Central Venous Catheter Maintenance Research Articles

A vascular access and midlines program can decrease hospital-acquired central line-associated bloodstream infections and cost to a community-based hospital.

BackgroundWe propose that substituting central lines with midlines can help reduce the total number of central line catheter-days as well as central line-associated bloodstream infections (CLABSIs), thereby reducing the associated costs and the resulting increased length of stay. A midline or vascular access program in a community hospital can bring about these positive changes.ObjectivesOur objective is to evaluate whether the institution of a midline program for vascular access at a community hospital can reduce the number of central line catheter-days and the associated CLABSI rate, incidence, and cost.Materials and methodsWe collected data on the number of central line catheter-days per year starting from 2012. We also collected data on the total number of patient-days during this period and the number of CLABSIs. We started Centers for Disease Control and Prevention (CDC)-based recommendations to help decrease CLABSIs in June 2014; this included the use of the central venous catheters (CVC) insertion bundles and CVC maintenance bundle. Chlorhexidine baths were also given to all patients with central lines. In June 2015, we started a midline program and tracked data till June 2017. We then compared the infection rates during these periods.ResultsWe conclude that instituting CDC recommendations to decrease CLABSIs did bring down the CLABSI rate; this decrease was not statistically significant. However, the addition of the midline program to replace central lines whenever possible, combined with universal CDC recommendations, did result in a significant decrease in both the number of central line days per patient-day and the CLABSI rate.ConclusionWe recommend hospitals to develop a midline program to help reduce the use of central line catheters when possible to reduce the total number of catheter-days and the CLABSI rate associated with them.

Catheter-related infections in patients with acute type II intestinal failure admitted to a national centre: Incidence and outcomes

The management of intestinal failure (IF) requires safe and sustained delivery of parenteral nutrition (PN). The long-term maintenance of central venous catheter (CVC) access is therefore vital, with meticulous catheter care and salvage of infected CVCs being of prime importance. CVC-related infection and loss of intravenous access are important causes of morbidity and mortality in IF. Avoidance, prompt recognition and appropriate management of CVC-related infections are crucial components of IF care. However, there are few, if any, data on the occurrence of CVC-related infections in patients with acute, type 2, IF managed on a dedicated IF unit and no data on the salvage outcomes of infected CVCs in this group of patients. This is a retrospective observational study conducted between January 2011 and July 2017. All patients with acute, type 2 IF newly admitted to a national U.K. IF unit (IFU) during these dates were included. All patients admitted to the unit with a CVC in place underwent immediate 'screening' paired central and peripheral blood cultures on arrival before the CVC was used for any infusate. A prospectively maintained database was used to record all confirmed catheter-related blood stream infections (BSI)/colonisations, demographic and clinical data. Diagnosis of catheter-related BSI/colonisation was based on quantitative and qualitative analysis of paired central and peripheral blood cultures. A standardized 10-14-day catheter salvage treatment protocol involving antibiotic and urokinase CVC locks and systemic antibiotic administration was used to salvage any infected or colonised CVCs, as appropriate. The CVC was not used for PN until successful salvage had been confirmed by negative blood cultures drawn 48h after antibiotic completion. The development of a subsequent catheter-related BSI was recorded for all patients, both during the remaining in-patient stay on the IFU and after discharge home on PN. Of the 509 patients with type 2 IF admitted to the IFU during the study period, 341 (54% female; mean age 54.6 (range 16-86 years)) had an indwelling CVC that had been placed in the referring hospital. Surgical complications and mesenteric ischaemia were the most common underlying disease aetiologies. Sixty-five of 341 (19.1%) patients had an infected/colonised CVC on the initial screening set of blood cultures. A successful CVC salvage rate of 91% was achieved in this cohort after antibiotic therapy. The subsequent in-patient catheter-related BSI rate for those admitted with a CVC (n=341) on the IFU was 0.042 per 1000 catheter days, over a total of 23,548 in-patient catheter days. Two hundred and seventy nine of 341 patients were discharged on home PN (HPN); with a subsequent catheter-related BSI rate on HPN of 0.22 per 1000 catheter days (mean duration of HPN=778 catheter days (range:)) over a follow-up period of 216,944 out-patient catheter days. There was no increased risk of HPN-related catheter-related BSI (p=0.09) or mortality (p=0.4) in those admitted with an infected CVC. This is the first study to report catheter-related BSI/colonisation rates and salvage outcomes in patients with type 2 IF newly admitted to a dedicated IF Unit. We report that nearly one-fifth of all patients were referred with evidence of a catheter related BSI/colonisation; despite this, successful catheter salvage is possible and, with stringent CVC care, an extremely low subsequent catheter related BSI rates can be achieved and maintained during in-patient stay on a dedicated IF Unit and after discharge on HPN. These data provide novel evidence to support ESPEN recommendations that patients with type 2 IF are managed on a dedicated IF Unit.

