Central Line Bundle Prevention of Catheter-Related Infections

Objectives Upon completion of this self-paced, the participant should be able to apply the knowledge towards the reduction and prevention of catheter-related bloodstream infections and central line infections. Participant should have knowledge on implementing all five components of care called the “central line bundle”. Participant should have knowledge of each of the five components of care in the central line bundle.

Main Menu Section 1: Introduction Section 2: Pathogenesis Section 3: Central Line Bundle Section 4: Hand Hygiene Section 5: Maximal Barrier Protection Section 6: Skin Antisepsis Section 7: Site Selection Section 8: Daily Review of Central Line Necessity Section 9: Impregnated Catheters Section 10: Replacement of Catheters Section 11: Catheter Site Dressings

Introduction (Section 1) Intravascular catheters are indispensable in modern-day medical practice, particularly in intensive care units (ICUs). Although such catheters provide necessary vascular access, their use puts patients at risk for local and systemic infectious complications, including local site infection, CRBSI (Catheter related blood stream infection), septic thrombophlebitis, endocarditis, and other metastatic infections (e.g., lung abscess, brain abscess, osteomyelitis, and endophthalmitis). Peripheral venous catheters are the devices most frequently used for vascular access. Although the incidence of local or bloodstream infections (BSIs) associated with peripheral venous catheters is usually low, serious infectious complications produce considerable annual morbidity because of the frequency with which such catheters are used. However, the majority of serious catheter-related infections are associated with central venous catheters (CVCs). A total of 250,000 cases of CVC-associated BSIs (CRBSI)have been estimated to occur annually. In this case, attributable mortality is an estimated 12%--25% for each infection, and the marginal cost to the health-care system is $25,000 per episode. Types of organisms that most commonly cause hospital-acquired BSIs are coagulase-negative staphylococci, followed by Staphylococcus aureus, enterococci, Candida spp and gram-negative bacilli.

Pathogenesis (Section 2) Migration of skin organisms at the insertion site into the cutaneous catheter tract with colonization of the catheter tip is the most common route of infection for peripherally inserted, short-term catheters. The adherence properties of a given microorganism also are important in the pathogenesis of catheter- related infection. For example, S. aureus can adhere to host proteins (e.g., fibronectin) commonly present on catheters. Coagulase-negative staphylococci adhere to polymer surfaces more readily than do other pathogens. Certain strains produce an extracellular polysaccharide often referred to as "slime“. In the presence of catheters, this slime potentiates the pathogenicity of coagulase-negative staphylococci by allowing them to withstand host defense mechanisms (e.g., acting as a barrier to engulfment and killing by polymorphonuclear leukocytes) or by making them less susceptible to antimicrobial agents (e.g., forming a matrix that binds antimicrobials before their contact with the organism cell wall). Candida spp., in the presence of glucose-containing fluids, might produce slime similar to that of their bacterial counterparts, potentially explaining the increased proportion of BSIs caused by fungal pathogens among patients receiving parenteral nutrition fluids.

Central Line Bundle (Section 3) Central Line Bundle: Care bundles, in general, are groupings of best practices with respect to a disease process that individually improve care, but when applied together result in substantially greater improvement. The Central Line (CL) bundle is a group of evidence – based interventions for patients with intravascular central catheters that, when implemented together, result in better outcomes than when implemented individually. Five Key Components: 1.Hand Hygiene 2.Maximal barrier precautions 3.Chlorhexidine skin antisepsis 4.Optimal catheter site selection, with subclavian vein as the preferred site for non-tunneled catheters 5.Daily review of line necessity, with prompt removal of unnecessary lines Compliance: Compliance with the central line bundle is measured by assessing completion of each item. A composite compliance is calculated based on the number of bundle components implemented per line placed divided by the total number of bundle components. The approach is most successful when all components are executed together.

