Kaiser Permanente's Policy On Central Venous Catheter

Article by Clancy (2009) explained central lines were a result of an estimated 250,000 blood stream infections and accounted for 30,000 to 62,000 patient deaths, then adding that each infection cost upwards of $36,000 and cumulatively add up to at least $9 billion in preventable costs annually. The article also explains how the mindset has changed from the cost of having a central line in place and expecting complications to lowering infection rates by an intentional interventional process/s. The article speaks of 5 basic steps to reduce CLABSI, hand washing, insertion techniques, skin cleansing, avoidance of certain sites and earlier removal of the CVC. Studies showed that these guidelines were only followed 62% of the time. The system was changed to ascertain that all the clinicians were in compliance. This prompted 5 interventions, education, a CVC insertion cart with all necessary equipment, physicians having to validate central line necessity, a concise checklist for bedside clinicians and the empower of nurses to stop procedures if guidelines were not followed. These low cost interventions from 11.3/1000 in catheter days in 1998 to zero in the fourth quarter of 2002.

Central line bundle is a group of evidence-based practice strategy for patient with central catheters, when implemented together, produce better outcomes than implemented individually (Institute of health care improvement, 2010.). The main elements of central line bundle are hand hygiene, maximal barrier precaution upon insertion, Chlorhexidine skin antisepsis, optimal catheter selection, and daily review of line necessity with prompt removal of unnecessary lines Aseptic technique when using and caring for a central line catheter can decrease the chance of contamination in this critically ill infants. Staff education on adherence to aseptic technique and strict central line care guidelines are essential to decreasing bloodstream infections.

In 2006, $200 million and an estimated 2,000 lives were saved by using a comprehensive safety program called the Keystone Project, which presented a checklist of five crucial steps for central-line catheter placement; as a result, a dramatic reduction in central-line associated bloodstream infections (CLABSIs) was observed. The agency also developed 19 simulation grants to establish a safe environment in which clinicians can obtain proficiency in various clinical settings and procedures such as treating acute myocardial infarction, ultrasound-guided central venous catheter placement, and the disclosure of medical errors (AHRQ, 2012, pp. 7 – 8).

At my facility, 34 units are inpatient units and five critical care units. Initial surveys can be given out to assess the staff’s understanding of CAUTIs, experience with Foley insertion and the rate of nurse driven discontinuation. This will give vital information on how different units use and manage Foley catheters for educational purposes. Additional education needs are reported to the clinical educators to confer on per department and online educational material can be assigned to staff members. Collaborating with the physicians, unit managers, nurse practitioners will be important because they have influence on early Foley discontinuation. They can ask the question of whether the patient’s Foley is still needed or can be discontinued? In addition, collaborating with the nursing research team will be essential in gaining more information on evidence-base practice on latest research on Foley catheters. Volunteers to serve on the Foley rounding teams will need to make daily rounds through the facility and track the occurrences of CAUTIs that is reported to unit managers. At the next meet, managers can discuss with the staff the progression of the project, encourage efforts toward a zero occurrence of CAUTI and give credit to staff member that continuously

Central venous catheters (CVCs) are frequently used in intensive care units (ICUs) for a number of reasons (measure central venous pressure, when peripheral veins are unable to be accessed, administration of medications/therapies and aspiration of blood samples) (Conroy, 2006, p. 98). Patients in this environment already have an increased risk of infection because of their treatments. Patient treatments commonly involve invasive devices or interventions (major surgery), antibiotic therapy (raises the risk of bacterial resistance) while steroid, chemotherapy and radiation therapy all suppress the immune system (Hatler, Hebden, Kaler, & Zack, 2010).

As mentioned above, there are a multitude of practices that are practice to decrease the prevalence of central line associated blood stream infections. To prevent central line associated bloodstream infections there are several steps before and during the insertion process as well as after the insertion of the line to decrease the risk of developing an infection. To begin with, it is important to avoid using the femoral vein for central venous catheter insertion is possible (Hsu, 2014). Avoiding the femoral vein is important because it is consider a dirty area of the body; therefore, the preferred site for the insertion of these lines is the subclavian vein because it is considered the area that is least likely to be infected. Furthermore,

The outcome of the audits on clinical practice which involved forty occasions of CVDC procedures revealed differences in routine practice. Nurses differ greatly in maintaining cleanliness of work area before opening the sterile supplies, preserving the dressing set’s sterility and if proper hand scrubbing was either finished or not before touching the catheter. There were also instances when either the patient or the nurse coughs and talks while the catheter was out in the open. Documentation audit results which included charts of fifty-five patients with CVDC demonstrated significant contrast of medical records in the bedside to the electronic database in the unit. It appears that logging of insertions and removals were done obediently on the electronic database compared to bedside medical records which accounts to merely 10 percent of catheter site appearance recorded and just 55 percent on documented CVC catheter care for each treatment. Based from the end results, the working party devised a standardised routine for managing central venous dialysis catheter in order to decrease differences in practise as well as to warrant evidence based practice. A standard haemodialysis treatment form has also been adjusted to include a part wherein the observations regarding the catheter exit site as well as dressing could be examined and recorded in every session of dialysis.

