Hospitals may be winning the fight, but there’s more work to do
Editor’s Note: In the United States, 75 percent of all healthcare-acquired infections are either urinary tract infections, surgical site infections, bloodstream infections or pneumonia, according to The Joint Commission. Experts believe that many of these infections are largely preventable when evidence-based practices are followed consistently over time. Recently a joint “call to action” to move toward the elimination of healthcare-acquired infections was set forth by a number of organizations, including the Centers for Disease Control and Prevention, the Association for Professionals in Infection Control and Epidemiology, the Society for Healthcare Epidemiology of America, and the Infectious Diseases Society of America. Understanding and tackling healthcare-acquired infections is a complex process. Although contracting executives won’t be clinical experts on the topic, they can play an important role in the fight against infections. In Part 1 of a multipart series on infection control topics, the Journal of Healthcare Contracting focuses on central-line-associated bloodstream infections.
Healthcare providers are doing a good job reducing the incidence of central-line-related bloodstream infections. But there’s more work to be done. In fact, the work never really stops. There will always be a need for education, vigilance and, of course, products to support the caregivers on the front lines. But the payoff is better patient care and lower costs.
“The high morbidity and mortality associated with [central-line-associated bloodstream infections], improved understanding of its pathogenesis and preventability, and the growing unwillingness of patients, payers, and patient advocates to look at [healthcare-acquired infections] as an acceptable risk has led to the emergence of a ‘zero tolerance’ mindset – an emphasis that organizations set the goal at eliminating [infections] rather than being comfortable with meeting national or local averages,” wrote The Joint Commission in its recently published, 136-page monograph, “Preventing Central-Line-Associated Bloodstream Infections: A Global Challenge, A Global Perspective.” Employing relatively simple evidence-based practices to reduce, if not eliminate, bloodstream infections appears to be within the reach of even resource-limited settings, says The Joint Commission.
What is a central-line associated bloodstream infection
A “central line” is an intravascular catheter that terminates at or close to the heart or in one of the large vessels that is used for infusion, withdrawal of blood, or hemodynamic monitoring, explains Jason Woodbury, director of IV therapy marketing, ICU Medical, San Clemente, Calif. For example, a Swan-Ganz catheter, with its tip in the right atrium and ventricle of the heart, is a central line, he says. Another type is the peripherally inserted central catheter, or PICC line. It is a long, slender, flexible tube that is inserted into a peripheral vein, typically in the upper arm, and advanced until the catheter tip terminates in a large vein in the chest near the heart to obtain intravenous access, says Woodbury. “It is similar to other central lines in that it terminates in a large vessel near the heart. However, unlike other central lines, its point of entry is from the periphery of the body, that is, the extremities.”
The terminology used to identify different types of catheters can be confusing, because many clinicians and researchers use different aspects of the catheter for informal reference, points out the Centers for Disease Control and Prevention. So, a catheter can be designated by the type of vessel it occupies (e.g., peripheral venous, central venous or arterial); its intended life span (e.g., temporary or short-term vs. permanent or long-term); its site of insertion (e.g., subclavian, femoral, internal jugular, peripheral, and peripherally inserted central catheter); its pathway from skin to vessel (e.g., tunneled vs. non-tunneled); its physical length (e.g., long vs. short); or some special characteristic of the catheter (e.g., presence or absence of a cuff, impregnation with heparin, antibiotics or antiseptics, and the number of lumens).
How infection occurs
Bloodstream infections are laboratory-confirmed infections that are not secondary to a community-acquired infection or a healthcare-acquired infection that occurs at another body site, explains Woodbury. For a bloodstream infection to be considered central-line-associated, a central line or umbilical catheter must have been in place at the time of, or within 48 hours before, the onset of the infection.
The CDC estimates that in intensive care units alone, there are 15 million central-vascular-catheter days – that is, the total number of days of exposure to these catheters among all patients. Given that, it’s no surprise that infection can occur. In fact, The Joint Commission reports that 80,000 central-line-related bloodstream infections occur in ICUs each year, and a total of 250,000 cases of bloodstream infections have been estimated to occur annually, if entire hospitals – not just ICUs – are assessed.
