Bloodstream Infections related
to Central Lines
LMC’s goal for 2011
0 infections for 11 months out of this year
What are the facts?
• Since 2008, the CDC has published
information estimating that 92,011 central
line associated bloodstream infections
(CLABSI’s) occur annually just in the United
States.
• Each case can increase hospital costs by
$5,734 up to $25,546.
• CLABSI’s cause an estimated 28,000 deaths
in ICU patients annually.
(APIC, 2009)
So what can we do?
• As always, we at LMC want the best
outcomes for our patients. LMC has set
goals for 2011 to significantly reduce any
bloodstream infections.
• Our central line policy and procedure has
been updated to include the most recent
evidence based information.
• LMC is also implementing care bundling for
central line insertion and care to decrease
CLABSI’s.
Central Line-Definition
• An intravascular catheter that terminates
into the inferior vena cava & used for
infusion, withdrawal of blood, & or for
hemodynamic monitoring (APIC, 2009).
Indications for Central Lines
•
•
•
•
Blood loss
Hypotension
Hemodialysis access
Total parenteral nutrition or other
hyperosmolar solutions
• Lack of peripheral venous access
• Infusion of medicines long-term
• Volume measurements
Anatomy & Physiology
Veins used for Central Venous
Access:
– Internal jugular vein
– Subclavian vein
– Femoral vein
– Basilic or Cephalic vein
(Scales, 2010)
Subclavian Vein
• Subclavian vein is a continuation of the axillary vein
and then joins the internal jugular vein to become
the innominate vein.
– In front of the clavicle.
– Behind and above the subclavian artery and separated
medially by
the Scalenus anterior and
the phrenic nerve.
– Below it sits at the first rib
and the pleura (Gray, 2000,
para 15).
Internal Jugular Vein
– The internal jugular vein receives blood
from the brain, the superficial parts of the
face, and the neck and has its origin at the
compartment of the jugular foramen, at the
base of the skull.
• Glossopharyngeal & hypoglossal nerves
pass forward between the vein and artery.
• Vagus nerve is between and
behind the internal jugular vein
and artery in a common sheath.
Internal Jugular Vein (cont)
• It runs in vertical direction on the
side of neck.
– Lateral to internal carotid artery
– Lateral to common carotid
– Unites with subclavian vein to
become the innominate vein.
Internal Jugular Vein (cont)
– At origin and termination there is a small
dilation bulb
– Above, internal jugular lies on Rectus capitis
lateralis, behind internal carotid artery and
nerves passing through jugular foramen
– At the root of the neck, the right internal
jugular vein, there is very little distance from
the common carotid artery and crosses the
beginning of the subclavian artery.
– Left vein usually smaller than the right (Gray,
2000, para 6).
Femoral Vein
“The neurovascular bundle consists of
the femoral vein, artery, and nerve,
and lies within the triangle in a
medial-to-lateral position. The
femoral sheath encloses the
femoral artery and vein, and the
nerve lies outside the
sheath…Distally in the leg, the
femoral vein lies almost posterior to
the artery” (Pal, 2009, para 6-9).
Basilic Veins
• Runs up the posterior surface of the ulnar
side of the forearm.
http://www.learnerhelp.com/images/cubital%20fossa%202.JPG
The Best Site ?
• Subclavian vein may have lower risk of
central line-associated bloodstream infection
(CLBSI)
– Increased risk of pneumothorax
– Increased bleeding
• Internal jugular vein less risk of
pneumothorax
– Disadvantage with obese patients
• Femoral vein increased risk of infection and
deep venous thrombosis in adults
– Hematoma
– Femoral artery puncture
• Basilic vein increased risk of thrombosis
(Wiegand & Carlson, 2005)
Types of Catheters
• Nontunneled catheters indicated for
short-term use
• Tunneled catheters
• Implanted catheters (ports)
• Peripheral inserted central catheters
(PICC)
Tunneled Catheters
• Associated with lower infection rates than
nontunelled
• More complex insertion and removal
• Indicated for chemotherapy, antibiotics,
parenteral feeding, blood products, and
frequent blood draws
• Long-term (>30 days) central venous
access
• With and without Dacron anchoring cuffs
Non-Tunneled Catheters
• Large-bore catheters – 6-8 in. long
• One to four lumens
• Short-term (<10 days) central venous access
• Highest risk of infection
• Easy to insert and remove
Implanted Ports
• Lowest rates of CLBSI
• Surgical insertion and removal
• Long-term intermittent therapy.
