4589 Preventing Central Line- Associated Bloodstream ...guides.aurorapictures.com/4589.pdf · Kimberly-Clark Health Care Education 3 Preventing Central Line-Associated Bloodstream

4589

Preventing Central Line-Associated Bloodstream

Infections (CLABSI)

Study Guide

2

PreventingCentral Line-AssociatedBloodstream Infections_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

(CLABSI)

ACKNOWLEDGEMENTSWe would like to express our sincere appreciation to the following individuals

Dennis G. Maki M.D.Ovid O. Meyer Professor of Medicine

University of WisconsinSchool of Medicine and Public Health

Rita McCormick, RNSenior Infection Control Practitioner

University of WisconsinHospital and Clinics

Keith A. Rains, RN, BSN, CICInfection Prevention Professional

ECHCS Denver Medical Center

April Tracy, RN BSN IPInfection Prevention/Control Coordinator

T. J. Samson Community Hospital

Jeanne E. Zack, PhD., RN, CICManager,

Infection Prevention and ControlMissouri Baptist Medical Center

Association for Vascular Accesswww.avainfo.org

© Envision, Inc. 2009

Video produced and distributed by:

Envision, Inc.644 West Iris DriveNashville, TN 37204

1-866-321-5066www.EnvisionInc.net

Kimberly-Clark Health Care Education 3

Preventing Central Line-AssociatedBloodstream Infections

(CLABSI)

Table of Contents

Instructions for Continuing Education Credit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

I. Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

II. Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

III. Central Lines and Their Uses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

IV. Central Line Infection Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

V. Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

VI. How Do We Create Change and Prevent Central Line Infections? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

VII. Catheter Selection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

VIII. Site Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

IX. Infection Prevention Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

X. Catheter Insertion Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

XI. Care and Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

XII. Patient Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

XIII. Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

XIV. Enhanced Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

XV. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

XVI. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

XVII. Post Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

XVIII. Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

A. Nursing Checklist: Central Venous Catheter Insertion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

B. “Save That Line” Poster and Note Card . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

XIX. Continuing Education Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

XX. Program Evaluation Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

XXI. Post Test Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

444

Instructions for Continuing Education CreditThis program has been approved by Envision, Inc. for 1.0 Contact Hour, Program Number 006CLABSI10.

Envision, Inc. is an approved provider by the California State Board of Registered Nursing, Provider Number CEP 15437

To obtain continuing education credit:

• View video presentation

• Review study guide

• Complete CE application form, including applicant information,test answers and evaluation section

• Forward the application form and $10 processing fee to:

Envision, Inc.644 West Iris DriveNashville, TN 372041-866-321-5066

• Certificates will be mailed within 4 weeks.

Preventing Central Line-AssociatedBloodstream Infections(CLABSI)



(CLABSI)

I. IntroductionCentral venous catheters (CVCs) are often essential when caring for patients in the acute, ambulatory, home care andlong term care settings. For instance, it is estimated that 48% of ICU patients have central venous catheters, accountingfor 15 million catheters days per year.1 And yet their use may be associated with bloodstream infections that producelife-threatening illnesses in millions of patients every year, and cost millions to treat.1,2

It is clear that central venous catheters (CVCs) are more likely to cause infection than peripherally inserted lines. Onestudy estimates approximately 90% of catheter-related bloodstream infections occur with central lines.3 Other studiesindicate they are responsible for a 10% to 30% increase in mortality in ICU patients.4-6 This may be because the use ofCVCs are almost exclusively inserted in this area, frequently placed in emergent situations, needed for extended periodsof time, and accessed repeatedly throughout the day.7,8 However, the majority of patients with central lines are actuallyoutside the ICU where lines tend to remain longer and there is substantial risk for infection.9-12

This is why the Centers for Medicare and Medicaid Services (CMS), the Department of Health and Human Services(DHHS), The Joint Commission, the World Health Organization (WHO), and the Association for Vascular Access (AVA) amongothers have all targeted central line-associated bloodstream infections (CLABSI) to be eliminated in healthcare settings.

Specifically,

• Preventing central line-associated bloodstream infections is a 2009 Joint Commission Patient Safety Goal13

• The DHHS has included CLABSI in their 5 year Action Plan to Prevent Healthcare-Associated Infections14

• CMS will not pay for vascular catheter-associated infections unless documented as present upon admission15

• WHO has presented Patient Safety Solutions to address the challenge of CLABSI16

This program will highlight prevention techniques outlined in The Guidelines for the Prevention of IntravascularCatheter-Related Infections by the Centers for Disease Control and Prevention (CDC),17 A Compendium of Strategiesto Reduce Healthcare Associated Infections In Acute Care Hospitals by HICPAC/SHEA/IDSA/APIC [the HealthcareInfection Control Practices Advisory Committee (HICPAC)/ Society for Healthcare Epidemiology of America (SHEA)/Infectious Diseases Society of America (IDSA)/ Association for Professionals in Infection Control (APIC)],18,19 Closingthe Quality Gap: A Critical Analysis of Quality Improvement Strategies by the Agency for Healthcare Research andQuality (AHRQ);20 intervention bundles by the Institute for Healthcare Improvement (IHI) Protecting 5 Million Lives FromHarm campaign;21 and other best practice research.

II. ObjectivesAfter viewing this program and completing the Study Guide, the learner will be able to:

• Define Central Line-Associated Bloodstream Infections (CLABSI)

• Identify the various types of central lines and their uses

• Discuss how catheter and site selection can affect the development of CLABSI

• Discuss measures to prevent the development of CLABSI during insertion, care and maintenance of central lines

III. Central Lines and Their UsesThe National Healthcare Safety Network (NHSN) defines a central line as a catheter that terminates at or close tothe heart or in one of the great vessels. These great vessels include the aorta, pulmonary artery, superior vena cava,inferior vena cava, brachiocephalic veins, internal jugular veins, subclavian veins, external iliac veins and commonfemoral veins.22

Central lines also include peripherally inserted central catheters or PICCs. A PICC is inserted in a peripheral vein, suchas the cephalic, basilic, or brachial vein, and then advanced toward the heart until the tip terminates in either the distalsuperior vena cava or cavoatrial junction.23

Central lines may be short or long term devices, and include catheters, ports, tunneled and nontunneled devices.

