Follow the basics to keep your patients safe.
Takeaways:
· Central line–associated bloodstream infection prevention requires meticulous attention to insertion, care, and maintenance of central lines.
· Collaboration between front line staff, the infection prevention team, and vascular access specialists can help identify opportunities for improving care of patients with vascular access devices.
Editor’s note: This is the first in a two-part series on central line–associated bloodstream infections (CLABSIs). Part 1 focuses on indications and insertions. Part 2 will discuss maintenance and what to do if a CLABSI occurs.
THE COST of CLABSIs is high both for patients and for organizations. Although progress in reducing these infections has been made, they remain a common problem in hospitals. CLABSIs increase mortality risk and can cost an organization about $45,000 per case. (See CLABSI defined.)
CLABSI prevention strategies fall into three categories: clinical indications, insertion, and care and maintenance. In this first of a two-part series, we’ll focus on indications and insertion.
Clinical indications
An often overlooked first step in CLABSI prevention is asking whether a central line is clinically indicated. Central line access poses risks beyond CLABSI, including deep vein thrombosis, bleeding, pneumothorax, and arrhythmias. An interprofessional team can work together to establish organizational criteria for central line use and help all units adopt them. The team should represent infectious diseases, hospitalists, nephrology, critical care, emergency, administration, pharmacy, vascular access, infection prevention, information technology, and frontline nursing staff. Use evidence-based practice to develop central line criteria, and include protocols for establishing individual patient need, choosing a device, and preventing device complications.
Evidence-based practice
The Centers for Disease Control and Prevention (CDC) guidelines and Infusion Nurses Society (INS) standards discuss basic concepts for appropriate device selection. Other documents, such as The Joint Commission CLABSI Toolkit and the “Compendium of strategies to prevent healthcare-associated infections in acute care hospitals” from the Society for Healthcare Epidemiology of America (SHEA), emphasize daily review of central lines to determine if their continued use is necessary.
Recent publications (for example the Michigan Appropriateness Guide for Intravenous Catheters [MAGIC]) offer direction for clarifying the indications most broadly accepted for central line use. Based on expert consensus, recommendations for preferred vascular access devices should be based on patient characteristics (for example, difficult venous access), appropriateness of infusate for peripheral administration, and anticipated therapy duration. These broad considerations are easily adopted into order sets and are available as a free, downloadable smartphone application (www.improvepicc.com).
Individual patient need
Early in a patient’s admission, the healthcare team should discuss appropriate vascular access, indications, and vessel health and preservation. If a line is placed, review its continued use daily. When it’s no longer needed, develop a plan for appropriate, reliable access for the patient’s ongoing needs.
Device options and complications
Vascular access isn’t synonymous with central access. Hospitals that have added midline catheters to their vascular access options have consistently reported substantial decreases in central line days. This suggests an over-reliance on central lines without a true need for them. Midlines (longer/extended dwell peripheral catheters) may offer an option for patients with difficult venous access who may otherwise have been escalated to a central line, when no valid central line indication existed. Because midlines are considered peripheral catheters, care must be taken to ensure that only peripherally compatible infusates are given. A vascular access consult can provide the necessary recommendations for evidence-based device selection.
Excess lumens substantially increase CLABSI and deep vein thrombosis risk. Including extra lumens “just in case” isn’t acceptable. Studies show that defaulting to single-lumen central lines, establishing specific criteria for multi-lumen devices, combined with provider, nursing, and pharmacist education supported by real-time monitoring and feedback contribute to positive outcomes. The University of Michigan published these criteria for the use of multi-lumen devices:
- simultaneous administration of multiple incompatible medications
- total parenteral nutrition infusion with concurrent need for additional I.V. medications
- simultaneous use of continuous vesicant or irritant chemotherapy with other medications
- need for vasopressors.
Calculators and simulation studies (improvepicc.com) can help you evaluate the potential decreases in CLABSI and deep vein thrombosis risk if you change the relative percentages of triple-, double-, and single-lumen central lines in your organization.
Current reimbursement penalties focus only on CLABSI and don’t include reporting of short peripheral catheter and midline infections. Frontline staff can be patient advocates and ensure that line selection is a clinical decision guided solely by the patient’s access needs. Choosing devices without fully understanding their infection rates and other complications could expose patients to significant risk.
Shared governance, patient safety committees, and infection prevention committees can encourage organizations to expand their surveillance scope to include all device-associated infections, not just those from central lines, and request complication rate information for all devices used by the vascular access team. Fully understanding benefits and complications of vascular access devices helps frontline staff advocate for safe access.
