Catheter Care Bundle for Prevention of Central Line Associated Infection (CLABSI)

STUDY PURPOSE: To develop an evidence-based guideline on central venous catheter (CVC) care for patients with cancer

TYPE OF STUDY: Systematic review

DATABASES USED: MEDLINE (PubMed) and the Cochrane Collaboration Library

KEYWORDS: Authors did not state which keywords were utilized.

INCLUSION CRITERIA: As long as the randomized clinical trials included a majority of patients with cancer, they were included for this review. Most recent trials were included as opposed to older trials. Authors searched from 1980–July 2012 in databases that were published in English.

EXCLUSION CRITERIA: No specific exclusion criteria were mentioned by authors. Randomized controlled trials (RCTs) were excluded if patients with CVCs were compared to patients with permanent catheters.

TOTAL REFERENCES RETRIEVED = 133, plus an unspecified number of pre-existing guidelines that were discovered during the search

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: 108 RCTs of patients with cancer and 25 meta-analyses or systematic reviews were found in the search. Several pre-existing guidelines also were discovered during the literature search.

• FINAL NUMBER STUDIES INCLUDED = 133, plus an unspecified number of pre-existing guidelines that were discovered during the search, 108 RCTs, and 25 meta-analyses
• KEY SAMPLE CHARACTERISTICS: Patients with cancer; patients with cancer with CVC access

• PHASE OF CARE: Active antitumor treatment     
• APPLICATIONS: Pediatrics, elder care, palliative care

Not enough evidence was found to suggest only one type of CVC for patients or to suggest only one insertion site or approach for tunneled lines. A CVC bundle should be used for line insertion and maintenance. 

Evidence is insufficient to recommend one type of CVC for patients with cancer. The choice of catheter needs to be patient-specific, avoiding femoral lines because of increased risk of infection. Hand hygiene, barrier precautions during catheter insertion and utilization, and chlorhexidine skin antisepsis during insertion are recommended to prevent catheter-related infections. Cultures should be drawn prior to antibiotic administration when an infection is suspected.

• No major limitations identified in meta-analysis

Hand hygiene and maximum barrier protection should be used during any type of catheter manipulation to avoid infection. Routine flushing with normal saline is recommended for patency. Blood cultures should be collected from CVCs prior to antibiotic administration. Tissue plasminogen activator should be used for catheters with patency issues. Routine prophylaxis with anticoagulants is not recommended for catheter-associated thrombus.

To summarize existing adult and pediatric data on central venous catheter (CVC)-related bloodstream infections (BSIs) and identify models of care that can improve pediatric oncology outcomes.

Databases searched were PubMed, CINAHL, and Google Scholar (1998–2010).

Keywords searched were CVC, BSI, and pediatric oncology.

Patients were included if they

• Had a central venous access device.
• Had the device in place 48 hours prior to development of symptoms and/or culture.
• Had a confirmed culture unrelated to another site.
• Reported a fever of higher than 100.4ºF.

No exclusion criteria were specified.

• The total number of studies included was 24. 
• The studies provided 8,682 total cases; the sample range was not relevant.
• Patients were either adult or pediatric in terrtiarty hospitals or intensive care units. 
• Diagnoses involved were not described, although pediatric oncology was included.
   

• Patients were undergoing the active antitumor treatment phase of care. 
• The study has clinical applicability for pediatrics.

Strategies to reduce CVC-related BSIs reported were summarized.  In regard to insertion site selection and catheter type, some data supported the use of an externalized catheter versus a port in children.  Use of impregnated catheters in children is controversial. Evidence-based guidelines (CVC “bundles”) have been shown to be effective to reduce BSI rates.

Bundles include

• Hand hygiene
• Full barriers at insertion
• Chlorhexidine skin cleansing
• Avoiding the femoral site
• Removal of all unnecessary catheters.

For CVC education, studies showed that annual education enhanced adherence to policy.

Findings suggested that the implementation of CVC care bundles was effective in reducing CVC-related BSI rates.
 

Most studies involved critical care patients and not necessarily those with cancer who would be more immunocompromised.  There was limited research information on pediatric oncology cases.

This review supported the use of CVC care bundles to reduce rates of CVC-related BSIs.  Findings suggested that regular and repeated education on CVC care can improve adherence to care protocols.

To assess the feasibility of instituting a multicenter effort to standardize central line (CL) care and CL-associated bloodstream infection (CLABSI) tracking while quantifying the impact of standardizing these processes on CLABSI rates among pediatric patients

A CL maintenance bundle was developed using Centers for Disease control and Prevention guidelines and recommendations as well as best practices from previous pediatric CLABSI efforts. These guidelines included (a) a reduction in the number of CL manipulations and entries, (b) the maintenance of a sterile entry to CL (hand hygiene and sterilization of port), (c) and standardized CL care practices (date and time cap, tubing/dressing/needle changes, standardized procedure). Tubing changes were every 96 hours and every 24 hours for blood products and lipids. Staff members audited the CLABSI bundle practice monthly using a standard form and submitted unit profile information. Teams met in two-day learning sessions annually and interacted monthly via webinars.

