CHAPTER 12. Infection Prevention and Control
Mary McGoldrick, MS, RN, CRNI®∗
Definitions, 204
Immune System and Susceptibility to Infection, 205
Indications of Infection, 206
Prevention of Catheter-Associated Infections, 208
Peripheral Venous Catheter, 211
Central Venous Catheter Infection Prevention Strategies, 211
Additional Infection Prevention Measures, 214
Safe Work and Injection Practices, 215
IV-Related Infections, 216
IV Product and Catheter-Related Contamination, 217
Flushing the Catheter, 219
Endogenous Sources of Microorganisms, 219
Exogenous Sources of Microorganisms, 219
Infection Prevention and Control in the Alternative Care Setting, 220
Surveillance in Infusion Therapy, 221
Definition of a Central Line–Associated Bloodstream Infection, 221
Central Line Insertion Practices’ Adherence Monitoring, 222
Patient and Caregiver Education, 223
Patient Safety, 224
Staff Competencies, 224
Summary, 224
Healthcare–associated infections are 1 of the top 10 leading causes of death in the United States (CDC, 2008b). In American hospitals alone, health care–associated infections account for an estimated 1.7 million infections and 98,987 associated deaths each year. Of these infections, 14% or 30,665 deaths were caused by or associated with a bloodstream infection (Klevins et al, 2007). Hospital-acquired infections are an emerging national issue with many states enacting laws requiring hospitals to publicly report their rates of infections. Given that the cost of care for a patient with a catheter-related bloodstream infection is $45,000 (CDC, 2002b), these infections could cost up to $2.3 billion on an annual basis. On October 1, 2008, as part of the Centers for Medicare & Medicaid Services’ (CMS) Deficit Reduction Act (DRA) of 2005, Medicare reimbursement to hospitals for preventable vascular catheter–related infections will end.
Venous access devices (VADs) are an integral component of providing venous access in the management of patients that are critically and chronically ill, and continue to be used in the inpatient and outpatient settings. However, VADs disrupt the integrity of the skin, making infection with bacteria and/or fungi possible. Infection may spread to the bloodstream (bacteremia), and hemodynamic changes and organ dysfunction (severe sepsis) may ensue, possibly leading to death. Approximately 90% of catheter-associated bloodstream infections occur with central venous catheters (CVCs) (Mermel, 2000). Almost half (48%) of all patients in an intensive care unit (ICU) have central venous catheters, which accounts for approximately 15 million central venous catheter-days per year in ICUs alone. Studies of catheter-related bloodstream infections that control for the underlying severity of illness suggest that attributable mortality for these infections is between 4% and 20%. In addition, healthcare-associated bloodstream infections prolong hospitalization by a mean of 7 days. Estimates of attributable cost per bloodstream infection are between $3700 and $29,000 (Soufir et al, 1999).
DEFINITIONS
To understand the principles of infection prevention and control, it is important to understand some key concepts. The following infection control terms are briefly defined and discussed.
An infection is the transmission of microorganisms into a host after evading or overcoming defense mechanisms, resulting in the organism’s proliferation and invasion within host tissue(s). Host responses to infection may include clinical symptoms or may be subclinical, with manifestations of disease mediated by direct organism pathogenesis and/or a function of cell-mediated or antibody responses that result in the destruction of host tissues (Siegel et al, 2007).
Colonization is the proliferation of microorganisms on or within body sites without a detectable host immune response, cellular damage, or clinical expression. In many instances, the terms colonization and carriage are synonymous. The presence of a microorganism within a host may occur with varying duration, but may become a source of potential transmission (Siegel et al, 2007). Colonization also refers to the persistent presence of microorganisms at a particular site. Certain species of bacteria form colonies on the surface of the skin or in certain regions of the body. For example, the colonization of Escherichia coli is considered normal in the bowels; however, its presence in the bladder is not considered normal and can result in a urinary tract infection. Likewise, Staphylococcus aureus found in the nares or on the epidermal surface of the skin is considered normal; however, its presence in the bloodstream can contribute to bacteremia.
Bacteria entering the blood can cause serious problems called a bloodstream infection or bacteremia. A bacteremia is a bloodstream infection that is identified by a positive blood culture. Bacteremias are commonly classified as primary and secondary. A primary bloodstream infection has no identified underlying source, but is usually associated with the use of IV devices. A secondary bloodstream infection arises from an existing infectious source. This is also called hematogenous seeding from a distant site of infection. Central venous and arterial catheters can be colonized from remote, unrelated sites of infection. Most fungal vascular access infections appear to be the result of hematogenous seeding from another site of infection. An example is a patient with burns or an intraabdominal wound infection being at risk for developing a secondary bloodstream infection. Signs and symptoms of bacteremia include fever, chills, hypotension, and a positive blood culture.