Hand Hygiene (Section 4) Hand Hygiene and Aseptic Technique –For short peripheral catheters, good hand hygiene before catheter insertion or maintenance, combined with proper aseptic technique during catheter manipulation, provides protection against infection. Gloves are required by the Occupational Safety and Health Administration as standard precautions for the prevention of bloodborne pathogen exposure. Use of gloves does not obviate the need for hand hygiene. –Observe proper hand-hygiene procedures either by washing hands with conventional antiseptic-containing soap and water or with waterless alcohol- based gels or foams. – Appropriate times for hand hygiene include: Before and after palpating insertion sites Before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter When hands are obviously soiled or contaminated Before and after invasive procedures Between patients Before donning and after removing gloves After using the bathroom

Maximal Barrier Precaution (Section 5) Aseptic Technique during catheter insertion: Maximal sterile barrier precautions during the insertion of CVCs substantially reduces the incidence of Catheter Related Blood Stream Infections (CRBSI) and local site infections. For operator placing the central line and for those assisting in the procedure, maximal barrier precautions means strict compliance with hand hygiene and wearing: cap – should cover all hair mask – should cover nose and mouth tightly sterile gown sterile gloves –Patient must be covered head to toe with a large sterile full body drape, with a small opening for the site of insertion When adherence to aseptic technique cannot be ensured (i.e., when catheters are inserted during a medical emergency), replace all catheters as soon as possible and not to exceed 48 hours.

Skin Antisepsis (Section 6) Skin Antisepsis – Chlorhexidine gluconate (CHG): preparation of central venous and arterial sites with a 2% chlorhexidine gluconate (CHG) has been proven to provide better skin antisepsis than other antiseptic agents such as povidone-iodine solutions. –Cutaneous antisepsis 1. Prepare skin with antiseptic/detergent chlorhexidine 2% in 70% alcohol 2.Pinch wings on the chlorhexidine applicator to break open the ampule. Hold the applicator down to allow the solution to saturate the pad. 3.Press sponge against skin, apply chlorhexidine solution using a back-and-forth friction scrub for at least 30 seconds. Do not wipe or blot 4.Allow antiseptic solution time to dry completely before puncturing the site (  2 minutes) Do not routinely use arterial or venous cutdown procedures as a method to insert catheters. Providone-iodine or 70% alcohol may be used with chlorhexidine sensitive patients Chlorhexidine is contraindicated for procedures involving the meninges and on children less than 2 months.

Site Selection (Section 7) Optimal Site Selection –Subclavian vein site, when not contraindicated, is the preferred site of non-tunneled catheters in adults to reduce the risk for infection. –Weigh the risk and benefits of placing a catheter at a recommended site to reduce infectious complications against the risk for mechanical complications (e.g., pneumothorax, subclavian artery puncture, subclavian vein laceration, subclavian vein stenosis, hemothorax, thrombosis, air embolism, and catheter misplacement). –Phlebitis has long been recognized as a risk for infection. For adults, lower extremity insertion sites are associated with a higher risk for infection than are upper extremity sites. In addition, hand veins have a lower risk for phlebitis than do veins on the wrist or upper arm. –The density of skin flora at the catheter insertion site is a major risk factor for CRBSI. Catheters inserted into an internal jugular vein have been associated with higher risk for infection than those inserted into a subclavian. –Femoral catheters have been demonstrated to have relatively high colonization rates when used in adults. Femoral catheters should be avoided, when possible, because they are associated with a higher risk for deep venous thrombosis than are internal jugular or subclavian catheters and because of a presumption that such catheters are more likely to become infected.

Daily Review of Central Line Necessity (Section 8) Prompt removal of unnecessary lines: Daily review of central line necessity will prevent unnecessary delays in removing lines that are no longer needed. Many times, central lines remain in place simply because they provide reliable access and because personnel have not considered removing them. However, it is clear that the risk of infection increased over time as the line remains in place and that the risk of infection decreases if the line is removed. Daily review of line necessity should be included as part of multi-disciplinary rounds. Assessment for removal of central lines should be included as part of the patient’s daily goal sheets Date and time of line placement should be recorded for record keeping purposes and evaluation by staff to aid in decision making.

Impregnated Catheters (Section 9) Antimicrobial/Antiseptic Impregnated Catheters and Cuffs: Certain catheters and cuffs that are coated or impregnated with antimicrobial or antiseptic agents can decrease the risk for CRBSI and potentially decrease hospital costs associated with treating CRBSIs, despite the additional acquisition cost of an antimicrobial/antiseptic impregnated catheter. Chlorhexidine/Silver sulfadiazine: Catheters coated with chlorhexidine/silver sulfadiazine only on the external luminal surface have been studied as a means to reduce CRBSI. The benefit for the patients who receive these catheters will be realized within the first 14 days. IV injection ports : –Clean injection ports with 70% alcohol or an iodophor before accessing the system. –Cap all stopcocks when not in use.

