Estimates show that, in the U.S., about 41,000 cases of central line-associated bloodstream infections (CLABSIs) occur in hospitals each year (CDC, 2014). CLABSI is a preventable complication that lengthens the hospital stay and increases the cost of care. It is a cause of patients’ lost productivity and undue suffering. Since 2008, the Center for Medicare and Medicaid (CMS) has also refused to reimburse CLABSI-related care. The negative implications for the patient and the organization call for prevention using evidence-based practice (EBP).
Accessing the hub of peripherally inserted central catheters (PICCs) is a common source of infection (Moureau, 2010). This paper is an inquiry as to the best practice in disinfecting PICCs prior to access. Specifically, the clinical question is stated as, “Is cleansing the PICC hub with chlorhexidine more effective in preventing infections in central lines than cleaning with alcohol?” A literature search limited as much as possible to nursing research databases was conducted to retrieve the most relevant and best evidences generated within the last five years. A critical appraisal of the literature followed after which the evidences were synthesized and integrated. The aim was to generate recommendations for practice.
Appraisal and Synthesis of the Evidence
Smith (2010) describes a case study of the CLABSI prevention practices in dialysis care provided by an academic medical center. The prevention practices were part of a continuous quality improvement (QI) effort led by a multidisciplinary team. The team conducts periodic literature reviews on central venous access practices with the aim of creating policies to standardize care. The performance measure monitored was catheter infection rates. Hub care involved a 30-second scrub done twice using a 70% alcohol pad prior to access. The facility saw sustained improvements in catheter infection rates when they employed this practice in conjunction with evidence-based interventions that included dressing changes, skin preparation, sterile barrier precautions, and use of needleless systems.
Simmons, Bryson & Porter (2011) used an innovative experimental model to test the effectiveness of different durations of 70% alcohol scrubbing in reducing bacterial colony counts. Central catheter hubs were inoculated with bacteria and scrubbed with alcohol for 3, 10, and 15-second durations. The lines were flushed and samples were taken for bacterial culture. There were no significant differences in the colony counts based on duration of scrubbing. However, the use of alcohol scrubs for whichever duration was more effective compared to controls. Similar to the case study by Smith (2010), it did not employ a comparison with chlorhexidine.
A literature review on the bundling of care for patients with central venous catheters was performed by Miller-Hoover & Small (2009). One systematic review included in this review recommended the use of 2% chlorhexidine for antisepsis of the central line as part of the care bundle. The said review accessed only one database and only one researcher appraised the evidence. The bundle was aimed to be a set of practices for the prevention of CLABSI. Bundling was determined to be more effective in reducing CLABSI rates compared to implementing fragmented prevention practices. Another review conducted by Frasca, Dahyot-Fizelier (2010) validates the above recommendation for using chlorhexidine in hub decontamination.
Meanwhile, a multidisciplinary working group recently updated the CDC comprehensive, national guideline for CLABSI prevention. In the area of hub disinfection, the use of either >0.5% chlorhexidine, 70% alcohol, 10% povidone iodine, or iodophor for scrubbing is appropriate in reducing the risk of contamination (O’Grady et al., 2011). The results meant there was inadequate evidence of the superiority of one solution as compared to others. Based on a synthesis of the study results, the evidence was designated Category IA which meant that the recommendation was strongly supported by high quality clinical, experimental, or epidemiologic studies (O’Grady et al., 2011). Category IA corresponds to a strong recommendation for implementation.
The lack of studies comparing the effectiveness of chlorhexidine to alcohol in disinfecting catheter hubs is validated by the articles reviewed for this paper. In searching the databases, most comparisons between these two disinfectants concerned skin antisepsis before central catheter insertion or during dressing changes. Some studies included comparisons with povidone iodine and chlorhexidine. To a lesser extent, other comparisons related to disinfection of catheter connectors, tubing, and caps. There were no comparative studies focused solely on PICCs. In addition, the trend in research for the past five years was that of employing multiple strategies in the prevention of CLABSI wherein the catheter hub care is only one component. With regard to effectiveness in disinfection, experimental models rather than actual patients are also increasingly being used presumably to promote patient safety. However, this outcome is not a direct measure of prevention where direct measures are CLABSI incidence or rate.
Integration of the Evidences
Quantitative studies within the last five years focusing on central catheter hub disinfection show that both chlorhexidine and alcohol are effective cleansing agents for use in central catheter hub care. Performance measures, i.e. CLABSI incidence or rate and bacterial colony counts, support this conclusion. There is no ideal scrubbing duration when alcohol is used. Methodologies varied from an experimental model, quality improvement case study, systematic review for guideline development, and descriptive literature review. Further research is needed to establish which agent is the most effective in CLABSI prevention.
Practice Decision
Hospitals can use either 70% alcohol for up to 15 seconds of scrubbing or >0.5% chlorhexidine when cleansing PICC hubs prior to access. However, alcohol is more cost-effective (Scales, 2011) and is an important consideration when there are limitations in facility resources. Evidence-based central catheter hub care should be part of a multimodal quality improvement initiative and not implemented as a sole preventive intervention for CLABSI. The reason is that CLABSI is a complex problem influenced by the patient, clinical practices, and organizational factors.
References
Center for Disease Control and Prevention (2014). Central line-associated bloodstream infection (CLABSI) event. Retrieved from http://www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf
Frasca, D., Dahyot-Fizelier, C., & Mimoz, O. (2010. Prevention of central venous catheter- related infection in the intensive care unit. Critical Care, 14(212), 1-8. Retrieved from http://ccforum.com/content/14/2/212
Miller-Hoover, S.R., & Small, L. (2009). Research evidence review and appraisal: Pediatric central venous catheter care bundling. Pediatric Nursing, 35(3), 191-201. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/19681380
Moureau, N.L. (2010). Keeping needleless connectors clean, part 1. Nursing 2014, 40(5), 18-19. doi: 10.1097/01.NURSE.0000371119.85145.99.
O’Grady, N.P., Alexander, M., Burns, L.A., Dellinger, E.P., Garland, J., Heard, S.O., Healthcare Infection Control Practices Advisory Committee (2011). Guidelines for the prevention of intravascular catheter-related infections. Clinical Infectious Diseases, 52(1), e162-e193. doi: 10.1093/cid/cir257.
Scales, K. (2011). Reducing infection associated with central venous access devices. Nursing Standard, 25(36), 49-56. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21702355
Simmons, S., Bryson, C., & Porter, S. (2011). “Scrub the Hub” cleaning duration and reduction in bacterial load on central venous catheters. Critical Care Nursing Quarterly, 34(1), 31-35. doi: 10.1097/CNQ.0b013e3182048073.
Smith, N.C. (2010). Prevention of hemodialysis central line-associated bloodstream infections in acutely ill individuals. Nephrology Nursing Journal, 37(5), 523-529. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20973306
