Literature review of CVL
Introduction
The management of the sick with serious disease like cancer requires a stable central venous access to be used for a variety of treatment that includes antibiotic and blood samples or product. It also allows the resuscitation of fluid, hemodialysis and parenteral nutrition and cytotoxic chemotherapy to access blood-stream so that medical professionals can observe and microbial culturing of the patient. In addition, it is used to monitor the pressure of central venous. The importance of educating the patient was emphasized too so as to avoid keeping the patients in darkness and not knowing what is happening to them health wise. It is the right of patients to know how they are fairing. The training intended for new registered nurses so that they can be conversant with the various central venous lines used at the hospital. Types of VCL include the following; PICC lines, Hickman, skin-tunneled central venous (STCV) and Groshong catheter, subcutaneous port, totally implantable venous access system (TIVAS). Central venous line enables intra-venous (IV) access for the duration of 2-21 days and even years depending with how critical the patient might be.
Central venous access devices (CVAD) are usually inserted to main veins with the help of a radiological guidance; some varieties are also directed under the skin, e.g., STCV. Most of the CVADs may be made using silicone or polyuethane having 1-3 lumens with different colors. According to United States of America CDC, close to six million patients requires CVL per year most of whom are in critical condition and will be treated at the ICU. CVAD is very useful in treating a patient, but they need total concentration, sober mind and understanding of the tools for it to function effectively. However, if not used as per the guidelines, then it can cause more harm than gain because of the CRBSI that can lead to death. Thus, new registered nurses must be trained on how to use so as to save the life of the patient.
Literature Review
CVAD are divided into the following major categories namely; Long-term, short-term depending on the duration it last on the patient’s body (Wildgruber et al., 2014). Temporary catheters are always placed at the bedside using the femoral vein. While subclavian or internal jugular and among the three, femoral have been found to have the highest number of infection and may only be used if the rest two are not an option. According to Lorente et al. (2011), the research done shows that femoral vein insertion site has a higher incidence rate of infection than subclavian insertion. Moreover, statistics shows these rates are 10.1 in femoral and 3.9 in subclavian respectively in 1000 days of catheter on patients. Research also found that there is there is a lower rate of thrombosis formation in subclavian than femoral, i.e. 1.8% to 21.1% respectively. Thus, quite a number of guidelines recommend avoiding the use of femoral insertion; it also shows that the rate of catheter related bloodstream infection to prevent is higher with tracheostomy presence than without in subclavian sites.
However, it was further found that the presence of the tracheostomy in jugular sites has a higher infection compared to femoral insertion sites. There are no recommendations guidelines and comparisons of relative data on the infection between subclavian and femoral venous catheter areas with the use of tracheotomy in response to these circumstances. Therefore, the research above deduces that clinicians should use subclavian insertion that has fewer risks of infection while attending to patients at the hospital as it is considered safer vascular access. This is because there will be fewer number of deaths cause by the same thrombosis and another health care associated infection (HAIs) like pneumonia caused by the presence of microorganisms on the site.
According to U.S CDC, Long-term catheter devices are available with two to three lumen and have different colors. These catheters are mostly placed at the radiology suite or operating room under strict sterile techniques available so as to prevent any infection (Scales, 2010). PICC lines are peripherally inserted and is referred as central catheter because the ends at the central circulation and the uses ranges from intermediate up to long term for infusions and blood draws. In united states only, close to 6 million CVC are used at the hospital setting every year ranging from short to long term CVL devices. The results also show that with 2 million reported infections per annum, 100,000 deaths occur yearly hence the necessity of medical improvement at the health care facilities is vital to reduce the loss of life.
There are three common types of complications associated with CVC, namely; thrombotic, mechanical and infectious (Kaur, Mathai & Abraham, 2012). Complete or partial thrombotic occlusion occurs in 3% to 39% due to the use of the catheter, while complications of mechanical such as hematoma, arterial puncturing accidental and pneumothorax is 6% to 20%. Lastly, infectious incidences either complete or partial is at the rate of 6% to 27% and remains the most severe complication since it remains accompanied with 13% to 26% mortality rate. Apart from the cost of the patient in terms of complications and discomfort of having an infection, the financial expenses to the hospice are $30000 to $60000 for each catheter-related bloodstream infection.