• N = 28 separate units  
• KEY DISEASE CHARACTERISTICS: 50% hematology or oncology and transplant; 36% hematology or oncology; 7.1% oncology and transplant; and 7.1% transplant only
• OTHER KEY SAMPLE CHARACTERISTICS: Units varied in size (8–48 beds); two thirds of teams were Magnet hospitals; 93% of patients were afebrile, neutropenic, postintensive chemotherapy patients with acute myeloid leukemia in inpatient settings waiting for count recovery; none of the units used antimicrobial impregnated catheters; a third used chlorhexidine gluconate baths in at least some patients; half involved patients and families in daily rounds

• SITE: Multi-site    
• SETTING TYPE: Inpatient    
• LOCATION: United States

• PHASE OF CARE: Active antitumor treatment
• APPLICATIONS: Pediatrics

Cohort comparison study

Teams reported baseline data regarding CLABSI from January 2006 and October 2009. These data were compared to the intervention period from November 2009 to August 2012. CLABSIs were tracked as number per 1,000 CL days per month. CLABSIs occurring more than 48 hours after hospital admission and less than 48 hours prior to hospital discharge were deemed inpatient events and included in measurements.

Across 46 months, precollaborative effort CLABSI rates were 2.85 per 1,000 CL days. During the first 34 months after the intervention, that rate was 2.04 per 1,000 CL days (p = 0.05). The odds for having no CLABSIs per unit per month was 2.59 higher during the collaborative intervention (p = 0.01). The compliance with recommended CL maintenance increased rapidly over the first year from 38% at baseline to 79% by the end of the first year. It remained at a rate of 81%–86% during the remainder of the intervention period.

The 28% reduction during the first 2.5 years suggested the elimination of about 290 CLABSIs over that period with an estimated reported cost savings of about $11 million. It was feasible to implement a standardized CL maintenance care bundle, track CL infections with standardized definitions, and generate benchmark data across a large network of centers. The implementation of a standardized catheter care bundle in a multi-instutituional collaborative effort was associated with reduced CLABSI rates.

• Risk of bias (no control group)
• Measurement validity/reliability questionable
• Other limitations/explanation: Retrospective study design; reliability of self-reported adherence to all aspects of the care protocol was not examined; patient characteristics in terms of infection risk were not described

Nurses are on the front lines when it comes to CLABSI prevention. This report demonstrated the effectiveness of a multisite collaborative initiative to reduce CLABSI rates. The implementation of a specific care bundle, monthly practice auditing, monthly webinars, and annual education of care teams involved was reported to be effective. This report provides suggested approaches for such initiatives and demonstrates associated improvement in quality and cost reduction.

To investigate the effects of the implementation of a central line catheter care bundle on infection rates.

A working group comprised of physicians specializing in pediatric hematology-oncology, infectious diseases, anesthesiology, and surgery, as well as infection-control professionals, a phlebotomy service leader, and several nursing leaders, was formed to focus on improvement in central line-associated blood stream infection (CLABSI) rates. Team members were educated in quality improvement for a four-month period and developed techniques to improve the safety culture, identify best practices for insertion and line maintenance, and disseminate information to clinical care providers. A catheter care bundle was implemented, including proper hand hygiene, dressing change frequency, skin cleansing with chlorhexidine, tubing changes at least every 96 hours, chlorhexidine used for bathing, and standards for central line entry. Pre- and postimplementation data were analyzed at six months from the beginning of the effort and at 17 months.

• One hundred thirty patients were included.
• One hundred two CLABSI events occurred.  
• All participants were pediatric patients with cancer; some had undergone hematopoietic cell transplantation (HCT).

• Single site 
• Inpatient
• Michigan

This was a descriptive observational study.

• Nurse self-report of bundle care compliance
• CLABSI rate (calculated as events by number of patient days)
• Agency for Healthcare Research & Quality (AHRQ) patient safety culture survey
• CLABSI identification according to National Healthcare Safety Network (NHSN) methods

Self-reported adherence to catheter bundle care was more than 90% in most areas.  Lowest compliance areas were bathing practices and “all or none” (compliance with everything) areas in the first six months.  These both improved to more than 85% at 17 months. The preintervention CLABSI rate was 5.55% in patients undergoing bone marrow transplantation (BMT) and 1.81% in non-BMT patients. Postintervention CLABSI rates were 2.96% in BMT patients and 1.04% in non-BMT patients (p < 0.04). Patient safety culture survey results reflected improvement; however, sample sizes were small with low response rates, and comparisons were not statistically significant.

