Reducing Central Venous Line Infection
Eileen D. Ibanez Medical Careers Institute

Introduction Central venous access devices are used to administer chemotherapy, long-term antibiotics, parenteral nutrition, fluids and blood transfusion therapy. It is used for treatment of patients requiring long-term treatment for various health care disorders (WebMd, n.d.). Central venous catheters can also increase the risk of hospital-acquired bloodstream infections, which in turn will increase the length of hospital stay, total costs of care and risk of mortality (Hatler, Buckwald, Salas-Allison & Murphy-Taylor, 2009). The lack of use in consistent protocols for central venous access devices accrue an approximately 250,000 bloodstream infections in U.S hospitals yearly (Hatler et al., 2009). An estimated 90,000 deaths a year result from these bloodstream infections associated with intravascular catheters (Hatler et al., 2009). The health care system averages $25,000 to $40,000 per incidence (Mathers, 2011). The identification of proper and/or improper practice and application of evidence-based practice protocols is essential to keeping catheter patency and prevention of infections.
Definition of Topic Stated by the authors of Evidence-based Practice to Reduce Central Line Infections, “a catheter related blood stream infection is defined as a positive blood culture with clinical or microbiologic evidence that strongly implicates the catheter as the source of infection” (Render et al., 2006, p. 254). What, besides what we already are taught to perform, can be further done to reduce the percentage of blood stream infection in central venous catheters and access devices? Existing practices used for infection control of central line placement include maximal barrier precautions, which consists of strict compliance with hand hygiene, wearing a cap, mask, sterile gown, and gloves, and use of an ant-infective coating for the catheter. Nursing care includes dressing site care, aseptic port handling and prompt removal of central access device to maintain infectious free catheters (Hatler et al., 2009). Ways to help improve education is to develop a consistent and valid check off list that can be used to standardize aseptic practice with evidence-based guidelines and to determine how an educational program on central venous access care can affect nurses’ overall knowledge (Labeu et al., 2008).
Relevance and Significance
Doctors and nurse practitioners insert central venous lines, but the responsibility for the care of the central venous access devices and lines lies primarily with nurses. The priority nursing goal is prevention of infection (Scales, 2011). Using standardized protocols, including the removal of betadine in central kits, a larger drape to allow for a more sterile field and a checklist for sequential line insertion improve accuracy (Render et al., 2006). By ensuring the knowledge and skills necessary to prevent harm, nurses can focus on patient care and live up to the trust those patients and their families instill in their nurses (Scales, 2011).
Evidence Findings In the research associated with Mather’s Evidence based practice: improving outcomes with patients with a central venous access device, is focused towards continued education on standardized flushing protocols. In-hospital services were provided for a regional medical facility in Williamsport, Pennsylvania (Mathers, 2011). Data for the research was attained through a knowledge based questionnaire and direct observation. Data was taken prior to education series to allow for baseline analysis. The research analysis was comprised of a questionnaire containing content knowledge questions relating to central venous access device flushing and a tool used to evaluate nurses’ central device flushing technique. The tool was comprised of a yes or no survey administrated by a research proctor. Analysis shows that an significant increase from pre-educational values. Knowledge outcome scores increased from by 19.89% and skill outcomes increased by 31% (Mathers, 2011). Continued in-service education offers validity of the research. Not only was their an improvement in knowledge base but techniques in central device flush improved. The reliability of the research provided limitations to proper observation of all nurses in pre and post educational stages in flushing techniques. This decreases the accuracy in percentage of improvement from base line data in skill. Outcomes in knowledge skill still ranks higher than base line analysis (Mathers, 2011). In the greater metropolitan area of Cincinnati, research allowed for comparison between ten different hospitals within the area. Hospitals implemented one change a month from standard infection control with central venous devices. These changes were observed and recorded and then presented to other hospitals regarding change in improvement. A change in skin cleanser with chlorhexidine instead of betadine has helped to decrease blood stream infection associated with central lines (Render et al., 2006). Skin cleansing should consist of a 30-second scrub, followed by a 30-second dry period. The accessibility to purchase modifiable central line trays and accessory packs, that which includes a gown, facemask and cap allowed for increased reliability (Render et al., 2006). Adherence to face masks helps to prevent airborne contamination and securing intravenous tubing helps to prevent tugging at the entry site. (Hatler et al., 2009) Patency is improved with the use of positive-pressure valve caps. These positive-pressure valve caps work to prevent reflux of blood and catheter lumen occlusion. Actual flushing techniques also impact patency of central lines. Flushing technique varies with the type of valve cap used and in house education should be provided for staff nurses to ensure best practice and patient outcomes (Mathers, 2011). The ethics committee of Ghent University Hospital in Ghent, Germany establish a knowledge based questionnaire to evaluate nurses’ knowledge of proper prevention of infections with central venous catheters. 762 critical care nurses were evaluated on 10 question regarding: The frequency of CVC changes, frequency of changes in CVCs over a guide wire, frequency of changes in pressure transducers and tubing, use of coated CVCs, frequency of changes of catheter dressings, use of gauze and polyurethane catheter, dressings,
