Cutting Out CLABSIs: Preventing Central Line-Associated Bloodstream Infections

Section 1: Introduction

About This Course

Central line-associated bloodstream infections (CLABSIs) affect an estimated 400,000 patients each year in the United States (AHRQ, 2018). CLABSIs can cause serious infections and lengthen hospital stays, inflate medical costs, and increase the risk of morbidity and mortality. Nurses can play a significant role in reducing these troubling facts. Adhering to a group of evidence-based interventions known as the central line bundle has been proven to reduce the incidence of CLABSIs in healthcare settings. Components of the central line bundle focus on the proper insertion and maintenance of central lines to reduce infection rates. The nurse’s understanding of CLABSI, evidence-based bundle practices, and guidelines for the proper maintenance of central line catheters can improve patient outcomes significantly.

The goal of this educational program is to provide nurses in acute care settings with information about the severity and causes of central line-associated bloodstream infections and describe evidence-based interventions for the proper insertion and maintenance of central lines.

Learning Objectives

After taking this course, you should be able to:

• Describe the severity of CLABSIs.
• Explain the causes and risk factors of CLABSIs.
• Describe the five components of the central-line bundle.

Section 2: Course Content

A Lurking Danger

A silent killer lurks in every U.S. hospital: central line-associated bloodstream infection (CLABSI). It is estimated that each year approximately 400,000 CLABSIs occur in the United States (AHRQ, 2018). It is difficult to measure the mortality rate independently related to CLABSI because patient deaths are affected by multiple comorbidities. Three national data resources in the U.S. were used to estimate the annual number of deaths associated with healthcare-associated infections (HAIs) to be 98,987. About one in three of these HAIs were due to CLABSIs. Therefore, the case fatality rate was about 12.3% (The Joint Commission, 2012). CLABSIs are usually serious infections (e.g., sepsis) that lengthen hospital stay, inflate medical cost, and increase the risk of mortality (The Joint Commission, 2012). The good news is that CLABSIs are preventable, and nurses have the power to reduce these troubling numbers (Zimlichman et al., 2013).

This module focuses on preventing potentially deadly central venous catheter-associated bloodstream infections. Patients with a CLABSI stay in the hospital about 12 days longer than patients without a CLABSI (The Joint Commission, 2012). The average CLABSI case cost ranges from $16,550 to $49,650, and CLABSI is associated with about 24,000 patient deaths each year (The Joint Commission, 2012). Simulations have shown, with 95% confidence, that CLABSIs are the costliest HAIs (Zimlichman et al., 2013). Given this data, efforts to reduce the rate of CLABSIs are vital to improving healthcare quality and patient safety.

The Institute for Healthcare Improvement (IHI) recommends five key measures based on best-practice guidelines to fight CLABSI (IHI, 2012):

• Appropriate hand hygiene
• Utilizing maximal barrier precautions on insertion of the central venous catheter (CVC)
• Skin antisepsis using chlorhexidine
• Optimal catheter site selection
• Reviewing line necessity daily and removing lines promptly when they are no longer necessary

Together, this group of evidence-based interventions is called the “central-line bundle” (IHI, 2012). The nurse’s understanding of CLABSI and evidence-based bundle practices can improve patient outcomes significantly.

Central Line Basics

A central line, or central venous catheter (CVC), is a catheter inserted into patients who require frequent or continuous injections of medications, fluids, nutritional support, or therapies such as chemotherapy or dialysis (CDC, 2020). It is an intravascular device used for infusion, withdrawal of blood, or hemodynamic monitoring whose tip terminates at or close to the heart or in one of the great vessels. Location of central line placement depends on multiple factors including anatomy, body habitus, and infection risk. The most common insertion sites for adults are the subclavian vein (preferred), internal jugular vein, or femoral vein. The umbilical vein is more commonly used in neonates. The tip of the catheter most commonly terminates in the superior vena cava in adults. Based on specific patient factors and the purpose of the catheter, other great vessels in which the tip can terminate include the (CDC, 2020):

• Aorta
• Pulmonary artery
• Inferior vena cava
• Brachiocephalic veins
• Internal jugular veins
• Subclavian vein
• External iliac veins
• Common iliac veins
• Femoral veins
• Umbilical artery and umbilical vein (neonates)

Types of Central Lines

A central line can be permanent or temporary. The CDC recognizes three different types of central lines for CLABSI reporting purposes (CDC, 2020):

• Permanent central lines can be accessed repeatedly for ongoing treatment such as dialysis or chemotherapy. These include tunneled catheters (such as those used for dialysis) as well as implanted catheters (such as ports).
• Temporary central lines are not tunneled or implanted. These may pose greater inconvenience or discomfort to the patient as their lumens protrude from the insertion site for the duration of their placement.
• Umbilical catheters are inserted through the umbilical artery or vein in neonates.

Central lines are crucial to medical management, particularly in intensive care, during major surgery, and during resuscitation because they provide secure vascular access and reliable hemodynamic measurement. However, central lines can cause multiple complications and the risks vs. benefits should be considered before placement.

Mechanical complications may occur simply from insertion. Some examples of mechanical complications include (O’Grady et al., 2017):

• Pneumothorax
• Subclavian artery puncture or vein laceration
• Subclavian vein stenosis
• Hemothorax
• Air embolism
• Thrombosis
• Catheter misplacement

Local infections at the insertion site can occur as well as systemic infections, such as CLABSI. An estimated 90% of all bloodstream infections are related to central venous access devices (AHRQ, 2018). CLABSI is a common culprit related to other specific infection-related complications including:

• Septic thrombophlebitis
• Endocarditis
• Metastatic infection
  • Lung abscess
  • Brain abscess
  • Osteomyelitis
  • Endophthalmitis
  • Septic arthritis

Despite the risks associated with CVC insertion, the secure access and monitoring they provide make them necessary in the management of critically ill or chronically ill patients. For this reason, CLABSIs remain a significant focus in the prevention of healthcare-acquired infections.