Central lines are placed for various reasons:23,24

• To provide venous access for administration of IV therapies, such as antibiotics and chemotherapy agents

• The infusion of parenteral nutrition

• To facilitate high-flow access for plasmapheresis and hemodialysis

• When there are no peripheral sites available or when multiple lines are needed

• To provide access for the insertion of intracardiac catheters for hemodynamic monitoring

IV. Central Line Infection DefinitionsCLABSI are measured by the CDC and the NHSN Manual: Patient Safety Component Protocols by the following criteriaas laboratory-confirmed bloodstream infection (LCBI) for surveillance:20,22

Criterion #1:

• The patient has a recognized pathogen cultured from 1 or more blood cultures,And

• The organism cultured from blood is not related to an infection at another site.

Criterion #2:

• The patient has at least 1 of the following signs or symptoms: fever (>38°C), chills or hypotension,And

• Signs and symptoms and positive laboratory results are not related to an infection at another site,

And• Common skin contaminant (e.g. diphtheroids [Corynebacterium spp.], Baccilus [not B. anthracis] spp.,

Propionibacterium spp., coagulase-negative staphylococci [including S. epidermidis], viridans group streptococci,Aerococcus spp., or Micrococcus spp.) is cultured from two or more blood cultures drawn on separate occasions.

Criterion #3:

• Patient ≤ 1 year of age has at least one of the following signs or symptoms: fever (>38°C rectal), hypothermia(<37°C, rectal), apnea, or bradycardia,

And• Signs and symptoms and positive laboratory results are not related to an infection at another site,

And• Common skin contaminant (e.g. diphtheroids [Corynebacterium spp.], Baccilus [not B. anthracis] spp.,

Propionibacterium spp., coagulase-negative staphylococci [including S. epidermidis], viridans group streptococci,Aerococcus spp., or Micrococcus spp.) is cultured from two or more blood cultures drawn on separate occasions.

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(CLABSI)

Clinical Sepsis (CSEP): CSEP may be used only to report a primary BSI in neonates and infants. To report a CSEP,the following criterion must be met:

Patient ≤ 1 year of age has at least one of the following clinical signs and symptoms with no other recognized cause:fever >38°C, rectal), hypothermia (<37°C, rectal), apnea, or bradycardia,AndBlood culture not done or no organisms or antigen detected in blood and no apparent infection at another site andphysician institutes treatment for sepsis.

V. PathogenesisThe most common pathogens identified with CLABSI are Staphylococcus aureus, coagulase-negative staphylococci,enterococci, gram-negative organisms including Extended Spectrum Beta Lactamase (ESBLs) and Candida species.11

Some patients are more likely to develop central line infections than others. These include patients with:19

• Co-morbidities or existing infections

• Prematurity and partially developed immune systems

• Neutropenia or insufficient mature white blood cells

• Total Parenteral Nutrition or TPN indicating malnourishment or severe underlying disease

• Patients who have had a prolonged hospital stay before insertion and may be colonized withhospital-associated or drug-resistant organisms

Other risk factors include:19

• Prolonged duration of catheter use

• Insertion of multiple catheters

• Emergency insertion of catheters with less than ideal aseptic conditions

• Repeated access to catheters

• Femoral and internal jugular catheterization

• Substandard care of the catheter

Most catheter-related BSI are due to microbes that colonize catheter hubs and the skin surrounding the insertion sitein various ways:25,26

• By migrating inside the lumen from colonized hubs, and occasionally from contaminated infusate

• By migrating along the outside of the lumen from colonized skin

• By travelling via blood from distant infection sites and seeding the catheter

• By adhering to fibrin sheaths or thrombus (clots) and developing mature biofilm

VI. How Do We Create Change and Prevent Central Line Infections?The key to preventing CLABSI is to educate clinicians on how to change or eliminate practices that create risk of infec-tion in patients, while avoiding interventions that may encourage the emergence of antimicrobial resistance.

Staff should be educated on:17-19,27

• Guidelines and best practices to prevent CLABSI

• Indications for CVC use

• Insertion and maintenance of catheters to ensure knowledge and competency

• Proper infection control measures to prevent CLABSI

• Using a catheter insertion checklist

Education programs that emphasize CVC insertion, care and maintenance result in decreases in cost, morbidity andmortality. Consistent reinforcement through ongoing education will remind clinicians of best practices and will continueto decrease CLABSI rates.17,28-31

The use of infection prevention “bundles” are highly encouraged for lowering infection rates. Bundles are a group ofindividual practices drawn from best evidence research that when implemented together result in better patient outcomes.For example, along with a reduction of CLABSI rates per 1,000 device days, the DHHS announced a national 5 yearprevention target of 100% compliance with central line bundles for non-emergent insertions.14

The key components of the IHI’s Central Line Bundle are: 21

• Hand hygiene

• Maximal barrier precautions upon insertion

• Chlorhexidine skin antisepsis

• Optimal catheter site selection, with the chest site (axillary, cephalic and subclavian veins) vein asthe preferred site for non-tunneled catheters

• Daily review of line necessity with prompt removal of unnecessary lines

The Association for Vascular Access’s SAVE That Line campaign to prevent catheter-related bloodstream infectionspromotes four basic principles:32

S – Scrupulous hand hygiene

A – Aseptic technique during catheter insertion and care

V – Vigorous friction to catheter hub prior to entry

E - Ensuring patency of the device

We will discuss bundle elements as well as other recommended practices in this study guide.

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(CLABSI)

VII. Catheter SelectionThe following interventions can be applied to the selection and insertion of a catheter.

First, consider whether the catheter is completely necessary, or whether there are any other alternatives.