Sepsis, or septicemia, is a systemic infection in the circulating blood caused by pathogenic microorganisms or their toxins. Septicemia can occur when microorganisms migrate into the bloodstream and cause a profound systemic reaction. Intravascular device–related septicemia is often caused by Staphylococci (especially coagulase-negative Staphylococci), Trichophyton beiglii, Corynebacterium species, Candida species, Fusarium species, or Malassezia furfur (Bennet and Brachman, 1998).
Septicemia is a serious, life-threatening infection that gets worse very quickly. Septicemia can begin with spiking fevers, chills, rapid breathing, and rapid heart rate and the person will appear very ill. The symptoms can rapidly progress to shock with decreased body temperature (hypothermia), falling blood pressure, confusion or other changes in mental status, and blood clotting problems that lead to petechiae and ecchymosis. There also may be decreased or no urine output. Septicemia is not common, but when it does occur the effects can be devastating. Septicemia can rapidly lead to adult respiratory distress syndrome (ARDS), septic shock, and death. Septic shock has a high death rate, exceeding 50%, and the outcome depends on the type of organism involved, and how quickly the patient is hospitalized (National Library of Medicine, 2008). Nurses must be aware of the patient’s history, possible risk factors, and the clinical signs and symptoms of septicemia, and implement prompt interventions when septicemia is suspected.
Phlebitis is an inflammation of the vein. Since phlebitis is an inflammatory process and not an infectious process it is addressed in Chapter 23 and Chapter 25, which discuss the complications associated with peripheral and central venous catheters.
IMMUNE SYSTEM AND SUSCEPTIBILITY TO INFECTION
The body’s normal defense system includes the skin; the lining of the nose, mouth, and gastrointestinal tract; and certain blood cells (i.e., leukocytes or white blood cells) that are part of the immune system. All of these systems work to protect the body from microorganisms that cause infections. When a venipuncture is performed, the body’s first line of defense, the skin, is broken, providing a mode of entry for many microorganisms such as fungi, bacteria, and viruses. The immune system, which is a complex network of cells and organs, responds to this invasion of microorganisms.
Leukocytes (white blood cells) are an important component of the immune system. Neutrophils and lymphocytes compose 80% to 90% of the total white blood cell (WBC) count. Granulocytes and monocytes are the foundation of the body’s nonspecific immune response. Neutrophils, referred to as polymorphonuclear leukocytes, are the body’s first line of defense against infection. Segments are mature neutrophils. When infections occur, the bone marrow releases immature neutrophils (sometimes identified as bands) that, together with mature neutrophils, engulf and destroy bacteria. This phenomenon is referred to as a shift to the left. Polymorphonuclear leukocytes can destroy invading bacteria and remain in the peripheral blood for 6 to 10 hours before moving into tissue, performing their function, and dying (Gaynes et al, 1991). Neutrophils are the first cells to appear in large numbers within exudates in the initial inflammation stages.
The next leukocyte in the line of defense is the monocyte cell, also referred to as a macrophage. Neutrophils and monocytes engulf and partially digest, or phagocytize, invading antigens. Monocytes are slower to respond to infections and inflammatory diseases and respond late in the acute phase of infection, but once activated, they are stronger than neutrophils, ingesting larger particles of debris and continue to function during the chronic phase.
Lymphocytes have the ability to recognize specific antigens from any foreign living organism, such as viruses, fungi, and bacteria. An increase in the number of lymphocytes (lymphocytosis) occurs in viral infections. Lymphocytes can be divided into two main subgroups: T cells and B cells. B cells produce immunoglobulins, and T cells are responsible for effector and regulatory functions. Cell-mediated immunity is the responsibility of the effector T cells. This includes defense against intracellular bacterial or fungal infections, cytolysis of virus-infected cells, allograft rejection, graft-versus-host reaction, and certain types of tumor immunity (Gaynes et al, 1991). Regulatory T cells moderate the functions of effector T cells and B cells by inducing or suppressing proliferation and differentiation of these cells.
There are four subsets within the T cell system: (1) helper/inducer T lymphocytes (CD4 cells) induce other T cells, and helper B cells produce antibodies. Interleukin-2 (IL-2), a growth factor produced by T cells, stimulates the proliferation and differentiation of activated T cells. IL-1, a cytokine released by macrophages, stimulates CD4 cells to produce IL-2 (Gaynes et al, 1991); (2) delayed hypersensitivity T lymphocytes produce chemotactic lymphokines in response to particulate and soluble antigens. One of the chemotactic lymphokines macrophage-activating factor, induces membrane alterations that cause clumping and immobilization of cells. This factor, interferon, has several functions, including inhibiting tumor cell growth; (3) cytotoxic T lymphocytes destroy antigen-specific target cells on contact; (4) suppressor T lymphocytes (CD8) consist of three cells—inducer, effector, and transducer—that regulate humoral and cell-mediated responses (Gaynes et al, 1991).
