Nursing Center - Journal Issue

MORTALITY FOR central line-associated bloodstream infections (CLABSIs) is 12% to 25%, making them among the most deadly of healthcare-associated infections (HAIs). CLABSIS are also expensive: the average cost per case is upwards of $26,000.1,2 The good news is that the incidence of CLABSI in ICU patients across the United States has been reduced from an estimated 43,000 in 2001 to 18,000 in 2009-a 58% reduction. The CDC estimates that this reduction represents 3,000 to 6,000 lives saved and a cost saving of $414 million in ICUs in 2009 alone.3 Better yet, some hospitals report zero CLABSIS in their ICUs.4

So how did they make these improvements? By using best practices. This article presents the latest evidence-based recommendations for CLABSI prevention and discusses the implications for direct care nurses.

The 2011 CDC recommendations for prevention of CLABSI are published in a 58-page document that can be accessed at http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf. Not intended to be a comprehensive review, this article focuses on Category 1A and 1B recommendations specifically for the nursing care of patients with central venous catheters. Category 1C recommendations are regulatory requirements and beyond the scope of this article. The CLABSI bundle discussed next is encompassed within these recommendations. (For definitions of rankings, see How the CDC categorizes recommendations.)

A bundle of best practices

The CDC, the Institute for Healthcare Improvement (IHI), and the Society for Healthcare Epidemiology of America have been recommending best practices for central line insertion for over a decade.2 In 2005, the IHI 100,000 Lives Campaign introduced a "bundle" approach to prevent CLABSI and other HAIs.5,6 (See Bundle up.) These initiatives have paid off and hospitals across the country are seeing results.

Data from 158 Pennsylvania hospitals in 2009 demonstrated that hospitals that consistently followed three of the recommended bundle practices achieved an average CLABSI rate of 0.51 CLABSI/1,000 central line days versus 3.33/1,000 central line days for the hospitals not demonstrating consistent use of the practices.2 The three bundle practices are:

* use of maximal sterile barriers during insertion.

* chlorhexidine site preparation.

* documentation of daily review of central line necessity to facilitate early removal.

A review of how CLABSI develops reveals why the recommended interventions are so effective.

Table How the CDC ca... - Click to enlarge in new window

Table How the CDC categorizes recommendations

Four sources of contamination

The guidelines for prevention of CLABSI target four potential sources of contamination of catheters and subsequent bloodstream infection.7 The first two are the most common sources of contamination and the ones healthcare professionals can help prevent during daily care of these patients (see Going to the source).

1. Skin organisms can be introduced during catheter insertion or by contaminated dressings before skin epithelialization has occurred. In these circumstances, referred to as extraluminal, bacteria migrate along the catheter track from the skin. This route of infection is likely in CLABSIS that occur within the first week of catheterization.

2. Contamination of the catheter or hub by hands or devices that deliver bacteria into the catheter lumen is termed intraluminal. This can happen at any time during the catheter dwell.

3. When an infection originates from another site in the body, bacteria travel through the bloodstream from the infection site and infect the catheter (referred to as hematogenously seeded).

4. Contaminated infusate can also result in a CLABSI.8

Biofilm, which can contribute to development of CLABSI, is a matrix of fluid and cells that forms on the surface of virtually every invasive device, including urinary and I.V. catheters. Biofilm creates an ecosystem for microorganisms and protects them from the body's inflammatory and immune responses, as well as from antimicrobial therapy. The longer the catheter remains in the body, the greater the chance of biofilm embolization and subsequent bloodstream infection.2,9 The inevitability of biofilm is another reason catheters should be removed as soon as they're no longer needed.

Current CDC recommendations

The content of the CDC's recommendations can be organized into three areas meaningful to nursing:7

* education, training, and staffing

* appropriate selection of catheter and site

* hand hygiene and sterile technique.

These three areas encompass the CLABSI bundle but are more comprehensive. For details, see Applying recommendations to practice.