What is a CLABSI?

To cause a catheter-related infection, microorganisms must access the bloodstream via the outside (extraluminal) or inside (intraluminal) surface of the catheter tube. Microorganisms can enter the bloodstream in several ways (O’Grady et al., 2017):

• Skin contaminants enter through the insertion site and migrate along the catheter, colonizing at the tip (most common).
• The catheter hub or catheter comes into direct contact with contaminated hands, fluids, or devices.
• Microorganisms travel through the bloodstream and adhere to the catheter from a distant localized infection, such as pneumonia or a wound.
• The infusing substances are contaminated (rare).

Again, the most common route of infection is migration of skin organisms at the insertion site, making aseptic technique during insertion and site care with dressing changes crucial to preventing contamination (O’Grady et al., 2017). After accessing the bloodstream, free-floating bacteria adhere to the catheter surface and form a microcolony. This leads to the formation of a biofilm, which allows sustained bacterial growth and spread throughout the bloodstream.

Clinicians should understand the difference between clinical and surveillance definitions of CLABSI. The clinical definition is physician-driven and based on clinical signs and symptoms of BSI or sepsis, the blood culture laboratory results, and the presence of a central line. The surveillance definition of CLABSI is more specific and less subjective, and it relies on positive blood culture results and the presence of a central line.

The CLABSI definition in this module, developed by the Centers for Disease Control and Prevention (CDC) and the National Healthcare Safety Network (NHSN), has been adopted by most healthcare facilities to generate facility-specific CLABSI rates. This definition lists essential criteria for surveillance of CLABSI and succinctly describes the methodology that should be used in CLABSI surveillance systems conducted by healthcare facilities.

According to the CDC/NHSN, CLABSI is a laboratory-confirmed BSI, such as bacteremia/fungemia, in a patient with a central line when no other infection source with the same microorganism is found. If a patient develops a BSI within two calendar days (or 48 hours) of insertion or removal of a central line, the BSI is said to be associated with the central line (CDC, 2020). If more than two calendar days pass between central line removal and the onset of infection, convincing evidence must exist before the infection can be classified as related to the central line (CDC, 2020).

Two criteria must be met before a BSI is classified as a CLABSI:

• The patient must have both a central line and a laboratory-confirmed BSI.
• The signs, symptoms, and blood culture laboratory results must not be related to an infection at another site.

If the same organism is found at a site other than the bloodstream, it is a secondary BSI rather than a primary BSI. For example, if both blood and wound culture results have shown Pseudomonas aeruginosa, the BSI is secondary, because the microorganism may have migrated from the infected wound into the bloodstream (CDC, 2020).

Surveillance CLABSI Definition by CDC/NHSN

Using the CDC/NHSN surveillance definitions for reporting purposes, a laboratory-confirmed BSI requires that one of the following three criteria be met (CDC, 2020):

Criterion 1 (both elements must be confirmed):

• • The patient (any age) has a recognized pathogen identified from one or more blood specimens by a culture- or nonculture-based microbiological testing method that is performed for purposes of clinical diagnosis or treatment.
  • The pathogen is not related to an infection at another site.

Criterion 2 (all elements must be confirmed):

• • The patient (any age) has at least ONE of the following signs or symptoms: fever (greater than 100.4°F [38°C]), chills, or hypotension.
  • The signs, symptoms, and positive laboratory results are not related to an infection at another site.
  • A common skin contaminant is identified in two or more blood specimens drawn by a culture- or nonculture-based microbiological testing method. The cultures should be performed for purposes of clinical diagnosis or treatment on separate occasions, occurring within one calendar day of each other. The same skin contaminant must be found in both results.
    • Examples of common skin contaminates: diphtheroids (Corynebacterium spp. not C. diphtheriae), Bacillus spp. (not B. anthracis), Propionibacterium spp., coagulase-negative staphylococci (including S. epidermidis), viridans group streptococci, Aerococcus spp., or Micrococcus spp.

Criterion 3 (all elements must be confirmed):

• • A patient younger than 1 year has at least one of the following signs or symptoms: fever (greater than 100.4°F [38°C], core), hypothermia (less than 96.8°F [36°C], core), apnea, or bradycardia.
  • The signs, symptoms, and positive laboratory results are not related to an infection at another site.
  • A common skin contaminant is identified in two or more blood specimens drawn by a culture- or nonculture-based microbiological testing method. The cultures should be performed for purposes of clinical diagnosis or treatment on separate occasions, occurring within one calendar day of each other. The same skin contaminant must be found in both results.
    • Examples of common skin contaminates: diphtheroids (Corynebacterium spp. not C. diphtheriae), Bacillus spp. (not B. anthracis), Propionibacterium spp., coagulase-negative staphylococci (including S. epidermidis), viridans group streptococci, Aerococcus spp., or Micrococcus spp.

A new criterion was added to the CDC/NHSN CLABSI module: mucosal barrier injury laboratory-confirmed BSI. This criterion is for patients with allogeneic hematopoietic stem cell transplant within a year or for patients with neutropenia, defined as at least two separate days with values of absolute neutrophil count or total white blood cell count less than 500 cells/mm on or within three calendar days before the date the positive blood culture was collected (Zimlichman et al., 2013). The criterion also defines specifically the pathogens found in the blood culture (CDC, 2020).

The CLABSI criteria do not include catheter tip culture or treatment with antibiotics; therapeutic options are clinical decisions made by healthcare providers.

