People admitted to intensive care units and those with chronic health care problems often require long‐term vascular access. Central venous access devices are used for administering intravenous medications, blood sampling, and sometimes hemodialysis. As a hemodialysis nurse for more than a year before I transitioned to the Intensive Care Unit, I am familiar with handling of central venous catheter (CVC) because of the basic training I received while I was in the Hemodialysis Unit. One of the biggest differences that I encountered when I transferred to the ICU is the handling of CVC, including intrajugular catheter, subclavian catheter, femoral catheter, PICC, and implanted catheters (ports).
CLABSI is defined as a laboratory-confirmed bloodstream infection that occurs when an eligible BSI organism is identified and a central line is present when the BSI is laboratory confirmed. (CDC, 2022) Clinically, CLABSI occurs when these three criteria exist: 1) clinical signs of infection, 2) no alternate source of bloodstream infection, and 3) positive blood culture from a peripheral vein with catheter tip/segment culture that matches the organism grown from blood. (Mermel et al., 2009) In the ICU, some of the evidence-based CLABSI Bundle of Care recommendations are not translated into practice properly, or the current practice is not congruent with the best, latest recommendations. For instance, in accessing catheter hubs, needleless connectors, or injection ports, they are scrubbed with chlorhexidine swabs prior to each use, however, not done long enough. ICHE Compendium 2022 recommends vigorously applying mechanical friction with an alcoholic chlorhexidine preparation, or 70% alcohol for a minimum of 5 seconds. (Buetti et al., 2022) In addition, change of administration sets for continuous infusion is done every 72 hours in our unit despite CDC’s recommendation to replace administration sets that are continuously used, including secondary sets and add-on devices, no more frequently than at 96-hour intervals, but at least every 7 days in patients not receiving blood, blood products or fat emulsions. (CDC, 2024) This is supported by the study conducted by Rickard et al., (2021) investigating the effect of infusion set replacement intervals on catheter-related bloodstream infections, authors concluded that bloodstream infections did not differ between groups with sets changed every 7 or 4 days. Moreover, topical antibiotic creams, specifically Mupirocin, are sometimes used, despite CDC’s advice against the use of topical antibiotic ointment or creams on insertion sites, except for dialysis catheters, because of their potential to promote fungal infections and antimicrobial resistance. (CDC, 2024) ICHE Compendium also discourages the use of Mupirocin ointment to the catheter insertion site due to the potential damage to polyurethane catheters. (Buetti et al., 2022)
As a new nurse, it felt intimidating to educate more experienced colleagues, however, having knowledge on the care of CVC, I shared with them the evidenced-based practices and resources in a respectful and non-offensive manner. More importantly, I modeled the practices, and stayed consistent to encourage others to adopt them. With the strategy I shared with them, it is difficult to ascertain outcome measures including CLABSI rate and hospital readmissions because we do not have hospital administrators overseeing the incidence of CLABSI as far as I know, thus, no data available. Complying with the strategy, however, is potentially cost-saving on the part of nurses and patients. Avoiding unnecessary administration set replacement and use of antibacterial ointment reduces costs, workloads, and environmental manufacture and waste.
Given the chance to initiate change in our unit and if faced with CLABSI, I would consider implementing the following strategies to further enhance patient safety. First, I would suggest updating our Central Line Bundle Checklists based on the up-to-date evidence available. We do have a CLABSI checklist in our unit, however, it was based on old studies. For instance, the data on changing of administration sets every 3 days was based on a 2005 study which is outdated. Second, posting of “Scrub the hubs” signages. While scrubbing the hub was already in place, I would advocate for increasing the use of chlorhexidine swabs for disinfection for at least 5 seconds before accessing CVC. Third, I would propose more in-depth training and simulation drills for staff on proper central line care, including troubleshooting common issues like catheter occlusion and dressing changes, which could further reduce the risk of infection. Finally, I would suggest involvement of Infection Control Teams to monitor for CLABSI incidence rate and to conduct audits of the team’s compliance with the updated central line bundle.
References:
Centers for Disease Control and Prevention. (2022). Bloodstream Infection Event (Central Line-Associated Bloodstream Infection and non-central line-associated Bloodstream Infection). https://www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf
Mermel, Leonard A., Allon, M., Bouza, E., Craven, Donald E., Flynn, P., O’Grady, Naomi P., Raad, Issam I., Rijnders, Bart J. A., Sherertz, Robert J., & Warren, David K. (2009). Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter‐Related Infection: 2009 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases, 49(1), 1–45. https://doi.org/10.1086/599376
Buetti, N., Marschall, J., Drees, M., Fakih, M. G., Hadaway, L., Maragakis, L. L., Monsees, E., Novosad, S., O’Grady, N. P., Rupp, M. E., Wolf, J., Yokoe, D., & Mermel, L. A. (2022). Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 update. Infection Control & Hospital Epidemiology, 43(5), 1–17. https://doi.org/10.1017/ice.2022.87
CDC. (2024, May 10). Summary of Recommendations. Infection Control. https://www.cdc.gov/infection-control/hcp/intravascular-catheter-related-infections/summary-recommendations.html#cdc_generic_section_1-1-education-training-and-staffing
Rickard, C. M., Marsh, N. M., Larsen, E. N., McGrail, M. R., Graves, N., Runnegar, N., Webster, J., Corley, A., McMillan, D., Gowardman, J. R., Long, D. A., Fraser, J. F., Gill, F. J., Young, J., Murgo, M., Alexandrou, E., Choudhury, M. A., Chan, R. J., Gavin, N. C., & Daud, A. (2021). Effect of infusion set replacement intervals on catheter-related bloodstream infections (RSVP): a randomised, controlled, equivalence (central venous access device)–non-inferiority (peripheral arterial catheter) trial. The Lancet, 397(10283), 1447–1458. https://doi.org/10.1016/S0140-6736(21)00351-2