Central line bundle maintenance among adults in a university hospital intensive care unit in São Paulo, Brazil: a best practice implementation project.

This implementation project aimed to identify the current practice in regards to central venous catheters (CVCs) maintenance to improve knowledge amongst nursing staff and to assess increased compliance with evidence-based best practice. Central venous catheters are considered an important therapeutic resource for the administration of fluids, drugs, blood, collection of blood samples and hemodynamic monitoring. Despite the benefits, catheter use is associated with complications such as primary infection of the catheter-related bloodstream. This project utilized the audit and feedback model using the Joanna Briggs Institute Practical Application of Clinical Evidence System. Nine of 10 criteria were audited through direct observation of nursing professionals or patient records in relation to CVC maintenance, and one criterion involved direct questioning of nursing staff. Baseline and follow-up audits were conducted in a 12-bed adult intensive care unit in a university hospital. The baseline audit revealed deficits between current practice and best practice in some criteria. Barriers to implementation of CVC maintenance best practice criteria were identified, and the strategies were implemented. The post-implementation (follow-up) audit showed improvement in compliance to best practice guidelines in all of the audit criteria, except in one criterion: the use of sterile gloves or surgical tweezers during the execution of the dressing. Best practice in CVC care was achieved in the hospital, strengthening and guiding nursing care, as well as highlighting the importance of nursing records throughout the care process. However, this project highlighted the need to improve compliance through follow-up audits and periodic training to support best practice.

Enhanced central venous catheter bundle for pediatric parenteral-dependent intestinal failure

Central line-associated bloodstream infections (CLABSIs) cause substantial morbidity and increase antimicrobial use and length of stay among hospitalized children in the United States. CLABSI occurs more frequently among high-risk pediatric patients, such as those with intestinal failure (IF) who are parenteral nutrition (PN) dependent. Following an increase in CLABSI rates, a quality improvement (QI) initiative was implemented. Using QI methodology, an enhanced central venous catheter (CVC) maintenance bundle was developed and implemented on 2 units for pediatric PN-dependent patients with IF. CLABSI rates were prospectively monitored pre- and postimplementation, and bundle element adherence was monitored. Enhanced bundle elements included chlorhexidine-impregnated patch, daily bathing, ethanol locks, 2 nurses for CVC care in a distraction-free zone, peripheral laboratory draws, bundling routine laboratory tests, and PN administration set changes every 24 hours. Adherence to enhanced bundle elements increased to >90% over 3 months. CLABSI rates averaged 1.41 per 1,000 central line days preimplementation compared with 0.40 per 1,000 device days postimplementation (P = .003), an 85% absolute reduction in CLABSI rates over 12 months. Patients with IF are at an increased risk for CLABSI. Enhanced CVC maintenance bundles that specifically target prevention practices in this population may be beneficial.

Predictors and Prevalence of Central Line Associated Blood Stream Infections Among Adult Patients in Critical Care Units -Kenyatta National Hospital