Will the catheter be short or long term? Long term catheters can be surgically implanted ports, or have a cuff onthe catheter which acts as a barrier to invading skin organisms. Insertion requires additional skill and is often done ina procedure or operating room.17

PICC lines are being used more and more in the acute setting since specially trained nurses may now insert them atthe bedside. The use of ultrasound equipment ensures easy access to the vessel for good results. Many nurses preferPICCs as the care and maintenance of the device may be easier and preferable to other central lines. However,comparative studies are lacking as to whether PICC lines actually reduce rates of infection. One study suggests PICCshave comparable infection rates to conventional CVC’s placed in the internal jugular and subclavian veins and are morevulnerable to thrombosis and dislodgement.33

Catheter material selection may also reduce infections. Silicone or polyurethane catheters appear to be associatedwith fewer infectious complications than catheters made of other materials.17 In addition, there are antibiotic-impregnatedand antimicrobial-coated devices that have shown good results in clinical studies. The use of these types of cathetersmay be considered by facilities to enhance their infection prevention efforts.17,25 However, this technology should not bea substitution for educating staff on insertion and site care maintenance of the CVC.

Central venous catheters should have the least number of lumens necessary for care.17 PICCs may have single,dual or triple lumens; while tunneled and non-tunneled CVCs may have one to five lumens.

VIII. Site SelectionIdeally, you should choose insertion sites with the lowest density of flora or colonization rates, as well assites with the lowest risk of non-infectious complications such as deep vein thrombosis, bleeding or mechanicalcomplications.34

However, it is important to weigh the risks and benefits of placing a device at a site to reduce infectious complicationsagainst the risk for mechanical complications, which include pneumothorax, subclavian artery puncture, subclavianvein laceration, subclavian vein stenosis, hemothorax, thrombosis, air embolisms, and catheter misplacement.17,34

The chest (subclavian, axillary and cephalic veins) site is recommended for adult patients to minimize infection risk fornon-tunneled CVC placement, but has potential for the greatest mechanical complications.21,34

The femoral site has the highest risk of infection and deep vein thrombosis in adults and should be avoided in adultpatients, but may be a necessary option for children.18,19,21

In addition, patient factors may also dictate the insertion site and type of catheter, such as:34

• Pre-existing catheters, history of complications, or treatments such as mechanical ventilationand anticoagulation therapy

• The comfort of the patient and anticipated duration of the catheter

• How well the catheter can remain secured and maintained aseptically

IX. Infection Prevention BasicsBasic but vital infection prevention practices should be followed by all healthcare professionals involved in the insertion,care and maintenance of the central venous catheter.

This includes practicing scrupulous hand hygiene according to CDC and WHO guidelines at the following times:18,19,27

• When hands are visibly soiled

• Before and after:– Patient care activities– Palpating the insertion site– Inserting, replacing, accessing, repairing, or dressing a catheter– Before donning gloves– After glove removal

Hand hygiene should be a part of the central line placement checklist.21

Follow Standard Precautions at all times, and Isolation Precautions when indicated.

Ensure that Environmental Services and Equipment Processing personnel follow guidelines for optimal cleaningof surfaces and sterilization of equipment.

X. Catheter Insertion Practices1. Have a credentialed healthcare professional insert the central line.19

The more highly trained and specialized the professional, the less likely the potential for infection or other complications.

2. Maintain aseptic technique during the insertion of central line catheters.17,34

3. Use maximal barrier precautions for the insertion of CVCs, including PICCs and guidewire exchanges.17-19,21,27

CVCs carry a substantially higher risk of infection than peripherally inserted catheters; therefore, the level ofprecautions must be greater to prevent infection. This means using a cap, mask, sterile gown, sterile gloves, anda full body sterile drape, just as with any other surgical procedure that carries a risk of infection.17,21,34-36 If afull size drape is not available, use two drapes to cover the patient.21

4. Use a catheter kit or cart containing all necessary items for aseptic insertion.18,19

Items in a catheter insertion kit should be packaged sterile, and processed items cleaned and sterilized properly.19

5. Prior to the insertion, apply an appropriate antiseptic to the insertion site and allow to completely air dry.19,21,34

Use a chlorhexidine-based antiseptic for skin preparation in patients older than 2 months of age.18 Use a concentrationof at least 0.5% chlorhexidine gluconate.18,19 2% chlorhexidine gluconate or CHG is the preferred skin antiseptic,but tincture of iodine, an iodophor, or 70% alcohol can be used.21,27,34

6. For patients with hemodialysis catheters and a history of recurrent Staphylococcus aureus CLABSI, applypovidone-iodine or polysporin ointment to the insertion site.19

7. Dress the insertion site using sterile gauze or sterile transparent, semi-permeable dressings to cover thecatheter site.17-19

While the type of dressing is a matter of facility preference, gauze dressings are desirable if there is blood oozingfrom the site. Be sure to use aseptic technique to open dressing packages and apply the dressing.

10


10



(CLABSI)


In addition, some facilities may elect to use CHG sponges routinely during the dressing of the site to prevent infections,while others may use them as an enhanced precaution if infection rates are higher than desired. This is based onstudies that show CHG impregnated sponges as part of the dressing over the insertion site may reduce catheterrelated infections.37,38

8. Avoid the use of antimicrobial prophylaxis during the insertion of short term or tunneled catheters, or whilecatheters are in place.19,25

This practice may prevent future resistance of antimicrobials. In addition, do not apply mupirocin ointment to insertionsites due to the risk of mupirocin resistance and damage to polyurethane catheters.18,19

9. Use a catheter checklist to ensure and document compliance with aseptic practices and related processesperformed during the placement of the catheter.18,19,21

The Compendium and SHEA/IDSA recommendations also include having the insertion observed by anappropriately trained clinician, and empowering healthcare personnel to stop a procedure if breaches in aseptictechnique are observed.18,19

XI. Care and MaintenanceDuring the care and maintenance of the catheter site, there are several important actions to keep in mind.