Potential causes of central-line associated bloodstream infections are many, and Woodbury points to three common ones:
- Exit site infections from patient exposure to the environment, caregiver, etc., which may lead to the migration of bacteria into the catheter and ultimately, into the bloodstream.
- Intraluminal bacterial migration from a contaminated catheter hub (that is, the end of the central venous catheter that connects to the blood lines or cap).
- Bacterial growth in biofilm on the surface of the catheter walls.
Why it’s important to stop them
Efforts to track, report, and prevent bloodstream infections have improved in recent years. As part of its “National Action Plan to Prevent Healthcare-Associated Infections,” the U.S. Department of Health and Human Services set a goal of reducing central line-associated bloodstream infections by 50 percent by 2013. Starting in 2011, hospitals throughout the country were required to track and report central-line-associated bloodstream infections in intensive care units in order to get an annual 2 percent Medicare payment increase.
Much progress has already been made. CDC reports a 58 percent decrease in central-line bloodstream infections among ICU patients in 2009, compared to 2001. In 2009 alone, reducing these infections saved about 3,000 to 6,000 lives and about $414 million in medical costs, compared with 2001. However, infections still occur in healthcare settings, and diligent prevention efforts must continue. CDC reports that in 2009, there were 23,000 central-line bloodstream infections in non-ICU inpatient wards, which supports the ongoing concern that the majority of such infections are occurring outside ICUs. And the CDC estimates that, in 2008 alone, 37,000 bloodstream infections occurred among patients receiving outpatient hemodialysis.
Caregivers regularly monitor catheter sites (through visual and tactile inspection) for signs of infection. If the nurse or staff member suspects an infection, they order lab tests. To be laboratory-confirmed, a central-line-associated bloodstream infection must meet one of the following criteria, says Woodbury:
- The patient has a recognized pathogen cultured from one or more blood cultures, and the organism cultured from blood is not related to an infection at another site.
- The patient has at least one of the following signs or symptoms: fever (>38C), chills, or hypotension; and signs, symptoms and positive laboratory results are not related to an infection at another site. In addition, common commensal is cultured from two or more blood cultures drawn on separate occasions.
- A patient under one year of age has at least one of the following signs or symptoms: fever (>38C core), hypothermia (0.5 percent prior to insertion.
- Avoiding routine central venous catheter replacement.
- Use of short-term central venous catheters and sponge dressings that contain antiseptics and antibiotics if infection rates do not decrease.
Infection control is key to preventing bloodstream infections. In its “Action Plan,” HHS identified the following infection control interventions:
- Determine the efficacy and unintended consequences (e.g., shift in pathogens causing central-line-associated bloodstream infections) of daily chlorhexidine bathing.
- Determine optimal strategies for catheter insertion, such as the role of IV therapy teams.
- Determine optimal use of antimicrobial-impregnated catheters.
- Develop strategies to limit biofilms as a means of preventing device-associated infections.
- Facilitate investigation into the optimal strategies for catheter maintenance, including: type of dressing (e.g. chlorhexidine vs. standard); use of antiseptics for cleaning catheter hubs; efficacy and optimal use of antimicrobial lock solutions, including unintended consequences of their use; optimal method of skin antisepsis for maintenance or insertion of catheters; and impact of the use of needleless connectors on bloodstream infection rates.
- Identify how to assure that catheters are promptly removed when no longer clinically necessary.
- Identify optimal catheter care in non-hospitalized patients.
As it is in all aspects of patient care, hand hygiene is crucial in the fight against central-line-associated bloodstream infections.
“Hand hygiene is generally accepted as the single most important measure in preventing the spread of infection,” says The Joint Commission in its monograph. “Both soap and water and alcohol-based hand rub products can be used to achieve proper hand hygiene. It is essential that healthcare personnel be knowledgeable of the recommended practices for hand hygiene and that they consistently adhere to them. Health care organizations need to integrate hand hygiene into routine procedures and have strong systems in place to support, monitor, and promote the correct behavior.”
CDC guidelines recommend that caregivers practice proven hand-hygiene techniques before and after palpating the site of catheter insertion; inserting the catheter; and accessing, replacing, repairing, or dressing the catheter.
