2. According to the National Health Safety Network (NHSN), a central
venous catheter or central line is “an intravascular catheter that :
o Terminates at or close to the heart or
o Is in one of the great vessels which is used for infusion, withdrawal of blood or
hemodynamic monitoring”.
The great vessels include the
o Aorta
o Pulmonary artery
o Superior and inferior vena cava
o Brachiocephalic veins
o Internal jugular veins
o Subclavian veins
o External iliac veins
o Common iliac veins
o Femoral veins,
o And in neonates, the umbilical artery/vein.
3. Venous access is one of the most basic yet critical components of
patient care both in hospital and ambulatory settings.
It is estimated that almost 300 million catheters are used each year
and nearly 3 million are central venous catheters (CVCs), otherwise
known as central lines.
They play an integral role in modern health care allowing for the
administration of IV fluids, medications, blood products, parenteral
nutrition as well as hemodialysis access and hemodynamic
monitoring.
For as long as patients have had CVC’s, infections have occurred.
o Central Venous Catheters are the most frequent cause of healthcare
associated bloodstream infection.
o An estimated 41,000 central line associated bloodstream infections occur in
U.S. Hospitals each year, causing prolonged hospital stays, increased
costs, and risk of mortality.
o Estimated costs for one central line infection ranges from $6,000 to
$30,000.
o Of all patients diagnosed with a central line infection, one in four will die.
4. Definition One
Central line-associated
bloodstream infections (CLABSI)
is a term used by US Centers for
Disease Control and
Prevention’s (CDC’s) National
Healthcare Safety Network
(NHSN)
Refers to a primary blood
stream infection in a patient that
had a central line within the 48
hour period before the
development of the blood
stream infection and is not
related to an infection at another
site.
Its definition is more practical for
Definition Two
Catheter related bloodstream
infection (CRBSI) is a more
clinical definition that requires
specific lab testing to identify the
catheter as the source for the
bloodstream infection and is not
typically used for surveillance
purposes.
There are 2 terms to describe intravascular catheter related infections and are
often used interchangeably even though their meanings differ.
5. National estimates of CLABSI rates are available through CDC’s NHSN, a
surveillance system of healthcare associated infections and are available on the
CDC’s website.
Recent acute rates range from 1.2 to 2.1 per 1000 catheter days.
The unit of measurement for these infections is based on the concept of "catheter
days." This combines the number of large vein catheters in use with the number of
days they are being used.
o For example, if in one particular month there were 12 cases of central line
associated bloodstream infections, the number of cases would be 12 for that
month.
o We want to be able to understand that number as a proportion of the total
number of days that patients had central lines. Thus, if 25 patients had central
lines during that month and, for purposes of example, each kept their line for 3
days, the number of catheter days would be 25 x 3 = 75 for that particular month.
The CLABSI Rate per 1,000 catheter days then would be 12/75 x 1000 = 160.
Even though the overall risk for central line related infections in the home setting are
low when compared to the inpatient setting, it is important to understand the
significant cost and human suffering related to this preventable problem.
Currently home health companies are not required to report incidences of catheter
related infections but are estimated to range from 0.24 to 0.45 per 1000 catheter
6. Risk factors for CLABSI can be either Intrinsic or
Extrinsic.
Age, gender, and underlying health conditions are all
examples of Intrinsic factors.
CLABSI rates are higher among children, particularly
neonates, and highest in Pediatric ICU’s, Adult Burn,
trauma and critical care units.
Hematological and Immunological deficient patients have
higher risk of CLABSI as well as underlying
gastrointestinal and cardiac diseases.
Female gender has lower incidences of CLABSI.
7. Extrinsic factors are potentially modifiable.
They include prolonged hospital stay prior to insertion of CVC,
multiple catheters, multi-lumen catheters, duration of catheter,
TPN administration, CVC site, and catheter type.
Femoral and internal jugular access sites have higher CLABSI
rates than subclavian sites in adult patients.
Non tunneled CVC’s account for the majority of CLABSIs.
Tunneled catheters and peripherally inserted central catheters
(PICC) have a lower rate of infection than non tunneled.
Implanted ports have the lowest infection rates.
Insertion procedure of central venous catheter plays a large
role in development of CLABSI.
Lack of maximum sterile barriers (cap, mask, sterile gloves,
sterile gown and full sterile drape) all increase risk as well as
insertion in an ICU or emergency department.
9. CLABSI can be prevented through proper insertion techniques,
management of the CVC while in place, and removal as soon as the
catheter is no longer necessary.
CVCs can be contaminated with microorganisms via 2 major routes,
extra-luminal and intra-luminal.
Extra luminal catheter infections typically occur within the first week
of placement.
The patient’s skin is considered the primary source of contamination
but can also include the healthcare provider’s hands.
During catheter insertion, organisms attach to the catheter as it
passes through the epidermis.
Attention to strict skin antisepsis and hand hygiene is likely the most
important intervention in preventing catheter associated infection.
10. Intra luminal infections occur when microorganisms directly enter
the internal catheter during manipulation of the IV system such as
accessing or connecting injection caps, tubing, or syringes to the
catheter.