Replacement of Catheters (Section 10) Selection and replacement of intravascular catheters –Replace all catheters inserted during a medical emergency or when adherence to aseptic technique cannot be ensured. –Use clinical judgment to determine when to replace a catheter that could be a source of infection (e.g., do not routinely replace catheters in patients whose only indication of infection is fever). –Select the catheter, insertion technique, and insertion site with the lowest risk for complications (infectious and noninfectious) for the anticipated type and duration of IV therapy

Catheter-Site Dressings (Section 11) Catheter-site dressing regimens Replace the catheter-site dressing when it becomes damp, loosened, soiled or when inspection of the site is necessary Use either sterile gauze or sterile transparent, semi-permeable dressing to cover the catheter site Change dressings at least weekly for adult and adolescent patients depending on the circumstances of the individual patient Do not use topical antibiotic ointment or creams on insertion sites (except when using dialysis catheters) because of their potential to promote fungal infections and antimicrobial resistance

Test Question #1 1.A total of 250, 000 cases of CVC-associated BSIs (CRBSI) have been estimated to occur annually. What is the estimated attributable mortality for each infection, and the marginal cost to the health-care system per episode? Completion of the entire composite bundle a.12-25% per infection and $25,000 per episode b.25-35% per infection and $25,000 per episode c.12-25% per infection and $50,000 per episode

Introduction (Section 1) Intravascular catheters are indispensable in modern-day medical practice, particularly in intensive care units (ICUs). Although such catheters provide necessary vascular access, their use puts patients at risk for local and systemic infectious complications, including local site infection, CRBSI (Catheter related blood stream infection), septic thrombophlebitis, endocarditis, and other metastatic infections (e.g., lung abscess, brain abscess, osteomyelitis, and endophthalmitis). Peripheral venous catheters are the devices most frequently used for vascular access. Although the incidence of local or bloodstream infections (BSIs) associated with peripheral venous catheters is usually low, serious infectious complications produce considerable annual morbidity because of the frequency with which such catheters are used. However, the majority of serious catheter-related infections are associated with central venous catheters (CVCs). A total of 250,000 cases of CVC-associated BSIs (CRBSI)have been estimated to occur annually. In this case, attributable mortality is an estimated 12%--25% for each infection, and the marginal cost to the health-care system is $25,000 per episode. Types of organisms that most commonly cause hospital-acquired BSIs are coagulase-negative staphylococci, followed by Staphylococcus aureus, enterococci, Candida spp and gram-negative bacilli.

Test Question #2 2.Micro-organisms that can produce an extracellular polysaccharide often referred to as “slime” that can adhere to the polymer surface of catheters is: a.Coagulase negative staphylococci b.Staphylococcus aureus c.Escherichia coli

Pathogenesis (Section 2) Migration of skin organisms at the insertion site into the cutaneous catheter tract with colonization of the catheter tip is the most common route of infection for peripherally inserted, short-term catheters. The adherence properties of a given microorganism also are important in the pathogenesis of catheter- related infection. For example, S. aureus can adhere to host proteins (e.g., fibronectin) commonly present on catheters. Coagulase-negative staphylococci adhere to polymer surfaces more readily than do other pathogens. Certain strains produce an extracellular polysaccharide often referred to as "slime“. In the presence of catheters, this slime potentiates the pathogenicity of coagulase-negative staphylococci by allowing them to withstand host defense mechanisms (e.g., acting as a barrier to engulfment and killing by polymorphonuclear leukocytes) or by making them less susceptible to antimicrobial agents (e.g., forming a matrix that binds antimicrobials before their contact with the organism cell wall). Candida spp., in the presence of glucose-containing fluids, might produce slime similar to that of their bacterial counterparts, potentially explaining the increased proportion of BSIs caused by fungal pathogens among patients receiving parenteral nutrition fluids.