Issues still under investigation

Many devices and products in the literature and on the market aren't currently endorsed with a Category I recommendation but carry a Category IC recommendation because they're safety devices designed to prevent needle sticks as required by the Occupational Safety and Health Administration (OSHA). For example, using needleless systems to access I.V. tubing in general carries a Category IC recommendation because they're safety devices designed to prevent needle sticks as required by OSHA's Bloodborne Pathogens Standard.10

Which type of needleless system is best for minimizing infection risks is a matter of debate. Some evidence suggests that the devices' mechanical valves are associated with increased infection risk. Consequently, the CDC provides a Category II recommendation that when needleless systems are used, a split septum valve may be preferred. This presents a dilemma for many organizations because currently many needleless devices with mechanical valves are on the market and in use.

Similarly, a few different types of chlorhexidine dressings are on the market. Using a chlorhexidine-impregnated sponge dressing for temporary short-term catheters in patients older than age 2 months has a Category IB recommendation if, after successful implementation of all other strategies, a facility's CLABSI rate still isn't reduced. But no recommendation has been offered for other types of chlorhexidine or antimicrobial dressings, so it's considered an unresolved issue.

Chlorhexidine bathing is currently being evaluated as a means to decrease infections in the hospitalized patient. One report describes a decrease in bloodstream infections from 3.6/1,000 patient days to 1/1,000 patient days after 6 months of chlorhexidine bathing.11 The CDC gives using a 2% chlorhexidine wash for daily skin cleansing a Category II recommendation.7

Table Applying recom... - Click to enlarge in new window

Table Applying recommendations to practice

Figure. Following th... - Click to enlarge in new window

Figure. Following the guidelines really works

Antimicrobial lock solution prophylaxis is a Category II recommendation only for patients with long-term catheters who have a history of multiple CLABSIS despite optimal maximal adherence to aseptic techniques. Sutureless securement devices also have a Category II recommendation.7

Nursing interventions for preventing infections

Nurses are positioned to influence many of the processes around prevention of CLABSI. Several unit-based initiatives have been recommended by the Johns Hopkins' Comprehensive Unit-Based Safety Program.12 These initiatives include:

* educating all staff on evidence-based practices to reduce CLABSI.

* implementing a checklist to ensure compliance with these practices.13

* empowering nurses to ensure compliance with the checklist.

* providing feedback on infection rates, including rates at the unit level.

* implementing monthly team meetings to assess progress.

Catheter insertion checklists and standardized supply kits or carts for line insertion are discussed in the guidelines and given a general recommendation.7 These measures are considered best practices and were required by The Joint Commission (TJC) as of January 1, 2010.2 Following the outcomes for CLABSI with graphs and reports is something nurses can do to heighten awareness of CLABSI and also to celebrate their successes. The National Healthcare Safety Network provides a national benchmark for CLABSI compared with like units and measured as number of CLABSI/1,000 central line days.14

Working with our patients as partners is the wave of the future and will be a necessity as healthcare reform continues to evolve. Teaching patients to report any changes or new discomfort in their catheter site to their healthcare provider is a CDC category II recommendation. TJC also requires that education on infection prevention be given to every patient before insertion of a central line and, as needed, their families.15 Every patient should be empowered to ask nurses and other healthcare professionals if they've cleaned their hands when they enter his or her room and before they work with any I.V. device.

Prevention of CLABSI is a team effort involving all healthcare disciplines, patients, and patient families. However, nurses intersect at all the key points and are in the best position to assure that CLABSI prevention recommendations are incorporated into practice.

Bundle up

As defined by the IHI, a bundle is a group of evidence-based interventions for patient care that improve care when used individually, and result in substantially better outcomes when implemented together. The 2011 CDC Guidelines for Prevention of CLABSI support these recommendations.

The IHI central line bundle consists of five key components:

1. hand hygiene

2. maximal sterile barrier precautions (cap, mask, sterile gown, gloves, and sterile full body drape for insertion)

3. chlorhexidine skin antisepsis

4. optimal catheter site selection (avoid femoral vein, the subclavian vein is the preferred site for nontunneled catheters)

5. daily review of line necessity with prompt removal of unnecessary lines.