Central Line Infections 2007

By Kelli Rosenthal, MS, RN, BC, CRNI, ANP, APRN, BC

The Institute for Healthcare Improvement’s "100,000 Lives Campaign" to reduce central line infections in participating U.S. hospitals throughout the U.S. showed that proper practice can spare patients from this dangerous and costly complication. Now that the campaign has proven its point, it’s more important than ever to keep in the front of your mind that patients with central venous access devices (CVAD) are at risk for such infections. Early identification and intervention are key in preventing progression to severe infection, which can lead to prolonged hospitalization or even death.

Catheter-related infections occur in several different ways: contamination of the device by skin flora on insertion; migration down the cannula tract from the skin; contamination through the hub during manipulation; and seeding from another site of infection. Rarely, a contaminated infusate may be the culprit. It’s also important to remember that the majority of vascular access device-related infections occur with percutaneously placed, non-tunneled catheters.

It is critically important to maintain all CVADs with an eye towards preventing infection. Even greater watchfulness is warranted when caring for patients who are at increased risk of developing a catheter-related bloodstream infection, including: immunocompromised patients (e.g., oncology patients, HIV+ patients, those receiving long-term steroids), patients with other infections, those with multi-lumen CVADs, and those receiving parenteral nutrition.

Signs and symptoms associated with catheter-related infection include:

Local:

Systemic:

The most effective ways of preventing catheter-related infections are:

When assisting with insertion of central lines, make sure that all appropriate sterile barriers, sterile gowns, masks, and chlorhexidine prep solutions are available and used during insertion. If you observe a break in sterile technique, diplomatically inform the inserter of the breach.

Once the CVAD is in place, you will be responsible for dressings, needleless system device changes, and administering infusions through these catheters. Perform site checks frequently (at least once per shift). Look for any drainage, redness, swelling, discomfort, or induration at the catheter insertion site or sutures. Palpate the site through the dressing, observing for tenderness or elevated skin temperature as compared with the non-catheterized site. Make sure that the dressing is intact and changed promptly when due, or when it is no longer clean, dry, and adherent on all sides. Report any abnormalities to the patient’s physician immediately.

CVAD dressing changes should be performed using sterile technique, including masks for both patient and nurse. Chlorhexidine gluconate skin preparation solutions are preferred. These should be applied with a back and forth motion, using plenty of friction to allow the solution to get as far as possible into the skin. If you use other skin prep solutions, e.g., 70% isopropyl alcohol and 10% povidone iodine, follow the manufacturer’s recommendations for use. All skin prep solutions must be allowed to dry before dressing application. CHG based preps usually recommend a 30-second prep, followed by 30 seconds to air dry. Povidone iodine solutions must be allowed a full two minutes to dry to fully protect the patient against all organisms found on the skin. Remove any excess prep solutions with sterile gauze before applying the securement device and dressing.

For additional protection against line infections, some facilities use CHG-impregnated sponges at the catheter exit site. If these are part of your agency protocol, make certain that you follow the manufacturer’s directions for use. Unless placed properly, these devices do not protect against infection.

Standards of practice recommend the use of a manufactured catheter stabilization device specifically engineered to prevent catheter movement into or out of the insertion site. If CVADs are not sutured in place (a practice associated with additional sources of infection), some method of stabilization other than the dressing must be employed. Proper catheter stabilization devices prevent other complications as well, such as air embolism, catheter malposition, and hemorrhage. Sterile tape, sterile wound closure strips, or a manufactured securement device MUST be used in order to comply with this standard aimed at preserving patient and nurse safety. Securement devices must be changed whenever the catheter dressing is changed.

Transparent, semi-permeable dressings (TSM) allow moisture vapor to escape from the dressing while remaining adherent. They allow visualization of the insertion site at all times. TSM dressings should be changed at least weekly (using sterile technique), and whenever they are no longer clean, dry, and adherent on all sides. Gauze should not be routinely used under TSM dressings – only when catheter sites have the potential for significant drainage. In this case, the dressings should be changed at least every 48 hours.

Needleless system devices must be aseptically replaced whenever the dressing is changed. Coordinate these changes with dressing and infusion tubing changes, whenever possible. Before removing the old needleless system device, swab the junction of the device and the catheter hub vigorously with alcohol. Close the clamp on an open-ended CVAD or have the patient perform the Valsalva maneuver when removing the old needleless system cap. Swab the threads of the hub with a second alcohol swab and aseptically place a new needleless system device. Prior to infusion through needleless system caps, swab the device vigorously (some manufacturers recommend a three second scrub) with alcohol, then aseptically attach the infusion tubing.

Fluid pathways must remain sterile. If an intermittent infusion tubing (i.e., piggyback tubing) is found uncapped, it must be replaced. If any infusion equipment has been contaminated, replace it immediately.

The care you provide to your patients’ central catheters using recommended techniques will minimize their risk of infection. Your routine care also offers many opportunities to observe your patient for the earliest signs of infectious complications. Remember, the Central Line Bundle primarily addresses the prevention of infection at the time of catheter insertion. Scrupulously adhering to the best practices identified to prevent catheter-related infections after insertion can be a matter of life or death. Want to learn more about keeping your patient infection free? Check out the Association for Vascular Access (AVA)’s SAVE that Line! campaign.

References

Rosenthal, K. Pinpointing intravascular device infections. Nursing Management. 34(6): 35-42. June 2003.

CDC. Guidelines for the prevention of intravascular catheter-related bloodstream infections. MMWR 2002;51:1-29.

Institute for Healthcare Improvement, Central Line Bundle.

Association for Vascular Access (AVA) SAVE That Line Campaign (2005).