Eliminating Infection Post CVC Insertion

Reducing The Risk of CVC Related Infections Post Insertion

Multiple lumen central venous catheters (CVCs) are used to administer large amounts of intravenous fluids, blood products, and medications. In the past, they were only used in the intensive care unit. However, they are now used in all areas of health care. CVCs are inserted through a large central vein like the subclavian vein, and they terminate at the junction of the superior vena cava and right atrium. There are cases where the catheter is inserted through the femoral vein and terminated in the inferior vena cava. However, this is not recommended due to the increased risk of infection. Catheters terminate in large veins where there is rapid blood flow around the tip of the catheter, allowing for the fluids and medications to be rapidly diluted and moved into the patient\'s circulation. The location, ease and rapid access of the CVCs to the patient\'s bloodstream increase the risk of developing catheter-related bloodstream infections or central line-associated bacteraemia (CLAB). Böll et al. (2021) indicates that the risks of using central lines are significant, and they are a significant risk factor for bloodstream infection, are associated with 2.27-fold increased mortality risk, and drive health care costs up (Frasca et al., 2010). The CLAB costs range from $21,400 to $110,000, representing a severe and ongoing patient safety risk and a significant economic burden for health care providers (Jacob & Gaynes, 2019).

The majority of CLABs are preventable by implementing evidence-based strategies available to health care professionals (Böll et al., 2021; Gupta et al., 2021). When compared to healthcare-associated infections (HAIs), CLABs have the highest number of preventable deaths. We could save between 5,000 to 20,000 lives annually with best practice implementation (Taylor et al., 2015). To assist in reducing and preventing CVC infections, the Institute for Healthcare Improvement (IHI) developed a care bundle to assist healthcare professionals in preventing CVCs. A care bundle is a set of evidence-based measures that, when implemented together, produce better outcomes and have a more significant impact than implementing individual measures (Gupta et al., 2021). The best practices recommended in the IHI care bundle are hand hygiene, maximal sterile barrier precautions upon insertion, chlorhexidine skin antisepsis, optimal site selection (avoidance of femoral vein in adults), and daily review of central line necessity and prompt removal of unnecessary lines.

Hand Hygiene

Hand hygiene is the most convenient and cost-effective strategy for preventing central line-associated bloodstream infections (CLABSI). The World Health Organization (WHO) proposed a multimodal strategy that includes five elements as an evidence-based approach for preventing HAIs (Ling et al., 2016). The five elements are before touching a patient, before performing a clean/aseptic procedure, after exposure to body fluid, after touching a patient, and after touching the patient\'s surroundings (Biehl et al., 2018). These hand hygiene strategies aim to ensure the nurse keeps their hands clean and does not transfer infections from one patient to another. By using a meticulous hand hygiene technique, nurses can decrease the risks of CVC related bloodstream infections. Myatra (2019) posit before nurses perform CVC care, they should ensure they have washed their hands either using a waterless alcohol-based product or using antibacterial soap with water. A waterless alcohol-based product is sufficient if the nurse\'s hands are not visibly soiled and they have not been to see another patient. However, to ensure the nurse\'s hands are clean, it is recommended that they wash their hands using soap and water. Hand hygiene should be performed before any CVC care (Jacob & Gaynes, 2019).

There is a considerable risk of acquiring an infection during CVCs\' insertion and maintenance care (Taylor et al., 2015). Proper hand hygiene assists in reducing the number of bacteria that come in contact with the catheter, helping reduce the patient\'s risk of developing an infection. Nurses involved in the care of patients in a high acuity environment should be educated on the importance of hand hygiene when handling or caring for a catheter. Nurses are charged with different tasks when caring for the patient, and they are required to change medication, draw blood, and change the dressing. In all these instances, the chance of bacterial infection increases with every touch on the catheter. Therefore, proper education and quality improvement programs should be implemented across the health care facility to educate nurses on the importance of clean hands. An educational intervention in catheter care will significantly improve patient outcomes (Ling et al., 2016). A simulation-based training program will be valuable for educating the nurses.