Caregivers must take care to practice aseptic technique when preparing the central venous catheter for insertion, says The Joint Commission. “Healthcare personnel should be attentive to maximal sterile barrier precautions, skin preparation, catheter selection, and use of catheter kits or carts. Maximal sterile barrier precautions require the [central venous catheter] inserter to wear a mask and cap, a sterile gown, and sterile gloves and to use a large (head-to-toe) sterile drape over the patient during the placement of a [central venous catheter] or exchange of a catheter over a guidewire.”
Reducing colonization of skin microorganisms at the insertion site is a critical component in preventing central-line-associated infections. Over the past 20 years, several studies have tried to determine the best antiseptic for skin cleansing before insertion and during manipulation of the central venous catheter, says The Joint Commission. While iodophors (for example, povidone-iodine, tincture of iodine) have been frequently used in the United States, a number of studies have shown that chlorhexidine gluconate preparations are superior to both iodophors and alcohol for skin antisepsis.
Chlorhexidine – which is also commonly used as the cleansing solution on a surgical site before incisions – has been found to kill the microorganisms that cause bloodstream infections more effectively than other cleansing compounds, says Woodbury. Bathing a patient daily in chlorhexidine is thought to keep organisms down.
The following summarizes The Joint Commission’s recommendations for skin antisepsis prior to insertion of the central venous catheter and during dressing changes:
- Apply antiseptics to clean skin.
- Apply chlorhexidine/alcohol in a concentration greater than 0.5 percent in alcohol.
- If there is a contraindication to chlorhexidine, apply tincture of iodine, an iodophor or alcohol as an alternative.
- Allow the antiseptic solution to dry before placing the catheter.
Recent investigations have demonstrated that adherence to recommended catheter insertion practices are usually followed by a dramatic reduction in infection rates, according to HHS.
The Joint Commission summarizes the evidence-based recommendations concerning catheter site dressing regimens:
- Use a sterile gauze or sterile, transparent semipermeable dressing to cover the insertion site.
- Use a gauze dressing if the patient is diaphoretic or if the site is oozing.
- Replace the dressing if it becomes damp, loosened, or visibly soiled.
- Replace gauze dressings every two days.
- Replace semipermeable dressings every seven days, except with pediatric patients, for whom the risk of dislodgement may outweigh the benefit of changing the dressing.
Securing the central venous catheter to stabilize and minimize mechanical trauma at the catheter entry site is believed to reduce phlebitis, reduce movement or dislodging of the catheter, and help prevent central-line-associated bloodstream infections by decreasing the level of bacterial colonization at the site. The Centers for Disease Control and Prevention recommends using a sutureless securement device to reduce the risk of intravascular device–related infection, reports The Joint Commission. One reason is that suturing the catheter to the skin disrupts the skin around the catheter site, which can lead to inflammation and increased levels of colonization. Using a sutureless device also eliminates the risk of sharps injury to healthcare personnel.
When to replace the catheter?
Knowing when – and when not to – replace catheters on the patient is crucial. “Prompt removal of central venous catheters is of paramount importance,” says Woodbury. “If there is no conduit to your bloodstream, the risk of [central-line-associated bloodstream infection] goes down.”
Among the CDC’s recommendations regarding replacement of central venous catheters, including PICCs and hemodialysis catheters, are these two:
- Do not routinely replace central venous catheters, PICCs, hemodialysis catheters, or pulmonary artery catheters.
- Do not remove central venous catheters or PICCs on the basis of fever alone. Use clinical judgment regarding the appropriateness of removing the catheter if infection is evidenced elsewhere or if a noninfectious cause of fever is suspected.
According to the CDC, there is no need to routinely replace peripheral catheters more frequently than every 72 to 96 hours. Midline catheters and peripheral catheters in children should only be replaced when clinically indicated.
CDC also recommends that the caregiver use new sterile gloves when handling a new catheter when guidewire exchanges are performed.
Administration sets should be replaced no more frequently than 72 to 96 hours after initiation of use, says CDC. Recent studies suggest that administration sets may be used safely for up to seven days if used in conjunction with antiseptic catheters or if fluids that enhance microbial growth (e.g., parenteral nutrition or blood) have not been used. When a fluid that enhances microbial growth is infused (e.g., fat emulsions and blood products), more frequent changes of administration sets are indicated, as these products have been identified as independent risk factors for central-line-associated bloodstream infections.