Blood cultures collected through central lines can have a higher chance of contamination than blood specimens drawn through peripheral venipuncture (CDC, 2020). Therefore, cultures ideally should be collected through venipuncture from two to four blood draws from separate sites. However, this may be difficult in patients with very poor peripheral venous access. Hospital administrators should work to ensure best practices in specimen collection. Blood cultures obtained from any site (through existing intravascular catheters, arterial lines, or venipuncture) must be considered in CLABSI surveillance.

Risk Factors for CLABSIs

Despite associated complications, central lines remain necessary, especially when caring for patients in critical condition. Identifying risk factors that increase the incidence of CLABSIs is vital to preventing them. Some risk factors can be reduced through improved clinical practice, while others cannot. Specific patient populations are more vulnerable to BSI, including (O’Grady et al., 2017; Marschall et al., 2014):

• Older adults
• Neonates or premature infants
• Patients with severe medical conditions
• Burn patients
• Patients with cancer
• Patients who are immunodeficient or immunocompromised
  • Patients with neutropenia
• Organ transplant patients
• Patients on dialysis

While we cannot control the types of patients needing central venous access, we can reduce the risk for CLABSI by improving clinical practice. Ongoing research has identified several variables relating to central lines that can be affected to reduce the risk of infection.

Number of Lumens

Multilumen central lines are indispensable in managing patients who require several IV medications, laboratory specimens, frequent blood product transfusions, and fluid resuscitations. However, they may be related to a higher rate of CLABSIs and thrombosis than single-lumen central lines (Ratz et al., 2016; Templeton et al., 2008). Multilumen catheters are manipulated more often, making colonization and bacterial growth at the tip more common. Hospital policies minimizing the number of lumens may reduce BSI and lower costs (Ratz et al., 2016). To reduce infection risk, the CDC recommends using the minimum number of lumens possible to meet the medical needs of the patient (O’Grady et al., 2017).

Site Selection

Use of the femoral vein for central line access in adults should be avoided under planned or controlled conditions (O’Grady et al., 2017; Marschall et al., 2014)). Femoral central lines have the highest rate of CLABSIs with increased incidence of deep vein thrombosis and catheter colonization. CLABSI due to gram-negative bacteria (e.g., E. coli and Enterobacter spp.) and yeasts is significantly higher in femoral CVC sites because of the proximity of the groin to the genital and perirectal area (Lorente et al., 2007).

The subclavian vein has the lowest rate of BSI, followed by the internal jugular vein. Therefore, the subclavian vein is preferred for inserting non-tunneled central catheters (O’Grady et al., 2017).

Umbilical catheters for neonates have special considerations and guidelines from the CDC. A link to the CDC website with these particular guidelines can be found in the Resources section at the end of this course.

Type of Infusion

Central lines used to administer dextrose-containing solutions, total parenteral nutrition (TPN), lipids, and blood-product transfusions are associated with increased incidence of BSI. Infusion of TPN and transfusion of blood products are considered a risk factor of CLABSI (O’Grady et al., 2017; Marschall et al., 2014). Microorganisms thrive in TPN and high-protein blood products. There is no recommendation regarding a specific port to use for either of these infusion types; however, tubing should be changed for these infusions at least every 24 hours (O-Grady et al., 2017).

Accessing the Central Line

The manner in which lines are accessed can pose additional risk for infection. To protect patients, clinicians must use good antiseptic technique before accessing the central line. The following measures should be followed as outlined by the CDC guidelines (O’Grady et al., 2017):

• Injection ports should be disinfected with an appropriate antiseptic before accessing the infusion system, with clinicians “scrubbing the hub” for at least 10-15 seconds.
  • Examples: chlorhexidine, povidone iodine, an iodophor or 70% alcohol
• Injection ports should be allowed time to dry before the infusion system is accessed.
• Only sterile devices should be used to access the injection port.
• Cap all stopcocks when the injection ports are not in use.

Catheter and Tubing Maintenance

Failure to properly flush and maintain the lumens of the catheter or the tubing used for administration can increase infection risk. After infusions of IV solutions that may enhance microbial growth, catheters should be flushed with sterile, preservative-free 0.9% sodium chloride, according to organization policies and procedures and the manufacturer’s recommendations for the type of catheter. CDC guidelines recommend the following to address catheter lumens and tubing (O’Grady et al., 2017):

• Tubing used to deliver lipid emulsions, blood, or blood products should be replaced within 24 hours of starting the infusion
• The tubing used to administer propofol infusions should be replaced every 6 or 12 hours, when the propofol vial is changed, and per the manufacturer’s instruction.
• Replace administration tubing sets not used for blood, blood products, or lipids at intervals no longer than 96 hours.

Other risk factors that may increase the incidence of CLABSIs include:

• Prolonged hospitalization before central line insertion
• Prolonged duration of catheterization
• Heavy microbial colonization at the insertion site
• Heavy microbial colonization of the catheter hub
• Inexperience of the clinician inserting the central line
• High nurse-to-patient ratio
  • Hospitals should keep nurse-to-patient ratios at least 2:1 in ICUs where nurses manage patients with central lines (Marschall et al., 2014).

Through increased awareness and improved practice, risk factors for CLABSIs can be effectively reduced to achieve optimal patient outcomes.

The Complexity of Infection

The development of a bloodstream infection (BSI) comprises complex interactions between the invading microorganism and immune system defenses. When infectious agents spread to the bloodstream, the fever-producing substances secreted by phagocytes will “turn up” the body’s hypothalamic temperature regulator. Vasodilation substances are released from the mediators of the inflammatory process in response to overwhelming infection. This triggers widespread vasodilation and reduced systemic vascular resistance, resulting in decreased blood pressure. The heart rate is altered (typically elevated) because of cardiac compensation. As a result, clinical presentation of BSI includes fever, chills, shaking, tachycardia, and hypotension. The timeline of infection can vary widely between patients, though an average time of eight days from insertion of a central line to onset of CLABSI has been reported (Lin et al., 2017).