use of 2% aqueous chlorhexidine for disinfecting the insertion site, use of antibiotic ointment, f frequency of changes in administration sets when lipid emulsions were administered, frequency of changes in administration sets when neither lipid emulsions nor blood products were administered. (Labeu, 2008, p.66)
Results show that nursing staff had misunderstandings about time frame for line and tubing changing along with proper dressing to be used at catheter sites and type of disinfected solution. A panel of experts were compiled, all holding a master’s degree nursing science, to determine validity and reliability of the research. The panel of 7 surveyed the questionnaire for face and content validation. The experts considered the questionnaire valid and relevant to nursing practice. According to the American Family Physician define the level of evidence as the guideline for labeling the strength of evidence in evidence based clinical review. (AAFP, n.d.) The three research studies used fall under the classification of a level B rating associated with a non-randomized trial and use of a cohort trial in two studies.
Usefulness of the Evidence Assessment of nurses’ knowledge of evidence-based strategies involving appropriate central venous catheter insertion and care allow for proper intervention. The use of survey outcomes can provide for continuous and better educational programs (Labeu et al., 2008). Programs can also facilitate proper in hospital supervision by management and physicians. The evidence prove that not only will misconceptions be corrected but skill techniques can properly be observed and improved (Mathers, 2011). It is imperative for medical facilities to not only focus on new incoming information but to also to provide reinstitution of old information. Improvements in aseptic and flushing techniques only further confirm the need to re-educate nurses on the basics of nursing care. Reiteration of skills and proper technique can have a clear influence on improving patient outcomes. Improved nursing practice translates into improved patient outcomes and progressing to the ultimate focus of all health care providers (Mathers, 2011). Evidence base recommendation could include quarterly evaluation that includes pre-education evaluation and post-evaluation. Random evaluations should be implemented by nursing floor managers to have a secondary evaluation provided within the same 3 months. Future studies are required to decide the proper frequency of in-service education (Mathers, 2008).
Summary
Application of evidence based practice for infection control with central venous catheter and access devices is pertinent for optimal patient care. With the combination of aseptic technique, knowledge regarding types of appropriate equipment, and use of standardized protocols a decrease in blood stream infection induced by catheters can be remarkably reduced. Improvement of knowledge and skill level can lead to increased job satisfaction, motivation of nurses to become more proactive in the use of evidenced based practices and show an increase in excitability to discovery new practices (Mathers, 2008). An understanding of evidence based practice can provoke nurses to pursue existing knowledge related to other nursing practices as well. Policy change will soon be advocated to transform nursing care from traditional to evidence-based practice. This can ultimately provide further advancement of nurses and improve the health care field as a whole (Mathers, 2008).

Reference
Central Venous Catheters-Topic Overview. (n.d.). WebMD - Better information. Better health. Retrieved January 13, 2012, from http://www.webmd.com/pain-management/tc/central- venous-catheters-topic-overview
Halter, C., Buchwald, L., Salas-Allison, Z., & Murphy-Taylor, C. (2009). Evaluating central venous catheter care in a pediatric intensive care unit. American Journal Of Critical Care, 18(6), 514-520. doi:10.4037/ajcc2009168
Labeau, S., Vereecke, A., Vandijck, D., Claes, B., & Blot, S. (2008). Critical care nurses' knowledge of evidence-based guidelines for preventing infections associated with central venous catheters: an evaluation questionnaire. American Journal Of Critical Care, 17(1), 65-72.
Mathers, D. (2011). Evidence-based Practice: Improving Outcomes for Patients with a Central Venous Access Device. Journal Of The Association For Vascular Access, 16(2), 64-72. doi:10.2309/java.16-2-3
Render, M., Brungs, S., Kotagal, U., Nicholson, M., Burns, P., Ellis, D., & ... Hirschhorn, L. (2006). Evidence-based practice to reduce central line infections. Joint Commission Journal On Quality & Patient Safety, 32(5), 253-260.
Scales, K. (2011). Reducing infection associated with central venous access devices. Nursing Standard, 25(36), 49-56.