Reducing CVC-Related Infection Risks After Insertion

Introduction to CVC Infections and Prevention Bundles

Multiple-lumen central venous catheters (CVCs) are used to administer large amounts of intravenous fluids, blood products, and medications. In the past, they were used only in the intensive care unit; however, they are now used in all areas of health care. CVCs are inserted through a large central vein such as the subclavian vein and terminate at the junction of the superior vena cava and right atrium. In some cases, the catheter is inserted through the femoral vein and terminates in the inferior vena cava, though this is not recommended due to the increased risk of infection. Catheters terminate in large veins where rapid blood flow around the catheter tip allows fluids and medications to be quickly diluted and moved into the patient's circulation. The location and rapid bloodstream access of CVCs increase the risk of developing catheter-related bloodstream infections, also known as central line-associated bloodstream infections (CLABSIs).

Böll et al. (2021) indicate that the risks of using central lines are significant: they are a major risk factor for bloodstream infection, are associated with a 2.27-fold increased mortality risk, and drive up health care costs (Frasca et al., 2010). CLABSI 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 CLABSIs are preventable through evidence-based strategies available to health care professionals (Böll et al., 2021; Gupta et al., 2021). When compared to other healthcare-associated infections (HAIs), CLABSIs account for the highest number of preventable deaths. Best practice implementation could save between 5,000 and 20,000 lives annually (Taylor et al., 2015). To assist in reducing and preventing CVC infections, the Institute for Healthcare Improvement (IHI) developed a care bundle for healthcare professionals. A care bundle is a set of evidence-based measures that, when implemented together, produce better outcomes and a more significant impact than implementing individual measures alone (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 the femoral vein in adults); and daily review of central line necessity with prompt removal of unnecessary lines.

Hand Hygiene

Hand hygiene is the most convenient and cost-effective strategy for preventing CLABSIs. 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 or 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 that nurses keep their hands clean and do not transfer infections between patients. By using meticulous hand hygiene technique, nurses can decrease the risks of CVC-related bloodstream infections. Myatra (2019) posits that before nurses perform CVC care, they should ensure they have washed their hands using either a waterless alcohol-based product or antibacterial soap and water. A waterless alcohol-based product is sufficient if the nurse's hands are not visibly soiled and they have not been in contact with another patient. However, washing with soap and water is recommended to ensure the hands are thoroughly clean. Hand hygiene should be performed before any CVC care (Jacob & Gaynes, 2019).

There is a considerable risk of acquiring an infection during CVC insertion and maintenance care (Taylor et al., 2015). Proper hand hygiene assists in reducing the number of bacteria that come into contact with the catheter, thereby reducing the patient's risk of developing an infection. Nurses working in high-acuity environments should be educated on the importance of hand hygiene when handling or caring for a catheter. Nurses are charged with various tasks—changing medications, drawing blood, and changing dressings—and in each of these instances, the chance of bacterial infection increases with every contact with the catheter. Therefore, proper education and quality improvement programs should be implemented across health care facilities. An educational intervention in catheter care will significantly improve patient outcomes (Ling et al., 2016), and a simulation-based training program will be especially valuable for educating 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 both alcoholic and aqueous solutions. Chlorhexidine has been shown through numerous studies to be more effective than povidone-iodine (Frasca et al., 2010). Given its superior rate of infection prevention, it is recommended that chlorhexidine be used instead of povidone-iodine prior to catheter insertion. Cleaning the skin aims to remove microorganisms at the insertion site and to clean the site during dressing changes (Silva & da Cruz, 2018).

Nurses are responsible for inserting catheters and changing their dressings and should therefore be provided with the most effective antiseptic available. The use of chlorhexidine depends on hospital policy, and nurses can advocate for its inclusion if the policy currently recommends povidone-iodine. Demonstrating its efficacy using evidence-based strategies will inform hospital administrators and make it easier to implement the change. With a 50% reduction in catheter-related bloodstream infection compared to povidone-iodine, building a case for the change is straightforward. Cleaning the patient's skin before catheter insertion is vital because it ensures the site is free of microorganisms that could migrate from the skin into the vein (Saliba et al., 2018). Because the catheter will pierce the skin, inadequate antiseptic preparation can result in infection at the time of insertion. The recommended cleaning strategy is to clean the area using an alcohol-based solution with a back-and-forth motion for approximately 30 seconds (Biehl et al., 2018). The area should then be left to air dry before catheter insertion (Silva & da Cruz, 2018).

Conclusion

Catheter-related bloodstream infection is one of the most common complications of central venous access and is a leading cause of nosocomial infection. It is preventable when nurses follow established guidelines and adhere to hospital policies and procedures. The post-insertion period is the most critical time for CVCs, and it is during this period that infection is most likely to occur. Without proper care, the patient can become infected in numerous ways.

The most effective strategies for preventing infection include: performing proper hand hygiene before and after handling a catheter; assessing the insertion area for infection at least once during each nursing shift; thoroughly cleaning and disinfecting the skin prior to catheter insertion; replacing catheter administration sets every 72 hours; conducting daily reviews of catheter necessity; and adequately dressing the insertion area. When followed consistently, these strategies have been shown to reduce and in some cases eliminate infection risks.

Nurses are the health care professionals most likely to interact with the catheter through medication administration, blood drawing, and dressing changes, making them the most likely inadvertent source of catheter-related infection. Therefore, nurses must be well trained in catheter management, and only experienced nurses should be assigned to care for patients with CVCs. Nursing education should place strong emphasis on infection prevention and proper catheter handling to safeguard patient outcomes.