The microbial profile of HAIs, including BSI, has changed over the past decades. In 1999, for the first time, more than half of all Staphylococcus aureus infections in ICUs were resistant to oxacillin. When S. aureus resists oxacillin, it is also classified as methicillin-resistant S. aureus (MRSA), which has become endemic in many locations and often causes outbreaks. MRSA contributes significantly to increases in morbidity, mortality, and healthcare costs (O’Grady et al., 2011; Zimlichman et al., 2013; Karlowsky et al., 2004). From 2009 to 2010, 54.6% of blood cultures that tested positive for S. aureus were found to be resistant to oxacillin/methicillin (Sievert et al., 2015).

From 2009 to 2010, the species of bacteria most frequently isolated from blood cultures were, in rank order, coagulase-negative staphylococci, Staphylococcus aureus, Enterococcus faecalis, Candida spp. or not otherwise specified, Klebsiella pneumoniae/oxytoca and Enterococcus faecium (Sievert et al., 2015). Coagulase-negative staphylococci and S. aureus were by far the most common, comprising 20.5% and 12.3% of CLABSIs, respectively (Sievert et al., 2015). A more recent study on a population in which the central line bundle was utilized reported that the most common classes of microorganisms found in CLABSI cases were Gram-negative bacteria (39.2%), Gram-positive bacteria (33.2%), and Candida spp. (27.6%) (Lin et al., 2017).

Regardless of the causative organism, CLABSIs are life-threatening infections that are preventable with adherence to evidence-based practices such as the central line bundle.

Bundled Together

The central line bundle correlates with the CDC’s BSI prevention guidelines (O’Grady et al., 2011; IHI, 2012). Use of the central line bundle dramatically reduces the incidence of CLABSI, and the reduction is sustainable (Richards et al., 2017; Scott et al., 2016). Research has shown that adhering to all elements of the central line bundle results in better outcomes than performing any of the five measures individually (Furuya et al., 2017; Lee et al., 2018). The following is a description of the five key components of the central line bundle in more detail (IHI, 2012).

Hand hygiene: Good hand hygiene is the cornerstone of infection prevention. Wearing sterile gloves does not eliminate the need for hand hygiene. Cleaning hands before inserting or manipulating a central line helps prevent contamination of central line sites and resultant BSIs. Hands should be washed with antimicrobial or non-antimicrobial soap and water with adequate rinsing, or cleaned with a waterless, alcohol-based hand sanitizer before donning sterile gloves.

The World Health Organization supports evidence from a study that identifies five key moments to perform hand hygiene (WHO, n.d.; Sax et al., 2007):

• Before coming into contact with a patient

• Before performing procedures that are clean or aseptic

• After exposure or risk of exposure to body fluids (and after removal of gloves)

• After coming into contact with a patient

• After coming into contact with the surroundings of a patient

Maximal barrier precautions on insertion: The CDC identifies the following to provide maximal barrier precautions (O’Grady et al., 2017):

• The clinician inserting the central line should wear the following:
  • Cap: All hair should be tucked under the cap
  • Mask: Mouth and nose should be covered tightly
  • Sterile gown
  • Sterile gloves
• The patient should be covered from head to toe with a sterile drape.
  • If a full-sized drape is unavailable, use two small drapes to cover the patient.
• A sterile dressing must be applied to the insertion site before the sterile barriers are removed.
• During insertion of all pulmonary artery catheters, a sterile sleeve should be used to protect the catheter.

Chlorhexidine skin antisepsis: The CDC recommends the following regarding skin antisepsis (O’Grady et al., 2017):

• >0.5% chlorhexidine gluconate (CHG) in 70% isopropyl alcohol should be used to disinfect the insertion site and for site care during dressing changes.
• To prepare the site, press the applicator against the insertion site and apply the antiseptic solution using a back-and-forth friction scrub for at least 30 seconds. Allow the solution to air dry completely, according to the manufacturer’s recommendation, before CVC insertion or placement of a sterile dressing.
• Clinicians should never wipe the skin or blot to dry.
• According to the CDC, no recommendation can be made for using chlorhexidine-based skin antisepsis on patients younger than 2 months.

Optimal catheter site selection: In adults, the subclavian vein is preferred for non-tunneled catheters (O’Grady et al., 2017). Subclavian venous access has a lower rate of CLABSI than internal jugular or femoral vein access. Caution should be used with subclavian placement because of the increased risk for mechanical complications (e.g., pneumothorax). Patient-specific medical risk factors (e.g., subclavian vein stenosis, coagulopathy, anatomic deformity) should be evaluated carefully when the insertion site is selected (O’Grady et al., 2017; IHI, 2012). For patients on hemodialysis or with advanced kidney disease, a fistula or graft is preferred to avoid subclavian vein stenosis (O’Grady et al., 2017).

• Ultrasound-Guided Insertion: Ultrasound scanners can be used to guide central line insertion to reduce the risk of mechanical complications. They have also been shown to reduce the number of sticks needed, which decreases the risk for CLABSI. For this reason, the CDC recommends the use of ultrasound scanners for insertion when they are available (O’Grady et al., 2017).

Daily review of line necessity with prompt removal of unnecessary lines: The risk of CLABSI is closely related to the length of time that a central line is in place. When physicians and nurses conduct a daily review, unnecessary central lines are more likely to be removed promptly. A daily review of central line necessity can be incorporated into multidisciplinary rounds and daily goal reports (IHI, 2012).

