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Preventing Central Line Infections: Best Practices and Guidelines

Learn about historical perspective, complications, morbidity, and mortality of Central Line Bloodstream Infections. Understand prevention strategies involving hand hygiene, maximal barrier precautions, and optimal site selection. Discover roles of physicians and nurses in insertion, maintenance, and education.

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Preventing Central Line Infections: Best Practices and Guidelines

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  1. Prevention Central Line Bloodstream Infections

  2. WASHYOUR HANDS

  3. Historical Perspective • 1850 Semmelweiss found increased rate of mortality with puerperal sepsis patients and advocated hand washing to stop spread of disease • Died in a mental institution, work never recognized as important

  4. Central venous catheters (CVC) • United States physicians insert > 5 million every year • Used for hemodynamic measurements, resuscitation, administration of medications and nutrition • 15% of patients will have a complication

  5. Complications of CVC • Mechanical complications 5-19% • Thrombotic complications 2-26% • Infectious complications 5-26% • N Engl J Med 2003;348:1123-33

  6. CVC Infectious Morbidity & Mortality in Hospitals • In the U.S. 15 million CVC days • 250,000 cases of CVC associated BSIs • Mortality 12-25% • Marginal cost is $25,000 per episode • Lowball $6.25 billion

  7. CVC Infectious Morbidity & Mortality in ICU • Average ICU rate of BSI 5.3/1000 catheter days • 80,000 BSIs/ year in ICUs • Studies show no increase in severity adjusted mortality to 35% increase in mortality • ? Attributable mortality

  8. CVC Infectious Cost in ICUs • Cost per infection is $34,508-$56,000 • Annual cost $296 million to $2.3 billion

  9. National Nosocomial Infection Surveillance System: CDC • Data January 1992-June 2001 • Group of nearly 300 hospitals • Med/surg rate major teaching 5.3% • Med/surg rate all others 3.8% • Rates influenced by severity, type of illness, elective or urgent placement and type of catheter

  10. Prevention of Central Line Bloodstream Infections • Review current training for effectiveness, completeness • Define nurses’ role • Mechanism for monitoring compliance with training prior to ICU rotation • Establish strategy for identifying and training those we missed • Communication plan to housestaff and attendings • Implement training requirements

  11. Central Line Bundle • Hand Hygiene • Maximal barrier precautions • Chlorhexidine skin antisepsis • Optimal site selection, subclavian vein preferred site • Daily review of need for line with prompt removal

  12. Physicians’ role: Preprocedure • Assess allergies • Verify consent form completed and in chart • Assemble supplies with nursing staff • Time out-right patient, right location, assess site • Review appropriate landmarks with attending • Subclavian preferred site if not contraindicated

  13. Physicians’ role: Prep • Remember to employ maximal barrier precautions • Put on hat/mask for everyone in room • Minimize number of people in room • Close door prior to start of procedure • Wash hands • Sterile gown/gloves • Chlorhexidine prep of site • Pinch wings of applicator to break ampoule • Hold applicator down to saturate pad • With sponge against skin, apply chlorhexidine for at least 30 seconds using a back and forth scrub • Allow chlorhexidine to dry completely before beginning line placement (~2 minutes)

  14. Physicians’ role: Insertion • Full body drape • Perform procedure • Transduce with pressure tubing to verify venous placement • Apply needleless caps, flush ports with saline • Suture catheter in place • Apply Biopatch • Apply Tegaderm • Appropriate disposal of kit/drapes • Order and check CXR for line placement • Procedure note in chart • Daily review of necessity of central line-advocate removal ASAP

  15. Nursing Education • Development of Nursing checklist • Nursing Ed for skills day/orientation • CPC committee • Update intranet with this information • Utilize ICU nursing administration to keep at the forefront of many QI projects

  16. Nurses’ role: Preinsertion • Inform patient/family of pending procedure • Assess allergies in chart • Verify informed consent present • Gather sterile supplies for maximum barrier precautions i.e. gowns, gloves, drapes, masks, hats • Needleless caps • Saline flush with syringes • Biopatch • Tegaderm

  17. Nurses’ role Insertion • Minimize number of people in room • Close door prior to start of procedure • Everyone in room with hat/mask • Everyone in room wash hands • Time out • Maximum barrier precautions • Monitor sterile process and alert for breaks in procedure • Clean site then apply Biopatch shiny or blue side up • Sterile occlusive dressing application • Obtain CXR for line placement • Inform family of outcome of procedure

  18. Nurses’ role Maintenance • Review need for line on daily basis • Advocate removal/PIC • Monitor site q shift for signs/symptoms of infection, irritation, redress if needed • Alcohol ports prior to every access • Tubing/needleless port change q 4 days and more often as needed

  19. WASHYOUR HANDS

  20. Before and After Patient Contact

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