Prevention of the Central Venous Infections

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Introduction

SIn 2000, the Institute of Medicine (IOM) published a document titled To Err is Human: Building a Safer Health System (Leape & Berwick, 2005). This document highlighted an important issue affecting patients, their families, healthcare practitioners and entire healthcare organizations. The issue is that of patient safety. The number of adverse events and deaths experienced by patients had been rising steadily over the decades.

Specifically, the report stated that “as many as 98,000 people die each year due to medical errors,” (Leape & Berwick, 2005, p. 2384). Majority of such events and deaths are caused by negligence either on the part of the healthcare practitioners or patients and therefore they could easily be avoided. Since the publication of “To Err is Human” patient safety has become an important element and component of health and medical care.

This paper examines one of the areas of medical care in which the number of deaths and adverse events is high. This area is the central venous catheter-related bloodstream infection (central venous CR-BSI). The paper will discuss the prevalence and incidence rate of central venous CR-BSI, their causes, consequences and prevention measures. Most importantly, the paper will focus on the central line bundle as an effective measure of preventing central venous CR-BSI.

Prevalence Rates, Causes and Consequences of Central Venous Catheter-related Bloodstream Infections

In the United States, between 48,600 and 80,000 cases of central venous catheter-related bloodstream infections are reported each year among patients admitted in the intensive care units alone (Berenholtz, Pronovost & Lipsett, 2004). This figure is significantly high when considering the total adult population of patients admitted in hospitals rather than just intensive care units. It is argued that almost 250,000 cases of central venous CR-BSI are reported in the U.S hospitals annually. Central venous CR-BSIs are a major problem facing healthcare systems. They are the third most common infections associated with medical care after ventilator-associated pneumonia and Foley catheter-associated urinary tract infections.

The main cause of these infections is the presence of microorganisms that either attack the catheters or infect the fluid pathway when the catheter is being inserted or during the use of the catheter (Maki, Kluger & Crnich, 2006). In the intensive care units, the risk of contracting central venous CR-BSI is higher than other hospital units because of the nature of care accorded to ICU patients. For instance, ICU patients may require the central venous catheter for longer periods of time thereby increasing the opportunities for microorganisms attack.

In addition, the frequency of manipulation and access of the catheters by nurses is higher among ICU patients because of the need to frequently administer fluids and medications as well as to collect blood sample for tests. All these factors increase the opportunity of infection by microorganisms. In addition to the microorganisms, the type of catheter devices used also determines the risk of developing the infections (Goetz, Wagener, Miller & Muder, 1998). Central venous catheter-related bloodstream infections have serious consequences not only for the patients but also for the healthcare organization.

Central venous CR-BSIs increase the mortality and morbidity rates of affected patients. It is estimated that among children, the mortality rate associated with central venous CR-BSI is 13 percent. Additionally, the length of stay for such patients increases by approximately 14.6 days in the ICU and 21.1 days in the hospital (Costello, 2008). Among adults, approximately 28,000 patients die every year in the United States from central venous CR-BSI.

Besides mortality and morbidity, central venous CR-BSIs increase the costs of health and medical care both to the patients and the healthcare organization. Pronovost et al. (2006) argue that a patient with central venous CR-BSI requires about $45,000 for treatment. Given the high number of such infections, it implies that healthcare organizations spend up to about $2.3 billion every year to treat patients with central venous CR-BSI.

Literature Review

It is disheartening to note the high rates of central venous CR-BSI yet these infections can be prevented if only the proper measures were followed. Various studies have been conducted to examine the prevention of central venous CR-BSI. For instance, Berenholtz et al. (2004) conducted a study to examine the effectiveness of several intervention strategies including: education program to increase the level of awareness among the healthcare practitioners; using checklists; creating a central catheter insertion cart; empowering nurses to take the best action; and minimization of the use of central venous catheters are much as possible.

These strategies worked and the researchers reported a decrease in the number of central venous CR-BSI by 43, a decrease in the number of deaths by 8 and a decrease in costs by $1,945,922 (Berenholtz et al., 2004, p. 2017). The researchers concluded that reducing the rates of central venous CR-BSI does not require strict adherence to guidelines. Instead, it requires an overhaul of the healthcare system so as to provide quality and safe medical and health care.