Eosinophils and basophils are other types of WBCs. During allergic reactions and parasitic conditions, as well as after radiation exposure, the number of eosinophils increases. When there is an increase in the levels of steroids, either during periods of stress or when administered parenterally, the number of eosinophils and basophils decreases.
The normal WBC count ranges from 4.1 to 10.9 × 10 9/L (Gaynes et al., 1991 and Jarvis et al., 1991). The WBC differential sorts the WBCs into its different types, and then counts each type and reports the percentage of each type. This information can indicate infectious processes, as well as the patient’s risk for infection. The normal values for a WBC differential are listed in Table 12-1.
| ∗The values listed are for adults and may vary depending on the lab’s reference ranges. | |
| Cell type | Normal range (Cells/mm 3) |
|---|---|
| Granulocytes | |
| Neutrophils (total) | 1.8-7.7 × 10 9/L |
| Eosinophils | 0-0.45 × 10 9/L |
| Basophils | 0-0.1 × 10 9/L |
| Agranular (Mononuclear) | |
| Lymphocytes | 1.0-4.8 × 10 9/L |
| Monocytes | 0-0.8 × 10 9/L |
Neutropenia refers to a decrease in the absolute neutrophil count (ANC). The neutrophil count is an absolute count, which means it is the actual number of neutrophils in a measured amount of blood (cells per microliter [μL]). The ANC is calculated by adding the percentage of neutrophils together with the percentage of bands (if present) and multiplying by the total WBC count percentage. Table 12-2 contains values of absolute neutrophil counts and correlates these values with the patient’s risk for infection.
| Absolute neutrophil count (Cells/μL) | Risk for infection |
|---|---|
| 1500-2000 | No increased risk |
| 1000-1500 | Slightly increased risk |
| 500-1000 | Moderately increased risk |
| Less than 500 | Severely increased risk |
In patients with neutropenia, the risk for infection has been linked to both the magnitude and duration of neutropenia. The depth of neutropenia is the most important factor, with an ANC of less than 500 μL being associated with a substantial risk for infection. The highest risk, however, is an ANC of less than 100 μL. In addition, patients with prolonged neutropenia (i.e., more than 7 days) are at higher risk for infection than patients who recover their granulocyte count in less than 1 week (Friese et al, 2006).
INDICATIONS OF INFECTION
FEVER
Body temperature is maintained within narrow limits by the hypothalamic temperature regulatory center in the brain. Fever (core body temperature elevated above normal) is often a sign of infection. When proper antibiotic therapy and host defenses work together to eradicate an infection, fever usually resolves; body temperature response is therefore a good measure of the effectiveness of antibiotic therapy. Exogenous chemicals, including antimicrobials and other medications, can sometimes cause fever. Concurrent corticosteroids, acetaminophen, aspirin, or other nonsteroidal anti-inflammatory drugs act as antipyretics; they may mask a fever and can complicate the monitoring of antimicrobial therapy.
The idea of using a designated temperature for fever is controversial, especially as many elderly persons have minimal or no temperature increase, and not all health care providers perform routine temperature checks on every patient in the absence of direct indications. However, for surveillance purposes, fever needs to be specified. Therefore fever is present when the patient’s temperature is 2.4° F greater than the baseline temperature. This is important to note since normal temperature in the elderly is usually lower than 98.6° F and an elderly patient can be running a fever at 99.0° F (Association for Professionals in Infection Control and Epidemiology, 2008). The CDC surveillance definitions located in Box 12-1 and Box 12-2 also contain specific fever parameters to be used in surveillance activities based on the patient’s age and care settings.
Box 12-1
CLASSIFICATION OF PRIMARY BLOODSTREAM INFECTIONS
Primary bloodstream infections are classified according to the criteria used, either as laboratory-confirmed bloodstream infection (LCBI) or as clinical sepsis (CSEP).
LABORATORY-CONFIRMED BLOODSTREAM INFECTION (LCBI)
The LCBI criteria 1 and 2 may be used for patients of any age, including patients ≤1 year of age, whereas LCBI criterion 3 may only be used for patients ≤1 year of age. LCBI must meet one of the following three criteria:
Criterion 1:
Patient has a recognized pathogen cultured from one or more blood cultures (i.e., a positive blood culture is when at least one bottle from a blood draw is reported by the laboratory as having grown organisms)
and
organism cultured from blood is not related to an infection at another site. (See notes 1 and 2.)
