Abstract
According to the Centers for Disease Control and Prevention, central line-associated bloodstream infections lead to the deaths of thousands of people every year in the United States. These infections actually represent about 10% of all hospital-acquired infections translating to about 71, 900 infections per year in US hospitals. Also, this condition adds billions of dollars to the total health care system costs. However, these infections are actually preventable. This paper analyzes literature related to this topic and tries to establish the best method for solving the problem of central line-associated bloodstream infections. The paper suggests the standardization of central line care elements through the adoption of central line bundles that consist of clear evidence-based protocols for carrying out central line. This solution is likely to lead to significance decrease in the risk and the rates of central line associated bloodstream infections. Several peer-reviewed articles will be used to support this suggestion.
A central line-associated bloodstream infection refers to a bloodstream infection that is laboratory confirmed, and that occurs in a patient who has had a central line in the past 48 hours. The central line-associated bloodstream infections are usually abbreviated as CLABSIs, and they occur when germs enter the bloodstream through the central line. As mentioned, these infections are preventable and recently, there has been a significant reduction in the prevalence of these infections in US hospitals. However, CLABSIs still present a major health problem, and they need to be eliminated completely. Significant research has been conducted on this area, and various recommendations have been given on how the problem of central line-associated bloodstream infections can be solved. An analysis of this research indicates that perhaps the best solution to this problem is essentially the standardization of central line care elements through the adoption of central line bundles that consist of clear evidence-based protocols for carrying out central line. This means that hospitals across the country will adopt the same central line best care elements that are evidence-based, and this will lead to a decline in these infections.
The standardization of central line care elements is, in fact, a solution that has been studied on, and its efficacy has been proven. Schulman et al., (2011) conducted a study of about 18 regional referral NICUs in the state of New York that had adopted central line insertion as well as maintenance bundles. The authors wanted to find out if this adoption of standardized bundles as well as the use of central line maintenance checklists had reduced the central line-associated bloodstream infections. The authors analyzed two periods, the pre-intervention period and the post-intervention period. The total study included more than 200 000 patient days and 55 000 central line days (Schulman et al., 2011). The authors found that the rates of CLABSI decreased by 67% statewide (Schulman et al., 2011). This, therefore, shows that the standardization of central line care elements can actually lead to the reduction of CLABSIs. It also shows that lack of standardization could actually be one of the primary factors that leads to high rates of these infections. Some hospital or care centers may have in place central line care elements that are not evidence based or that are not effective. When these care elements are standardized, it can result in the formulation of high-quality care elements that provide the best results. Standardization can involve the formulation of entirely new guidelines or using the ones that have already been proposed by experts or credible medical organizations and regulatory bodies.
Marschall et al. (2014) have authored a set of standardized guidelines on behalf of The Society for Healthcare Epidemiology of America that can be adopted by hospitals nationwide and therefore be used to prevent central line-associated bloodstream infections. These guidelines relate to several steps in the process of giving patients central line. For example, before insertion, hospitals should ensure that the health care personnel involved in the insertion, the care and the maintenance of central venous catheters are properly educated on general infection prevention strategies (Marschall et al., 2014). At insertion, a standard guideline is to put in place a process that ensures adherence to infection prevention practices including adherence to aseptic techniques. These should, for example, be documented and checklists should be provided to ensure that there is optimal insertion practices (Marschall et al., 2014). The other standard guideline is performing hand hygiene prior to catheter insertion or catheter manipulation, for example using antiseptic soap and water or alcohol-based waterless products. An all-inclusive catheter kit or cart should also be used (Marschall et al., 2014). Another recommendable standard guideline is the use of ultrasound guidance when performing internal jugular catheter infection. There should also be maximum sterile barrier precautions when inserting the CVCs. There are also other standard guidelines for post-insertion that can be adopted. For example, the catheter tubs, injection pots, and needles should be disinfected before the catheter can be accessed (Marschall et al., 2014). For CVCs that are non-tunneled, transparent dressings should be changed and site care performed with a chlorhexidine-based antiseptic every 5 to 7 days or immediately if the particular dressing is loose, damp or has been soiled (Marschall et al., 2014). Administration sets should also be used for lipid or blood products at intervals no longer than four days. Also, antimicrobial ointments should be used for hemodialysis catheter insertion sites (Marschall et al., 2014).
These are just some evidence-based practices for the prevention as well as the monitoring of CLABSIs. These practices encompass various care elements and if these practices are adopted, it means that the elements of care will be standardized, then there is likely to be a reduction in central line-associated bloodstream infections. These practices can be formulated in the form of a central line bundle campaign that essentially refers to a protocol that is put in place to ensure that procedures related to central line are performed using updated evidence-based techniques.