Catheter migration is caused as the organisms grow at the inside part of the catheter. While a BSI related to CVC occurs as the same organism is in both blood culture without any specialized source in the body and the segment of the catheter. An infection caused at the outlet site can take place when the area is occupied by bacteria that which move along the outer surface of the catheter. The site becomes soft, and the perulent removal within two centimeters of outlet position and bacteria contamination can also originate from the catheter hub. However, accessing the lumen when the disinfecting the hub properly then bacteria on the same hub can transmit to lumen and generate a place for bacteria to inhabit on catheter. There is a vital relationship between thrombosis and infection because when the former occurs, it provides a suitable place for the later to develop
There are some natural ways of interventions that may be used by clinicians to reduce the rate of bloodstream infections on patients at the hospital setup. The two primary interventions are; targeted utilization, evidence-based catheter placing practices. CDC established the said greatest methods after years of research and the report released in the year 2001 initiate a group of practices known as IHI bundle. The reason being CDC worked in collaboration with Institute for Health Improvement (IHI). The other intervention is an educational model that focuses on the best practices for every staff on maintenance and insertion of the catheter so as to lower the rate of CRBSI (Sacks, 2014). Most of the health care facilities are experiencing a decrease on the rate of infection globally after implementing these models. Central Line Bundle (CLB) refers to a group of evidence-based interventions on patients with catheters and that when implemented together, the outcome are much better than when implemented individually. Care bundles refer to groupings the best practices in relation to disease procedures that can improve care individually, but it resulted to a substantially greater improvement when both applied. Components of Central Line Bundle includes; Hand hygiene, optimum barrier safety measure after insertion, chlorhexidine skin antisepsis (Klieger et al., 2013). Also correct selection of the catheter site, and lastly reviewing of catheter line on a daily basis and removing unnecessary line.
After reviewing all the articles and researched done, analyzed and found the best evidenced based nursing problem that the CRBSI occur due to the lack of training for new RNs at the hospital. Since the problem is globally, the analysis includes those from developing countries with limited resource fulfilling the following conditions; (a) Applying methods and definitions of US CDC, NHSN and Nosocomial infection surveillance system. (b) Monitor patients at ICU. (c) Accessed medical sepsis of BSIs and also quite a lot of CRBSI. (d) Perform surveillance studies and identify extra rate of mortality and BSIs. (e) Evaluate the impacts of BSIs. All the experimental research done at the hospital ICU centers by different groups are also included in this profound study.
Results
Data extraction and analysis were done with the help of a computer software initially programmed; the CRBSI rate was analyzed. Ninety-six percent confidence intervals (CI) were tabulated, compared and calculated several rates between studies. The study was randomized and analyzed independently since it was done according to the definition of CDC and NHSN. The rate of CRBSI, extra mortality and impacts of interventions due to the infection also met the definition mentioned earlier.
Discussion
The review and research sufficiently show the variability in the mortality and the incidence resulting from CRBSIs in the developing countries and ranged from16 to 45 percent of cases per 1000 catheter days at intensive care unit. Some factors can give details of the various rates, with the variability on critical care practices and contagion control, differences in patient population and the methods used for collecting data with the infection of CRBSI. However, this rates are because these countries lack organizational structure in healthcare compared with the facilities available hence a higher number of infections due inadequate methods of surveillance (Rosenthal et al., 2011). To reduce the frequency of infections n these countries, the healthcare management and the country as a whole should focus on educating the RNs, feedback on infection rates and complying with infection control measures. In USA where the same services and resources are available, the rate of infection was lower since the clinicians had all the necessities to reduce the infections on patients at ICU and non-ICU setup.
Finally, the difference in the nurse to patient ratio is alarming such that clinicians treated more patient with limited time. Hence, it becomes contributing factor of higher BSIs at the ICU, thus, the proposal to the government to train and employ more RNs (Burling, 2010). According to studies and research, it was found that the frequency of mortality is high with patient with CRBSI compared to the patient without the infection. Thus, it is important for all the medical professionals to ensure that these infection is reduced by implementing the safety measures and guidelines while treating a patient. According to Burden et al. (2012), the measures include; addressing hand hygiene by lectures and posters. Avoiding femoral insertion, improving catheter placement by using right barrier precaution and applying a system where catheter is removes as soon as possible. In addition, chlorhexidine with disinfectant used for skin antisepsis has to be considered and work in a practical manner and implementing best practice. Proper procedures must be followed any time while performing catheter insertion so as to provide good results in the end. Teamwork is also an important factor in that all the team members at the intensive care unit mus coordinate the work done to avoid misunderstanding. Therefore, the supervisor must ensure that all these consideration put in place before beginning task.