1. Always maintain aseptic technique during catheter site care and maintenance in order to preventcatheter-related infections.17,34

2. Minimize hub manipulation.25

The greater the frequency of hub manipulation, the higher the risk for contamination, as every contact with thecatheter or hub can introduce microorganisms that can cause infection.25

3. Before accessing catheter hubs, needleless connectors and injection ports, disinfect them.17-19,25

Scrub them for at least 15 seconds with an alcohol and CHG preparation or 70% alcohol, according to manufacturerrecommendations, and allow to air dry to prevent entry of microorganisms and biofilms.19

4. Evaluate central lines daily for necessity, and remove the catheter as soon as no longer essential.18,21,34,39

The longer a catheter is left in place, the greater the risk for infection. Staff should consider removal when therapyis concluded or if there is reason to suspect a malfunction, infection or other catheter-related complication. A dailyreview of the line will help clinicians prevent unnecessary delays in removing a line that is no longer necessary tothe patient’s care.21 The IHI bundle recommends stating the line day during rounds to remind all clinicians howlong the line has been in place. For example, “today is line day 6.” However, daily review may not be appropriatefor catheters that are in place for long term use.21

5. Do not routinely replace CVCs or arterial catheters.17,21

Routine replacement has not been shown to lower rates of infection; and is not necessary as long as the integrityof the catheter polymer is stable for the expected use and duration of catheterization, and as long as catheters arefunctioning and have no evidence of causing local or systemic complications.17

6. Do not routinely use positive-pressure needleless connectors with mechanical valves before a thorough assessmentof risks, benefits, and education regarding proper use.19

The routine use of these devices have been associated with increased risk of CLABSI.41-44

7. Do not routinely use guidewire exchanges for non-tunneled catheters to prevent infection.17-19

However, guidewire exchanges may be used to replace a malfunctioning nontunneled catheter if noevidence of infection is present. Be sure to change gloves before handling the new catheter when performinga guidewire exchange.17

8. Change dressings aseptically, and on scheduled intervals.17,19

When changing dressings:

• Always practice good hand hygiene first and wear sterile gloves.17,18

• Change transparent dressings on non-tunneled catheters and perform site care every 5 to 7 days, or morefrequently if the dressing is soiled, loose or damp, or when inspection of the site is necessary.17,18,34

• For patients who cannot tolerate transparent dressings, use gauze dressings on non-tunneled cathetersand change them every 2 days unless soiled, loose or damp.17,18

• Change dressings on tunneled or implanted sites no more than once per week, unless soiled, loose or damp,until the insertion site has healed.1

• Use an appropriate antiseptic solution – preferably chlorhexadine gluconate - to clean the site duringevery dressing change.17,18

9. Follow flushing protocols for the specific type of line.Follow manufacturer instructions and established guidelines such as those by the Infusion Nurses Society (INS),available at www.ins1.org.

10. Replace administration sets at the proper intervals.17-19

Replace administration sets that are used for fluids other than blood, blood products or lipids at intervals not longerthan 96 hours.18,19 Sets should also be replaced if there is blood in the tubing that cannot be flushed through, asthis provides a breeding ground for bacteria. Replace tubing used to administer blood products or lipid emulsionswithin 24 hours of initiating the infusion.17

11. Use antimicrobial ointments for hemodialysis catheter insertion sites.18,19

Apply povidone-iodine or polysporin ointment to hemodialysis catheter insertion sites in patients with a history ofrecurrent Staphylococcus aureus CLABSI. However, mupirocin ointment should not be applied to the catheter insertionsite due to the risks of mupirocin resistance and damage to polyurethane catheters.19

XII. Patient EducationIf the patient is to be discharged home with a central line, the patient should be involved in the active preventionof infection.13

Consider providing the patient and family with the following information:

• Instructions as to proper care and maintenance of the insertion site

• How CLABSI occur

• Home health follow up if advised

• How caregivers should be preventing infections whenever accessing the line

XIII. SurveillanceDespite the release of guidelines by the CDC and other evidence based research, and high rates of CLABSI, reportssuggest that adherence to best practices remains low in US hospitals.22 Surveillance works hand in hand with aimsthat are set by the unit or facility for reducing CLABSI, as goals reflect true attempts at improvement.21

In order to determine whether these best practice recommendations are being adhered to and are preventing infection

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(CLABSI)

in your patient population, facilities should perform surveillance for CLABSI.17-19,22 The NHSN recommends surveillancein any type of patient care location where central lines are inserted.22 The NHSN would like reporting on using maximalbarrier precautions during insertion, avoiding the femoral insertion site if possible, and avoiding guidewire exchangeswhen CLABSI is suspected, among other information.40 This data should be compared with historical data as well asnational rates. Be sure to provide feedback to clinicians in order to promote what’s working, as well as identify areasthat need improvement.19

In alignment with National Patient Safety Goal #7, The Joint Commissions Elements of Performance #4 (EP4) willrequire surveillance and prevention efforts throughout the healthcare facility starting in January 2010.13,45 EP8 requireshospitals to measure CLABSI rates, monitor compliance with best practice or evidence-based guidelines, and evaluatethe effectiveness of current progress.45

XIV. Enhanced InterventionsAccording to the SHEA/IDSA practice recommendations,19 if the rates of infection continue to be high despite compliancewith basic CLABSI infection prevention practices, then the following enhanced interventions may be considered. Theymay be especially beneficial for patients with limited venous access, a history of recurrent CLABSI, at heightened riskfor severe sequelae from CLABSI, and for hospital units or patient populations with higher infection rates.19

1. Bathe ICU patients older than two months of age with a chlorhexidine preparation daily.19

The Food and Drug Administration has not approved the use of chlorhexidine products for children younger than2 months of age; therefore, use a povidone-iodine preparation on the insertion site for younger children, especiallylow birth weight neonates.