The Sutter Roseville Medical Center in California is cited as a success story in reducing the rates of central venous catheter-related bloodstream infections. The intervention program implemented by the hospital was initiated in 2005 through a re-examination of its processes, application of healthcare industry’s best practices as well as adoption of new technologies to reduce the risks of contracting central venous catheter-related bloodstream infections. Two years after the initiation of the intervention program, the Sutter Medical Center was able to reduce the incidence rate of central venous CR-BSI to zero. The team at the hospital assessed all the catheters they were using, the connectors and devices used to reinforce the catheters in place as well as the sites of insertion (Joch, 2008).

One of the changes the team made was the site of insertion from the Basilic vein to the vein in the center of the bicep which reduced the exposure to dirt and consequently the risk of infection. However, the new insertion site required the use of ultrasound machines which the hospital purchased and trained the nurses on how to use them. The hospital also empowered the nurses to identify patients who were most likely to need central venous catheters right from the point of admission.

This forced the hospital to increase the use of catheters from 60 lines to 200 lines per month. Most importantly, the Sutter Medical Center implemented a central line bundle, which is widely acclaimed to reduce the rates of central venous catheter-related bloodstream infections significantly. The success of the Sutter Medical Center in addressing central venous CR-BSI is attributed to a combination of factors: having the right resources, using the resources well, a commitment from the leaders, and a dedicated staff (Joch, 2008).

The Central Line Bundle

The central line bundle is defined as “a group of evidence-based interventions for patients with intravascular central catheters that, when implemented together, result in better outcomes than when implemented individually” (Institute for Health Improvement, 2003). The central line bundle has five major components namely: hand hygiene, maximal barrier protections upon insertion, chlorhexidine skin antisepsis, optimal catheter site selection, and daily review of line necessity with prompt removal of unnecessary lines.

Hand hygiene

This entails the cleanliness of the health practitioners handling the catheters. Hand hygiene is known to be the most importation preventive strategy against infections and a crucial initial step in carrying out a procedure on a patient. Hands should be cleaned with disinfect soap or alcohol-based gel before and after each of the procedures followed in catheter insertion.

Using maximal barrier precautions

When inserting the catheter, the patient should be donned in a sterile gown. Those present in the room and around the patient’s bed should also wear sterile gowns, sterile gloves and face masks. Like in an operating room, the nurses should create a ‘patient zone’ so as to promote a sterile environment. All those who are not directly involved with the procedure and not wearing sterile clothing should be out of the room during the insertion of the catheter (Mermel, 2008).

Chlorhexidine skin antisepsis

Before the catheter is inserted, the nurses and other healthcare practitioners involved in the procedure should prepare the patient’s skin using chlorhexidine. Chlorhexidine is used to disinfect the skin of the catheter site thereby reducing the chances of infection. Healthcare practitioners should be trained on the appropriate technique of applying chlorhexidine.

Selecting the optimal catheter site

The catheter insertion site chosen plays an important role in either promoting or inhibiting the catheter-related infections. This is because some sites are more exposed to the environment than others thereby increasing the risk of infection and contamination. O’Grady et al. (2002) produced guidelines for the prevention of central venous catheter-related bloodstream infections. They argued that the subclavian vein is the best site for a central line.

This is because patients’ movements do not easily disturb the catheter. In addition, it makes sterile dressing much easier and therefore it can easily be kept dry and in place. O’Grady et al. (2002) further state that if a femoral site is the choice of site (this happens mainly during emergency situations), it should be replaced by the subclavian vein.

Review of the necessity of lines

Central lines are important in assessing the hemodynamic status of the patients and to administer drugs that might be corrosive or irritating to the patients’ skin if administered externally. However, it is important to note that the risk of central venous catheter-related bloodstream infections increases with the duration of time. This implies that the risk is higher if the catheter is left in for a long period of time.

This therefore necessitates a regular review of the central lines to determine whether or not the central lines are required. This is especially important when the patient’s condition improves because the patient may not require intravenous medications and also the need for frequent drawing of blood samples may reduce. Moreover, the patient can be monitored non-invasively. As a result, the nurses should review the need for the central lines on a daily basis depending on the patient’s condition. If the central lines are not required anymore, they should be removed immediately to reduce the risk of infection (Institute for Healthcare Improvement, 2008).

