Running head: PREVENT CENTRAL LINE BLOODSTREAM INFECTIONS

Prevent Central Line Bloodstream Infections Christina (Ngu) Phoo Molloy College

PREVENT CENTRAL LINE BLOODSTREAM INFECTIONS Prevent Central Line Bloodstream Infections Central line bloodstream infections are most common type of health care-acquired infections (HAIs) which accounts for considerable high morbidity and mortality rates in all patient care settings. According to Centers for Disease Control and Prevention (CDC) in 2002, the estimated number of HAIs in U. S hospitals was 1.7 million; moreover, the bloodstream infection is a second leading cause of death, rating to be 31% among other types of infection from different sites. This increase has tremendous impact on the cost of health care (Segreti et

al., 2009). The Intravascular catheters inserted in the vena cava are called central lines or central vascular catheters (CVCs), and peripherally inserted central catheters are also known as PICCs; and both have greater chances for bloodstream infections. National JCAHO addresses standard goals to help promote quality and safety for patients in reducing risk of HAIs, assure safe practice in the area, and to minimize the cost of health care. Nurses are the primary professionals who are accountable in reducing such HAIs, ensuring patient safety, and to promote quality practice in the area of care. Therefore, a nurse must to have the essential knowledge with the safety measures which are mandated throughout the hospital. Central lines are most susceptible place for bloodstream infections. In fact, it occurs mainly due to improper handling and poor practice by nurses. The most important thing in prevention is through good hand hygiene, though, it is still remain poor by the nurses (Gorski, 2009). Other areas that need improvement are, aseptic technique with infusion, hub/needleless connector cleansing, clearing of catheters occlusions, and catheter securement (Gorski, 2009). Most nurses are unaware of the prevention process, and set of complications beyond the infection itself. The procedure of central catheter insertion and appropriate removal techniques are very essential in reducing infection rates (Gorski, 2009).

PREVENT CENTRAL LINE BLOODSTREAM INFECTIONS The steps for improvement in central line insertion must maintain accordingly to reduce risk of infections. Such steps involve before, during, and after catheter insertion. For example, before the initial insertion of central line, it is important to educate professional staff on risk of central line-associated bloodstream infections (CLABSIs). Then, assess the competency of professional staff on methods to prevent or reduce CLABSIs, and consider implementation of intravenous therapy teams. Thirdly, select the appropriate antimicrobial agents to control CLABSIs due to potential risk factors (Segreti et al., 2009). It is important to educate the patient and family members regarding central catheters and

CLABSIs. Ongoing process should be made in evaluating new device or technology to determine its effect on the rates of catheter-related infections (Segreti et al., 2009). In order to minimize the risk of transmission of pathogens from hospital environment, it is best to establish programs for education and assessment of inpatient environmental services (Segreti et al., 2009). Different types of catheters may also lead to risk of CLABSI, therefore, ensure a process to determine appropriate vascular access devices (Segreti et al., 2009). During central line insertion, it is best to avoid the femoral vein due to higher chances of infection from that area (Segreti et al., 2009). The most preferred placement is through a subclavian vein, however, each patient should be assessed individually by knowing the risks and common complications from the site. These risks include vascular hemorrhage, vascular spasm, and arterial puncture, as well as, a peripheral nerve injury and brachial nerve plexus (Hertzog & Waybill, 2008). PICCs have common complications as CVCs which include cardiac tamponade, air embolism, pneumothorax, hemothorax, hydrothorax, and thoracic duct injury (Hertzog & Waybill, 2008). The use of ultrasound technology during catheter placement is found to be faster and the most effective way in reducing these kinds of complications (Segreti et al., 2009).

PREVENT CENTRAL LINE BLOODSTREAM INFECTIONS After the central line insertion, it is important to maintain the quality of site and to

establish proper handling to reduce common CLABSIs. It is an essential nursing knowledge, care and management, also as per institution protocols and guidelines for patient safety. The standard components of care include proper dressing change techniques, administration set changes, and methods of catheter stabilization, in addition, catheters should be assessed daily (Segreti et al., 2009). Moreover, practice of good hand hygiene, appropriate barrier precautions with clean gloves, and disinfection of the catheter hub must to take seriously by nurses in further prevention of CLABSIs (Segreti et al., 2009). Throughout the process, CDC recommends to change the gauze dressing every 48 hours or less, when it becomes soiled to minimize risk of infections. The recommended time for transparent dressing is 5 to 7 days or less. Chlorhexidine is the most recommended and commonly used antiseptic for skin preparation (Segreti et al., 2009). A recent study showed that the use of chlorhexidine-containing sponge dressings reduced the rate of catheter related infections; indeed, it is one of SHEA strategies in minimizing complications (Segreti et al., 2009). The recommendation for administration set is to change at intervals, not more than 96 hours for tubing that is used for blood products, or lipids (Segreti et al., 2009). On the other hand, the primary and secondary continuous administration sets, exclude blood products or lipids are to change no more than 72 hours. The intermittent primary sets are change every 24 hours, and for any contaminated sets, should changed immediately (Segreti et al., 2009). It is important to ensure catheter patency, especially because any movement at the insertion can increase the chances of catheter related complications and the risk of infections (Segreti et al., 2009). Some data suggests that repeated manipulation of central lines for routine procedures such as blood sampling may increase the risk of catheter hub colonization and

