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Although the inci-dence of centralline–associatedbloodstream infec-tions (CLABSIs) has

decreased, the Centers forDisease Control and Preven-tion reports that an estimated30,100 of these infections stilloccur in the United Stateseach year, resulting in thou-sands of deaths and addingup to billions in costs. To re-duce CLABSIs, nurses needto address quality-control is-sues and make prevention adaily task. At Penn State Hershey

Medical Center, our 49-bedmedical-surgical unit uses centrallines for posttransplant medications,I.V. vesicants and antibiotics, andtotal parenteral nutrition. The unitaverages 230 central line patientdays per month. To address the is-sue of CLABSIs, we convened aninterprofessional team of nurses,physicians, phlebotomists, and in-fection prevention experts to imple-ment guidelines and recommenda-tions to reduce central line access.The team collaborated to create theNo Central Blood Line Draw pro-gram. We used the Plan-Do-Check-Act quality-improvement model toimplement changes in physician or-dering practices, phlebotomy andnursing workflow, patient educa-tion, and charge nurse competencyin central line blood draws.

How it works The unit’s education council mem-bers designed an education plan,which included teaching all staffabout the risks for infection whena central line is accessed. Chargenurses, the only nurses permittedto perform blood draws from cen-tral lines, reviewed the relevantpolicy and received specializedtraining in this and capillary bloodsampling. Laboratory and phle-botomy staff implemented labora-tory specimen bundling and ex-plained the process to staff.Collection times occur every 4hours beginning at 4 A.M. Anyspecimens ordered between thesecollection times are drawn on thenext collection cycle. Exceptionsinclude admission laboratory spec-

imens, coding or critically illpatients, stat blood cultures,blood cultures ordered be-fore initiating antibiotics,drug monitoring that occursat nonstandard lab times,and specimens needed aftera blood product transfusion. Nurses evaluate all patients

with a central line for theirwillingness to participate inthe No Central Blood LineDraw program. Patients natu-rally prefer having blooddrawn from a central line tobeing “stuck” with a needle,so we teach them about therelationship between access-ing central lines for blood

specimens and the risk of infectionwith each occurrence. We also de-veloped a patient education hand-out describing CLABSIs, strategiesused to prevent them, and how pa-tients can participate in their owncare. (See Keeping you safe.) Once patients agree to partici-

pate, staff and charge nurses eval-uate them for venous accessibilityfor peripheral blood specimens,and laboratory specimens are bun-dled and drawn by phlebotomy ornursing staff. We created a processflow chart to provide a visualguide for all staff. (See the Mak-ing the right decision: The No Cen-tral Line Blood Draw decision treeon page 44.)In addition to the steps and ex-

Reducing the risk of central line-associatedbloodstream infections

Limiting access limits infection.

By Krista Williamson, BSN, CMSRN, CNML; Lorie Gonzalez, MSN, BC-RN; Ashley Neusbaum, MSN, CMSRN; and Jaime Messing, BSN, RN

(continued on page 44)

ceptions identified in the flowchart, if a specimen can’t be ob-tained after four attempts or if thepatient is identified as having diffi-cult venous access, we evaluatehim or her for a foot or capillaryblood specimen. If a patient refus-es peripheral blood draws despiteCLABSI prevention awareness edu-cation, or if the patient meets oneof the exceptions, the physicianorders central line collection. Thecharge nurse documents this infor-mation in the unit charge nurse’sresource book, which contains pa-tients who have had a specimendrawn from their central line andwhy the line was accessed.

SuccessSince implementing No Central LineBlood Draw in October 2014, noparticipating patient has acquired aCLABSI, down from 2.99 infectionsper 1,000 central line days. In addi-tion, the number of times centrallines were accessed for specimencollection decreased from an aver-age of 6 to 1.4 times per day, andmislabeled or contaminated speci-mens sent to the laboratory weresignificantly reduced. Implementation of this innova-

tive process allowed for interprofes-sional collaboration and decreasedthe risk of patients acquiring CLAB-SIs. The process is now standardpractice on the unit, and it’s beingevaluated for implementation inother medical-surgical units.

All authors work at Penn State Hershey Medical Cen-ter in Hershey, Pennsylvania. Krista Williamson is anurse manager, Lorie Gonzalez is a nurse educator,Ashley Neusbaum is a clinical head nurse, and JaimeMessing is a staff nurse.

