Central venous catheter-related bloodstream infections: improving post-insertion catheter care

https://doi.org/10.1016/j.jhin.2008.09.016Get rights and content

Summary

Patients with central venous catheters (CVCs) are at increased risk of bloodstream infections and sepsis-related death. CVC-related bloodstream infections (CRBSIs) are costly and account for a significant proportion of hospital-acquired infections. The aim of this audit was to assess current practice and staff knowledge of CVC post-insertion care and therefore identify aspects of CVC care with potential for improvement. We conducted a prospective audit over 28 consecutive days at a university teaching hospital investigating current practice of CVC post-insertion care in wards with high CVC usage. A multiple choice questionnaire on best practice of CVC insertion and care was distributed among clinical staff. Rates of breaches in catheter care and CRBSIs were calculated and statistical significance assumed when P < 0.05. Data was recorded from 151 CVCs in 106 patients giving a total of 721 catheter days. In all, 323 breaches in care were identified giving a failure rate of 44.8%, with significant differences between intensive care unit (ICU) and non-ICU wards (P < 0.001). Dressings (not intact) and caps and taps (incorrectly placed) were identified as the major lapses in CVC care with 158 and 156 breaches per 1000 catheter days, respectively. During the study period four CRBSIs were identified, producing a CRBSI rate of 5.5 per 1000 catheter days (95% confidence interval: 0.12–10.97). There are several opportunities to improve CVC post-insertion care. Future interventions to improve reliability of care should focus on implementing best practice rather than further education.

Introduction

Central venous catheters (CVCs) are vascular infusion devices used for monitoring haemodynamic variables, renal replacement therapy and the administration of medication. The invasive nature of indwelling intravascular catheters predisposes the patient to a host of possible complications. Such complications can arise from the individual characteristics of each patient (e.g. difficulty in accessing subclavian or internal jugular veins) and may include mechanical complications (e.g. pneumothorax, haematoma, and arterial puncture), thrombotic and infectious complications.1, 2, 3, 4, 5

Healthcare-associated infection is a major cause of morbidity and mortality.6 Patients with CVCs are at markedly increased risk of bloodstream infections and sepsis-related death.7 It is estimated that up to 6000 patients in England per year may acquire a catheter-related bloodstream infection (CRBSI).8 Treatment costs of such infections are estimated to exceed £6000 per infection.9

The National Audit Office (NAO) report in 2000 on the control of hospital-acquired infection highlighted the need for improved education, training and audit of compliance with infection control guidelines.10 The National Institute for Clinical Excellence issued guidelines in 2003 for the prevention of healthcare-associated infection.11 Best practice in the use of CVCs incorporates the use of maximal sterile barrier precautions during catheter placement; highest standards of hand hygiene; 2% chlorhexidine gluconate for skin antisepsis; regular inspection of CVC insertion sites (dressings); documentation of CVC insertion and removal dates; maintaining closed systems (caps and taps closed); removal of CVCs if signs of infection are present and saline flushing of catheter lumens.

The aim of this study was to audit current standards of practice in CVC maintenance in high-use wards of a university teaching hospital, assess knowledge of standards of CVC care amongst staff in high-use wards and therefore identify aspects of CVC care with the potential for improvement.

Section snippets

Study setting and design

The study took place during one month in 2007 at the Queen Elizabeth Hosptial, a tertiary referral hospital in Birmingham. Clinical areas with the greatest use of CVCs were identified using hospital data on numbers of CVCs purchased.

A prospective audit of current standards of CVC care was undertaken in these high-use clinical areas. Staff knowledge of standards of best practice in CVC care was assessed in the same areas over the same period using a questionnaire.

Catheter care

The standard of post-insertion

Results

We identified five wards in our hospital with high CVC use: two general surgical wards with designated four-bedded post-operative areas (Surg 1 and Surg 2), an acute renal care ward (Renal) with six high-care beds, a specialised hepatobiliary unit with a nine bed high-dependency unit (HDU), and a general intensive care unit (ICU) with 16 available beds. We assumed that the annual hospital usage of CVCs correlated with the number of CVCs ordered, which was 3839 (3346 quad-lumen CVCs, and 493

Catheter care

The failure rate of 44.8% demonstrates very low reliability of CVC post-insertion care. Significantly lower breach rates were recorded in the ICU compared with other wards. Reasons for this difference may include: (i) the 1:1 ICU nurse-to-patient ratio facilitates optimal care; (ii) greater volume of CVC use in the ICU with more experience and confidence in CVC care; (iii) ICU staff are more aware of the need for rigorous infection control. Similar breach rates regardless of duration of CVC

References (20)

There are more references available in the full text version of this article.

Cited by (48)

  • Implementing a central venous catheter self-management education program for patients with cancer

    2016, European Journal of Oncology Nursing
    Citation Excerpt :

    We used a 20-item questionnaire, with each item having three possible answers (“I do not know,” true,” or “false”), to assess knowledge of CVC self-management. Because no valid and reliable instrument exists, we had to construct the self-reported questionnaire for this study, based on the content of the CVC management guidelines (Galloway, 2010; Shapey et al., 2009). The questionnaire comprises six subdomains: (i) function and structure of CVC (2 items), (ii) aseptic technique (6 items), (iii) assessment of insertion site (1 item), (iv) dressing (3 items), (v) heparinization and heparin storage (3 items), and (vi) complication prevention (5 items).

  • Catheter-related bloodstream infection: Burden of disease in a tertiary hospital

    2014, Journal of Hospital Infection
    Citation Excerpt :

    To the authors' knowledge, this is the first study to obtain data on the annual burden of disease of catheter-related bloodstream infections in a tertiary hospital, covering all hospital settings, and including short- and long-term catheters. A low level of compliance with some recommendations was observed during insertion or maintenance of catheters in the study hospital, in agreement with other studies.25 This suggests that in addition to the promotion of clear and updated clinical guidelines, there is a need for continuing staff education and periodic checks to assess gaps in practice and establish improvements.

  • Using a combined nursing and medical approach to reduce the incidence of central line associated bacteraemia in a New Zealand critical care unit: A clinical audit

    2013, Intensive and Critical Care Nursing
    Citation Excerpt :

    Critical care patients frequently require central lines (CLs) for haemodynamic monitoring, administering inotropes and intravenous nutrition (Shapey et al., 2009).

View all citing articles on Scopus

Previously presented at the Intensive Care Society State of the Art Meeting, London, December 2007.

View full text