2. Consider the use of antiseptic or antimicrobial impregnated CVCs.19

There are various catheters either impregnated with antiseptics such as chlorhexidine-silver sulfadiazine, orantimicrobials such as minocycline-rifampin that show clinical promise.46-50

3. Place chlorhexidine-containing sponge dressings at the insertion site in patients older than two months of age.19

4. Use antimicrobial locks by filling the lumen of the catheter with antimicrobial solution and leaving in place untilthe hub is re-accessed.19

This practice has shown great promise in clinical studies,51 but there are some studies that show concern regardingthe potential for systemic toxicity from leakage of the solution into the bloodstream, and for emergence of resistancein exposed organisms. Therefore, antibiotic lock solutions should be reserved for special circumstances.17,19

XV. ConclusionCentral line-associated bloodstream infections can be devastating to patients, family, and the healthcare system.But by implementing simple and practical infection prevention practices and best practice interventions, we canprevent CLABSI.

XVI. References1. Soufir L, Timsit JF, Mahe C, Carlet J, Regnier B, Chevret S. Attributable morbidity and mortality of catheter-related

septicemia in critically ill patients: a matched, risk-adjusted, cohort study. Infect Control Hosp Epidemiol.1999 Jun;20(6):396-401.

2. Saint S, Savel RH, Matthay MA. Enhancing the safety of critically ill patients by reducing urinary and centralvenous catheter-related infections. Am J Respir Crit Care Med. 2002 Jun 1;165(11):1475-9.

3. Mermel LA. Prevention of intravascular catheter-related infections. Annals of Internal Medicine. Mar 72000;132(5):391-402.

4. Warren DK, Kollef, MH. Prevention of hospital infection. Microbes Infect. 2005 Feb;7(2):268-74.

5. DeGaudio AR, Di Fillippo A. Device-related infections in critically ill patients. Part I: Prevention of catheter-relatedbloodstream infections. J Chemother. 2003 oct;15(5):419-27.

6. O’Grady NP. Applying the science to the prevention of catheter-related infections. J Crit Care. 2002 Jun;17(2):114-21.

7. Maki DG, Kluger DM, Crnich DJ. The risk of bloodstream infection in adults with different intravascular devices:a systematic review of 200 published prospective studies. Mayo Clin Proc 2006;81:1159-1171.

8. Esteve F, Pujol M, Limon E, et al. Bloodstream infection related to catheter connections: a prospective trial oftwo connection systems. J Hosp Infect 2007;67:30-34.

9. Climo M, Diekema D, Warren DK, et al. Prevalence of the use of central venous access devices within and outsideof the intensive care unit: results of a survey among hospitals in the prevention epicenter program of the Centersfor Disease Control and Prevention. Infect Control Hosp Epidemiol 2003;24:942-945.

10. Vonberg RP, Behnke M, Geffers C, et al. Device-associated infection rates for non-intensive care unit patients.Infect Control Hosp Epidemiol 2006;27:357-361.

11. Marschall J, Leone C, Jones M, Nihill D, Fraser V, Warren D. Catheter-Associated Bloodstream Infections inGeneral Medical Patients Outside the Intensive Care Unit: A Surveillance Study. Infect Control Hosp Epidemiol.August 2007, Vol. 28, No. 8.

12. Trick WE, Vernon MO, Welbel SF, Wisniewski MF, Jernigan JA, Weinstein RA. Unnecessary use of central venouscatheters: the need to look outside the intensive care unit. Infect Control Hosp Epidemiol 2004;25:266-268.

13. The Joint Commission 2009 National Patient Safety Goals. http://www.jointcommission.org/NR/rdonlyres/D619D05C-A682-47CB-874A-8DE16D21CE24/0/HAP_NPSG_Outline.pdf

14. U.S. Department of Health and Human Services. Action Plan to Prevent Healthcare-Associated Infections:Introduction. www.hhs.gov/ophs/initiatives/hai/introduction.html

15. Dept of Health and Human Services, Centers for Medicare and Medicaid Services. 42 CFR Parts 411, 412, 413,422, and 489 [CMS-1390-F]; [CMS-1531-IFC1]; [CMS-1531-IFC2] [CMS-1385-F4] RIN 0938-AP15; RIN 0938-AO35;RIN 0938-AO65. Medicare Program; Changes to the Hospital Inpatient Prospective Payment Systems and FiscalYear 2009 Rates; Payments for Graduate Medical Education in Certain Emergency Situations; Changes toDisclosure of Physician Ownership in Hospitals and Physician Self-Referral Rules; Updates to the Long-Term CareProspective Payment System; Updates to Certain IPPS-Excluded Hospitals; and Collection of Information RegardingFinancial Relationships Between Hospitals. http://www.cms.hhs.gov/AcuteInPatientPPS/downloads/CMS-1390-F.pdf

16. World Health Organization. WHO Collaborating Centre for Patient Safety.http://www.euro.who.int/healthsystems/Service/20070828_1

17. O’Grady N, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki DG, Masur H, McCormick RD, Mermel LA,Person ML, Raad II, Randolph A, Weinstein RA, HICPAC Advisory Committee. Guidelines for the Prevention ofIntravascular Catheter-Related Infections. Infect Control and Epidemiol 2003, Vol. 23, No. 12.

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18. Yokoe DS, Mermel LA, Anderson DJ, Arias KM, Burstin H, Calfee DP, et al. A Compendium of Strategies to PreventHealthcare-Associated Infections in Acute Care Hospitals. Infect Control and Hospital Epidemiol, October 2008,Vol.29, Suppl 1.

19. Marschall J, Mermel LA, Classen D, et al. Supplemental Article: SHEA/IDSA Practice Recommendations.Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals. Infect Controland Hospital Epidemiol, October 2008, Vol.29, Suppl 1.

20. AHRQ Evidence Report/Technology Assessment Number 9. Closing the Quality Gap: A Critical Analysis ofQuality Improvement Strategies. Volume 6- Prevention of Healthcare-Associated Infections. AHRQ PublicationNo. 04(07)-0051-6. January 2007.

