National Patient Safety Goals (NPSG) were introduced in 2002 in order to help address some of the issues that were responsible for causing a majority of the situations that were responsible for creating patient safety issues. These goals were implemented in order to put focus on what were deemed to be the most preventable of these issues. One of these goals is the prevention of central line-associated blood stream infections (Lyles, Fanikos, & Jewell, 2009).
Central venous catheters (CVC) are indispensable in the care of critically ill patients. However, their use is not without risk. Catheter-associated bloodstream infections (CA-BSI) are common healthcare-associated infections in intensive care unit (ICU) patients and have been estimated to occur in 3%-7% of all patients with CVC (Warren, et al., 2006). It is well documented that intravascular catheter related complications are associated with extending hospital length of stay, increasing direct costs and increasing ICU mortality. Clinicians insert approximately 7 million central venous access devices (CVAD) annually in the United States, and of these, 1 in 20 is associated with a CA-BSI, despite the use of the best available aseptic techniques during catheter insertion and maintenance. Overall, an estimated 250,000 CVAD-related CA-BSI occur annually, with an attributed mortality of 12.5% to 25% per occurrence. The national cost of treating CA-BSI equals $25,000 per infection, respectively, or $296 million to $2.3 billion in total. While the number of CA-BSI has remained relatively steady, vascular access device use has drastically increased, especially in nonhospital settings (Rosenthal, 2006).
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A vast amount of research is directed toward reducing these complications in an effort to improve patient outcomes. A review of the literature provides an overview of current recommendations concerning intravascular catheter care and research regarding the use of education programs to promote recommended practice.
The Centers for Disease Control and Prevention (CDC) published the Guidelines for the Prevention of Intravascular Catheter-Related Infections in 2002, which is the benchmark for all intravascular catheter care recommendations. The guidelines for CVC suggest the replacement of dressings every 7 days or when soiled or loosened, intravenous tubing changes every 72 hours, and the replacement of tubing used to administer blood products and lipid emulsions within 24 hours of infusion initiation (East & Jacoby, 2005). According to the CDC, approximately 53% of adult patients in intensive care units have a central venous catheter on any given day (Rupp, et al., 2005).
Skin cleansing of the insertion site is regarded as one of the most important measures for preventing catheter-related infection. Historically, povidone-iodine is an antiseptic that has been used during the insertion and maintenance of the intravascular devices. It works by penetrating the cell wall of the microorganism. More recently, chlorhexidine has been studied and found to be more effective as a skin antiseptic to prevent catheter-related infection. It works in less time, retains its antibacterial effect against flora longer, is not inactivated by the presence of blood or human protein, and causes minimal skin irritation. Chlorhexidine works by disrupting the microbial cell wall. It is active against many gram-positive and to a slightly lesser degree gram-negative bacterium (Astle & Jensen, 2005).
A multistep process is recommended to prevent CA-BSI that includes: educating staff, using maximal barrier precautions (e.g. a sterile gown and gloves, mask, cap, and large sterile drape), performing infection surveillance, and replacing occlusive dressing every 7 days or when needed (Buttes, Lattus, Stout, & Thomas, 2006). Other strongly recommended practices include proper hand hygiene, use of chlorhexidine gluconate for insertion site preparation, and avoidance
of routine catheter changes. Catheters impregnated with antimicrobial agents are recommended when infection rates are high or when catheters will remain in place for a considerable time (Krein, et al., 2007). Education of staff on the proper care of CVC is paramount in reducing the amount of CA-BSI. This is perhaps one of the most cost-effective methods of reducing CA-BSI (Ramritu, Halton, Cook, Whitby, & Graves, 2007).
A staff education program was initiated for the nursing personnel that primarily deal with CVC. This education program was aimed at training the ICU and step-down unitââ‚¬â„¢s nursing staff proper care and maintenance of the CVC. Education focused on proper care of the CVC, including when dressing changes should be performed e.g. every 7 days or when the dressing is soiled. Nurses were also trained in how to appropriately assist with CVC placement and the documentation tool that infection control utilizes to evaluate adherence to insertion guidelines. Posters were also placed in the nurseââ‚¬â„¢s break and conference areas that had educational material related to proper care of CVC. Documentation was also placed in the physicianââ‚¬â„¢s lounges that encouraged utilization of maximal barrier precautions during CVC insertion.
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The facility that was observed currently utilizes a few different means of measurement with regards to CA-BSI. First, a checklist is utilized during CVC insertion that evaluates adherence to insertion guidelines by the staff. This checklist is sent to infection control and entered into a database which is correlated with patient data regarding CA-BSI. Second, in patients that are identified as having a CA-BSI, after catheter removal, laboratory microbiological studies of the catheter, blood, and insertion site swabs are performed to identify causality of the infection.
Implementation Compared to Literature Suggestions
Practices that reduce the risk of CA-BSI include the following: (1) use of maximal barrier precautions during CVC insertion (i.e., a surgical mask, sterile gown, sterile gloves, and large sterile drapes), (2) placement of the catheter in the subclavian vein rather than the internal jugular or femoral vein, (3) changing catheters only when necessary, and (4) changing dressings on CVC exit sites when they become nonocclusive, soiled, or bloody. These practices have been incorporated into national guidelines. Currently, the Healthcare Infection Control Practices Advisory Committee (HICPAC) of the Centers for Disease Control and Prevention (CDC) recommends that hospitals implement comprehensive educational programs that teach proper CVC insertion and maintenance techniques (Warren, et al., 2006). These practices are mostly in line with what is implemented at the observed facility. One difference, which is not in line with these recommendations, is that the observed facility has a high number of internal jugular insertions rather than utilizing the subclavian vein. When asked about this, many of the physicians stated that access was easier to identify utilizing ultrasound during insertion and they preferred this method over subclavian insertion.
First, implementation of an education program for providers that is focused on infection control, especially the recommendation of utilizing the subclavian vein insertion for CVC placement as a first choice in patients that have no contraindications to this placement. Second, procuring the second-generation antiseptic catheter, coated with chlorhexidine and silver sulfadiazine on the internal and external surfaces, to more effectively prevent microbial colonization in patients that are identified as being at risk. Decreased bacterial colonization, a critical step in the pathogenesis of catheter-associated infection, may correlate with prevention of catheter-related bacteremia (Rupp, et al., 2005). Third, education and training needs to be expanded to any nurses that may be responsible for caring for a patient with a CVC. These areas include non-critical care areas such as pediatric and medical floors. Larger numbers of patients with CVC are now found in non-ICUs than in ICUs and that CA-BSI rates in those settings are higher. Catheter types and insertion sites vary greatly among settings. For example, jugular and femoral insertion sites are common in ICUs; subclavian and peripheral sites are more common elsewhere. So strategies for reducing CA-BSI must be tailored to the setting (Hadaway, 2006).
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