Although significant progress has been made in preventing some healthcare-associated infections (HAIs), this remains an important and needed focus in healthcare. According to Centers for Disease Control and Prevention (CDC), on any given day, about one in 31 hospital patients has at least one HAI. One of the most common and the most costly HAI is central line-associated blood stream infections (CLABSIs), which account for approximately $46,000 per case. According to the Joint Commission, 250,000 CLABSIs occur in the U.S. each year, and CLABSIs account for one-third of the estimated 100,000 annual deaths as a result of HAIs.
CLABSIs can lead to prolonged hospital stays and increase health care costs and mortality rates. Since 2008, CLABSIs have been designated by the Centers for Medicare and Medicaid Services (CMS) as a “Never Event,” meaning that hospitals are no longer reimbursed for the cost of their treatment. Along with their main objective to provide safe, high-quality care, there is an additional financial incentive for hospitals to do everything in their power to reduce the number of CLABSIs and other HAIs in their facilities.
Adhering to protocol
In an effort to lower CLABSI rates, the Institute for Healthcare Improvement introduced an infection prevention approach known as the central line insertion bundle. The bundle includes a series of evidence-based interventions that, when implemented together – or as a bundle – are more effective than when implemented individually. The Joint Commission, as part of its National Patient Safety Goal to prevent CLABSIs, requires all accredited hospitals to adhere to the components of the bundle – proper hand hygiene, maximal barrier precautions, chlorhexidine skin antisepsis, optimal site selection and daily review of whether the central line is needed.
In addition to this, the CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections created in 2011, and updated as recently as July 2018, outline in more specificity the central line bundle elements. By following a strict-but-simple protocol when inserting and maintaining central lines, CLABSIs can be greatly reduced. Some of the practices include:
- Education about the importance of maintaining sterility while inserting and maintaining central lines
- Use of a central venous catheter (CVC) cart with all necessary prep and insertion tools at bedside
- Use of a checklist to be sure all appropriate practices are followed
- Proper hand hygiene (washing with soap and water or an alcohol-based hand rub) before inserting, replacing, accessing, repairing or dressing the central line
- Maximal sterile barrier precautions, which include cap, mask, sterile gown, sterile gloves, sterile full-body drape when inserting CVCs and PICCs and for guidewire exchanges (Be sure to use low-linting drapes and PPE; lint contamination is a major cause of thrombosis.)
- Prepare clean skin with >0.5% chlorhexidine (CHG) with alcohol before insertion of the CVC; allow to dry on skin before inserting central line
- Using either sterile gauze or sterile, transparent, semipermeable dressing to cover the central line site
- Use of 2% CHG wash for daily skin cleansing
- No routine catheter replacements; replace only when necessary
- Stop non-emergent procedure if appropriate practice is breached
- Properly disinfect injection ports before accessing IV lines
- When a central line is no longer required, remove it as soon as possible
Hospitals face a number of challenges that can complicate their ability to adhere to established CLABSI protocols, which research shows can help to prevent costly HAIs.
Lack of time: The ever-increasing demands on a hospital’s nursing staff present real challenges. According to recent data, on average, a nurse performs 72.3 tasks related to patient care in a given hour, meaning there are 867.6 chances to miss protocols within a 12-hour shift. Given that procedures such as the removal of a central line dressing consist of multiple steps that need to be performed in a specific order without breaking the sterile field, this presents potentially significant room for error.
New staff: Many hospitals use travel nurses, who may not be as familiar with their specific protocols, or products used to adhere to them. In situations like this, setting up an assessment of their technique and approach to placing, maintaining and removing central lines, and educating new staff about your hospital’s CLABSI protocol can go a long way in helping to mitigate any issues.
Space constraints: Hospital rooms can offer limited workspace, meaning that performing dressing changes on central lines can be challenging. For this reason, at times the patient is used as the “table,” though it is not recommended as best practice. In situations such as this, having the right equipment that can aid in simplifying the desired process for the procedure while maintaining the sterile field can help.
Setting your staff and patients up for success
When attempting to refine and improve your hospital’s approach to preventing HAIs such as CLABSI, research has shown that following the CDC Guidelines and the central line insertion bundle chart to be a successful path forward. According to one study, following the central line insertion bundle exactly created the best scenario to lower CLABSI rates in participating hospitals, though following even one aspect of it well also helped. There are practices that can help set your staff and patients up for success, including:
- Cultivate protocol know-how: Like most endeavors, it all starts with education. Making sure the necessary hospital personnel have received training on the proper indications for intravascular catheter use, how to insert and maintain them aseptically, and general infection prevention control methods is crucial. Hold regular trainings, and provide accessible resources for staff to consult between trainings. Additionally, have a strong hand hygiene policy and set staff up for success by having the right equipment readily accessible.
- Dress the part and be prepared: It’s important to ensure you have the right personal protective equipment to follow maximal sterile barrier precautions as outlined in the hospital’s established protocol, and that staff has been trained on proper donning and doffing techniques. It’s also wise to have a checklist easily available so personnel have a dedicated place they can refresh themselves on the protocol.
- Inform patients of best practices: Hospital staff won’t be present in the patient room at all times. Therefore, it is wise to empower patients with helpful information about some approaches that will help keep their central line sterile, for example:
- Avoid touching the line as much as possible
- Don’t allow visitors to touch the line
- Make sure all visitors wash their hands before and after their visit
- Don’t get the line or the insertion site wet
- If the bandage over the insertion site, or the area around it, gets wet or dirty, or if the bandage comes off, tell a healthcare worker right away
While HAIs such as CLABSI remain a pervasive issue impacting quality, experience and cost of patient care, following established guidelines and recommendations as part of the central line insertion bundle provide a needed foundation for addressing the issue. Additionally, educating staff and giving careful consideration to supporting clinicians in their efforts to adhere to established protocols when making purchasing decisions are critical as well. The combination of these strategies can result in not only an improved experience for patients, but for the clinical staff charged with their care as well.