CATHETER-RELATED BLOODSTREAM infections (CRBSIs) are the most dangerous complication associated with I.V. therapy, increasing a patient's risk of morbidity and death, prolonging hospital stays, and requiring additional treatments that raise healthcare costs. Now that the Centers for Medicare and Medicaid Services no longer reimburses hospitals for CRBSIs that occur after hospital admission, the following strategies to reduce infections and improve patient outcome are even more important.
A growing risk
More than 7 million central venous access devices (CVADs) and 160 million peripheral I.V. catheters are placed each year in the United States.1 An average of 2.1 million critical care patients require CVADs, and nearly 34,000 cases of CRBSI are reported annually among ICU patients.2
Healthcare-associated infections cost billions of dollars each year. Patients with CRBSI spend more time in the ICU and in the hospital, need more medications and diagnostic studies, have higher catheter removal and reinsertion costs, use more supplies, and need additional healthcare provider visits. One CRBSI can cost $34,500 to $56,000.3
Implementation of best-practice strategies can reduce CRBSI significantly. Patient-safety initiatives by groups such as the Institute for Healthcare Improvement (IHI) and the Agency for Healthcare Research and Quality are leading the way to improvements by making information and tools easily accessible (more on this shortly). In the past, hospitals attempted budgetary savings by reducing I.V. teams, when creation of a full-time I.V. team is in the hospital's best interest in terms of savings and patient safety.4
Sources of CRBSI
Catheter-related infections are caused by bacterial or fungal contamination from outside or inside the body. Not all catheter infections develop into bloodstream infections, but when contamination is linked to daily use of CVADs (such as syringe access to deliver medications), the potential for CRBSI increases significantly. Contamination in this sense is microbial entry into a sterile I.V. system, and is classified as extraluminal contamination resulting in intraluminal infection.
Extraluminal contamination and colonization originate from points outside the catheter. This contamination can occur when bacteria on the skin stick to the catheter during insertion, as it travels through the skin into the vein. Contamination also can occur when skin flora from healthcare workers is transferred during catheter care, colonizing the catheter or catheter hub.
Intraluminal contamination occurs when microbes invade the I.V. fluids or fluid pathway. Touching sterile syringes, access points, or other equipment used to administer medications or fluids can cause bacteria to enter the catheter lumen and result in infection.
Skin prepping before catheter insertion reduces the bacterial concentration on the skin surface, but bacteria is present in many layers of skin, so that no matter how well you prep, some bacteria will remain. Following catheter insertion, bacteria reappear as layers of skin slough off. Chlorhexidine gluconate, a prepping agent, has proven broad-spectrum antimicrobial activity, and its residual effectiveness of up to 72 hours is better than povidone-iodine and other prepping agents. When used with alcohol, chlorhexidine provides a quick kill and sustained action against most bacteria present around a CVAD insertion site. The CDC recommends chlorhexidine for prepping along with the use of maximum sterile barriers for CVAD insertion as a primary means to reduce CRBSI.
Because intraluminal contamination also can occur with flushing (especially when multidose vials or bags are used), the CDC recommends using single-dose vials or prefilled syringes of flushing solution. Use strict sterile technique during catheter insertion, perform hand hygiene before and after procedures, and scrub the catheter hub with friction to help reduce contamination and ultimately infection.
Which interventions provide the most benefit for improving patient outcomes? Several facilities have reduced CRBSIs by implementing the IHI's central-line bundle, which focuses on hand hygiene, maximal barrier precautions, chlorhexidine skin antisepsis, choosing the best catheter insertion site, and daily review of line necessity with prompt removal of unnecessary lines.5
A study at the Mayo Clinic of Arizona evaluated a comprehensive central-line infection prevention strategy that included peripherally inserted central catheters (PICCs).2 Other measures included the standardized use of a line insertion cart, full barrier precautions, a team of specially trained individuals, daily monitoring and maintenance of vascular access, and a standardized CVAD maintenance, insertion, and competency program for healthcare providers emphasizing routine hand hygiene. This group placed fewer chest-inserted central catheters, instead using PICCs placed via ultrasound guidance. As a result, CRBSIs with chest-inserted central catheters were eliminated and the overall infection rate for all catheters dropped to 0.3 per 1,000 catheter days from the control average of 1.6 per 1,000 catheter days. Much of the success was attributed to substituting PICCs for other CVADs and to the systems approach with the study's central-line infection prevention strategy.
From theory to practice
Establishing a set of best practices, identifying key personnel to implement these practices, educating clinical staff on all levels, and evaluating for compliance are all crucial to reducing CRBSIs. Education isn't a one-time event, but should be repeated if CRBSI levels begin to rise or until acceptable CRBSI levels are achieved. Initial team training with written and performance competencies should be standard for PICC teams, and should be followed by annual education and competency assessment. Infection control practitioners are key to the educational process and help to establish checklists and monitoring tools, reporting the results to clinicians to create positive change.
By following simple best practices, you can help your facility decrease the rate of CRBSIs, saving lives and reducing costs.
1. Richardson DK. Vascular access nursing-practice, standards of care, and strategies to prevent infection: a review of flushing solutions and injection caps (part 3 of a 3-part series). J Assoc Vasc Access. 2007;12(2):74-84. [Context Link]
2. Patel BM, Dauenbauer CJ, Rady MY, et al. Impact of peripherally inserted central catheters on catheter-related bloodstream infections in the intensive care unit. J Patient Saf. 2007;3(3):142-148. [Context Link]
3. O'Grady NP, Alexander M, Dellinger EP, et al. Guidelines for the prevention of intravascular catheter-related infections. MMWR Recomm Rep. 2002;51(RR-10):1-26. [Context Link]
4. Kokotis K. Cost containment and infusion services. J Inf Nurs. 2005;28(Suppl 3):S22-32. [Context Link]
5. Institute for Healthcare Improvement. 5 Million Lives Campaign. http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/ImplementtheCen. [Context Link]