Research has shown that there is still an opportunity to improve adherence to central line insertion practice and that adherence to central line insertion practices (CLIP) is positively correlated with CLABSI rate reduction (The Joint Commission, 2012; Bukhari et al., 2014). Every healthcare facility should develop strategies, including leadership involvement, policy development, educational courses, simulation training, and compliance monitoring, to improve adherence to CLIP. Using an electronic health record system can help nurses maximize the benefits of CLABSI-prevention strategies (The Joint Commission, 2012).

Beyond the Bundle

The central-line bundle largely focuses on the insertion of the catheter rather than later management of the catheter site. The following are recommendations and guidelines for issues that emerge after the catheter is inserted.

Prophylaxis: Do not routinely administer intranasal or systemic antimicrobial prophylaxis before or during an intravascular catheter insertion in order to prevent catheter colonization or development of BSI (O’Grady et al., 2017).

The updated CDC guidelines state that if the CLABSI rate remains higher than the institutional goal despite other strategies (e.g., education and the central-line bundle), the use of antiseptic- or antibiotic-impregnated short-term central lines is recommended (O’Grady et al., 2017).

Guidewires: Guidewires can be used to replace catheters that are not functioning properly or to exchange a pulmonary artery catheter for a central line. This has become a common practice but can also introduce an additional infection risk. The CDC provides the following recommendations regarding the replacement of central lines and the use of guidewires (O’Grady et al., 2017):

• Guidewires should not be used when replacing catheters in patients who are suspected of having an infection.
• Routinely replacing central lines to prevent BSI is not recommended.
• If no evidence of CLABSI is present, use a guidewire exchange to replace a malfunctioning non-tunneled catheter as appropriate.
  • Clinicians should wear sterile gloves before handling the new catheter.
• Maximal sterile barrier precautions (including a cap; mask; sterile gown; sterile gloves; and a large, sterile full-body drape) must be applied during guidewire exchanges for intravascular catheters.
• A central line should be replaced as soon as possible (within 48 hours) if placed under conditions when aseptic technique could not be ensured, such as during medical emergencies.

Daily bathing with CHG: New research has shown that daily bathing with a 2% chlorhexidine skin cleansing product (for patients over 2 months of age) reduces the incidence of CLABSIs (Crnich & Maki, 2014; Marschall et al., 2014; Afonso et al., 2016). It is now an official recommendation from the CDC and The Joint Commission (O’Grady et al., 2017; The Joint Commission, 2012).

Catheter and insertion-site care (O’Grady et al., 2017; Marschall et al., 2014; The Joint Commission, 2013):

• Accessing the catheter: When accessing the catheter, all sides and the top of the hub or injection port should be scrubbed vigorously for 10-15 seconds with 70% alcohol, alcoholic chlorhexidine, or povidone iodine.
  • Caps that contain an antiseptic solution can be helpful in the prevention of CLABSIs but should be used in accordance with institutional policies (Marschall et al., 2014).
  • Caps, needleless access ports, or claves should be changed no more frequently than every 72 hours.

• Protect the catheter:

  • Precautions should be taken to protect the catheter from the introduction of organisms during showering; avoid submerging the catheter in water.

  • Patients with a tracheostomy are at increased risk for CLABSI if they have a central line at the internal jugular site. To protect the insertion site from being contaminated by respiratory secretions, nurses must keep the stoma clean and dry and change the tracheostomy holder when moist.

  • A suture-less securement device is recommended to minimize movement of the catheter, which decreases the risk of organism migration from the skin.

Dressing guidelines and recommendations (O’Grady et al., 2017, Marschall et al., 2014):

• For short-term, non-tunneled catheters: Dressings that are impregnated with chlorhexidine are recommended for patients aged 18 years and older to reduce CLABSIs.
  • There is insufficient research regarding the use of these dressings in patients younger than 18 year of age, and severe adverse skin reactions may occur in premature neonates.
• Apply sterile gauze or a sterile, transparent, semipermeable dressing to cover the catheter insertion site.
• If the patient is diaphoretic or if the site is bleeding or oozing, apply gauze dressing until this is resolved.
• Immediately replace a dressing that is soiled, loosened, or damp; or if moisture, drainage, or blood is present under the dressing.
• Routine dressing changes:
  • Site care with a chlorhexidine-based solution should be performed with each dressing change.
  • Transparent dressings for non-tunneled central lines should be changed routinely, at least every seven days.
  • Gauze dressings should be replaced at least every two days.
  • For some pediatric patients, dressings may be replaced less often because the risk of dislodging the catheter may outweigh the benefits associated with dressing changes.
  • Institutional central line care policies should address frequency of dressing changes.
• Do not use topical antibiotic creams or ointments on insertion sites other than for dialysis catheters or insertion sites. Such creams and ointments may promote antimicrobial resistance and fungal infections.

Assess the site: The CDC also reinforces the need for nurses to encourage patients to report any new pain or discomfort at the insertion site. If changes are reported, the nurse should remove the dressing completely and assess the site more closely. The site should also be directly assessed if the patient has a new onset of fever without another obvious source or if there is suspicion of a localized or systemic infection related to the catheter (O’Grady et al., 2017).

Sufficient staffing: The number of staff as well as the type of staff caring for patients with central lines can affect CLABSI rates. Research has shown that a lower nurse-to-patient ratio (2:1 or 1:1) can improve staff adherence to bundle measures, which reduces infection rates (Aloush & Alsaraireh, 2018). Having more float pool or flex staff caring for patients with central lines can increase the risk for CLABSIs, possibly due to a lack of training or frequent exposure to this specific patient population (Alonso-Echanove, 2003). The CDC aligns with these findings and recommends ensuring adequate and appropriate staffing to reduce CLABSI rates (O’Grady et al., 2017).

