Sandora, T.J., Graham, D.A., Conway, M., Dodson, B., Potter-Bynoe, G., & Margossian, S.P. (2014). Impact of needleless connector change frequency on central line-associated bloodstream infection rate. American Journal of Infection Control, 42, 485–489. 

DOI Link

Study Purpose

To determine the effect of changing needleless connectors (NC) frequently on central line–associated bloodstream infections (CLABSI) rates

Intervention Characteristics/Basic Study Process

The study was conducted among pediatric bone marrow transplantation (BMT) recipients and the oncology unit population, and was conducted and evaluated in three interrupted times. In time period 1, the healthcare professionals changed needleless connectors (NC) every 96 hours regardless of the infusion of blood products, lipids/total parenteral nutrition (TPN), and IV amphotericin B. In period 2, they changed NC every 24 hours only with blood products and lipids/TPN. In period 3, they changed the NC every 96 hours regardless of infusate. Moreover, they collected data on central venous catheter (CVC) bundle access, which involves hand hygiene and cleaning connectors with alcohol for 15 seconds. In a different general oncology unit, healthcare workers change connectors every 24 hours across all study periods. 

Sample Characteristics

  • N = None given, 44 CLABSI episodes    
  • AGE = Pediatric, no age specified
  • MALES: Not specified, FEMALES: Not specified
  • KEY DISEASE CHARACTERISTICS: Stem cell transplantation recipients and patients with cancer 
  • OTHER KEY SAMPLE CHARACTERISTICS: Blood product transfusion, lipids transfusion, and infusion of IV liposomal amphotericin B

Setting

  • SITE: Multi-site    
  • SETTING TYPE: Inpatient    
  • LOCATION: Boston, MA

Phase of Care and Clinical Applications

  • PHASE OF CARE: Multiple phases of care
  • APPLICATIONS: Pediatrics

Study Design

  • Retrospective cohort time series analysis

Measurement Instruments/Methods

  • Center for Disease Control (CDC) and the National Healthcare Safety Network (NHSN) guidelines for central venous catheter (CVC) care 
  • CLABSI rate was number of infections per 1,000 central-line days
  • CLABSI defined per National Healthcare Safety Network definitions

Results

There were significantly higher rates of CLABSI per 1,000 CVL days and per 1,000 transfusions compared with frequent changing of NC every 24 hours. In the study from years 2009–2012 with interrupted periods 1, 2 and 3 (p < 0.0001), the CLABSI were lower from period 2 to 3, reflecting the NC change frequency increase from every 24 hours to every 96 hours. Additionally, central-line access bundle with hand hygiene and cleaning the NC with alcohol for 15 seconds were reported to be high throughout the 3 study periods. The CLABSI rate with blood product and lipid infusions at baseline was 0.46. This increased to 3.73 during the period when connectors were changed every 24 hours, and decreased again to 0.004 with less frequent changes in period 3 (p < 0.001).

 

Conclusions

According to CDC and NHSN guidelines, NC should be changed every 24 hours, but this study suggests that frequent NC changes may increase the rate of CLABSI.

Limitations

  • Small sample (< 100)
  • Risk of bias (sample characteristics)
  • Measurement validity/reliability questionable
  • Sample size was not described appropriately.
  • Method of data collection and measurement for unit adherence to catheter care bundle guidelines was not described.

Nursing Implications

Nurses should follow CVC access bundle (i.e., hand hygiene, cleaning the NC with alcohol for 15 seconds) while handling CVCs. In addition, organizational policies may help decrease CLABSI and other infections among BMT recipients and patients with cancer as they are at a very high risk of acquiring bloodstream infections. The appropriate frequency of changing all IV line components is unclear. Additional research is needed to establish the evidence base for some infection prevention guidelines.