Most adult patients admitted in Critical Care Units (CCUs) have central venous catheters (CVCs). These catheters mostly remain in place for the entire period of hospitalization, hence the risk of developing Central Line Associated Bloodstream Infection (CLABSI). The burden of CLABSI has remained high despite the introduction of CLABSI care bundles increasing the morbidity, mortality, hospital stay and cost. Most CLABSIs are caused by factors attributed to patient characteristics, clinical care and institutional factors. The aim of this study was to determine the prevalence and predictors of CLABSIs among critically ill adult patients at CCUs of Kenyatta National Hospital. The study applied a cross-sectional descriptive design with stratified sampling and simple random sampling for each stratum. 86critical care nurses were selected from a total of 110 nurses using Yamane formulae. Medical records of critically ill patients’ that met the inclusion criteria were reviewed for the year 2015. An interviewee administered questionnaire and observation checklist were used to collect data from the nurses, and a data collection sheet was used to collect data from the medical records on prevalence of CLABSIs and patient characteristics. Descriptive statistics was used to summarize the data and inferential statistics (Chi-square test, Pearsons’ correlation) was used to establish relationships between variables. Data analysis was done using the Statistical Package for Social Sciences (SPSS) version 21.0. This study revealed that the prevalence of CLABSIs was 3.53%. Stepwise logistic regression revealed that, the patient predictors of CLABSIs in KNH CCUs were as follows; Neurological disorders as the underlying disease X2 (52) =15.249; 95% CI -0.199-0.158; P=0.946, increased length of hospitalization with CVC in situ X2 (52) =40.639; 95% CI 0.612-0.874; P< 0.001 and parenteral nutrition use X2 (52) =9.826; 95% CI 0.041-0.759; P=0.013. In addition, the nursing care related factors that predispose critically ill patients to CLABSIs in KNH CCUs were; Poor practices on hand hygiene before manipulation of infusion line which was observed in 81.8% of the CCNs, failure to remove unnecessary CVCs promptly, poor knowledge and practices on CVC maintenance and inadequate knowledge and outdated practices on changing intravenous administration system components.

A3 for Central Line-Associated Blood Stream Infections

SESSION TITLE: Quality Improvement 1 SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: An estimated 30,000 central line associated blood stream infections (CLABSIs) occur in U.S. Intensive Care Units (ICUs) each year. Patient mortality rates associated with CLABSI range from 12-25% and the cost of CLABSIs ranges from $3,700 to $36,000 per episode of care. To address this issue, we collaborated with hospital management to create a multidisciplinary team to enhance the care of patients with central venous catheters (CVCs) by using A3. A3 is a problem solving and continuous improvement approach first employed by Toyota and based on Edward Denning’s PDSA (Plan-Do-Study-Act).We implemented an A3 problem solving methodology in order to systematically reduce CLABSI among the medical and surgical ICUs. METHODS: A review of CLABSI related events across the various adult ICUs was performed. Initial and target states were established. The goal was to achieve a zero CLABSI rate by standardizing workflow for insertion, implementing strict guidelines for maintenance, and emphasizing early removal of CVCs. Gap analysis was used to identify multiple areas for improvement, which fell into five major categories: workflow, education, documentation, assessment and visual management. During subsequent monthly meetings, multiple small experiments were developed and implemented. Some of the products of these experiments include the creation of standardized central line insertion and maintenance checklists, a CVC insertion and maintenance audit tool, and a decision algorithm for line insertion and maintenance. RESULTS: We reviewed a total of 14,960 ICU patient days. Mean patient-days per month was 298 (range 210-379). Following the implementation of insertion and maintenance checklists in ICUs, we were able bring down our CLABSI Rate (CLABSI events /1000 patient days) from 2.25 to 0.00 to achieve our target goal of zero. CLABSI rates were reduced by 100% among adult ICU patients (p<0.001). Despite emphasis to reduce the use of central lines by early removal and consideration of alternative access, the device utilization ratio (defined as device utilization days divided by patient days) remained relatively constant (mean 0.30; range 0.23-0.39). These rates were sustained over the next nine months and checklists are permanently embedded in ICU work protocol. CONCLUSIONS: Our data demonstrates the effectiveness of the A3 approach for improving quality and safety among the different ICUs. Using this methodology, we were able to serially introduce several interventions that acted synergistically to eliminate CLABSI in the ICU. CLINICAL IMPLICATIONS: A3 provides an effective appraoch to problem solving and can be used in clinical setting to decrease and sustain lower CLABSI rates. DISCLOSURE: The following authors have nothing to disclose: Sikander Zulqarnain, Anton Dela Cruz, Gem Snagg, Raymonde Elysee, Jacqueline Syrus, Samir Fahmy No Product/Research Disclosure Information