Test Question #3 3.Maximal barrier precautions for the operator placing the central line and for those assisting in the procedure include: a.Cap (should cover all hair), mask (should cover nose and mouth tightly), sterile gloves b.Cap (should cover all hair), mask (should cover nose and mouth tightly), sterile gown c.Cap (should cover all hair), mask (should cover nose and mouth tightly), sterile gown, sterile gloves

Maximal Barrier Precaution (Section 5) Aseptic Technique during catheter insertion: Maximal sterile barrier precautions during the insertion of CVCs substantially reduces the incidence of Catheter Related Blood Stream Infections (CRBSI) and local site infections. For operator placing the central line and for those assisting in the procedure, maximal barrier precautions means strict compliance with hand hygiene and wearing: cap – should cover all hair mask – should cover nose and mouth tightly sterile gown sterile gloves –Patient must be covered head to toe with a large sterile full body drape, with a small opening for the site of insertion When adherence to aseptic technique cannot be ensured (i.e., when catheters are inserted during a medical emergency), replace all catheters as soon as possible and not to exceed 48 hours.

Test Question #4 4.Five key components of the Central Line bundle are a.Hand Hygiene, gowns, chlorhexidine skin antisepsis, optimal catheter site, and daily review of line necessity b.Hand Hygiene, maximal barrier precautions, chlorhexidine skin antisepsis, optimal catheter site, and daily review of line necessity c.Hand Hygiene, maximal barrier precautions, chlorhexidine skin antisepsis, jugular vein site, and daily review of line necessity

Central Line Bundle (Section 3) Central Line Bundle: Care bundles, in general, are groupings of best practices with respect to a disease process that individually improve care, but when applied together result in substantially greater improvement. The Central Line (CL) bundle is a group of evidence –based interventions for patients with intravascular central catheters that, when implemented together, result in better outcomes than when implemented individually. Five Key Components: 1.Hand Hygiene 2.Maximal barrier precautions 3.Chlorhexidine skin antisepsis 4.Optimal catheter site selection, with subclavian vein as the preferred site for non-tunneled catheters 5.Daily review of line necessity, with prompt removal of unnecessary lines Compliance: Compliance with the central line bundle is measured by assessing completion of each item. A composite compliance is calculated based on the number of bundle components implemented per line placed divided by the total number of bundle components. The approach is most successful when all components are executed together.

Test Question #5 1.When having a central line inserted, the patient must be covered head to toe with: a.A large sterile full body drape, with a small opening for the site of insertion b.A small sterile drape, with a small opening for the site of insertion c.A sterile half drape

Maximal Barrier Precaution (Section 5) Aseptic Technique during catheter insertion: Maximal sterile barrier precautions during the insertion of CVCs substantially reduces the incidence of Catheter Related Blood Stream Infections (CRBSI) and local site infections. For operator placing the central line and for those assisting in the procedure, maximal barrier precautions means strict compliance with hand hygiene and wearing: cap – should cover all hair mask – should cover nose and mouth tightly sterile gown sterile gloves –Patient must be covered head to toe with a large sterile full body drape, with a small opening for the site of insertion When adherence to aseptic technique cannot be ensured (i.e., when catheters are inserted during a medical emergency), replace all catheters as soon as possible and not to exceed 48 hours.

Test Question #6 6.Prior to inserting a central venous or arterial catheter, the best product to antiseptically clean the site is: a.Providone-iodine b.2% chlorhexidine gluconate (CHG) c.70% alcohol

Skin Antisepsis (Section 6) Skin Antisepsis – Chlorhexidine gluconate (CHG): preparation of central venous and arterial sites with a 2% chlorhexidine gluconate (CHG) has been proven to provide better skin antisepsis than other antiseptic agents such as povidone-iodine solutions. –Cutaneous antisepsis 1. Prepare skin with antiseptic/detergent chlorhexidine 2% in 70% alcohol 2.Pinch wings on the chlorhexidine applicator to break open the ampule. Hold the applicator down to allow the solution to saturate the pad. 3.Press sponge against skin, apply chlorhexidine solution using a back-and-forth friction scrub for at least 30 seconds. Do not wipe or blot 4.Allow antiseptic solution time to dry completely before puncturing the site (  2 minutes) Do not routinely use arterial or venous cutdown procedures as a method to insert catheters. Providone-iodine or 70% alcohol may be used with chlorhexidine sensitive patients

Test Question #7 7.The preferred site of non-tunneled catheters in adults to reduce the risk for infection is: a.Femoral vein b.Internal jugular c.Sub-clavian