The role of the registered nurse in central line catheter bundle compliance

The RN acts as an advocate for patient safety by ensuring the compliance of the central line catheter bundle. This is achieved by cross-monitoring the activities of the team members, providing a safety net within the team and minimizing the occurrence of errors. The nurse also has the responsibility of stopping the line if there is a fault in sterile technique or if the checklist has not been adhered to. Similarly, the nurse must voice her concern at least twice to ensure that the concern has been heard.

Evidence of the Effectiveness of the Central Line Bundle

The central line bundle has been used in various settings and studies examining the effectiveness of the central line bundle have reported impressive results. For instance, after two years of following a rigorous preventive program that included a central line bundle, the Sutter Medical Center was able to reduce the rate of central venous CR-BSI to zero (Joch, 2008). In another study conducted by Pronovost et al. (2006), the researchers studied the effect of the central line bundle on the rate of central venous CR-BSI in 103 intensive care units located in Michigan hospitals. At baseline, the average rate of central venous CR-BSI was 2.7 infections per 1000 catheter-days.

This average rate reduced to zero after the central line bundle was implemented in the ICUs. This result is similar to the result of the Sutter Medical Center. This shows that the use of the central line bundle as a preventive strategy is indeed effective in reducing the incidences of central venous CR-BSI.

Conclusion

Central venous catheter-related bloodstream infections are a common occurrence in hospitals, especially among intensive care units patients. Central venous CR-BSIs are caused by microorganisms that enter the catheter or in the fluid pathway. Risk factors for these infections include a prolonged use of the catheters, frequent manipulation of the catheters and the type of catheters used. The infections have serious consequences on the patients and the healthcare system in that they increase the mortality and morbidity rates and the costs incurred in providing medical care. Although there is a high rate of the infections, the infections can easily be prevented.

Various guidelines have been published for the prevention of central venous catheter-related bloodstream infections. Evidence from different published studies shows that central venous CR-BSIs are best prevented by a number of prevention strategies used in combination with each other, rather than in isolation from each other. This group of preventive strategies is referred to as the central line bundle. The evidence presented in this paper shows that central venous CR-BSI can be reduced to zero rate using the central line bundle, thereby making the central line bundle the most effective prevention strategy.

Reference List

Berenholtz, S. M., Pronovost, P. J., & Lipsett, P. A. (2004). Eliminating catheter-related bloodstream infections in the intensive care unit. Critical Care Medicine, 32(10) 2014-2020.

Costello, M. J., Forbes, D. M., Graham, D. A., & Potter-Bynoe, G., Sandora, T. J., & Laussen, P. C. (2008). Systematic intervention to reduce central line-associated bloodstream infection rates in a pediatric cardiac intensive care unit. Journal of the American Academy of Pediatrics, 121(5) 915-918.

Goetz, A, M., Wagener, M, M., Miller, J. M., & Muder, R. (1998). Risk of infection due to central venous catheters: Effect of site of placement and catheter type. Infection Control and Hospital Epidemiology Journal, 19(1), 842-845.

Institute for Healthcare Improvement. (2008). 5 Million Lives Campaign. Getting Started Kit: Supplement for Rural Hospitals. Web.

Institute for Health Improvement. (2003). Implementing the Central Line Bundle. Web.

Joch, A. (2008). Sutter’s bundle of joy: Hospital cuts catheter-related bloodstream infection. Materials Management in Health Care, 17(6), 7-9.

Leape, L. L., & Berwick, D. M. (2005). Five years after To Err Is Human: What have we learned? Journal of the American Medical Association, 293(1), 2384-2390.

Maki, G., Kluger, M., & Crnich, J. (2006). The risk of bloodstream infection in adults with different intravascular devices: A systematic review of 200 published prospective studies. Mayo Clinic Procedures, 81(1), 1159-1171.

Mermel, L. A. (2000). Prevention of intravascular catheter-related infections. Annals of Internal Medicine, 132(5), 391-402.

O’Grady, N. P., Alexander, M., Dellinger, E. P., Gerberding, J., Heard, O., Maki, D, G., et al. (2002). Guidelines for the prevention of intravascular catheter-related infections. CDC Morbidity and Mortality Weekly Report, 51(10), 1-29.

Pronovost, P., Needham, D., Berenholtz, S., Sinopoli, D., Haitao, C., Cosgrove, S., et al. (2006). An intervention to decrease catheter-related bloodstream infections in the ICU. New England Journal of Medicine, 355 (1), 2725-2732.

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