Criterion 2:
Patient has at least one of the following signs or symptoms: fever (>38° C), chills, or hypotension
and
signs and symptoms and positive laboratory results are not related to an infection at another site
and
common skin contaminant (i.e., diphtheroids [ Corynebacterium spp.], Bacillus [not B. anthracis] spp., Propionibacterium spp., coagulase-negative staphylococci [including S. epidermidis], viridans group streptococci, Aerococcus spp., Micrococcus spp.) is cultured from two or more blood cultures drawn on separate occasions. (See notes 3 and 4.)
Criterion 3:
Patient ≤1 year of age has at least one of the following signs or symptoms: fever (>38° C, rectal), hypothermia (<37° C, rectal), apnea, or bradycardia
and
signs and symptoms and positive laboratory results are not related to an infection at another site
and
common skin contaminant (i.e., diphtheroids [ Corynebacterium spp.], Bacillus [not B. anthracis] spp., Propionibacterium spp., coagulase-negative staphylococci [including S. epidermidis], viridans group streptococci, Aerococcus spp., Micrococcus spp.) is cultured from two or more blood cultures drawn on separate occasions. (See notes 3, 4, and 5.)
Notes:
1. In criterion 1, the phrase “one or more blood cultures” means that at least one bottle from a blood draw is reported by the laboratory as having grown organisms (i.e., a positive blood culture).
2. In criterion 1, the term “recognized pathogen” does not include organisms considered common skin contaminants (see criteria 2 and 3 for a list of common skin contaminants). A few of the recognized pathogens are S. aureus, Enterococcus spp., Escherichia coli, Pseudomonas spp., Klebsiella spp., and Candida spp.
3. In criteria 2 and 3, the phrase “two or more blood cultures drawn on separate occasions” means (1) that blood from at least two blood draws was collected within 2 days of each other (e.g., blood draws on Monday and Tuesday or Monday and Wednesday would be acceptable for blood cultures drawn on separate occasions, but blood draws on Monday and Thursday would be too far apart in time to meet this criterion), and (2) that at least one bottle from each blood draw is reported by the laboratory as having grown the same common skin contaminant organism (i.e., is a positive blood culture). (See note 4 for determining sameness of organisms.)
a. For example, an adult patient has blood drawn at 8 am and again at 8:15 am of the same day. Blood from each blood draw is inoculated into two bottles and incubated (four bottles total). If one bottle from each blood draw set is positive for coagulase-negative staphylococci, this part of the criterion is met.
b. For example, a neonate has blood drawn for culture on Tuesday and again on Saturday and both grow the same common skin contaminant. Because the time between these blood cultures exceeds the 2-day period for blood draws stipulated in criteria 2 and 3, this part of the criteria is not met.
c. A blood culture may consist of a single bottle for a pediatric blood draw because of volume constraints. Therefore to meet this part of the criterion, each bottle from two or more draws would have to be culture-positive for the same skin contaminant.
4. There are several issues to consider when determining sameness of organisms.
a. If the common skin contaminant is identified to the species level from one culture, and a companion culture is identified with only a descriptive name (i.e., to the genus level), then it is assumed that the organisms are the same. The speciated organism should be reported as the infecting pathogen (see examples below).
| Culture | Companion culture | Report as |
|---|---|---|
| S. epidermidis | Coagulase-negative staphylococci | S. epidermidis |
| Bacillus spp. (not anthracis) | B. cereus | B. cereus |
| S. salivarius | S. viridans | S. salivarius |
b. If common skin contaminant organisms from the cultures are speciated but no antibiograms are done or they are done for only one of the isolates, it is assumed that the organisms are the same.
c. If the common skin contaminants from the cultures have antibiograms that are different for two or more antimicrobial agents, it is assumed that the organisms are not the same (see table below).
d. For the purpose of NHSN antibiogram reporting, the category interpretation of intermediate (I) should not be used to distinguish whether two organisms are different.
| Organism name | Isolate A | Isolate B | Report as |
|---|---|---|---|
| S. epidermidis | All drugs S | All drugs S | Same |
| S. epidermidis | OX R Cefaz R | OX S Cefaz S | Different |
| Corynebacterium spp. | Pen G R Cipro S | Pen G S Cipro R | Different |
| Streptococcus viridans | All drugs S | All drugs S Except Erth R | Same |
5. For patients <1 year of age, the following temperature equivalents for fever and hypothermia may be used:
Fever: 38° C rectal/tympanic/temporal artery = 37° C oral = 36° C axillary
Hypothermia: 37° C rectal/tympanic/temporal artery = 36° C oral = 35° C axillary
CLINICAL SEPSIS (CSEP)
The CSEP definition may be used only to report a primary BSI in neonates and infants (i.e., patients ≤1 year of age) and must meet the following criteria:
Criterion:
Patient ≤1 year of age has at least one of the following clinical signs or symptoms with no other recognized cause: fever (>38° C, rectal), hypothermia (<37° C, rectal), apnea, or bradycardia
and
blood culture not done or no organisms detected in blood
and
no apparent infection at another site
and
Physician Institutes treatment for sepsis
From the Centers for Disease Control and Prevention, 2008. Accessed 7/2/08 from http://www.cdc.gov/ncidod/dhqp/nhsn.html.