Additionally, direct contamination from patient’s skin or own body
fluids can occur.
Less commonly, catheters become seeded from a secondary site of
infection such as a UTI or pneumonia.
Rarely, contamination of infusate such as IV fluid or medication can
be the source of infection.
11. Within minutes of venous access device insertion into the
bloodstream, the patient’s body reacts to the presence of a
foreign body and the damage to the endothelial lining of the
vein.
A fibrin layer or sheath begins to form on the catheter surface.
o Within 24 hours, a layer of platelets and white blood cells are
trapped in the fibrin layer.
o A thrombus may eventually form.
Like the fibrin layer, biofilm formation begins at the same time.
o Microorganisms introduced through the skin during venipuncture
and infusions colonize and interact with the fibrin.
o Some bacteria produce an extracellular polysaccharide known as
slime, which protects the bacteria from antibiotics.
o Bacteria from the biofilm that detach from either the internal or
external catheter surface can lead to a catheter associated
bloodstream infection.
o It can also result in a serious focal infection such as endocarditis.
o Once a biofilm is formed, eradication is difficult thus elimination of
microbial entry is paramount to prevention.
13. Coagulase negative staphylococci, staphylococcal
aureus, aerobic gram negative bacilli and Candida
albicans most commonly cause catheter related
bloodstream infections.
In most cases of non-tunneled CVC related bacteremia
or fungemia, the catheter should be removed.
For management of tunneled CVCs and implanted ports,
the decision to remove the device should be based on
the
o severity of the illness,
o presence of complications such as endocarditis, tunnel infection,
septic thrombosis or metastatic seeding.
14. Safe and reliable venous access is an important issue in
daily practice to prevent CLABSI.
In the acute care setting “bundles” or groups of
evidenced-based interventions have been created for
patients with central lines.
Conceived by the Institute for Healthcare Improvement
(IHI) these “bundles” result in better outcomes than when
implemented individually.
While there are no evidence-based “bundles” specific to
the homecare setting we must utilize the standards
provided and adapt to them to the homecare setting.
15. The key components of the IHI Bundle are:
o Hand hygiene
• http://www.ihi.org/knowledge/Pages/Changes/HandHygiene.aspx
o Maximum barrier Precautions upon Insertion
• http://www.ihi.org/knowledge/Pages/Changes/MaximalBarrierPrecaution
sUponInsertion.aspx
o Chlorhexidine Skin Antisepsis
• http://www.ihi.org/knowledge/Pages/Changes/ChlorhexidineSkinAntisep
sis.aspx
o Optimal Catheter Site selection, with avoidance in femoral vein for
Central Venous Access in adult patients
• http://www.ihi.org/knowledge/Pages/Changes/OptimalCatheterSiteSelec
tionwithAvoidanceofFemoralVeinforCentralVenousAccessinAdultPatient
s.aspx
o Daily review of Line Necessity with prompt removal of Unnecessary
Lines
• http://www.ihi.org/knowledge/Pages/Changes/DailyReviewofLineNeces
sitywithPromptRemovalofUnnecessaryLines.aspx
16. Since implementing the 5 elements in the Central Line
Bundle which was created in the 1990’s, hospitals
across the nation have seen results in lowering the
incidence of central line infections.
The CDC’s recommendations for Vascular catheter-
related infection prevention provides further measures
but are not limited to:
o Dressing change frequency
o Catheter replacement
o Antisepsis of injection ports
o Catheter selection
o Prophylactic antimicrobials
o Education.
17. Infections in the acute and home setting are preventable.
As a healthcare provider and role model, we must be
knowledgeable about infection transmission.
We must hold the highest standards and adhere to and
educate infection prevention interventions such as hand
hygiene, aseptic technique and infusion-related care.
It is our responsibility to ensure our patients receive the
best care determined by evidence-based research.
Tools to reduce and eliminate infections have been
provided to us. It is our role to utilize these tools to
improve our patients’ outcomes.
18. Joint Commission.org: Preventing Central Line-Associated Bloodstream Infections: A Global
Challenge, A Global Perspective
http://www.jointcommission.org/preventing_clabsi/
Gorski, L. Home Healthcare Nurse: 2010(28) 221-229
NHIA.org: CVAD guidelines for Home Infusion 2011(17)29-36
Poole, S. NHIA.org: Central Line Infection: Improving Our Surveillance, Treatment and Prevention
in the Home Setting 2009(15)31-35
CDC: 2011 Guidelines for the Prevention of Intravascular Catheter Related Infections
http://www.cdc.gov/hicpac/bsi/bsi-guidelines-2011.html
IHI: Implement the Central Line Bundle
http://www.ihi.org/knowledge/Pages/Changes/ImplementtheCentralLineBundle.aspx
Seigel, M, Kramer-Cain, J. Advance For Nurses: Vascular Catheter-Associated Infections. Learn
what measures can and should be taken. http://nursing.advanceweb.com/Article/Vascular-
Catheter-Associated-Infections-2.aspx