Skin Antisepsis

Skin antisepsis is a vital preventive measure for reducing or eliminating catheter-related infections. Chlorhexidine and povidone-iodine are the most commonly used antiseptic agents available as alcoholic and aqueous solutions. Chlorhexidine has been shown through numerous studies to be more effective than povidone-iodine (Frasca et al., 2010). With a better rate of infection prevention, it is recommended that chlorhexidine be used instead of povidone-iodine prior to insertion of the catheter. Cleaning of the skin aims at removing microorganisms at the insertion site and cleaning the insertion site during dressing change (Silva & da Cruz, 2018). Nurses are responsible for inserting and changing the dressing of the catheter. Therefore, they should be provided with the most effective antiseptic. Using chlorhexidine depends on hospital policy, and nurses can push for the inclusion of its use if the hospital policy recommends povidone-iodine. Demonstrating its efficacy using evidence-based strategies will inform the hospital administrators, making it easy to implement the change. With a 50% reduction in catheter-related bloodstream infection compared to povidone-iodine, it would not be difficult to make a case for the change. Cleaning the patient\'s skin is vital before the insertion of the catheter because it ensures the site is clean and there are no chances of microorganisms moving from the skin to the vein (Saliba et al., 2018). Considering that the catheter will pierce the skin, if not adequately cleaned with an antiseptic agent, the patient can get an infection during the insertion of the catheter. The best cleaning strategy is to clean the area using an alcoholic-based solution with a back-and-forth motion for about 30 seconds (Biehl et al., 2018). The area should be left to air dry before catheter insertion takes place (Silva & da Cruz, 2018).

Accessing The Catheter Hub

There should be disinfection of the hubs on the CVCs before they are accessed (Taylor et al., 2015). These hubs are a common source of bacterial colonization, and they serve as immediate portals for microorganism entry into the intraluminal surface of the catheter. Whenever the hub is accessed to infuse medication or draw blood, there is an increased risk of microorganisms entering the patient\'s bloodstream. Microorganisms can be channelled into the catheter and bloodstream from the surface of the catheter hub. Syringes and needleless connectors attached to the hub can be prime areas for microorganisms (Wu et al., 2020). Drug and blood particles and tape residue offer a prime environment for organisms to multiply. Therefore, each time the hub is accessed, it should be cleaned with a new alcohol pad before being accessed (Silva & da Cruz, 2018). Disinfection will assist in reducing the number of organisms on the hub that can be channelled into the patient\'s bloodstream. Also, nurses should be advised to never draw blood through the access cap found at the end of the central venous catheter. Blood should be drawn by attaching the syringe directly to the catheter hub. According to Gahlot et al. (2014); (Saliba et al., 2018) the steps for drawing blood are to remove the access cap, clean the catheter hub with alcohol, and attach a syringe. The access cap should be replaced with a new sterile cap when done drawing blood. Whenever the access cap is removed or becomes contaminated, it should be replaced with a new cap (Hallam et al., 2018).

The best time interval for replacing the intravenous administration sets should be 72 hours (Gahlot et al., 2014). Different studies have demonstrated that replacing the administration sets 72 hours after initiation is safe and cost-effective. The tubing used for administering the products should be replaced within 24 hours or after the end of the administration (Wu et al., 2020). Frequent catheter hub access increases catheter-related infection risk (Myatra, 2019). Overall, for extended catheterization, there is an increased risk of infection related to the duration of the catheter stay. It is recommended that another method be used for the administration of drugs and food when possible. Catheter necessity should be done daily to ensure that it does not stay longer than needed (Myatra, 2019; Taylor et al., 2015; Yang et al., 2021). It has been shown that risks of infection increase the longer a catheter remains in place. A catheter that is no longer needed should be promptly removed (Gahlot et al., 2014).