• No external catheter
• Low maintenance
PICC
• Ambulatory or outpatient therapy
• Easy to insert and remove
• Longevity
• Incidence of malposition greater
What is care bundling?
• “Care bundles, in general, are groupings
of best practices with respect to a
disease process that individually improve
care, but when applied together result in
substantially greater improvement”
(www.ihi.org).
• Evidence based research on care
bundling has shown positive impact.
Central Line Bundle
• Defined as “A group of evidence-based
interventions for patients with
intravascular central catheters that, when
implemented together, result in better
outcomes than when implemented
individually” (www.ihi.org).
Central Line Insertion
Bundle
•
Cleanse hands (ask if unsure)
•
Use chlorhexidine
•
•
Use maximal barrier precautions
– Wear sterile gloves, cap, mask, & gown (for
the physician placing the central line)
– Large drape to cover patient
All personnel in room wear a mask
Central Line Maintenance
Bundle
•
Review daily for continuous need
•
Maintain occlusive dressing
•
Change dressing per hospital protocol
•
Scrub hub for minimum of 15 seconds
prior to accessing the line
•
Hand hygiene before & after procedure
• Performing each bundling step in order
when either assisting with a central line
insertion or caring for a central line will
help to reduce your patient’s risk for
infection.
Instructional Video
http://lexloop/videopages/Central_line_dressing_change2010.html
Right click on link above and choose “open
in new window”. This will allow you to return
to the PowerPoint after viewing video.
Another Safety Feature with
Central Lines
• In dealing with central line and patient
safety – another concern is making sure
you as the practitioner are certain of the
type of central line placed.
• LMC has an increasing number of
patients presenting with ports that are
power-rated and there are special needs
to be considered.
PowerPort Implanted
Infusion Devices
• Implanted ports that are PowerPorts or
power-rated (able to withstand higher psi,
such as with CT contrast) have to be
identified using specific criteria.
• It can be very detrimental to mistake these
devices and use with too much psi with a
non power-rated port. Patient safety is our
utmost focus here.
Power Port
• Power needles for power ports will only
be used when the RN is able to verify
that the port in place is in fact a power
port.
• Verification must be done as follows:
– The patient has a card/ documentation
verifying that it is a power port.
– The patient’s medical record indicates they
have a power port.
• Note: Verbalization from the patient is not
acceptable confirmation.
If documentation not
available
• If the RN is unable to verify the port as a
power port through acceptable
documentation, then only the Huber Plus
Safety needle will be used.
• Again one of the two documentation
criteria provided must be present to
access port with a power needle.
THANK YOU!!!
• Again quality patient outcomes
are our focus at LMC.
• Thank you for taking time to
put patient safety first.
References
• APIC. (2009). Guide to the elimination of catheter-related
bloodstream infections. Washington: APIC.
• Gray, H. (2000). The veins of the neck. In W. H. Lewis
(Ed.), Anatomy of the human body. Retrieved from
http:/www.bartleby.com/107/168.html (Original work
published 1918)
• Implement the Central Line Bundle (nd) Institute for
Healthcare Improvement. Retrieved from www.ihi.org.
• Pal, N. (2009, April). Central Venous Access,Femoral
Vein. Emedicine. Retrieved from
http://emedicine.medscape.com/article/80279-overview
• Scales, K. (2010). Central venous access devices part
1:Devices for acute care. British Journal of Nursing,19(2),
88-92. Retrieved from CINAHL Plus with Full Text
• Wiegand, D. & Carlson, K. (2005). AACN Procedure
manual for critical care. St. Louis: Elsevier Saunders.