As frontline caregivers, nurses can help their patients avoid a bloodstream infection resulting from a central line, also known as a central venous catheter. To do this, you need to know how the infection develops, which prevention strategies are recommended, and why it’s critical to follow the guidelines. Only highly trained staff should insert central lines.
The CDC has defined the term “central line” as a catheter whose tip terminates in a great vessel (these include the aorta, pulmonary artery, superior vena cava, inferior vena cava, brachiocephalic veins, internal jugular veins, subclavian veins, external iliac veins, and femoral veins). Note that this also includes peripherally inserted central catheters, or PICC lines.
A bloodstream infection is considered to be associated with a central line if the line was in use during the 48-hour period before the infection developed. These central line associated bloodstream infections must be laboratory confirmed, or the patient must meet the clinical criteria for a diagnosis of sepsis.
CLABSI is among the most serious of the hospital-acquired infections, proving fatal for between 12 and 25 percent of the patients affected. CLABSIs are also on the list of preventable hospital-acquired infections that Medicare will no longer pay for.
Approximately 48 percent of ICU patients have a central line, according to a widely cited statistic. The risk of infection in the ICU is often higher than in general inpatient settings.
Prevention Strategies for Nurses
All nurses should be aware of the “central line bundle.” The term refers to a group of five evidence-based strategies (described below) for the insertion and management of central lines. When implemented together, the bundled strategies result in better outcomes than when each strategy is implemented individually. In addition, the bundle approach promotes teamwork and collaboration among members of a multi-disciplinary care team.
The central line bundle has proved effective in many case studies, which are described in a paper issued by the IHI.
The central line bundle has five key components:
- Hand hygiene. Hands should be washed before and after palpating insertion sites or accessing, replacing, or dressing a catheter. Process changes can improve compliance in this area and are easy to implement: include hand hygiene on the checklist for central lines, keep alcohol-based hygiene dispensers prominently placed, and post signs on patient rooms as reminders to staff.
- Maximal barrier precautions. One study found that the odds of developing CLABSI were six times higher when the line was placed without maximal barrier precautions. For the patient, these precautions involve covering the patient with a large sterile drape, with a small opening at the insertion site. For clinicians, it means using as mask, cap, sterile gown, and sterile gloves, the same as for surgical procedures. The best way to ensure compliance with this precaution is to keep all necessary equipment stocked together, to avoid the difficulty of hunting down supplies.
- Chlorhexidine skin antisepsis. Research shows that chlorhexidine provides better protection from infection than other antiseptic agents. It should be applied to the insertion site using a back-and-forth friction scrub for at least 30 seconds, and allowed to dry completely before the line is inserted. Again, it’s easy to enhance compliance by including this step on the central line checklist and keeping chlorhexidine solution handy where central line equipment is stored – many pre-packaged central line kits include povodine-iodine solution instead, and the IHI recommends avoiding these.
- Optimal catheter site selection. Evidence-based guidelines recommend avoiding the femoral vein for catheter insertion in adult patients, as studies have shown this site correlates with higher infection rates. Some research indicates that use of the subclavian site correlates with lower infection rates than does the jugular insertion site. However, the bundle approach is based solely on lowering the likelihood of CLABSI, and recognizes that other medical factors should be considered when deciding where to place the line. (A physician should do a risk/benefit analysis as to which insertion site is most appropriate for the individual patient, with input from care team members.)
- Daily assessment of central line necessity. The goal here is to promptly remove lines that are no longer clearly needed for optimal care of the patient – and not to leave them in place for convenient access. The risk of infection increases over time as the line remains in place. (When central lines are placed for long-term use, as in chemotherapy, weekly review of necessity may be appropriate.)
Other elements of prevention, such as daily site care regimens and selection of dressing materials, are not included in the central line bundle but are likely to be prescribed by protocols designed by a hospital’s infection control team, based on the research literature and on CDC recommendations. Nursing staff should follow these as well, and incorporate them into checklists and workflows.
The CDC has issued its 2011 Guidelines for the Prevention of Intravascular Catheter-Related Infections (PDF). This is a detailed, highly technical document most suitable for infection control staff members who are accountable for developing protocols and training clinicians in their use.
And if you’re interested in planning, implementing, and evaluating infection prevention and control measures, consider making this field your career specialty. As a first step, you can develop new skills and empower yourself with knowledge through an online RN to MSN degree with a specialization in infection control from American Sentinel University, an innovative, accredited provider of online nursing degrees.