21. Institute for Healthcare Improvement. Protecting 5 Million Lives From Harm campaign. Getting Started Kit:Prevent Central Line Infections, How-To Guide. Cambridge, MA, 2008. www.ihi.org

22. Centers for Disease Control and Prevention. The National Healthcare Safety Network (NHSN) Manual.Patient Safety Component Protocol. Last updated January 2008.

23. Central Venous Catheters – Topic Overview from WebMD. www.webmd.com/a-to-z-guides.central-venous-catheers-topic-overview

24. Center Venous Catheter Placement – Department of Surgery, Baylor College of Medicine, Texas, Houston.www.debakeydepartmentofsurgery.org/

25. Mermel LA. Prevention of Intravascular Catheter-Related Infections. Ann Intern Med. 2000;132:391-402.

26. Safar N. Maki, DG. Inflammation at the insertion site is not predictive of catheter-related bloodstream infectionwith short-term, noncuffed central venous catheters. Critical Care Medicine. 30(12):2632-2635, December 2002.

27. American Association of Critical-Care Nurses. AACN Practice Alert: Preventing Catheter Related BloodstreamInfection. www.aacn.org/WD/Practice/Docs/Preventing_Catheter_Related_Bloodstream_Infections_9-2005.pdf

28. Gnass SA, Barboza L, Bilicich D, Angeloro P, Teriver W, Grenovero S, Basualdo J. Prevention of central venouscatheter-related bloodstream infections using non-technologic strategies. Infect Control Hosp Epidemiol.2004 Aug;25(8):675-7.

29. Sherertz RJ, Ely EW, Westbrook DM, et al. Education of physicians-in-training can decrease the risk for vascularcatheter infection. Ann Intern Med. 2000;132:641:648.

30. Coopersmith CM, Rebmann TL, Zack JE, Ward MR, Corcoran RM, Schallom ME, Sona CS, Buchman TG, Boyle WA,Polish LB, Fraser VJ. Effect of an education program on decreasing catheter-related bloodstream infections in thesurgical intensive care unit. Crit Care Med. 2002 Jan;30(1):59-64.

31. Berenholiz SM, Pronovoist PJ, Lipsett PA, Hobson D, Ersing K, Farley JE, et al. Eliminating catheter-relatedbloodstream infections in the intensive care unit. Crit Care Med. 2004 Oct;32(10);201-20.

32. Association for Vascular Access: SAVE That Line! Campaign. www.avainfo.org

33. Tariq M, Juang DT. PICCing the best access for your patient. Critical Care 2006, 10:315doi:10.1186/cc5031.

34. U.S. Department of Health and Human Services. Action Plan to Prevent Healthcare-Associated Infections:Prevention – Prioritized Recommendations. 2008. www.hhs.gov/ophs/initiatives/hai/prevention.html

35. Chaiyakunapruk N, Veenstra DL, Lipsky BA, et al. Chlorhexidine compared with povidone-iodine solutionfor vascular catheter-site care: a meta-analysis. Ann Intern Med. 2002 Jun;4;136(11):792-801.t

36. Hu KK, Lipsky BA, Veenstra DL, et al. Using maximal sterile barriers to prevent central venous catheter-relatedinfection: a systemic evidence-based review. Am J Infect Control. 2004 May;32(3):142-6.

37. Jean-François Timsit, et al. Chlorhexidine-Impregnated Sponges and Less Frequent Dressing Changes forPrevention of Catheter-Related Infections in Critically Ill Adults. JAMA. 2009;301(12):1231-1241

38. Perencevich EN, Pittet D. Preventing Catheter-Related Bloodstream Infections: Thinking Outside the Checklist.JAMA. 2009;301(12):1285-1287.

39. Eggiman P, Sax H, Pittet D. Catheter-related infections. Microbes Infect. 2004 Sep;6(11)1033-42.

40. Centers for Disease Control and Prevention/NSHN. National Healthcare Safety Network. Central Line InsertionPractices (CLIP) Training Course. http://www.cdc.gov/nhsn/wc_CLIP.html

41. Maragakis LL, Bradley KL, Song X, et al. Increased catheter-related bloodstream infection rates after theintroduction of a new mechanical valve intravenous access port. Infect Control Hosp Epidemiol 2006;27:67-70.

42. Field K, McFarlane C, Cheng AC, et al. Incidence of catheter-related bloodstream infection among patients witha needleless, mechanical valve-based intravenous connector in an Australian hemotology-oncology unit. InfectControl Hosp Epidemiol 2007;28:684-688.

43. Salgado CD, Chinnes L, Paczesny TH, Cantey JR. Increased rate of catheter-related bloodstream infectionassociated with the use of an intravascular needleless valve. Clin Infect Dis 2007;28:684-688.

44. Rupp ME, Sholtz LA, Jourdan DR, et al. Outbreak of bloodstream infection temporarily associated with theuse of an intravascular needleless valve. Clin Infect Dis 2007;44:1408-1414.

45. The Joint Commission. 2009 Standards. Elements of Performance EP4 and EP8.

46. Raad I, Darouiche R, Dupuis J. Central venous catheters coated with minocycline and rifampin for the preventionof catheter-related colonization and bloodstream infections: a randomized, double-blind trial. The Texas MedicalCenter Catheter Study Group. Ann Intern Med 1997;127:267-274

47. Veenstra DL, Saint S, Saha S, Lumley T, Sullivan SD. Efficacy of antiseptic-impregnated central venous cathetersin preventing catheter-related bloodstream infections: a meta-analysis. JAMA 1999;282:261-267.

48. Darouiche RO, Raad II, Heard SO, et al. A comparison of two antimicrobial-impregnated central venous catheters:Catheter Study Group. N Engl J Med 1999;340:1-8.

49. Hanna HA, Raad II, Hackett B, et al., M.D. Anderson Catheter Study Group. Antibiotic-impregnated cathetersassociated with significant decrease in nosocomial and multidrug-resistant bacteremias in critically ill patients.Chest 2003;124:1030-1038.