Selected referencesCenters for Disease Control and Prevention.Bloodstream infection event (central line-as-sociated bloodstream infection and non-cen-tral line–associated bloodstream infection).January 2016. www.cdc.gov/nhsn/pdfs/psc-manual/4psc_CLABScurrent.pdf

Centers for Disease Control and Prevention.FAQs about catheter-associated bloodstreaminfections. (n.d.). www.cdc.gov/hai/pdfs/bsi/BSI_tagged.pdf

Centers for Disease Control and Prevention.

Vital signs: Central line–associated bloodstream infections—United States, 2001, 2008,and 2009. MMWR Morb Mortal Wkly Rep.2011;60(8):243-8.

Marschall J, Mermel LA, Fakih M, et al.Strategies to prevent central line–associat-ed bloodstream infections in acute carehospitals: 2014 update. Infect Control Hosp

Epidemiol. 2014;35(7):753-71.

Wilson MZ, Rafferty C, Deeter D, ComitoMA, Hollenbeak CS. Attributable costs ofcentral line–associated bloodstream infec-tions in a pediatric hematology/oncologypopulation. Am J Infect Control. 2014;42(11):1157-60.

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At Penn State Hershey Medical Center, our goal is to create the highest level ofquality, safety, and value to you. As part of our commitment, the 5th Floor AcuteCare Unit wants to minimize the risk of central line–associated bloodstream infec-tions (CLABSIs).

What’s a CLABSI? A central line or central catheter is a tube that’s placed into a patient’s large vein,usually in the neck, chest, arm, or groin. It’s used to draw blood and give fluids ormedications. It may be left in place for several weeks. A bloodstream infection canoccur when bacteria or other germs travel down a central line and enter theblood. If you develop a CLABSI, you may become ill with fever and chills or theskin around the line may become sore and red.

What are we doing to prevent CLABSIs? To prevent infections, doctors and nurses will:

• limit or eliminate how many times the central line is accessed.

• obtain lab specimens from somewhere other than the central line, such as avein in the arm.

• perform proper hand hygiene, including washing hands and wearing gloveswhen handling the central line.

• cover the port of your I.V. tubing and central line with a green cap for disinfec-tion and protection.

• wash their hands and wear gloves when changing the bandage that covers thearea where the central line enters your skin.

• ensure a specially trained nurse changes your dressing once a week or asneeded. The team will use a special patch that contains anti-infection proper-ties and a special solution that helps keep your dressing secure.

• frequently check your central line site and dressing.

• decide every day if you need to have the central line, so it can be removed assoon as it’s no longer needed.

• carefully handle all medications and fluids that are given through your centralline.

• offer you the opportunity to take a daily bath with 2% chlorhexidine gluconatecloths (CHG wipes) to reduce the risk of infection.

How can you help prevent a CLABSI? • If you don’t see your doctors and nurses clean their hands, please ask them to

do so.

• Immediately notify the nursing staff if your bandage comes off or becomeswet, dirty, or loose.

• Speak to your nurse before showering. He or she will give you a special cover-ing to keep your central line dry.

• Tell your nurse or doctor if the area around your central line becomes red orsore.

• Don’t let family or friends touch the central line, and encourage them to washtheir hands every time they enter or leave your room.

• To help prevent infection, ask your healthcare team about your central line andits care. For example, ask why you need a central line and who changes yourcentral line dressing.

Keeping You Safe (continued from page 42)

(continued on page 46)

46 American Nurse Today Volume 12, Number 5 AmericanNurseToday.com

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The No Central Line Blood Draw decision tree This decision tree helps staff understand and remember the process for limiting central line access and specifies exceptions.

END

END

ENDEND

NO

NO

NO

NO

NO NO NO

NO

END

YES

YES

YES

YES

YES

YES

YES YES

YES

Order forblood work

Blood work requestbundled per

policy?

Contactprovider tochange order

Pt has CVAD?

Peripheraldraw

Pt has dialysiscatheter?

Specimenneeded from0500-2300?

RN/designee obtains

peripherally?

RN/designee collects

capillary sample?

RN/designeenotifies CN

Dialysis during scheduledblood collection

time?

Phlebotomist collects

peripherally?

Phlebotomist collects capillary

sample?

CN assessesreason for exception

Contact dialysis to obtain specimen

CN collectsspecimen from CVAD

CN logs collection

from CVAD inexceptions log

CVAD = central venous access deviceCN = charge nursePt = patient