Box 12-2
APIC-CDC HICPAC SURVEILLANCE DEFINITIONS IN HOME HEALTH CARE AND HOME HOSPICE INFECTIONS
LABORATORY-CONFIRMED BLOODSTREAM INFECTION (LCBSI) (must meet one of the following three criteria):
Criterion 1:
• Patient has a recognized pathogen cultured from one or more blood cultures and
• Organism cultured from blood is not related to an infection at another site.
Criterion 2:
• Patient has at least one of the following three signs or symptoms: fever (≥100.4° F [(≥38° C]), or chills, or hypotension and
• Signs and symptoms and positive laboratory results are not related to an infection at another site and
• Common skin contaminant (e.g., diphtheroids [ Corynebacterium spp.], Bacillus [not B. anthracis] spp., Propionibacterium spp., coagulase-negative staphylococci [including S. epidermidis], viridans group streptococci, Aerococcus spp., Micrococcus spp.) is cultured from two or more blood cultures drawn on separate occasions.
Criterion 3:
• Patient aged <1 year has at least one of the four following signs or symptoms:
fever (≥100.4° F [(≥38° C]) rectal/tympanic/temporal artery, (≥37° C oral), (≥36° C axillary); or hypothermia (<98.6° F [<37° C]) rectal/tympanic/temporal artery, (≥36° C oral), (≥35° C axillary); or apnea; or bradycardia and
• Signs and symptoms and positive laboratory results are not related to an infection at another site and
• Common skin contaminant (e.g., diphtheroids [ Corynebacterium spp.], Bacillus [not B. anthracis] spp., Propionibacterium spp., coagulase-negative staphylococci [including S. epidermidis], viridans group streptococci, Aerococcus spp., Micrococcus spp.) is cultured from two or more blood cultures drawn on separate occasions.
CLINICAL SEPSIS (CSEP) (must meet the criteria below):
• Must have at least one of the following clinical signs with no other recognized cause: fever, or hypotension (systolic pressure <90 mm Hg), or hypothermia, or apnea, or bradycardia and
• Meets all of the following:
Blood culture not done or no organisms detected in blood.
No apparent infection at another site.
Physician institutes treatment for sepsis.
Hospital admission for clinical sepsis and/or death attributable to clinical sepsis.
Association for Professionals in Infection Control and Epidemiology (Feb 2008): APIC-CDC HICPAC surveillance definitions in home health care and home hospice infections. Accessed 7/2/08 from http://www.apic.org/AM/Template.cfm?Section=Guidelines&CONTENTID=10427&TEMPLATE=/CM/ContentDisplay.cfm.
Another indicator of infection and response to antimicrobial therapy is the peripheral leukocyte count (WBC count). The WBC count is typically elevated in response to an acute bacterial infection. Because of the short life span of leukocytes, the WBC count usually drops rapidly during successful treatment. Patients with low leukocyte counts (neutropenia) may respond poorly to therapy for infection. Similarly, patients with other defects in humoral or cellular immunity may have impaired neutrophil function and be at risk for bacterial and fungal infections despite normal leukocyte counts. Noninfectious causes of elevated leukocyte counts include myeloproliferative disorders, trauma, acute myocardial infarction, and corticosteroid or lithium therapy.
INFECTION IN THE NEUTROPENIC PATIENT
Patients who are immunocompromised are at greater risk for developing an intravascular device–related infection. Infection is a frequent problem in patients with neutropenia, with sepsis being the most common cause of chemotherapy-induced death (Rosenthal, 2001). The usual signs and symptoms of infection (i.e., erythema, pain, redness, drainage, pulmonary infiltrates, or pyuria) are not present in the patient with neutropenia. This may be attributable to the patient’s lack of polymorphonuclear neutrophils, which normally would be recruited to the site(s) of infection to incite the inflammatory response. Therefore a neutropenic patient with an indwelling venous access device may not trigger the “usual” signs of infection (i.e., erythema, drainage at the exit site). The hallmark of infection in the neutropenic patient is fever. Sometimes an infection will develop without a fever, and the patient may have a sudden onset of weakness, hypotension, or confusion (Rosenthal, 2001). The presence of febrile neutropenia is a medical emergency that often results in hospitalization. Febrile neutropenia has been defined by the National Comprehensive Cancer Network (NCCN) as the presence of fever (>38.3° C at a single reading or ≥38.0° C over 1 hour) and severe neutropenia (ANC <500 μL or <1000 μL and a predicted decline to ≤500 μL over the next 48 hours) (NCCN, 2006). Initial infections in the neutropenic patient are typically bacterial, and involve gram-positive organisms such as Staphylococcus aureus and gram-negative organisms such as Pseudomonas aeruginosa, Escherichia coli, Klebsiella, and Serratia species (Rosenthal, 2001). The majority of infections occurring in immunocompromised patients result from colonization of organisms from within the patient’s own mouth or intestinal tract.