PREVENT CENTRAL LINE BLOODSTREAM INFECTIONS subsequent systemic infection (Segreti et al., 2009, p. 130). Accidental complications may also take place. For example, dislodgment or catheter migration may lead to infiltration and extravasations (Hertzog & Waybill, 2008). In some cases, the catheter may be damaged by needle puncture, stretching, or wear and tear on the tubing connections (Hertzog & Waybill, 2008). Excessive delivery pressure can rupture the PICC. Compression and motion points can cause a pinch-off syndrome leading to catheter fracture. If complete, the tip can embolize to the heart and lung (Hertzog & Waybill, 2008, p. 160).

Thrombotic occlusions are frequent causes of catheter colonization and sepsis, along with losing catheter patency. It occurs in 2% to 8% of PICC insertion (Hertzog & Waybill, 2008, p. 160). Components of a catheter patency care . . . include catheter flush with normal saline and/or heparin, use of antireflux devices, and standing orders . . . Methods of flushing and flush solutions will vary based on the type of catheter used as well as with the use of antireflux devices . . . or positive/neutral pressure needleless connectors (Segreti et al., 2009, p. 131). Use of heparin to avoid clots in central vascular catheters, thereby reducing the risk of infection, has long been a common practice in healthcare institutions (Meyer, 2009, p. 82). The antibioticlock combination of minocycline and ethylenediaminetetraacetic acid (EDTA) has been demonstrated . . . to prevent the likelihood of clotting, as well as acting as a bacterial agent, decreasing the presence of biofilm on catheter surfaces (Meyer, 2009, p. 83). There are issues with central catheter dressings in relation to increased colonization and moisture retention with these dressings producing the bacteria. Chlorhexidine impregnated patches are becoming more commonly used in conjunction with transparent semipermeable polyurethane dressings as a method of decreasing central catheter-associated bloodstream infections (Meyer, 2009, p. 81). Transparent dressings reliably secure the device, permit

PREVENT CENTRAL LINE BLOODSTREAM INFECTIONS continuous visual inspection of the catheter site, permit patient to bathe and shower without saturating the dressing, and require less frequent changes than do standard gauze and tape dressing (Meyer, 2009, p. 81). Nurses are responsible for providing IV therapy. Their knowledge and skill can minimize infusion related complications and affect patient safety, satisfaction, healthcare costs, and length of hospital stay (Dychter, Gold, Carson, & Haller, 2012, p. 89). Therefore, nurses must to be aware of such complications regarding the extent of hospital infections especially for central lines, follow proper guidelines from own hospital since every hospital is different in protocol, and maintain quality care and management to improve patient safety and satisfaction. Finally, the Certified Registered Nurse Infusion (CRNI) credential is the only nationally

accredited certification for infusion nursing, indeed, it requires of passing a national certification examination (Dychter, Gold, Carson, & Haller, 2012).

PREVENT CENTRAL LINE BLOODSTREAM INFECTIONS References

Dychter, S., Gold, D., Carson, D., & Haller, M. (2012). A review of complications and economic considerations of peripheral access. Journal of Infusion Nursing, 35(2), 84-91. doi:10.1097/NAN.0b013e31824237ce Gorski, L. (2009). Speaking standards . . . Journal of Infusion Nursing, 32(6), 311-312. doi:10.1097/NAN.0b013e3181be0760 Hertzog, D., & Waybill, P. (2008). Complications and controversies associated with peripherally inserted central catheters. Journal of Infusion Nursing, 31(3), 159-163. doi:10.1097/01.NAN.0000317702.66395.f1 Meyer, J. (2009). A broad-spectrum look at catheter-related bloodstream infections: many aspects, many populations. Journal of Infusion Nursing, 32(2), 80-86. doi:10.1097/NAN.0b013e318198d30c Segreti, J., Garcia, S., Gorski, L., Moureau, N., Shomo, J., Zack, J., . . . Moody, M. (2009). Consensus conference on prevention of central line-associated bloodstream infections: 2009. Journal of Infusion Nursing, 34(2), 126-133. doi:10.1097/NAN.0b013e31820b8a3e