Needleless components should be changed at least as frequently as the administration set, says CDC. But there is no benefit to changing them more frequently than every 72 hours. Similarly, needleless connectors shouldn’t be changed more frequently than every 72 hours or according to manufacturers’ recommendations for the purpose of reducing infection rates.
Providers should ensure that all components of the needleless system are compatible to minimize leaks and breaks in the system. They can also minimize contamination risk by scrubbing the access port with an appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70 percent alcohol), and accessing the port only with sterile devices.
Supply chain professionals should outfit standardized supply carts or kits with all the necessary supplies and equipment for central line catheter insertion and maintenance, recommends The Joint Commission. “It is essential that the carts or kits are always stocked and readily accessible. Procedures should be established for used carts to be switched out in a timely manner for newly cleaned and stocked carts.”
More product considerations
Some central venous catheters and cuffs are coated or impregnated with antimicrobials (for example, minocycline/rifampin) or antiseptics (for example, chlorhexidine/silver sulfadiazine) to prevent colonization and hence, bloodstream infections. “Evidence-based guidelines strongly support the use of antimicrobial- or antiseptic-impregnated catheters if [central-line-associated bloodstream infection] rates are not decreasing after the implementation of a comprehensive strategy to reduce those rates,” says The Joint Commission.
While these catheters and cuffs may cost more, they can decrease costs associated with treating bloodstream infections, says CDC. “The decision to use chlorhexidine/silver sulfadiazine- or minocycline/rifampin-impregnated catheters should be based on the need to enhance prevention of [central-line-associated bloodstream infections] after bundled standard procedures have been implemented (e.g., educating personnel, using maximal sterile barrier precautions, and using >0.5 percent chlorhexidine preparation with alcohol for skin antisepsis) and then balanced against the concern for emergence of resistant pathogens and the cost of implementing this strategy.”
Clinicians have many more issues to consider in their fight against central-line-associated bloodstream infections, including antibiotic prophylaxis, anticoagulants, etc. But faced with a mountain of research and evidence-based recommendations, making the right decisions isn’t always easy.
“To evaluate evidence-based practices, healthcare personnel must have both the ability and time to interpret evidence appropriately, using critical thinking skills to effectively evaluate clinical research findings,” says The Joint Commission. “Compounding this challenge, research findings can have mixed or even conflicting results.”
Clinical practice guidelines, developed by groups of experts, can make the clinician’s job easier. But studies show that even when presented with such guidelines, healthcare personnel don’t necessarily adhere to them. In fact, adherence to clinical practice guidelines has been estimated to vary anywhere between 20 percent and 100 percent, according to The Joint Commission.
Experts have developed programs to overcome barriers to adherence to clinical practice guidelines, reports The Joint Commission. One such program has five steps:
- Assemble an interdisciplinary team, composed of front-line workers, administrators, and quality improvement staff.
- Identify barriers by observing staff attempting to use the [clinical practice guideline] and by talking with staff about their agreement with the guideline or their suggestions to improve adherence to it.
- Summarize the barriers in writing, as collected by several members of the interdisciplinary team.
- Prioritize the barriers, based on the likelihood of actually experiencing each barrier and the probability that the barrier would lead to non-adherence.
- Develop an action plan for each targeted barrier that includes a leader, predetermined dates to monitor progress, and the measures most appropriate for each action.
“Zero bloodstream infections is certainly a goal for most, if not all, providers,” says Woodbury. And it’s a realistic one. “Some facilities have maintained zero for long periods of time,” he says.
For further information
Few if any contracting executives will become experts on the complex topic of central-line-associated bloodstream infections. However, Journal of Healthcare Contracting readers can learn about some of the issues and some of the terminology by reviewing these fairly easy-to-read, comprehensive on-line resources.
- Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011,” Centers for Disease Control and Prevention, http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf.
- “Preventing Central-Line-Associated Bloodstream Infections: A Global Challenge, A Global Perspective,” The Joint Commission, http://www.jointcommission.org/assets/1/18/CLABSI_Monograph.pdf
- “National Action Plan to Prevent Healthcare-Associated Infections: Roadmap to Elimination,” U.S. Department of Health and Human Services, http://www.hhs.gov/ash/initiatives/hai/infection.html