A recent study showed approximately a 50% reduction in CLABSI rates when central line maintenance measures and the auditing process were standardized (Mathew et al., 2020). This study focused on scrubbing the hub, changing the needleless connector, CHG bathing, changing intravenous tubing, procedures for drawing blood cultures, and protecting the environment around the central line (Mathew et al., 2020). The results of this research reinforce the importance of not only proper insertion practices but also adhering to appropriate maintenance measures that can prevent infection.

All of these guidelines and recommendations are particularly important for nurses as they are the primary caregivers at the bedside after a central line is in place.

Adherence and Room for Improvement

As mentioned earlier in this course, the central line bundle and associated recommendations are most effective in reducing infection rates with compliance of all components. In one of the largest studies completed, which involved over 1,000 ICUs in the United States, only 38% of the units reported full compliance with bundle measures (Furuya et al., 2016). This is concerning considering the large amount of evidence proving the effectiveness of the central line bundle in reducing CLABSI rates and protecting vulnerable populations.

An analysis of existing research found that there is an abundance of research that proves the effectiveness of bundle measures and proper maintenance of central lines. It has been suggested that focus should shift from effectiveness of the bundle to improving adherence to bundle and maintenance measures (Ista et al., 2016).

Some barriers to adherence that have been identified include time constraints, lack of education, and lack of appropriate supplies (such as complete insertion kits or full body drapes) (Lee et al., 2018). Many providers continue to use the femoral site for central lines due to convenience. This can be due to anatomical considerations or attempts to decrease the risk for mechanical complications such as pneumothorax, however, infection prevention should take priority (Lee et al., 2018). Nurses should be empowered to advocate for appropriate site selection for planned and controlled insertions. Nurses can also encourage providers to strive for maximal barrier precautions, cover the entire patient, and ensure that supplies are available to do so.

It has also been found that taking the time to do daily assessments of line necessity is a challenge for the healthcare team. This bundle measure was found to have the greatest need for improvement (Valencia et al., 2016). In a report of nurse opinions on the importance of bundle measures, daily evaluation of necessity was thought to be one of the least important and least performed bundle measures (Ng’ambi, 2018). Although it may take extra time, it is important for nurses to be involved in the daily assessment of central line necessity and to advocate for their removal as soon as possible. Bedside nurses are essential for identifying and relaying information about the progression of a patient’s condition. This is especially important when certain medications such as vasopressors or TPN have been titrated or are no longer needed, and a physician may be unaware of recent changes. Nurses have the power to decrease CLABSI rates simply through facilitating removal when they are no longer needed.

Implementing an ongoing auditing process has also been shown to contribute to the reduction of CLABSIs (Mathew et al., 2020). By holding staff accountable and continually “checking the boxes”, compliance can improve, therefore decreasing infection rates. Consistent monitoring of compliance through an auditing process has also been found to be an area in need of significant improvement (Valencia et al., 2016).

Nurses in Charge

Nurses should be educated on the indications for central line insertion, proper insertion procedures, standardized care of central lines based on institutional policy, and the prevention of CLABSI. The Joint Commission requires nurses who care for central lines to attend hands-on training and competency validation to ensure proficiency of these skills (The Joint Commission, 2013). A hospital’s senior leadership is responsible for ensuring support for the nursing department and the infection prevention and control program that prevents CLABSIs. Healthcare providers are responsible for ensuring that optimal CLABSI prevention practice is always followed (Marschall et al., 2014).

To implement the central line bundle and ensure adherence, nurses should be empowered to supervise the insertion procedure. Nurses should have the authority to terminate procedures if they observe violations of hand hygiene, sterile technique, or evidence-based guidelines for the prevention of intravascular catheter-related infections.

Healthcare providers should be educated to increase their awareness of evidence-based infection prevention practice. Insertion kits, maximum barriers, and applicators with 2% chlorhexidine gluconate in 70% isopropyl alcohol should be kept in one location, such as on a single cart so that clinicians can obtain all central line insertion supplies easily. A central line insertion checklist should be developed to document adherence, and data should be collected for benchmarking (Marschall et al., 2014; Crnich & Maki, 2014). Nursing administrators should provide feedback to the appropriate healthcare providers on unit trends in the incidence and prevalence of CLABSIs and on the strategies to prevent them.

More and more patients are discharged with central lines in the form of PICCs, implanted ports, or dialysis catheters. Patients and families must be educated before discharge on caring for the catheter and preventing CLABSI. Providing written material can help the patient retain information. The Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America collaborated with the CDC on a compendium of practice recommendations to prevent HAIs, including CLABSIs. Clinicians can use this compendium as a reference (Marschall et al., 2014).

Joining Efforts

The Centers for Medicare & Medicaid Services (2020) identified 14 categories of hospital-acquired conditions in the Inpatient Prospective Payment System Fiscal Year 2013 Final Rule. Vascular catheter-associated infection is one of 14 categories. In addition, hospitals accredited by The Joint Commission must establish practices to prevent CLABSI (The Joint Commission, 2019). Preventing CLABSI is a national patient safety goal (NPSG.07.04.01): Use proven guidelines to prevent infection of the blood from central lines. This Joint Commission requirement covers short- and long-term CVC and peripherally inserted central catheter lines (The Joint Commission, 2019).

Hospital administrators and the public are more aware than ever of the need to prevent HAIs. CLABSI is associated with increased medical expenses, morbidity, and mortality. It is largely preventable with evidence-based guidelines and an increasing awareness of the nurse’s role and ability to advocate for best care practices. A CLABSI rate of zero is the goal; patient safety is the priority.

Section 4: Conclusion

Summary

Now that you have finished viewing the course content, you should have learned the following:

• The severity of CLABSIs
• The causes and risk factors of CLABSIs
• The five components of the central-line bundle

Course Contributor

The content for this course was created by May M. Riley, MSN, MPH, RN, ACNP, CCRN, CIC, FAPIC. She is an infection control consultant at Stanford Health Care and a consultant editor for Critical Care Nursing Clinics of North America.