Conclusion
In conclusion, United States of America, catheter-related bloodstream infections (CRBSI) has remained the most serious and dangerous complication of central venous line and number one in causing of nosocomial infection at the intensive care unit. A combination of several measures must be used at the heath care facility so as to prevent CRBSI. The most vital is the use of a checklist so as to guide maintenance and insertion of the catheter; thorough training and educating new RNs in the management of central venous line and vascular access. In addition, clinicians must use sterile barrier as a precaution when inserting a catheter, adequate nurse to patient ratio, cleaning of hands using alcohol-based solution and hand-rub before and after handling any intra-venous line. When nurses use chlorhexidine solution for antisepsis of skin, performing subclavian vein anytime possible and by removing the catheter at the right time and by a qualified RN will also assist in reducing catheter-related bloodstream infection.
Moreover, use of CVC coated with antimicrobial should only be reserved for intensive care unit where the prevalence of CRBSI is high even though the recommended guidelines and standards adhered. Even though the new RNs will be adequately trained to use CVL access catheter, competent medical professionals must be there to assess them. The qualified medical practitioners will be there to ensure that the registered nurses do the right thing as with any other tools or devices. The same done until they become competent enough in adhering to infection deterrence measures and using central venous catheters. Lastly, etiquette is also an important factor in the prevention of CRBSI because the fingernails can be a place where microorganisms are transferred to the entry point which is an area around the insertion point.
Recommendation
There have been intervening years to ensure that the health care is done in a professional way of using CVL. The reason being to reduce the number of patient’s catheter-related bloodstream infection (Walz, Memtsoudis & Heard, 2010). This update has come up with a witness to several numbers of approaches, technologies and practices that have eliminated and controlled the vascular access infection at the healthcare intensive care unit. Understanding the best guidelines in accessing and addressing the central venous line complexity of behavior and culture are important too so that new RNs know the approach used.
Reference
Burden, A. R., Torjman, M. C., Dy, G. E., Jaffe, J. D., Littman, J. J., Nawar, F., & Reboli, A. C. (2012). Prevention of central venous catheter-related bloodstream infections: is it time to add simulation training to the prevention bundle? Journal Of Clinical Anesthesia, 24(7), 555-560. doi:10.1016/j.jclinane.2012.04.006
Burling, S. (2010). Study: Lower nurse-to-patient ratio would save lives in some states. Philadelphia Inquirer, The (PA).
Kaur, R., Mathai, A. S., & Abraham, J. (2012). Mechanical and infectious complications of central venous catheterizations in a tertiary-level intensive care unit in northern India. Indian Journal Of Anaesthesia, 56(4), 376-381. doi:10.4103/0019-5049.100823
Klieger, S. B., Potter-Bynoe, G., Quach, C., Sandora, T. J., & Coffin, S. E. (2013). Beyond the bundle: a survey of central line-associated bloodstream infection prevention practices used in US and Canadian pediatric hospitals. Infection Control And Hospital Epidemiology: The Official Journal Of The Society Of Hospital Epidemiologists Of America, 34(11), 1208-1210. doi:10.1086/673447
Lorente, L., Jiménez, A., Martín, M. M., Palmero, S., Jiménez, J. J., & Mora, M. L. (2011). Lower incidence of catheter-related bloodstream infection in subclavian venous access in the presence of tracheostomy than in femoral venous access: prospective observational study. Clinical Microbiology And Infection: The Official Publication Of The European Society Of Clinical Microbiology And Infectious Diseases, 17(6), 870-872. doi:10.1111/j.1469-0691.2010.03406.x
Rosenthal, V. D., Udwadia, F. E., Muñoz, H. J., Erben, N., Higuera, F., Abidi, K., & Graves, N. (2011). Time-dependent analysis of extra length of stay and mortality due to ventilator- associated pneumonia in intensive-care units of ten limited-resources countries: findings of the international nosocomial infection control consortium (INICC). Epidemiology And Infection, 139(11), 1757-1763. doi:10.1017/S0950268811000094
Sacks, G. D., Diggs, B. S., Hadjizacharia, P., Green, D., Salim, A., & Malinoski, D. J. (2014). Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit using the Institute for Healthcare Improvement central line bundle. American Journal Of Surgery, 207(6), 817-823. doi:10.1016/j.amjsurg.2013.08.041
Scales, K. (2010). Central venous access devices: Part 2 For intermediate and long-term use. British Journal Of Nursing, (suppl), S20-S25.
Walz, J. M., Memtsoudis, S. G., & Heard, S. O. (2010). Prevention of central venous catheter bloodstream infections. Journal Of Intensive Care Medicine, 25(3), 131-138. doi:10.1177/0885066609358952
Wildgruber, M., Borgmeyer, S., Haller, B., Jansen, H., Gaa, J., Kiechle, M., & Berger, H. (2014). Short-term and long-term outcome of radiological-guided insertion of central venous access port devices implanted at the forearm: a retrospective monocenter analysis in 1704 patients. European Radiology.