PREVENTION OF CATHETER-ASSOCIATED INFECTIONS
The incidence of catheter-associated infections can be reduced by implementing policies and procedures that are based on evidence from authoritative bodies such as the Centers for Disease Control and Prevention (CDC), the National Quality Forum (NQF), the Institute for Healthcare Improvement (IHI), and from professional nursing organizations, such as the Infusion Nurses Society (INS) that has developed the Infusion Nursing Standards of Practice (INS, 2006).
PRINCIPLES OF ASEPSIS
Adhering to the principles of aseptic technique can decrease the risk of catheter-associated infection. Aseptic technique should be maintained for the insertion and care of all intravascular catheters. Appropriate aseptic technique does not necessarily require sterile gloves; a new pair of disposable nonsterile gloves can be used in conjunction with a “no-touch” technique for the insertion of peripheral venous catheters (CDC, 2002b). Discussion as to when sterile and nonsterile gloves should be worn and hand hygiene performed is noted within the infection prevention discussion that follows. The Infusion Nurses Society’s policy and procedure on how to perform aseptic technique is noted in Box 12-3.
Box 12-3
ASEPTIC TECHNIQUE
POLICY
Aseptic technique is described as performing procedures in a manner that will minimize the chance of contamination or introduction of pathogens.
Aseptic technique shall be an integral component of every infusion-related procedure.
PROCEDURE
1. Hand Hygiene
• Wash hands using the appropriate antiseptic soap or solution before and after all patient contact.
2. Site Preparation
• Use antiseptic solution to prepare skin before venipuncture. Recommended solutions include:
• Alchol
• Chlorhexidine gluconate
• Povidone-iodine
• Tincture of iodine
3. Use of Personal Protective Equipment (PPE)
• Don cap, mask, gown, protective eyewear, and gloves, as needed.
4. Site Care and Maintenance
• Inspect site routinely for signs of catheter-associated complications.
• Rotate peripheral venous access sites routinely.
• Change administration sets and site dressing routinely.
• Maintain closed system on infusion administration systems.
5. Equipment and Supplies
• Inspect all solution containers for integrity before initiation of therapy.
• Check expiration dates.
• Inspect all administration sets, add-on devices, and junction securement devices before use to ensure protective coverings are intact and product integrity is not compromised.
• Visually inspect vascular access device (VAD) before insertion.
• Routinely cleanse durable medical equipment (DME) with disinfectant that is effective in preventing cross-contamination.
From Infusion Nurses Society: Polices and procedures for infusion nurses, ed 3, Norwood, Mass, 2006, Author.
INSTITUTE FOR HEALTHCARE IMPROVEMENT’S CENTRAL LINE BUNDLE
The Institute for Healthcare Improvement (IHI), an independent not-for-profit organization, led the improvement of health care by formulating care bundles. Care bundles are groupings of best practices that when applied together result in better outcomes when followed for every patient, every single time. When a bundle element is missed, the patient is at much greater risk for serious complications. The central line bundle is a group of five evidence-based interventions for patients with intravascular central catheters to prevent catheter-associated bloodstream infections that include the following:
1. Hand hygiene
2. Maximal barrier precautions
3. Chlorhexidine skin antisepsis
4. Optimal catheter site selection, with the subclavian vein as the preferred site for nontunneled catheters
5. Daily review of line necessity, with prompt removal of unnecessary lines (IHI, 2008)
Hospitals that have implemented the central line bundle have demonstrated striking reductions in the rate of central line infections. A statewide effort in Michigan to implement the central line bundle resulted in a 66% reduction in catheter-related bloodstream infection rates over an 18-month period (Pronovost et al, 2006). In another study, Berenholtz et al demonstrated that ICUs that implemented multifaceted interventions similar to the central line bundle nearly eliminated catheter-related bloodstream infections (Berenholtz et al, 2004).