CLABSI definedCentral line–associated bloodstream infection (CLABSI) is a surveillance (not clinical) protocol standardized by the Centers for Disease Control and Prevention (CDC) and used for internal quality-improvement efforts and required state and federal public reporting. The definition is part of a detailed protocol that must be precisely followed to allow for accurate comparison of infection incidence. Ongoing revisions (published at least annually) are incorporated into the protocols.
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Insertion
After the care team determines that central access is required and the type of access (acute central venous catheter, tunneled catheter, peripherally inserted central catheter, totally implanted device) is chosen, plan the insertion, including use of antimicrobial lines (if indi- cated) and insertion checklists and bundles.
Antimicrobial lines
Based on organizational goals and current infection incidence, consider an antimicrobial line. Studies, including those from the author’s institution, have shown substantial reductions in CLABSI when this technology is used.
Checklists and bundles
Central line insertion checklists or bundles—hand hy- giene, maximum sterile barrier precautions (head-to-toe sterile drape, mask, cap, sterile gown, sterile gloves), chlorhexidine skin prep (unless contraindicated), and, when possible, avoidance of the femoral vein—are the cornerstone to CLABSI prevention. Incorporating the checklist into the electronic health record (EHR) will reinforce and verify its use across all central venous access devices in all settings within the organization.
Using the checklist in conjunction with a trained observer helps ensure that all elements of the insertion process are followed. The
observer should record each step of the checklist in the EHR and provide real-time feedback if any element is missed. Some checklists have the option of “yes” or “yes, with coaching” to emphasize the importance of an active review process. Some organizations have adopted a “stop the line” approach, which further empowers the observer to stop a procedure that’s not complying with safety expectations. Another strategy organizations use is to have a formal process for following up (peer review or individualized coaching from division leaders, hospital epidemiologists, and administration) with clinicians who don’t adhere to the checklist even when coached to determine barriers to compliance and to reinforce that using the checklist is compulsory.
Central line insertion that doesn’t comply with the checklist (for example, a line inserted in an emergency situation) should be documented as emergent, and the line should be flagged for removal within 24 to 48 hours based on the organization’s policies. To avoid this situation, organizations may want to consider using intraosseous devices as bridges for emergent vascular access. They allow time for the patient to stabilize and provide an opportunity for safe insertion of the most appropriate device for continued therapy.
Limitations aid prevention
CLABSI prevention begins with limiting central access line use to established indications. When central lines are indicated, checklists and bundles can help ensure proper insertion. The next article in this series will focus on access line maintenance and what to do if a CLABSI occurs.
Michelle DeVries is senior infection control officer for Methodist Hospitals in Gary, Indiana, and is an adjunct research fellow at Griffith University in Australia. She serves on the speakers bureau for Access Scientific, Becton Dickinson, Ethicon, and Eloquest.
Selected references
Blanco-Mavillard I, Rodríguez-Calero MA, Castro-Sánchez E, Bennasar-Veny M, De Pedro-Gómez J. Appraising the quality standard underpinning international clinical practice guidelines for the selection and care of vascular access devices: A systematic review of reviews. BMJ Open. 2018;8(10):e021040.
Bozaan D, Skicki D, Brancaccio A, et al. Less lumens-less risk: A pilot intervention to increase the use of single-lumen peripherally inserted central catheters. J Hosp Med. 2019;14(1):42-6.
Centers for Disease Control and Prevention. Healthcare-associated infections: Current HAI progress report. March 19, 2019. cdc.gov/hai/data/portal/progress-report.html
Cheng HY, Lu CY, Huang LM, Lee PI, Chen JM, Chang LY. Increased frequency of peripheral venipunctures raises the risk of central-line associated bloodstream infection in neonates with peripherally inserted central venous catheters. J Microbiol Immunol Infect. 2016;49(2):230-6.
Chopra V, Flanders SA, Saint S, et al. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results from a multispecialty panel using the RAND/UCLA appropriateness method. Ann Intern Med. 2015;163(suppl 6):S1-40.
Gorski L, Hadaway L, Hagle ME, McGoldrick M, Orr M, Doellman D. Infusion therapy standards of practice. J Infus Nurs. 2016;39(suppl 1):S1-159.
Kornbau C, Lee KC, Hughes GD, Firstenberg MS. Central line complications. Int J Crit Illn Inj Sci. 2015;5(3):170-8.