The content for this course was revised by Laura Bell, BSN, RN, CCRN. Laura is a SME writer for Relias with 12 years of acute care experience in nursing. She began working in critical care at Wake Med Cary Hospital in 2011 and obtained her CCRN certification in 2016. She continues to work in the intensive care unit at Wake Med Cary Hospital as a supplemental staff nurse.

Resources

CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections: https://www.cdc.gov/infectioncontrol/pdf/guidelines/bsi-guidelines-H.pdf

Summary of Recommendations from the CDC: https://www.cdc.gov/infectioncontrol/guidelines/bsi/index.html#rec20

CDC Surveillance Information and Criteria for Blood Stream Infection: https://www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf

CDC TAP Central Line-Associated Bloodstream Infections (CLABSI) Implementation Guide: Links to Example Resources

https://www.cdc.gov/hai/prevent/tap/clabsi.html

The Joint Commission CLABSI Toolkit: https://www.jointcommission.org/resources/patient-safety-topics/infection-prevention-and-control/central-line-associated-bloodstream-infections-toolkit-and-monograph/

References

Afonso, E., Blot, K, & Blot, S. (2016). Prevention of hospital-acquired bloodstream infections through chlorhexidine gluconate-impregnated washcloth bathing in intensive care units: A systematic review and meta-analysis of randomized crossover trials. Eurosurveillance, 21(46). https://doi.org/10.2807/1560-7917.ES.2016.21.46.30400

Agency for Healthcare Research and Quality (AHRQ). (2018). Appendix 3: Guidelines to prevent central line-associated blood stream infections. https://www.ahrq.gov/hai/clabsi-tools/appendix-3.html#sl4

Alonso-Echanove, J., Edwards, J. R., Richards, M. J., Brennan, P., Venezia, R. A., Keen, J., Ashline, V., Kirkland, K., Chou, E., Hupert, M., Veeder, A. V., Speas, J., Kaye, J., Sharma, K., Martin, A., Moroz, V. D., & Gaynes, R. P. (2003). Effect of nurse staffing and antimicrobial-impregnated central venous catheters on the risk for bloodstream infections in intensive care units. Infection Control and Hospital Epidemiology, 24(12), 916-925. https://doi.org/10.1086/502160

Aloush, S. M. & Alsaraireh, F. A. (2018). Nurses’ compliance with central line associated blood stream infection prevention guideline. Saudi Medical Journal, 39(3), 273-279. doi: 10.15537/smj.2018.3.21497

Bukhari, S. Z., Banjar, A., Baghdadi, S. S., Baltow, B. A., Ashshi, A. M., & Hussain, W. M. (2014). Central line associated blood stream infection rate after intervention and comparing outcome with National Healthcare Safety Network and International Nosocomial Infection Control Consortium data. Annals of Medical and Health Sciences Research, 4(5), 682-686. doi: 10.4103/2141-9248.141499

Centers for Disease Control and Prevention. (2020, January). Bloodstream infection event (central line-associated infection and non-central line-associated bloodstream infection). http://www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf

Centers for Medicare and Medicaid Services (CMS). (2020, February 11). Hospital-acquired conditions. https://www.cms.gov/medicare/medicare-fee-for-service-payment/hospitalacqcond/hospital-acquired_conditions.html

Crnich, C. J. & Maki, D. G. (2014). Intravascular device infection. In P. Grota, APIC Text of Infection Control and Epidemiology (4th ed.). Association for Professionals in Infection Control and Epidemiology.

Furuya, Y. E., Dick, A. W., Herzig, C. T., Pogorzelska-Maziarz, M., Larson, E. L., & Stone, P. W. (2016). Central line-associated bloodstream infections reduction and bundle compliance in ICUs: A national study. Infection Control and Hospital Epidemiology, 37(7), 805-810. doi: 10.1017/ice.2016.67

Institute for Healthcare Improvement (IHI). (2012). Central line infection. http://www.ihi.org/topics/centrallineinfection/Pages/default.aspx

Ista, E., van der Hoven, B., Kornelisse, R. F., van der Starre, C., Vos, M. C., Boersma, E., & Helder, O. K. (2016). Effectiveness of insertion and maintenance bundles to prevent central-line-associated bloodstream infections in critically ill patients of all ages: A systematic review and meta-analysis. The Lancet Infectious Diseases, 16(6), 724–734. doi: 10.1016/S1473-3099(15)00409-0

Karlowsky, J. A., Jones, M. E., Draghi, D. C., Thornsberry, C., Sahm, D. F., & Volturo, G. A. (2004). Prevalence and antimicrobial susceptibilities of bacteria isolated from blood cultures of hospitalized patients in the United States in 2002. Annals of Clinical Microbiology and Antimicrobials, 3(7). doi: 10.1186/1476-0711-3-7

Lee, K. H., Cho, N. H., Jeong, S. J., Kim, A. N., Han, S. H., & Song, Y. G. (2018). Effect of central line bundle compliance on central line-associated bloodstream infections. Yonsei Medical Journal, 59(3), 376-382. doi: 10.3349/ymj.2018.59.3.376

Lin, K. Y., Cheng, A., Chang, Y. C., Hung, M. C., Wang, J. T., Sheng, W. H., Hseuh, P. R., Chen, Y. C., & Chang, S. C. (2017). Central line-associated bloodstream infections among critically-ill patients in the era of bundle care. Journal of Microbiology, Immunology, and Infection, 50(3), 339-348. https://doi.org/10.1016/j.jmii.2015.07.001

Lorente, L., Jimenez, A., Santana, M., Iribarren, J. L., Jimenez, J. J., Martin, M., & Mora, M. (2007). Microorganisms responsible for intravascular catheter-related bloodstream infection according to the catheter site. Critical Care Medicine, 35(10), 2424-2427. doi: 10.1097/01.CCM.0000284589.63641.B8

Marschall, J., Mermel, L. A., Fakih, M., Hadaway, L., Kallen, A., O’Grady, N., Pettis, A. M., Rupp, M. E., Sandora, T., Maragakis, L. L., & Yokoe, D. S. (2014). Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infection Control and Hospital Epidemiology, 35(7), 753-771.

