Evidence-Based Policy and Practice: Central Venous Catheter -- Sterile vs. Clean Techniques Central line infections can be serious and even life threatening but the threat is largely preventable when proper cleaning techniques are used. This paper provides a description of this problem, a review of the relevant literature concerning central venous catheters and the sterile vs. clean technique to demonstrate that the latter is the superior approach. Finally, a description of the central venous catheter process that is currently in use at a tertiary healthcare facility is followed by a summary of the research and important findings concerning these issues in the conclusion.

Chronic intravenous therapy introduces a number of significant challenges for patients and caregivers alike who are required to become proficient with the sterile preparation of the medication, operation of the pump, and care of the central venous catheter to prevent catheter-related bloodstream infections (Doran, Ivy, Barst, Hill & Murall, 2011). Catheter-related bloodstream infections are well documented risks that are associated with central venous catheter use (Doran et al., 2011). Likewise, Lorente, Henry & Martin (2005) emphasize that, "Central venous catheters are commonly used in critically ill patients for the administration of fluids, medications, blood products and parenteral nutrition, for the insertion of a transvenous pacing electrode and to monitor hemodynamic status" (p. 631). Although precise figures are not available, some indication of the prevalence of use of central venous catheter use can be discerned from the results of a clinical study by EPIC that found more than three-quarters (78%) of critically ill patients had some type of form of central venous catheters inserted (Lorente et al., 2005).

Central venous catheterization can result in a number of adverse outcomes, including infection, hemorrhage and thrombosis (Lorente et al., 2005). The growing attention being paid to catheter-related infections concerns their inordinately high mortality rates and high concomitant costs that are associated with the intervention (Lorente et al., 2005). Current estimates indicate that between 1% and 13% of central venous catheterization develop a central venous catheter-associated blood stream infection (Lorente et al., 2005). Despite the growing body of evidence concerning central venous catheterization-related infections, there remains a dearth of studies that have investigated the problem in detail (Lorente et al., 2005), a gap in the research that this study will help fill.

Review of the Literature

Because the risk is well documented, all clinicians, patients and caregivers should follow effective methods of preventing central venous catheter-associated blood stream infections (Kovner & Knickman, 2005). Even with the best precautions in place, though, central venous catheter-associated blood stream infections can still occur (Lorente et al., 2005). A study of 281 hospitalized patients requiring 298 triple-lumen, polyurethane venous catheters in five university-based medical centers conducted by Raad, Darouiche and Dupuis (1997) used 147 catheters pretreated with tridodecylmethyl-ammonium chloride and coated with minocycline and rifampin with 151 untreated, uncoated catheters used as controls. These researchers used quantitative catheter cultures, blood cultures, and molecular typing of organisms to determine catheter-related colonization and bloodstream infections to evaluate the efficacy of the intervention.

The results of this randomized, double-blind study showed that the experimental and control groups with comparable in terms of age, gender, preexisting diseases, degree of immunosuppression, therapeutic interventions, and risk factors for catheter infections (Raad et al., 1997). According to these researchers, "Colonization occurred in 36 (26%) uncoated catheters and 11 (8%) coated catheters (P < 0.001). Catheter-related bloodstream infection developed in 7 patients (5%) with uncoated catheters and no patients with coated catheters (P < 0.01)" (Raad et al., 1997, p. 273). The statistical analysis of the study's findings indicated that coating catheters with minocycline and rifampin provided an independent protective factor against catheter-related colonization with no adverse effects related to the coated catheters or antimicrobial resistance being identified (Raad et al., 1997). These researchers concluded that sterile catheters can save money and lives (Raad et al., 1997).

A study by Carratala, Niubo and Fernandez-Sevilla (1999) evaluated the efficacy of an antibiotic-lock technique for the prevention of catheter-related...

According to these clinicians, "Patients with nontunneled, multilumen central venous catheters were assigned in a randomized, double-blinded manner to receive either 10 U. Of heparin per ml (57 patients) or 10 U. Of heparin per ml and 25 ?g of vancomycin per ml (60 patients), which were instilled in the catheter lumen and which were allowed to dwell in the catheter lumen for 1 h every 2 days" (Carratala et al., 1999).
The randomized, double-blind study by Carratala and his associates used the following protocols:

Insertion-site and hub swabs were taken twice weekly.

The primary and secondary end points of the trial were significant colonization of the catheter hub and catheter-related bacteremia, respectively.

The key findings that resulted from this study included the following:

Significant colonization of the catheter hub occurred in nine (15.8%) patients receiving heparin (seven patients were colonized with Staphylococcus epidermidis, one patient was colonized with Staphylococcus capitis, and one patient was colonized with Corynebacterium sp.),

None of the catheter hubs of the patients receiving heparin and vancomycin were colonized (P = 0.001).

Catheter-related bacteremia developed in four (7%) patients receiving heparin (three patients had S. epidermidis bacteremia and one patient had S. capitisbacteremia),

None of the patients in the heparin and vancomycin group had catheter-related bacteremia (P = 0.05).

The times to catheter hub colonization and to catheter-related bacteremia by the Kaplan-Meier method were longer in patients receiving heparin and vancomycin than in patients receiving heparin alone (P = 0.004 and P = 0.06, respectively).

These results indicate that sterile techniques were more effective in reducing the incidence of catheter-related infections (Carratala et al., 1999).

Finally, a prospective and observational study conducted by Lorente and his associates in a 24-bed medical surgical intensive care unit of a 650-bed university hospital included all consecutive patients admitted to the ICU during the 3-year period 1 May 2000 to 30 April 2003 for a total of 2,018 patients. The number of central venous catheterization and the number of days of that the patients were catheterized were as follows:

Global, 2,595 and 18,999;

Subclavian, 917 and 8,239;

Jugular, 1,390 and 8,361;

Femoral, 288 and 2,399.

The catheters used in the Lorente et al. study were radiopaque polyurethane catheters rather than antimicrobial-coated and catheter placement and maintenance were performed using the following protocol:

1. The catheters were inserted by physicians with the following sterile-barrier precautions: use of large sterile drapes around the insertion site, surgical antiseptic hand wash, and sterile gown, gloves, mask and cap.

2. The skin insertion site was first disinfected with 10% povidone-iodine and anesthetized with 2% mepivacaine.

3. The catheters were percutaneously inserted using the Seldinger technique and were fixed to the skin with 2-0 silk suture.

4. After the line insertion, the area surrounding the catheter was cleaned with a sterile gauze soaked with povidone-iodine and a dry sterile gauze occlusive dressing covered the site.

5. No topical antimicrobial ointment was applied to insertion sites (Lorente et al., 2005).

The results of the study showed that the incidence of catheter-related local infections was statistically higher for femoral vs. jugular (15.83 versus 7.65, p < 0.001) and subclavian (15.83 versus 1.57, p < 0.001) accesses, in addition, the incidence of catheter-related local infections was also higher for jugular vs. subclavian access (7.65 versus 1.57, p < 0.001). Further, the incidence of catheter-related bloodstream infection density was found to be statistically higher for femoral vs. jugular (8.34 versus 2.99, p = 0.002) and subclavian (8.34 versus 0.97, p < 0.001) accesses as well as being higher for jugular than for subclavian access (2.99 versus 0.97, p = 0.005) (Lorente et al., 2005). One of the key findings that emerged from the Lorente et al. (2005) study was that, "In order to minimize catheter-related infection, it is necessary to monitor its incidence and to implement preventive measures" (p. 635).

Description of the Process

Central venous catheterization should follow the recommendations from O'Grady, Alexander and Dellinger (2004)…