Laan BJ, Spijkerman IJ, Godfried MH, et al. De-implementation strategy to reduce the inappropriate use of urinary and intravenous CATheters: Study protocol for the RICAT-study. BMC Infect Dis. 2017;17(1):53.
Marschall J, Mermel LA, Fakih M, et al. Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(7):753-71.
Moureau N, Sigl G, Hill M. How to establish an effective midline program: A case study of 2 hospitals. J Assoc Vasc Access. 2015;20(3):179-88.
O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis. 2011;52(9):e162-93.
Pathak R, Gangina S, Jairam F, Hinton K. A vascular access and midlines program can decrease hospital-acquired central line-associated bloodstream infections and cost to a community-based hospital. Ther Clin Risk Manag. 2018;14:1453-6.
Pathak R, Patel A, Enuh H, Adekunle O, Shrisgantharajah V, Diaz K. The incidence of central line-associated bacteremia after the introduction of midline catheters in a ventilator unit population. Infect Dis Clin Pract (Baltim Md). 2015;23(3):131-4.
Pittiruti M, Scoppettuolo G, Dolcetti L, et al. Clinical experience of a subcutaneously anchored sutureless system for securing central venous catheters. Br J Nurs. 2019;28(2):S4-14.
Quan KA, Cousins SM, Porter DD, et al. Electronic health record solutions to reduce central line-associated bloodstream infections by enhancing documentation of central line insertion practices, line days, and daily line necessity. Am J Infect Control. 2016;44(4):438-43.
Ratz D, Hofer T, Flanders SA, Saint S, Chopra V. Limiting the number of lumens in peripherally inserted central catheters to improve outcomes and reduce cost: A simulation study. Infect Control Hosp Epidemiol. 2016;37(7):811-7.
Rupp ME, Karnatak R. Intravascular catheter-related bloodstream infections. Infect Dis Clin North Am. 2018;32(4):765-87.
Zimlichman E, Henderson D, Tamir O, et al. Health care-associated infections: A meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med. 2013;173(22):2039-46.
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2 Comments.
Hi Cindy,
Thanks for the nice comment and for your question. CDC, INS and SHEA all have suggestions on when an antimicrobial line is considered. In my own organization, it is our standard for PICCs and CICCs. The specific wording from the various guidances is:
CDC
Use a (chlorhexidine/silver sulfadiazine or minocycline/rifampin -) impregnated CVC in patients whose catheter is expected to remain in place >5 days if, after successful implementation of a comprehensive strategy to reduce rates of CLABSI, the CLABSI rate is not decreasing. The comprehensive strategy should include at least the following three components: educating persons who insert and maintain catheters, use of maximal sterile barrier precautions, and a >0.5% chlorhexidine preparation with alcohol for skin antisepsis during CVC insertion. (CATEGORY IA)
INS
Collaborate with the interprofessional team to consider anti-infective CVADs in the following circumstances, as anti-infective CVADs have shown a decrease in colonization and/or CLABSI in some settings. (I)
Expected dwell of more than 5 days.
CLABSI rate remains high even after employing other preventive strategies
Patients with enhanced risk of infection (ie, neutropenic, transplant, burn, or critically ill patients).
Emergency insertions.
SHEA
Use antiseptic- or antimicrobial-impregnated CVCs in adult patients (quality of evidence: I).
a. The risk of CLABSI is reduced with some currently marketed antiseptic-impregnated (eg, chlorhexidine- silver sulfadiazine) catheters and antimicrobial- impregnated (eg, minocycline-rifampin) catheters. Use such catheters in the following instances.
i. Hospital units or patient populations have a CLABSI rate above institutional goals despite compliance with basic CLABSI prevention practices. Some evidence suggests that use of anti- microbial CVCs may have no additional benefit in patient care units that have already established a low incidence of catheter infections.
ii. Patients have limited venous access and a history of recurrent CLABSI.
iii. Patients are at heightened risk of severe sequelae from a CLABSI (eg, patients with recently implanted intravascular devices, such as a prosthetic heart valve or aortic graft).
Hello to the editor!
I would like to say how much I appreciated this article. I have been doing CLABSI surveillance for my hospital for 1 ½ years, and this information is so timely and relevant. I plan on getting with our vascular access team to learn more about our processes at my institution. I have a question. There is the statement that “antimicrobial lines should be used (if indicated)”. How is that indication determined? Are their specific criteria, or is it individually determined based on each patient and the care team making that decision? It seems to me that if a patient meets the criteria for a central line, an antimicrobial line should always be indicated. I’m still learning, so I will see what I can find out. I look forward to part 2! Thank you!!