Mathew, R., Simms, A., Wood, M., Taylor, K., Ferrari, S., Rhein, M., Margallo, D., Bain, L., Valencia, A. K., Bargmann-Lasche, J., Donnelly, L., & Lee, G. M. (2020). Reduction of central line-associated bloodstream infection through focus on the mesosystem: Standardization, data, and accountability. Pediatric Quality and Safety, 5(2). doi: 10.1097/pq9.0000000000000272

Ng’ambi, D. (2018). Opinions of nurses in ICU on the importance and utilization of the CLABSI prevention bundle in an academic hospital in Gauteng. [Master’s thesis, University of the Witwatersrand, Johannesburg). http://wiredspace.wits.ac.za/bitstream/handle/10539/29116/Ng’ambi.dorica.research%20report.pdf?sequence=1

O’Grady, N. P., Alexander, M., Burns, L. A., Dellinger, E. P., Garland, J., Heard, S. O., Lipsett, P. A., Masur, H., Mermel, L. A, Pearson, M. L., Raad, I. I., Randolph, A., Rupp, M. E., Saint, S., & the Healthcare Infection Control Practices Advisory Committee (HICPA). (2017). Guidelines for the Prevention of Intravascular Catheter-Related Infections. Centers for Disease Control and Prevention. https://www.cdc.gov/infectioncontrol/pdf/guidelines/bsi-guidelines-H.pdf

Ratz, D., Hofer, T., Flanders, S. A., Saint, S., & Chopra, V. (2016). Limiting the number of lumens in peripherally inserted central catheters to improve outcomes and reduce cost: a simulation study. Infection Control and Hospital Epidemiology, 37(7), 811-817. doi: 10.1017/ice.2016.55

Richards, G. A., Brink, A. J., Messina, A. P., Feldman, C., Swart, K., & van den Bergh, D. (2017). Stepwise introduction of the ‘Best Care Always’ central-line-associated bloodstream infection prevention bundle in a network of South African hospitals. Journal of Hospital Infection, 97(1), 86-92. doi: 10.1016/j.jhin.2017.05.013

Sax, H., Allegranzi, B., Uçkay, I., Larson, E., Boyce, J., & Pittet, D. (2007). ‘My five moments for hygiene’: A user-centered design approach to understand, train, monitor, and report hand hygiene. Journal of Hospital Infection, 67, 9-21. doi:10.1016/j.jhin.2007.06.004

Scott, S. K., Gohil, S. K., Quan, K., & Huang, S. S. (2016) Marked reduction in compliance with central line insertion practices (CLIP) when accounting for missing CLIP data and incomplete line capture. American Journal of Infection Control, 44(2), 242-244. doi: 10.1016/j.ajic.2015.09.007

Sievert, D. M., Ricks, P., Edwards, J. R., Schneider, A., Patel, J., Srinivasan, A., Kallen, A., Limbago, B., Fridkin, S., & National Healthcare Safety Network (NHSN) Team and Participating NHSN Facilities. (2015). Antimicrobial-resistant pathogens associated with healthcare-associated infections: summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2009-2010. Infection Control Hospital Epidemiology, 34(1), 1-14. doi: 10.1086/668770

Templeton, A., Schlegel, M., Fleisch, F., Rettenmund, G., Schobi, B., Henz, S., & Eich, G. (2008). Multilumen central venous catheters increase risk for catheter-related bloodstream infection: Prospective surveillance study. Infection, 36(4), 322-327. doi: 10.1007/s15010-008-7314-x

The Joint Commission. (2012). Preventing Central Line–Associated Bloodstream Infections: A Global Challenge, a Global Perspective. https://www.jointcommission.org/-/media/deprecated-unorganized/imported-assets/tjc/system-folders/topics-library/clabsi_monographpdf.pdf?db=web&hash=86103821F3C7FF8A7683C933EA0CB391

The Joint Commission. (2013, November 20). Preventing central line-associated bloodstream infections: Useful tools, an international perspective. Nov 20, 2013. http://www.jointcommission.org/CLABSIToolkit

The Joint Commission. (2019). 2019 Hospital national patient safety goals. https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2019_hap_npsgs_final2.pdf?db=web&hash=D549154BF89A129B026D9F853D889F69

Valencia, C., Hammami, N., Agodi, A., Lepape, A., Herrejon, E. P., Blot, S., Vincent, J. L., & Lambert, M. L. (2016). Poor adherence to guidelines for preventing central line-associated bloodstream infections (CLABSI): Results of a worldwide survey. Antimicrobial Resistance and Infection Control, 49. doi: 10.1186/s13756-016-0139-y

World Health Organization (WHO). (n.d.). Infection prevention and control: My 5 moments for hand hygiene. https://www.who.int/infection-prevention/campaigns/clean-hands/5moments/en/

Zimlichman, E., Henderson, D., Tamir, O., Franz, C., Song, P., Yamin, C. K., Keohane, C., Denham, C. & Bates, D. W. (2013). Health-care associated infections: A meta-analysis of costs and financial impact on the US health care system. JAMA Internal Medicine, 173(22), 2039-2046. doi:10.1001/jamainternmed.2013.9763