50. Hanna H, Benjamin R, Chatzinikolaou I, et al. Long-term silicone central venous catheters impregnated withminocycline and rifampin decrease rates of catheter-related bloodstream infection in cancer patients: a prospectiverandomized clinical trial. J Clin Oncol 2004;22:3163-3171.

51. Garland JS, Alex CP, Henrickson KJ, McAuliff TL, Maki DG. A Vancomycin-Heparin Lock Solution for Prevention ofNosocomial Bloodstream Infection in Critically Ill Neonates With Peripherally Inserted Central Venous Catheters: AProspective, Randomized Trial. Pediatrics. Vol. 116 No. 2 August 2005, pp. e198-e205 (doi:10.1542/peds.2004-2674)

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XVII. Post Test

1. The following can be said about central lines except:

A A central line is a catheter that terminates at or close to the heart or inone of the great vessels

B Central lines are always long term devicesC Central lines include peripherally inserted central catheters (PICCs)D The majority of patients with central lines are actually outside the ICU

2. Patients who are more likely to develop CLABSI include:

A Those with prolonged hospital stays before insertion and who may have MDROsB Those receiving Total Parenteral Nutrition (TPN) or have neutropeniaC Patients with multiple catheters or prolonged catheter useD All of the above

3. When selecting insertion sites:

A Choose insertion sites with the lowest density of flora or colonization ratesand with the lowest risk of non-infectious complications

B Avoid the femoral site whenever possibleC Consider patient factors and preferencesD All of the above

4. Maximal barrier precautions include:

A A cap, mask, sterile gloves and partial sterile drapeB A cap, mask, sterile gloves, sterile gown, and full body drapeC A mask, gown, clean gloves and sheetsD A mask, sterile gown, clean gloves and full body drape

5. Considerations during catheter insertion include:

A Using a catheter kit or cart containing all necessary itemsB Applying povidone-iodine or polysporin ointment to all insertion sitesC Using a chlorhexidine antiseptic on the insertion site after insertionD Dressing the insertion site with clean dressings

6. During care and maintenance of the insertion site, perform the following except:

A Maintain aseptic techniqueB Disinfect hubs, needleless connectors and injection ports with 70% alcohol

or chlorhexidine solution and allow to air dryC Routinely replace CVCs in order to prevent infectionD Minimize hub manipulation

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7. The following can be said about keeping a line in place:

A The longer a catheter is left in place, the greater the risk of infectionB Consider removing the catheter when therapy is concluded or there is reason

to suspect a complicationC A daily review of the line will help clinicians prevent unnecessary delays in

removing a line that is no longer neededD All of the above

8. When changing dressings the following should be considered:

A Always practice good hand hygiene and wear clean glovesB Perform site care and change dressings on nontunneled catheters every 5-7 daysC Change gauze dressings on nontunneled catheters every 5-7 daysD Change dressings on tunneled catheters every 2-3 days

9. Surveillance is used for all except:

A To work hand in hand with goals set by the facility to reduce CLABSI ratesB To spy on clinicians to make sure they are performing infection prevention measuresC To compare facility rates with national rates of infectionD To provide feedback to clinicians in order to promote what’s working, and identify

areas that need improvement

10. The following are enhanced interventions that can be used if rates of infection continueto be high despite compliance with basic CLABSI infection prevention practices:

A Using antiseptic or antimicrobial impregnated CVCs or antimicrobial locksB Bathing all patients with a chlorhexidine preparation daily or placing chlorhexidine-containing

sponge dressings on all patientsC None of the aboveD All of the above



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XVIII Tools

Nursing Checklist: Central Venous Catheter Insertion

Department: ! CCU ! MICU ! TICU ! NSICU ! SICU ! BICU ! PCCU ! NICU ! Other ___________________________

MR#:_________________________________________________________________________________________________________________________ Date: ___________/___________/___________

Time Start (1st needle stick): _________:_________ ! a.m. ! p.m. Time End (catheter sutured): _________:_________ ! a.m. ! p.m.

Type of Catheter: Insertion Site: Side: Indications for use: Check if:! Double lumen ! Internal Jugular ! Right ! Pressors ! Consent obtained! Triple lumen ! Subclavian ! Left ! Hemodynamic mont. ! Pt/Family teaching done! Introducer ! Femoral ! Fluids/blood products ! Guidewire exchange! Swan-Ganz ! Other (specify) ! Frequent lab draws! Vascath __________________

List all sites where insertion was attempted: ! RIJ ! LIJ ! RSC ! LSC ! RF ! LF ! Other (specify) _______________________

The provider inserting this line:A. Handed-off his/her pager before the procedure? ! Yes ! No ! Didn’t askB. Washed hands immediately prior to procedure? ! Yes ! No ! Didn’t askC. Has previously placed at least five (5) central lines? ! Yes ! No* ! Didn’t ask* If “No”, was this procedure supervised by someone with at least five (5) central lines experience? ! Yes ! No ! Didn’t ask

Barrier precautions (check any used): ! Sterile gloves ! Sterile gown ! Mask ! Sterile towels ! Full body drape

Describe the level of training of the person who actually inserted the line?! Medical student ! Intern (PGY-1) ! Resident (PGY-2+) ! Fellow ! Attending ! Nurse Practitioner

How many different needle sticks did the patient receive (number of skin breaks)?! 1 ! 2 ! 3 ! 4 ! 5 ! 6+ ! Unknown

Was the sterile field maintained throughout the entire procedure? ! Yes ! No

Pre-insertion skin prop (check any used):! Alcohol ! Betadine (povidone-iodine) ! Chlorhexidine ! Other (specify) _______________________________________________________________

Describe the circumstances under which this line was placed:! Non-emergent ! Emergent (life-threatening or code situation) ! Pre-existing infection

Follow-up CXR: ! Ordered ! Not ordered (specify reason) _________________________________________________________________________________________

CXR findings (check all that apply):! No pneumothorax ! Pneumothorax (describe action taken) ______________________________________________________________________________

! Catheter in good position ! Catheter position adjusted (describe) ____________________________________________________________________________

Type of dressing: ! Bio-occlusive ! Gauze ! Other (specify ___________________________________________________________________________________

Dressing applied by: ! Nurse ! Proceduralist ! Other (specify) ______________________________________________________________________________

Patient tolerated the procedure well? ! Yes ! No ! Comments: _________________________________________________________________________

Complications? ! None ! Placement unsuccessful ! Other (describe) _______________________________________________________________________

Note: Please make 2nd copy and file in Patient Chart, and return original copy to the designated location in the ICU.