Site Selection (Section 7) Optimal Site Selection – Subclavian vein site, when not contraindicated, is the preferred site of non-tunneled catheters in adults to reduce the risk for infection. –Weigh the risk and benefits of placing a catheter at a recommended site to reduce infectious complications against the risk for mechanical complications (e.g., pneumothorax, subclavian artery puncture, subclavian vein laceration, subclavian vein stenosis, hemothorax, thrombosis, air embolism, and catheter misplacement). –Phlebitis has long been recognized as a risk for infection. For adults, lower extremity insertion sites are associated with a higher risk for infection than are upper extremity sites. In addition, hand veins have a lower risk for phlebitis than do veins on the wrist or upper arm. –The density of skin flora at the catheter insertion site is a major risk factor for CRBSI. Catheters inserted into an internal jugular vein have been associated with higher risk for infection than those inserted into a subclavian or femoral vein. –Femoral catheters have been demonstrated to have relatively high colonization rates when used in adults. Femoral catheters should be avoided, when possible, because they are associated with a higher risk for deep venous thrombosis than are internal jugular or subclavian catheters and because of a presumption that such catheters are more likely to become infected.

Test Question #8 1.In order to prevent unnecessary delays in removing lines that are no longer needed and reduce the risk of infection, central lines should be reviewed for necessity: a.Daily b.Weekly c.At shift change

Daily Review of Central Line Necessity (Section 8) Prompt removal of unnecessary lines: Daily review of central line necessity will prevent unnecessary delays in removing lines that are no longer needed. Many times, central lines remain in place simply because they provide reliable access and because personnel have not considered removing them. However, it is clear that the risk of infection increased over time as the line remains in place and that the risk of infection decreases if the line is removed. Daily review of line necessity should be included as part of multi- disciplinary rounds. Assessment for removal of central lines should be included as part of the patient’s daily goal sheets Date and time of line placement should be recorded for record keeping purposes and evaluation by staff to aid in decision making.

Test Question #9 9.Compliance with the central line bundle is measured by assessing: a.Completion of each item b.Completion of the number of bundle components implemented per line placed divided by the total number of bundle components c.Completion of each item and completion of the number of bundle components implemented per line placed divided by the total number of bundle components

Central Line Bundle (Section 3) Central Line Bundle: Care bundles, in general, are groupings of best practices with respect to a disease process that individually improve care, but when applied together result in substantially greater improvement. The Central Line (CL) bundle is a group of evidence –based interventions for patients with intravascular central catheters that, when implemented together, result in better outcomes than when implemented individually. Five Key Components: 1.Hand Hygiene 2.Maximal barrier precautions 3.Chlorhexidine skin antisepsis 4.Optimal catheter site selection, with subclavian vein as the preferred site for non-tunneled catheters 5.Daily review of line necessity, with prompt removal of unnecessary lines Compliance: Compliance with the central line bundle is measured by assessing completion of each item. A composite compliance is calculated based on the number of bundle components implemented per line placed divided by the total number of bundle components. The approach is most successful when all components are executed together.

Test Question #10 10.Catheters inserted during a medical emergency or when adherence to aseptic technique cannot be ensured should be: a.Replaced when convenient b.Replaced as soon as possible and not to exceed 48 hours c.Removed when no longer needed

Maximal Barrier Precaution (Section 5) Aseptic Technique during catheter insertion: Maximal sterile barrier precautions during the insertion of CVCs substantially reduces the incidence of Catheter Related Blood Stream Infections (CRBSI) and local site infections. For operator placing the central line and for those assisting in the procedure, maximal barrier precautions means strict compliance with hand hygiene and wearing: cap – should cover all hair mask – should cover nose and mouth tightly sterile gown sterile gloves –Patient must be covered head to toe with a large sterile full body drape, with a small opening for the site of insertion When adherence to aseptic technique cannot be ensured (i.e., when catheters are inserted during a medical emergency), replace all catheters as soon as possible and not to exceed 48 hours.

Additional Resources References: Information for this SLP is from – Guidelines for the Prevention of Intravascular Catheter- Related Infections, CDC MMWR, April 9, 2002, 51(RR10);1-26 – Institute for Healthcare Institute 100,000 Lives campaign

Give us your feedback We hope you have found this tutorial useful. Feel free to call Infection Control with any questions you have. –Susan Ray, M.D. (404) –Mary Cole, R.N. (404) We appreciate the use of this educational module and thank: Carondelet Health Network for allowing us to adapt their work for our use Thank you!

Reminder Please remember to submit completed test to Medical Staff Services at