1) Central venous catheters are a major cause of bloodstream infections, with approximately 90% occurring through CVCs. Between 500-4000 patients die annually from CVC-related BSIs. 2) The Institute for Healthcare Improvement developed bundles of best practices to prevent CVC-related BSIs which include hand hygiene, maximal sterile barriers, chlorhexidine skin antisepsis, and optimal site selection. When these bundles are applied consistently, they result in greater reductions in infection rates. 3) Hospitals have implemented policies and provided supplies to help staff consistently follow the CVC bundle. This includes designated CVC insertion carts stocked with supplies, requirement that physicians use full sterile barriers, and

1. Central Venous Lines and
Blood Stream Infections
Breaking out the Bundles
Elizabeth Gilger, RN, CCRN
Medical University of South Carolina

2. Infection Control
Did you know?
Approximately 90% of catheter related
blood stream infections (BSI) occur with
central venous catheters (CVC)
Between 500 and 4,000 patients die
annually from BSI
Institute for Healthcare Improvement, 2007

3. Infection Control
Did you know?
Mortality of ventilated patients who
develop VAP is 46 %
$40,000 is the estimated cost
accumulated due to VAP
Institute for Healthcare Improvement, 2007

4. Blood Stream Infections
Disruption of the integrity of the skin
creates an avenue for infection
Infection spreads to the bloodstream
leading to Hemodynamic changes and
organ dysfunction and potentially may lead
to death

5. Institute for Healthcare
Improvement (IHI)
Developed in 1991 to improve health care
worldwide
Developed improvement measures based on
research. Many of these measures had been
previously recommended by CDC in their
guidelines for the prevention of CVL related
bloodstream infections.
Incorporated bundles into the healthcare culture
to ensure standardized practice

6. What is a bundle???
Bundles are groupings of best
practices with respect to a
disease process that
individually improve care, but
when applied together result in
substantially greater
improvement.
Institute for Healthcare Improvement, 2007

7. Central Line Bundle
Hand Hygiene
Maximal Barrier Precautions Upon
Insertion
Chlorhexidine Skin Antisepsis
Optimal Catheter Site Selection, with
Subclavian Vein as the Preferred Site for
Non-Tunneled Catheters
Daily Review of Line Necessity with
Prompt Removal of Unnecessary Lines

8. Think Outside the Bundle
CVL Assessment
– Each shift, assess for patency, site condition
and dressing patency
– If the CVL was placed in a true clinical
emergency, the line is to be changed after 24
hours

9. Think Outside the Bundle
CVL Care
– Change transparent dressings every 7 days,
those you cannot visualize the site i.e. gauze
dressing, change every 24 hours
– Change tubing and caps every 72 hours
– Cleanse caps prior to tubing change, IVP
medication or flushing with alcohol swab. Use
friction!

10. Insertion
Site selection-recommended site in adults is the
subclavian site. For pediatrics-no data.
Full barrier precautions should be used-MDs
should use gown, hat, gloves and mask. If you
are in and out of the room, wear a mask. If you
stand there the entire time, you should use full
barriers, too.
Antibiotic impregnated catheters recommended
for lines that are anticipated to remain 7 days or
more.

11. Policy 75-A
Prior to placement of the line, someone, usually the RN,
is designated to monitor the sterile field and practice.
This designee must stop the procedure if the
appropriate steps are not followed.
If the patient is conscious, the designee will stop the
procedure by saying “Break Scrub”: indicating to the
clinician that the bundle has not been followed and the
procedure must be stopped.
If the clinician does not stop the procedure, the RN is to
notify the nurse manager.
Find this checklist on the Clinician’s Order site at
http://www.musc.edu/cce/ORDFRMS/

13. CVL Insertion Carts and Supplies
To facilitate adherence to the bundle, carts
are being purchased for nursing units
These carts will hold necessary supplies
Physicians have participated in the
selection of drapes for the adult and
pediatric populations.
A variety of drapes are available in
different styles and sizes.

14. CVL Cart
1. After use, clean cart thoroughly with Cavicide.
2. For isolated patients, avoid taking cart inside the room.
3. Restock after each use from the Pyxis, charging supplies to the
patient.
4. Check daily to make sure lock is secure.
3 rolls of tape 6 OpSites 6 Chlorapreps
2 boats 4 x 4s 4 Biopatch
6 10 ml syringes 4 packs KY 4 vial adaptors
2 transducer covers 4 vials 30 ml saline 6 injection ports
3 sterile gowns
Sterile Gloves: 2 of Box of hats Box of masks
each 6.5, 7,
7.5 and 8
2 Proxima Drapes 2 Arrow Drapes
2 triple lumens 1 Long Quinton 2 Cordis
2 quad lumens 1 Short Quinton

15. And wash your hands!!!!!!!!
You can’t be
too clean!!!
http://www.learnovation.com/johnwise_samples.htm

16. Question 1
1. Which of the following personal
protective equipment are required to be
worn by the physician for central venous
line insertion?
a) Gloves and gown
b) Gloves, gown and mask
c) Gloves, gown, mask, and hat
d) None of the above

17. Question 2
2. The preferred site for central venous line
placement in adults is
a) Jugular vein
b) Femoral vein
c) Subclavian vein
d) All of the above are acceptable

18. Question 3
3. The Central Line Bundle includes all of
the following except:
a) Hand hygiene
b) Daily review of line necessity
c) Ensuring optimal site selection
d) Chlorhexidine skin antipsesis
e) Keeping the HOB elevated 30 degrees

19. Question 4
4. The RN or designee in the CVL
placement procedure has the authority to
stop the procedure if sterile technique is
broken by saying:
a) “Time Out”
b) “Break Scrub”
c) “STOP!”
d) The RN or designee cannot stop the
procedure

20. CONSISTENCY IS BEST PRACTICE