As a result of the risk factors that have been associated with this medical procedure, various strategies have been implemented to help reduce if not eliminate the threat of central venous related contagions post insertion. Some of these strategies include the following; disinfection of the needleless connectors, hubs, as well as the injection ports before the use of the central venous catheter (Pongruangporn et al. 2013). Drawing from various research findings on the prevention of CVCs associated infections post insertion, the infection of the center, commonly referred to as the hub of the catheter as a result of the non-sterile access technique has been identified to be the main path for developing infections associated with the insertion of the catheter. Lowering contamination through

Bloodstream infections are a common outcome of patients with a central line and are known to be a cause of mortality in hospitals. There are a multitude of risk factors that can contribute to a central line-associated bloodstream infection (CLABSI). This can include, but are not limited to, intrinsic factors that are not controllable by healthcare team members, such as a patient’s age, underlying diseases or conditions, and patients’ gender. There are also extrinsic factors that are within the control of healthcare members, such as prolonged hospitalization before for central line insertion, nutrition, location of site, multilumen lines, deficiency of sterile barriers for central line insertion and effective cleaning of ports (The Joint Commission,

One of the most vulnerable populations within the healthcare setting include pediatrics. Due to undeveloped immune systems as well as underdeveloped body systems, the pediatric population deals with unique challenges in comparison with, perhaps, the adult population. As pediatrics have an increased risk for infection, one important safety concern in the hospital setting includes central line associated infections. A central line-associated bloodstream infection must be confirmed by a laboratory as a primary infection in which the catheter was in place for greater than 2 days and the line was also secured on the day of or the day before the event (Centers for Disease Control and Prevention, 2016). When pediatric patient’s experience central

Patients who are expected to have long hospital stays and extensive IV therapy are likely to receive a peripherally inserted central catheter (PICC). PICC lines have been found to be a relatively safe and cost effective route to administer long term intravenous (IV) medications such as antibiotics, chemotherapy and total parenteral nutrition (TPN). These devices are most often inserted at the patient’s bedside by nurses who have received advanced training in the placement of PICC lines. Evidence based practice for sterile technique during insertion has been established and as a result, infection rates remain relatively low. There is one going debate, however, as to the safety of these catheters in patients who are at an increased risk

However, one of the most critical advances to the prevention of central line-associated bloodstream is the identification of individual risk factors that are linked to this condition. They include long hospital stays prior to venous catheterization, heavy microbial colonization within the insertion site, prolonged duration of catheterization, and femoral or internal jugular vein insertion (Goode, Fink, Krugman, Oman & Traditi, 2011). Other simple preventive measures include: performing hand hygiene, using sterile gloves,

Another article which also supported the idea of preventing infection by the use of antimicrobial catheter was “The Influence of an Antimicrobial Peripherally Inserted Central Catheter on Central Line-Associated Bloodstream Infections in a Hospital Environment” by Glenell S. Rutkoff, MSN, RN, CGRN. This research included 2 groups consisting of 260 patients each. The nonintervention group included adult, hospitalized patients who received an unprotected single- or dual lumen PICC during a 6-month period. The intervention group included adult, hospitalized patients who had the study antimicrobial PICC placed during a 6-month period. This study found that the 2 groups were not significantly different when they were compared using c2 for homogeneity of age, gender (P ¼ .09), ethnicity (P ¼ .047), and unit (P ¼ .01). There was a statistically significant decrease in the rate of CLABSI from 4.18/1,000 catheter days to 0.47/1,000 catheter days when the antimicrobial PICC was used. With the information provided by both of these research articles it can be concluded that the implementation of antimicrobial and antibiotic use in central lines, diminishes the risk for infection (Rutkoff, 2014).

Over the years, the nursing practice has developed mechanisms towards improving service delivery through research and management training. The fight against Catheter-Associated Urinary Tract Infections (CAUTIs) is one area that continuously attracts a lot of concern in nursing. Indwelling urinary catheters (IUC) have been the best option in addressing CAUTI (Wilde et al., 2013). But this has resulted in more health risks and compromised service delivery among nurses, calling for new ways to either upgrade the existing mechanisms or invent new methods over the same. As a result, the American Nurses Association, in conjunction with St. Francis Hospital clinical nurse specialists is working on a pilot program that is in the last stages of its review. The program developed an evidence-based tool to be used in catheterization. Its main focus is to determine how health facilities can work together to improve the quality of service delivery through good management, as well as evaluation of its implication on performance, training, and future nursing practice (St. Francis Hospital and Medical Center, 2016). As a result, this paper examines the milestone achieved by St Francis Hospital towards quality improvement in catheter-associated urinary tract contagions.

Central venous catheters (CVC) have various uses for patients in both the inpatient and outpatient settings. Their purposes range from administration of total parenteral nutrition, to administration of vesicant medication, to providing access to patients with poor peripheral vascularity, as well as hemodynamic monitoring (Alexandrou, Spencer, Frost, Parr, Davidson, & Hillman, 2009, p. 1485). Traditionally, insertion of CVCs have been performed by surgeons and internal radiologists. However, with the advancement of roles in nursing, there has been ongoing research supporting the pro stance on the practice of nurse-led central venous catheter insertion.