Signature: _________________________________________________________________________________________________________________ Date: ___________/___________/___________

Used with permission from Vanderbilt University Hospital, © 2009.

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“Save That Line” Poster and Note card



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Card Front Card Back

PosterThis Poster is also included on theResource CD as a PDF documentwhich may be downloaded to yourcomputer and printed.

The document size is 8.5” x 11,” andhas been designed in full color. It mayalso be printed in black & white.

This is an excellent resource to hangin your office and other public areaswithin your facility.

Note CardThis Note Card is also included on theResource CD as a PDF document whichmay be downloaded to your computerand printed.

The document size is 4.25” x 5.5.”It is 2-sided, full color. Ideally, thenote card is designed to be printed onthicker paper (card stock). However, ifprinted on standard paper, it may betrimmed to size.

This is an excellent resource to handout as a pocket reference.

XIX. Continuing Education ApplicationPlease print clearly and fill in all data to ensure accurate record-keeping.

Preventing Central Line-Associated Bloodstream Infections: (CLABSI)

LEARNING OBJECTIVES

1. Define Central Line-Associated Bloodstream Infections (CLABSI)

2. Identify the various types of central lines and their uses

3. Discuss how catheter and site selection can affect the development of CLABSI

4. Discuss measures to prevent the development of CLABSI during insertion, care and maintenance of central lines

CE CREDITS BY MAILThis program has been approved by Envision, Inc. for 1.0 Contact Hour, Program Number 006CLABSI10.

Envision, Inc. is an approved provider by the California State Board of Registered Nursing, Provider Number CEP 15437

Please complete this form in its entirety and submit to Envision, Inc. along with the $10.00 CE processing fee.Please mail completed forms and fee to: Envision Inc., 644 West Iris Drive, Nashville, TN 37204. CE certificateswill be mailed within four weeks after receipt of this completed form. Thank you.

Name:_______________________________________________________________________________________________________________________________________________________________________________________________________

Address:___________________________________________________________________________________________________________________________________________________________________________________________________

City:_____________________________________________________________________________________________________________________ State:_____________________________ Zip:_____________________________________

Daytime Telehone:____________________________________________________________________________ E-mail:________________________________________________________________________________________

Date of Application:_______________/_______________/______________ RN/LPN License #: ___________________________________________________________________ State:______________________

TEST ANSWERSCircle only one choice for your answer to each question.

1. A B C D 6. A B C D

2. A B C D 7. A B C D

3. A B C D 8. A B C D

4. A B C D 9. A B C D

5. A B C D 10. A B C D

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XX. Program Evaluation FormPlease circle the number that reflects your extent of agreement with each statement:

Evaluate this program in each of the categories by using the following rating scale: Poor Satisfactory Good Excellent

1. Program content resulted in achievement of the statedlearning objective #1 1 2 3 4




5. The content met my expectations 1 2 3 4

6. Information presented can be applied to my practice 1 2 3 4

7. Information provided is helpful in achieving my professional goals 1 2 3 4

8. Content was organized and easy to follow 1 2 3 4

9. The information presented is current and relative 1 2 3 4

10. This method of delivery met my learning needs 1 2 3 4

11. The content in this course was presented without bias of anycommercial product or drug 1 2 3 4

12. To complete this self paced program, which includes watchingthe video presentation and reviewing the study guide, it took me ____________________________________________________ minutes/hours.



(CLABSI)

XXI. Post Test Answers

1. B. Central lines are always long term devices. Central lines may be short or long term devices and includecatheters, ports, tunneled and nontunneled devices.

2. D. All of the above. Other risk factors include emergency insertion of catheters under less than ideal conditions;patients with comorbidities or existing infections; patients with repeated access to catheters; and patients withprematurity and partially developed immune systems.

3. D. All of the above. In addition, the risks and benefits of placing a device at a site to reduce infectiouscomplications may need to be weighed against the risk for mechanical complications.

4. B. A cap, mask, sterile gloves, sterile gown, and full body drape.

5. A. Using a catheter kit or cart containing all necessary items. B is wrong as you should only applypovidone-iodine or polysporin to patients with hemodialysis catheters and a history of recurrent S. aureus CLABSI.C is wrong in that you use a chlorhexidine preparation before insertion of the catheter. D is wrong in that youdress the insertion site using sterile gauze or transparent dressings.

6. C. Routinely replace CVCs in order to prevent infection. This is incorrect, as routine replacement has notbeen shown to lower rates of infection, and is not necessary as long as the catheter integrity is stable and thecatheter is functioning with no evidence of complications.

7. D. All of the above.

8. B. Perform site care and change dressings on nontunneled catheters every 5-7 days. A is incorrect asyou should wear sterile gloves to work aseptically on the insertion site. C is incorrect as gauze dressings shouldbe changed every 2 days; and dressings on tunneled catheters should not be changed more than once per week,unless soiled, loose or damp.

9. B. To spy on clinicians to make sure they are performing infection prevention measures. Surveillance isa positive measure that should never be construed as “spying” or a negative measure, and in fact results in thereduction of infection rates that improve patient care.

10. A. Using antiseptic or antimicrobial impregnated CVCs and antimicrobial locks. B is incorrect aschlorhexidine preparations should not be used on patients under 2 months of age.

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Notes



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