Povidone-Iodine solution can be used2.

There is evidence that antiseptic or antimicrobial impregnated CVC’s can further reduce the rates of Blood Stream Infections1.

  • The FDA has not approved these catheters for children younger than 2 months6.
  • The antiseptic catheters are impregnated with Chlorhexidine‐silver sulfadiazine.
  • The antimicrobial catheters are impregnated with minocycline‐rifampin.

Another evidence based practice gaining popularity is the use of Chlorhexidine containing sponge dressings6. Again, these are not approved for use in low-birth weight neonates and children younger than 2 months. However, these dressings can be used in patients with a high risk for severe complications (patients with recently implanted intravascular devices, such as a prosthetic heart valve or aortic graft)6.

Site Avoidance and Risks

The Centers for Disease Control recommends the avoidance of the femoral vein for central line insertions8. Femoral vein access has been associated with greater risk of infection and deep venous thrombosis in adults. Subclavian access sites are believed to have the lowest rate of infection6. Adult patients with a Body Mass index greater than 28.4 have been found to be at even higher risk rate when the femoral vein is accessed6. Femoral vein access in children has not been associated with a higher risk of infection. In patients with renal failure, the subclavian vein should be avoided in order to minimize stenosis and affect future vascular access options8.

Health care providers must take into account the patients age, size, the relative risk of mechanical complications, and if sedation is necessary. Further, the use of peripherally inserted CVC’s is not an evidence-based solution to minimize the potential for a blood stream infection8. The CDC also recommends the use of a sutureless securement device in order to hold the catheter in place. Stitching and sutures have a tendency to further inflame the skin and cause further discomfort. Sutureless securement devices have been found to decrease phlebitis and catheter movement.

After the Insertion

Disinfecting (using Chlorhexidine) the catheter ports, needleless connectors, and injection ports is necessary in order to ensure a sterile setting1. Should the dressing or gauze become saturated, damp, loosened, or visibly soiled then it should be changed immediately.

Routine assessment of the need for the CVC should be performed; once it is determined that the CVC is no longer needed, it should be promptly removed3. The longer a CVC is inserted, the higher the risk for Central Line Blood Stream Infection6.

The relatively new practice of bathing a patient with a Chlorhexidine solution has been found to further decrease the likelihood of a CLABSI6. Several ICU’s implemented a daily Chlorhexidine solution for departments that had higher than benchmark CLABSI rates and found reductions in the amount of Central Line Associated Blood Stream Infections.

Measuring and Surveillance

“In order to improve something, we must first be able to measure to it”. This famous quote from the business management world perfectly ties into Central Line Associated Blood Stream Infection Reductions. It is crucial that health care leadership teams identify the desired benchmarks for their system (the National Healthcare Safety Network is a good resource for national rates) 4. Routine assessment of all internal processes can help further drive down the rates of CLABSI. Additionally, it is crucial that leadership teams identify a way to routinely communicate progress and goals to all level of the staff. Some units have found that posters with “_____ days since a Central Line Associated Blood Stream Infection” have helped communicate current progress. Should a blood stream infection occur, it should be looked at as an investigational teaching opportunity for the staff. Personnel from the infection prevention and control program, laboratory, and information technology departments are responsible for ensuring that systems are in place
to support a surveillance program.

Central Line Associated Blood Stream Infections are preventable and are something that health care teams can directly affect. The above listed items are by no means the only options, but they are a selection of best practices based on literature. As with any quality improvement initiative, a proper literature review and check process is needed before implementing any new initiative into standard practice within your organization.

References

(1)Burrell, Anthony et al. (2011) Aseptic Insertion of Central Venous Lines to Reduce Bacteraemia. Med J Aust 194 (11): 583-587. Retrieved from: https://www.mja.com.au/journal/2011/194/11/aseptic-insertion-central-venous-lines-reduce-bacteraemia
(2)Central Line Insertion and Maintenance Guideline. (2012). The Australian and New Zealand Intensive Care Society. Retrieved from: http://www.clabsi.com.au/resources
(3)Central Line Insertion Care Team Checklist. (May 2009). Agency for Health Care Research and Quality. Rockville, MD. Retrieved from: http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/cli-checklist.html
(4)CLABSI Baseline Prevention Practices Assessment Tool for States Establishing HAI Prevention Collaboratives using ARRA Funds. (2013) Centers for Disease Control and Prevention. Retrieved from: http://www.cdc.gov/HAI/recoveryact/PDF/CLABSI_EvalQuestions_Final.pdf
(5)Coopersmith CM, Rebmann TL, Zack JE, et al. Effect of an education program on decreasing catheter‐related bloodstream infections in the surgical intensive care unit. Crit Care Med 2002; 30:59‐64.
(6)Marschall et al. (2008). Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals. Infection Control and Hospital Epidemiology. Published by: The University of Chicago Press on behalf of The Society for Healthcare epidemiology of America. 29S1:S22-S30. DOI: 10.1086/591059. http://www.jstor.org/stable/10.1086/591059.
(7)National Patient Safety Goals Effective January 1, 2014. (2014). The Joint Commission. Retrieved from:
http://www.jointcommission.org/assets/1/6/HAP_NPSG_Chapter_2014.pdf
(8)The National Healthcare Safety Network (NHSN) Manual: Patient Safety Component Protocol. (March 2009). The National Center for Preparedness, Detection and Control of Infectious Diseases. 11-20. Atlanta, GA. Retrieved from: http://www.cdc.gov/nhsn/PDFs/pscManual/pscManual_current.pdf
(9)Tanner J, Norrie P, Melen K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev. 2011 Nov 9; 11:CD004122 (10)Warren DK, Quadir WW, Hollenbeak CS, et al. Attributable cost of catheter‐associated bloodstream infection among intensive care patients in a nonteaching hospital. Crit Care Med 2006; 34:2084‐2089.

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Course Evaluation

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