NATIONAL QUALITY FORUM SAFE PRACTICES
The National Quality Forum (NQF) has endorsed 30 “safe practices” that should be universally used in health care settings to reduce the risk of harm resulting from processes, systems, or environments of care and to improve care. Of the 30 safe practices, safe practice number 20 requires adherence to effective methods for preventing central venous catheter–associated bloodstream infections and also suggests that the requirements be specific in policies and procedures. NQF safe practice number 20 includes all of the following elements:
• Wash hands or use an alcohol-based hand rub before and after insertion or care of the central line.
• Use maximal barrier precautions in preparation for line insertion, including each of the following: cap, mask, sterile gown, sterile gloves, and large sterile sheet.
• Perform skin antisepsis, preferably using 2% chlorhexidine-based preparation before catheter insertion; chlorhexidine may be contraindicated for use in very low birth weight (VLBW) infants.
• Select the optimal catheter site for each patient; for the prevention of infection, the subclavian vein is the preferred site for nontunneled catheters in adults. The optimal catheter site selection for the infant or child is specific to his or her size, condition, and accessibility factors.
• Replace the catheter site dressings as specified by Centers for Disease Control and Prevention (CDC) guidelines.
• Perform daily assessment of central line necessity, and promptly remove unnecessary lines (NQF, 2006).
GENERAL INFECTION PREVENTION STRATEGIES
Hand hygiene
Hand hygiene is an important activity to prevent cross-contamination and a health care–associated infection resulting from the insertion or ongoing care and maintenance of a venous access device. The health care workers’ (HCWs) hands are the greatest potential source for transmission of potentially infectious organisms to other patients. The following are Category IA, IB and IC recommendations that are strongly recommended or required for implementation by the CDC’s Guideline for Hand Hygiene in Health-Care Settings and the National Quality Forum’s endorsed Safe Practices for Better Healthcare. These recommendations are designed to improve hand hygiene practices and to reduce the transmission of pathogenic microorganisms to patients and personnel in health care settings:
1. Indications for handwashing and hand antisepsis
A. When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water (IA).
B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described below in items IC – H (IA). Alternatively, wash hands with an antimicrobial soap and water in all clinical situations described below in items IC – H (IB).
C. Decontaminate hands before having direct contact with patients (IB).
D. Decontaminate hands before donning sterile gloves when inserting a central intravascular catheter (IB).
E. Decontaminate hands before inserting peripheral vascular catheters, or other invasive devices that do not require a surgical procedure (IB).
F. Decontaminate hands after contact with a patient’s intact skin (IB).
G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled (IA).
H. Decontaminate hands after removing gloves (IB).
I. Before eating and after using a restroom, wash hands with a non-antimicrobial soap and water or with an antimicrobial soap and water (IB).
2. Hand hygiene technique
A. When decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry (IB). Follow the manufacturer’s recommendations regarding the volume of product to use.
B. When washing hands with soap and water, wet hands first with water, apply to hands an amount of product recommended by the manufacturer, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet (IB). Avoid using hot water, because repeated exposure to hot water may increase the risk of dermatitis (IB).
3. Selection of hand hygiene agents
A. Provide personnel with efficacious hand hygiene products that have low irritancy potential, particularly when these products are used multiple times per shift (IB).
B. To maximize acceptance of hand hygiene products by HCWs, solicit input from these employees regarding the feel, fragrance, and skin tolerance of any products under consideration. The cost of hand hygiene products should not be the primary factor influencing product selection (IB).
C. Do not add soap to a partially empty soap dispenser. This practice of “topping off” dispensers can lead to bacterial contamination of soap (IA).
4. Skin care
A. Provide HCWs with hand lotions or creams to minimize the occurrence of irritant contact dermatitis associated with hand antisepsis or handwashing (IA).
B. Solicit information from manufacturers regarding any effects that hand lotions, creams, or alcohol-based hand antiseptics may have on the persistent effects of antimicrobial soaps being used in the institution (IB).
5. Other aspects of hand hygiene
A. Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (e.g., those in intensive care units or operating rooms) (IA).
B. Wear gloves when contact with blood or other potentially infectious materials, mucous membranes, and nonintact skin could occur (IC).
C. Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient, and do not wash gloves between uses with different patients (IB) (CDC, 2002a).
In addition, the CDC’s Guidelines for the Prevention of Intravascular Catheter-Related Infections requires that hand hygiene be performed before and after palpating catheter insertion sites, as well as before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter (CDC, 2002b).
PERIPHERAL VENOUS CATHETER
SKIN ANTISEPSIS
When the skin is prepared for the insertion of a peripheral intravenous catheter, cleaning an area 2 to 4 inches in diameter is generally considered safe and acceptable. When tincture of iodine is used for skin antisepsis before catheter insertion, it should be removed with alcohol because it may cause skin irritation (INS, 2006). The catheter insertion site should not be palpated after the skin has been cleansed with the antiseptic unless palpated with sterile gloves.