Proper Dressing Change Technique

The most common nursing function involves changing the CVC dressing. Each facility will have its policy and procedures related to CVC dressing changes. However, some factors have been proven to reduce the patient\'s risk of a bloodstream infection when changing the dressing. First, it is recommended to use a transparent semipermeable dressing over gauze dressings. Transparent dressings allow for continuous visual inspection of the catheter site. If the patient is sweating or the site is bleeding or oozing, a gauze dressing can be used. According to Frasca et al. (2010) a transparent dressing gives nurses a visual of the site, and they can easily spot signs of infection. Some of the infection signs might be redness of the insertion site, drainage, and pain. The insertion site should be assessed at least once during each shift. A transparent dressing should be changed every seven days (Myatra, 2019). When the dressing becomes loose, damp, or soiled or if it must be removed to examine the insertion site, then the entire dressing must be replaced—replacing parts of a dressing increases the risks of infection because there might be microorganisms present and covering them with a new dressing prevent their recognition. When the insertion site is soiled, it should be adequately cleaned to remove any dirt. Doing a partial dressing change creates a suitable environment for microorganisms to multiply.

Occlusive dressings trap moisture on the skin, providing an ideal environment for rapid local microflora growth (Heimann et al., 2018). Insertion dressings must be permeable to water vapour. Transparent dressings are popular, and they allow patients to have baths and showers without saturating the dressing, require frequent changes, and are time-saving for the staff (Yang et al., 2021). Compared to gauze dressings, staff can quickly check the dressing for infection without having to peel it back (Frasca et al., 2010).

Ensure Appropriate Nursing Staff Levels

To deliver quality care, there should be an appropriate nurse staff level. Staff shortages brought about by cost-cutting decisions, increased patient complexity, ageing population, and ageing workforce places stress on nurse working conditions, affecting patient care and overall outcomes. When it comes to CVCs, when a health care facility does not have enough nurse staffing levels, nurses will be overworked, and they are less likely to pay attention to critical aspects when accessing central lines. Due to increased pressure and workloads, nurses will skip some vital steps regarding cleanliness and checking of the insertion site (Hallam et al., 2018). These lead to an increased risk of the patient developing an infection. To improve the care offered, nurses should not be overworked, and there should be a good mix of nurse-to-patient levels (Buetti et al., 2021). Eliminating unsafe nursing practices is not only about policies and procedures it also covers having enough staff to cover a shift. With a higher level of nurse staff handling CVCs, infection risks will be reduced, and patient outcomes will improve. However, with a reduced workforce, even if the hospital maintains its most experienced staff, their chances of making mistakes increases with burnout (Ohtake et al., 2018).

Hospital policies should ensure that only experienced nurses are allowed to handle CVCs. These nurses can be guided to offer training to the less experienced to ensure they too can begin managing CVCs. Only trained personnel should be allowed to handle any central intravenous catheters. This includes accessing the catheter, checking for infection, changing medication, drawing blood, and changing the dressing. Experienced and trained staff will have the capability to properly handle the catheter taking care not to infect the patient (Lopes Pires et al., 2021). Since the nurses are experienced, they can quickly tell when an infection starts to develop, allowing for prompt action to be taken early. Changing the dressing will be done in a sanitary manner to prevent infection, and the nurse knows how to perform the change.

Nurse Training and Education

Nurses charged with looking after patients with CVCs should have undergone proper training on inserting and managing a catheter properly. The training is vital as it allows nurses to gain experience dealing with patients who have a catheter under the watchful eyes of an experienced nurse (Myatra, 2019). Training is essential for preventing infection since the nurse will be taking extra precautions, and they will know the impact of infection on the patient. Extra care is always taken when dealing with CVC patients because they are susceptible to infection (Turan et al., 2018). Therefore, nurses should be taken for continuous training on new innovations and strategies that have been developed. Hospital policy should also demand that only certain nurses handle patients with CVCs. To reduce the chance that an inexperienced nurse is given the task of handling a patient with a CVC and they have no experience with such cases, implementing a hospital policy that mandates only experienced nurses to handle such patients will prevent avoidable risks from being taken. Inexperienced nurses can refuse to undertake such roles and demand that only those with proper training handle the patient (Buetti et al., 2021; Lopes Pires et al., 2021).