The efficacy of such as central line bundle was also studied by Galpern et al. (2008). They authors collected data on patients in a critical care unit of the New York Methodist Hospital, who had a central venous catheter placed in them. After collection of data for about five months, a multidisciplinary team was assembled, and this team created a central line bundle that was to be used when the placement of central venous catheters was taking place (Galpern et al., 2008). This bundle, for example, included guidelines on hand hygiene, maxima barrier practices, the preparation of the skin using chloro-prep, the use of a central line cart and the avoidance of femoral lines (Galpern et al., 2008). Therefore, after the formulation of this bundle, all insertions of central venous catheters were supposed to follow this bundle. The study continued for 24 months whereby a total of 9,938 central lines drawn from 1,395 central venous catheters were assessed (Galpern et al., 2008). The results showed that the number of CLABSIs after the intervention decreased from 5.0 to 0.90 (P < .001). This study is, therefore, proof that implementing a central line bundle campaign can actually lead to decreased central line-associated blood stream infections (Galpern et al., 2008).
In recent times, there has been increased adoption of central line bundle elements in many intensive care units across the United States although compliance with these bundles is still a matter of concern. Furuya et al., (2011) conducted a study centered on National Healthcare Safety Network (NHSN) hospitals to assess their adoption of central line bundles and the effectiveness of these bundles in preventing CLABSIs. It was found that in 250 hospitals that presented their statistics, the mean CLABSI rate was about 2.1 per 1000 central line days (Furuya et al., 2011). Also, 49% of hospitals reported that they had a written CL bundle in place. However, only about 38% showed high compliance with the bundle. Also, it was shown that when an intensive care unit had a clear policy and high compliance with the CL bundles, CLABSI rates were low. Therefore, Furuya et al., (2011) recommend that central line bundles be implemented in ICUs across the country and in addition, compliance policies should also be put in place.
In another study conducted by Guerin et al., (2008) that focused on the same, the effectiveness of post insertion central line bundles was proven. Here, the bundles encompassed several interventions which included the inspection of the insertion site daily, the performance of site care if the dressing was soiled, wet or had not been changed for one week, hand hygiene performance, alcohol scrub application to the infusion for about fifteen seconds before every entry, among others (Guerin et al., 2008). The study showed that there was a significant reduction of CLABSIs and the general risk for CLABSIs during the after intervention period as compared to before the intervention was 0.19 at a confidence level of 95% and when P= .004 (Guerin et al., 2008).
The same results were shown by Jeong et al., (2013) who also conducted a study on four intensive care units to investigate the effects of central line bundles on CLABSIs rates. The central line bundle in this case encompassed several intervention techniques that included active surveillance as well as personnel training on hand hygiene. A CL insertion checklist with clear guidelines was also provided, and systemic training on the bundle was conducted (Jeong et al., 2013). This training resulted in increased adherence to the CL bundle and in addition, there was significant decrease in the rates of CLABSIs especially among children where the rate went down to 0.0 from 3.7 per 1000 catheter days (P = .014) (Jeong et al., 2013).
Conclusively, it is clear that although central line-associated bloodstream infections cause many deaths yearly and increase the health care cost burden, they are actually preventable. Research seems to indicate that the adoption of a central line bundle which refers to a protocol for ensuring that procedures related to central line are performed using updated evidence-based techniques can lead to a massive reduction in CLABSIs. Hospitals are therefore encouraged to formulate such bundles and also enact compliance policies. These bundles as mentioned should encompass several evidence-based guidelines such as the inspection of the insertion site daily, disinfecting the catheter tubs, injection pots and needles before the catheter can be accessed, the performance of site care if the dressing is soiled, wet, hand hygiene, use of an catheter cart or kit that is all-inclusive, the use of antimicrobial ointments for the hemodialysis catheter insertion sites and so on. This will ensure that the problem of CLABSIs infections is solved.
References
Furuya, E. Y., Dick, A., Perencevich, E. N., Pogorzelska, M., Goldmann, D., & Stone, P. W. (2011). Central line bundle implementation in US intensive care units and impact on bloodstream infections. PloS one, 6(1), e15452.
Galpern, D., Guerrero, A., Tu, A., Fahoum, B., & Wise, L. (2008). Effectiveness of a central line bundle campaign on line-associated infections in the intensive care unit. Surgery, 144(4), 492-495.
Guerin, K., Wagner, J., Rains, K., & Bessesen, M. (2010). Reduction in central line-associated bloodstream infections by implementation of a postinsertion care bundle. American journal of infection control, 38(6), 430-433.
Jeong, I. S., Park, S. M., Lee, J. M., Song, J. Y., & Lee, S. J. (2013). Effect of central line bundle on central line-associated bloodstream infections in intensive care units. American journal of infection control, 41(8), 710-716.
Marschall, J., Mermel, L. A., Fakih, M., Hadaway, L., Kallen, A., O’Grady, N. P. & Yokoe, D. S. (2014). Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infection Control & Hospital Epidemiology, 35(7), 753-771.
Schulman, J., Stricof, R., Stevens, T. P., Horgan, M., Gase, K., Holzman, I. R. & Simmonds, A. (2011). Statewide NICU central-line-associated bloodstream infection rates decline after bundles and checklists. Pediatrics, 127(3), 436-444.