Findings showed that the institutional initiative used here was effective in reducing CLABSI rates.

• Measurement validity/reliability was questionable.
• CLABSI calculation did not use catheter patient days as the denominator, which influenced the results. 
• Self-reported compliance may not be accurate. 
• Specific implementation, dissemination, monitoring, and feedback methods were not described.

Comprehensive institutional initiatives can improve quality of care. Catheter care bundle implementation was effective in reducing overall CLABSI rates as measured here. Results showed that it took time to achieve improvement in compliance with all aspects of catheter care.

To investigate whether a multidisciplinary, best practice central line maintenance care bundle reduces central line-associated blood stream infection (CLABSI) rates in hospitalized pediatric oncology patients and to further delineate the epidemiology of CLABSIs in this population.

The organization joined an effort to improve quality, focusing on CLABSI elimination through the implementation of best practice central line care bundles. The care bundle used was based on relevant Centers for Disease Control and Prevention (CDC) guidelines, including daily site assessment and dressings based on CDC recommendations; procedures for cap, tubing, dressing, and needle changes; catheter site care; and catheter hub, cap, and tubing care. Education on the Children’s Hospital Association (CHA) central line care bundle of reduction of line entries, aseptic entries into the line, and aseptic procedures when changing line components was performed. Nursing self-practice audits were performed prospectively, with a one day per week random nursing shift sampling for all patients with central lines. Targeted interventions were performed to improve compliance, including staff feedback of CLABSI rates, discussion in daily rounds, and mini root cause analysis in cases of CLABSI development. Ongoing individual and group education was performed based on the findings.

• Thirty patients (64% male, 36% female) were included.
• There were 14,059 central line days.
• Average age was 10.5 years.
• Key disease characteristics were hematologic and solid tumors and bone marrow transplantation (BMT).

• Single site 
• Inpatient 
• University-affiliated pediatric hospital in Maryland

• Patients were undergoing the active antitumor treatment phase of care. 
• The study has clinical applicability for pediatrics.

This study was a prospective, interupted time series.

• Anonymous nursing self-practice audits were performed on a randomly chosen nursing shift, one day every week, as a sampling strategy for all unit patients with central lines. Nursing practice was only recorded as compliant with one of the bundle elements if every part of that bundle was documented as completed appropriately.
• The CLABSI rate was defined as CLABSIs per 1,000 central line days.

The unit experienced a 20% decrease in CLABSI rates after the implementation of the intervention (p = 0.58). Secondary analyses indicated that the second year of the intervention had a 64% decline in CLABSI rates below baseline (p = 0.091), suggesting that a long ramp-up period may be necessary to achieve effective change. At the end of 24 months of continuous improvement efforts, 35% of patients were not receiving all bundle elements.

Although the implementation of best practices for central line care to decrease CLABSIs is a viable intervention, the long time to significant results should be seriously considered ongoing education, and monitoring would be required, potentially increasing costs and decreasing staff interest in the intervention.

• Small sample size (<100 patients)
• Findings were not generalizable.
• It is unclear if the results from a single-institution study can be generalized to nontertiary care inpatient pediatric oncology units that do not care for a large number of BMT recipients.
• Strategies described here for improvement activities included some but not all of those strategies shown by evidence to be effective. Staff did not adhere to bundle care 35% of the time, but there is no information about the causes of the lack of adherence.
• Various patient types and types of central lines were included, with a varied risk of infection.
• The heterogeneity of the sample and lack of sufficient sample size for related subgroup analysis limited the ability to draw firm conclusions. 
• The relationship between bundle adherence and infection development were not fully discussed.

CLABSI prevention efforts focusing on central line maintenance are difficult, rely directly on front-line staff participation, and require patience for culture change but also have a profound effect on each nurse who has worked to prevent an infection from occurring.  Nurses need to be aware of the evidence regarding effective approaches to improve guideline adherence and performance of evidence-based practice and use known effective strategies.  Causes of nonadherence to guidelines need to be identified in order for ongoing improvement.  With bundle approaches, it might be useful to analyze which bundle items are truly critical to the outcome.

To provide evidence-based recommendations for the prevention of intravascular catheter-related infections for healthcare personnel who insert and care for intravascular catheters and for those responsible for surveillance and infection control in hospital, outpatient, and home health settings. Patients addressed in the guidelines were adult and pediatric patients with intravascular catheters.

The resource is comprised of evidence-based guidelines. For the development process, evidence was categorized as category 1A to category 2 based on strength of recommendation and support from clinical or epidemiological studies.

