Central venous catheter-related bloodstream infections: improving post-insertion catheter care☆
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.
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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
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Previously presented at the Intensive Care Society State of the Art Meeting, London, December 2007.