SITE CARE
A transparent, semipermeable dressing over a peripheral intravenous catheter should be changed when the catheter is replaced and immediately if the integrity of the dressing is compromised (INS, 2006). When the dressing is replaced, touch contamination of the catheter insertion site should be avoided.
INSERTION SITE
In adults, an upper extremity site should be selected for the insertion of a peripheral venous catheter, rather than a lower extremity site. If a peripheral venous catheter is inserted in a lower extremity site, it should be moved to an upper extremity site as soon as possible. In pediatric patients, the hand, the dorsum of the foot, or the scalp can be used as the catheter insertion site (INS, 2006).
Peripheral intravenous catheters should be selected on the basis of the intended purpose and duration of use, known complications (e.g., phlebitis and infiltration), and experience of individual clinicians. Steel needles for the administration of fluids and medication that might cause tissue necrosis if extravasation occurs should be avoided (CDC, 2002b). A peripheral venous access device should never be readvanced (INS, 2006). Prophylactic topical antimicrobial or antiseptic ointment or cream should not be routinely applied to the insertion site of a peripheral venous catheter (CDC, 2002b).
The peripheral venous catheter insertion site should be inspected visually and palpated for tenderness only through the intact dressing (if the patient has no signs or symptoms of an infection). If there is tenderness, fever without an obvious source, or symptoms of a local or bloodstream infection, the dressing should be removed and the site directly inspected. Gauze and opaque dressings should not be removed if the patient has no clinical signs of infection.
The peripheral venous catheter should be removed if the patient develops signs of phlebitis (e.g., warmth, tenderness, erythema, and palpable venous cord), infection, or a malfunctioning catheter. Peripheral venous catheters should be removed at least every 72 hours (INS, 2006) or up to 96 hours (CDC, 2002b), and immediately upon suspected contamination, complication, or therapy discontinuation in adults to prevent phlebitis. If sites for venous access are limited and no evidence of phlebitis or infection is present, peripheral venous catheters can be left in place for longer periods, although the patient and the insertion site should be closely monitored and appropriate information documented. Peripheral venous catheters may be left in place in children until the intravenous therapy is completed or unless complications (e.g., phlebitis and infiltration) occur (CDC, 2002b). Injection caps or valves on peripheral short venous catheters should be changed when the catheter is replaced (CDC, 2002b).
ADMINISTRATION SET
The primary administration set change shall coincide with the peripheral catheter change and with initiation of a new container of solution. The secondary set change will coincide with the change of the primary administration set and with the initiation of a new container of solution. Primary intermittent administration sets shall be changed every 24 hours and immediately upon suspected contamination, or when the integrity of the product or system has been compromised (INS, 2006).
MIDLINE CATHETER
A midline catheter is considered a peripheral venous catheter as it does not enter a central vein. It is inserted 3 to 8 inches via the antecubital fossa with the distal tip dwelling in the proximal basilic or cephalic veins at or below the axillary level and distal to the shoulder (Centers for Disease Control and Prevention, 2002b and Infusion Nurses Society, 2006). A midline catheter should be selected when the duration of intravenous therapy will likely exceed 6 days. A midline catheter should not be routinely replaced to reduce the risk of infection (CDC, 2002b).
CENTRAL VENOUS CATHETER INFECTION PREVENTION STRATEGIES
MAXIMAL BARRIER PRECAUTIONS
Maximal barrier precautions should be used to reduce the chance of catheter contamination and a subsequent catheter-associated bloodstream infection. For the individual placing the central line and for those assisting in the procedure, maximal barrier precautions means strict compliance with hand hygiene and wearing a cap, mask, sterile gown, and sterile gloves. The cap should cover all hair and the mask should cover the nose and mouth tightly. For the patient, applying maximal barrier precautions means covering the patient from head to toe with a sterile drape, with a small opening for the site of insertion (Centers for Disease Control and Prevention, 2002b, Infusion Nurses Society, 2006, National Quality Forum (NQF): Safe practices for better healthcare, update 2006, 2006 and Institute for Healthcare Improvement, 2008).
PREINSERTION VENOUS ACCESS DEVICE INFECTION PREVENTION STRATEGIES
Skin preparation
If excess hair needs to be removed from the skin before skin antisepsis for the insertion of a catheter, the hair should be removed with scissors or an electric clipper. Shaving with a razor is not recommended because it may cause microabrasions that can damage skin integrity, which can increase the risk of infection. Removing the hair by using a depilatory is not recommended because of the potential for an allergic reaction (INS, 2006).
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