• Patients were undergoing multiple phases of care.
• The study has clinical applicability for pediatrics. 

The results were not summarized.

The guidelines provided extensive recommendations regarding the education and training of staff; selection of catheters and sites, including avoidance of the femoral vein for central venous access and use of the central venous catheter with the minimum number of ports needed; hand hygiene; use of maximal sterile barrier precautions for insertion; skin preparation with alcohol, iodine, or chlorhexidine; use of standard catheter site dressing regimens; specific aspects of care for umbilical and dialysis catheters; and use of piggybacks, stopcocks, and catheter flushing. Guideline recommendations include a bundling of multiple recommendations: antimicrobial-impregnated catheters and cuffs are recommended in patients with long-term use if the organizational central line-associated blood stream infection (CLABSI) rate is not decreasing despite the implementation of comprehensive strategies for improvement. Lower-level (category II) recommendations include the use of prophylactic antimicrobial lock solutions in patients with long-term catheters who have a history of CLABSIs despite optimal aseptic technique as well as daily cleansing of patients in the intensive care unit with 2% chlorhexidine-impregnated washcloths. Recommends changing IV administration sets no more often than every 96 hours unless used for blood products. For needleless components, recommends changing according to administration set timing as above, and states no benefit to changing more than every 72 hours.

Provides extensive recommendations for management of all types of intravenous catheters and system components. Nurses should refer to the full set of guidelines for all specific aspects of care.

To identify risk factors for developing catheter-related infections (CRIs) and interventions to prevent CRIs in patients with central venous catheters (CVCs)

The guidelines were developed by reviewing studies to identify populations at risk and interventions effective in preventing CRIs. Key words searched included catheter-related infections, guidelines, neutropenia, antimicrobial treatment, infection prophylaxis, and biofilm.

Strict procedures for hygiene during insertion of CVCs are effective in avoiding infections. CVC insertion through the subclavian vein rather than the internal jugular is better for preventing infections, but other risks, including severe hemorrhage, need to be assessed.  

For dressing changes and insertion site prep, chlorhexidine solution is preferred over aqueous polyvidone-iodine solutions, and alcoholic chlorhexidine solution, alcoholic polyvidone solutions, or 70% propranolol are alternatives noted to be safe. One randomized, controlled study showed that using alcoholic chlorhexidine in sequence with aqueous polyvidone-iodine was superior to using them as single agents.

Routine catheter replacement, systemic prophylactic antibiotic therapy prior to catheter insertion, and applying antibiotic ointment to the catheter site all show no benefit in preventing infections. Sterile gauze dressing changes every two days and transparent film dressings changed weekly are recommended in the absence of inflammation or loss of dressing integrity, but more frequent dressing changes do not reduce CRIs.

Infusion tubing is recommended to be changed every 72 hours with the exception of systems used for lipid emulsions recommended to be changed every 24 hours. Transfusion tubing should include standard filters for red blood cells or platelets and German regulations are specific about filter changes every six hours, noting that replacing filters at earlier intervals does not lower infection rate. Only one randomized trial of patients with cancer with nontunneled minocycline/rifampin-coated CVCs reported a decrease in bloodstream infections that were catheter-related. Recent randomized studies do not show a correlation between CRIs and the number of catheter lumen, as reported by earlier nonrandomized studies recommending single-lumen catheters.

Recommendations include

• Adhering to hygiene principles when inserting CVCs and employing standardized aseptic placement, using subclavian vein versus internal jugular vein for vascular access, and using catheters impregnated with antiseptics like chlorhexidine/silver sulfadiazine or antibiotics including minocycline/rifampin have been effective in reduction of catheter colonization. 
• Educating nurses and physicians.
• Using ultrasound guidance during insertion. 

Routine replacement of catheters is not effective in reducing CRIs. Antibiotic ointment at insertion site or applied to nostrils is not recommended. Systemic antibiotics are not recommended prior to CVC insertion as prophylaxis.

• No conflict of interest concerns were addressed.

Age (pediatrics), grade of neutropenia, catheter type, disease diagnosis, nurse-to-patient ratio, administration of parental nutrition, and number of days the patient has the CVC may all contribute to the risk of developing CRIs. It was suggested in two studies that in the hematologic/oncologic population, subclinical thrombosis of the catheterized vein as seen on ultrasound could be a significant risk factor for developing CRIs. Although some of the studies show benefit of antibiotic flushes to reduce CRIs, there are no prospective randomized, double-blind studies involving adults or pediatric patients with hematologic or solid tumors to determine if this practice will result in development of resistant bacteria. Although recommendations were shown in text and table using the A–E, I–III grading and evidence, no definitions or key were presented in this article.