Preventing Catheter-Related Bloodstream Infections
Hadaway (2006) sought to provide practice guidance to nurses for catheter-related bloodstream infections (CR-BSI). The points of emphasis included short peripheral catheters, but the main focus was infections associated with central venous catheters (CVC) because these occur more often and result in more severe adverse outcomes. To support these practice recommendations, Hadaway relied on CVC best practice guidelines published by the Institute for Healthcare Improvement (IHI). The information provided is designed to assist nurses to implement best practices in the area of CR-BSI. In addition, infection rate statistics and recommendations from the Centers for Disease Control and Prevention (CDC) were presented to show why this is important.
Hadaway (2006) discusses the five IHI guidelines for reducing the incidence of CR-BSIs. This is the best practice for reducing CR-BSIs and this is why. The argument is the best practice is improving hand hygiene, barrier precautions, antiseptic use, insertion site selection, and catheter insertion and removal techniques.
This author is writing to educate nurses on how to keep their hands from becoming contaminated. This is a big problem because it is easy for nurses to contaminate their hands as they care for patients and transition from one procedure to another (Hadaway, 2006). For this reason, the IHI recommends that infusion procedures be performed first before all other patient care tasks. Alcohol-based hand cleaners are appropriate for most routine tasks, but if the hands have been visibly contaminated with bodily fluids then a good scrubbing with antimicrobial soap is indicated. Hand care is also important, because damaged skin can more easily harbor microbes. The use of emollients is recommended to promote a healthy skin barrier. Gloves should be changed and hands decontaminated before a catheter is inserted or removed, or when administering an infusion. Fingernails are important because long nails, false nails, or fingernail polish can harbor dangerous microbes. Nurses who place peripherally inserted central catheters (PICCs) or work with CVCs in an ICU should have short, natural nails only.
Maximum barrier protections are recommended for the insertion of CVCs, including those inserted peripherally (Hadaway, 2006). Sterile gown, gloves, face mask, and cap should be worn. In addition, the patient should be completely covered during the procedure except for the insertion location. The recommended antiseptic is 2 or 3.15% chlorhexidine gluconate in 70% isopropyl alcohol because the incidence of CR-BSIs and skin problems are reduced compared to other common antiseptics. With respect to insertion site choice, the IHI recommends subclavian over jugular or femoral due to neck movement and hair growth. Hadaway (2006), however, notes that studies investigating insertion site choice were published over 20 years ago with no clear winner. The CDC recommended the subclavian for nontunneled, noncuffed catheters in 2002, but noted that all choices pose risks for infections and other adverse events. Cather replacement should be based on the emergence of local or systemic complications observed during daily monitoring, but unused catheters should always be removed immediately. Since the skin is a primary source of infections, replacing catheters using the same insertion site is not recommended.
Implementing a program to reduce the incidence of CR-BSIs, according to the IHI, requires setting realistic target goals, establishing surveillance criteria, and designing an intervention program (Hadaway, 2006). This process has been called PDSA for Planning a small-scale change, Doing the test, Studying the results, and Acting upon the outcomes. The intervention can include in-service training for proper catheter insertion techniques and a self-study component consisting of fact sheets, pretest and posttest training, and posters. Another IHI recommendation is to give nurses the authority to stop a catheter insertion if they notice that the established protocol is not being followed correctly. Creating a checklist is a good way to implement this safety measure.
A large number of studies have revealed that single lumen catheters carry a higher risk of CR-BSI than multiple lumen devices, but the risks of mechanical complications are greater (Hadaway, 2006). Compared to split-septum devices, several hospital studies have revealed a higher risk of CR-BSIs with the use of mechanical valve devices, but the underlying cause is unclear. Antimicrobial-impregnated catheters should also be used when catheter dwell time is expected to exceed 5 days or when institutions are faced with an intractably high CR-BSI incidence rate. Research findings also suggest that up to 4,000 lives per year could be saved through the use of chlorhexidine-soaked sponge patches.
Theoretically, the number of patient lives that could be saved annually if CR-BSIs are eliminated could be as high as 50,000; however, something as simple as implementing a CVC insertion checklist could still prevent serious adverse outcomes, including death (Hadaway, 2006). Since the primary sources of CR-BSIs are the patient’s skin and CVC practice techniques, most infections are hypothetically preventable. The recommended prevention steps are simple and relatively inexpensive, especially when compared to the risk of patient harm, so doing otherwise would be morally and ethically wrong.
It would be hard for me to imagine caring for an ICU patient with a CVC that I have inserted and maintained, only to watch as they suffer and succumb to a CR-BSI infection because I knowingly failed to follow the recommended best practice guidelines. While mistakes will happen to everyone, these guidelines and recommendations are intended to minimize the impact of human error on patient safety.
Hadaway, L.C. (2006). Best-practice interventions: Keeping central line infection at bay. Nursing, 36(4), 58-63.
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