Controlling catheter-related bloodstream infections through a multi-centre educational programme for intensive care units

Bloodstream infections (BSIs) associated with insertion and maintenance of central venous catheters (CRBSIs) are the most frequent causes of healthcare-associated infections in intensive care units (ICUs). They are responsible for increased length of hospital stay and additional healthcare costs. To investigate whether an educational programme aimed at healthcare workers resulted in a significant change in the level and trend of infections. The research was conducted in five Italian ICUs from July 2012 to August 2014. Surveillance and educational interventions to control infections were applied. Compliance with hand hygiene procedures was assessed via relative risk and 95% confidence interval. Interrupted time-series analysis was used to investigate the change in level and trend of infection during the intervention. Compliance with hand hygiene procedures improved during the intervention for all staff groups, but physicians showed the lowest compliance rates (nurses from 52.4% to 92.1%; nurse aides from 71.0% to 92%; physicians from 71.0% to 92%; P<0.001). Significant reductions of 21-55% in CRBSI were observed during the intervention. Small improvements in the monthly infection trend were also observed, but these were not statistically significant. An educational programme focusing on general good infection control practice, rather than CVC care bundles, led to a decreased CRBSI rate, even if the improvement was not sustained over time. Continuous performance feedback should be provided to promote long-term adherence to guidelines among all health workers.

Preventing catheter-related bloodstream infections from a central venous catheter

Central venous catheters are useful for a variety of clinical situations being used in delivery of fluids and drugs, monitoring, and allowing for large volume of blood to be aspirated. Despite their usefulness, placement of venous access catheters is accompanied by the potential of causing catheter-related bloodstream infection (CRBSI). Attention to preparation of the catheter insertion site, selection of appropriate catheter material, proper hand hygiene, and optimal dressing material and methods play a large role in reduction of CRBSI. A central venous catheter maintenance protocol outlining dressing evaluation and changes, cleaning of the insertion site, and conditions for catheter removal will further improve the chances of an infection-free patient. Veterinary nurses play a vital role in the placement and maintenance of central venous catheters and influence a positive patient outcome.

Application of process quality monitoring for the control of hospital infection in ICU

Objective To explore the effect of process quality monitoring for hospital infection control of ICU. Methods A total of 265 critically ill patients admitted to ICU were chosen as the control group from April 1, 2014 to March 31, 2015, who were strictly enforced three cluster strategies to prevent catheter related blood stream infection (CRBSI), catheter-associated urinary tract infection (CAUTI) and ventilator–associated pneumonia (VAP) with periodical data monitoring in ICU. Another 292 critically ill patients admitted to ICU were chosen as the observation group from April 1, 2015 to March 31,2016, who were added 3 measures of process quality monitoring on the basis of implementation method of the control group. The incidence of CRBSI, CAUTI and VAP time were compared between two groups. Results There was statistically significant difference on the incidence rate of the CRBSI between the two groups (χ2=4.504, P=0.034), which was respectively 1.79% (5/280) and 5.10% (13/255). There was statistically significant difference in the incidence rate of CAUTI between the two groups (χ2=5.708, P=0.017), which was respectively 3.48% (10/287) and 8.27% (21/254). There was statistically significant difference on the incidence rate of VAP between the two groups (χ2=8.291, P=0.004), which was respectively 3.48% (10/287) and 8.27% (21/254). Mean time of mechanical ventilation in the observation group and the control group was respectively (2.14±1.40) days and (3.37±2.01) days, there was no significant difference (P=0.073). Mean time of ICU stay in the observation group and the control group was respectively (6.04±1.04) days and (11.92±1.90) days, there was statistical significance (t=-1.840, P=0.024). Number of qualified central venous catheter maintenance, perineum clean and oral care had negative relevance with number of patients with CRBSI, CAUTI and VAP, correlation coefficient in the observation group was respectively -0.701, -0.618, -0.677, there was statistical significance (P < 0.05). Conclusions The implementation of quality monitoring can reduce the number of patients with CRBSI, CAUTI and VAP, which suggests wide application in ICU. Key words: Intensive care unit; Process quality; Hospital infection

A Cohort Study on Nurse-Led Checklist Intervention to Reduce Catheter-Related Bloodstream Infection in an Intensive Care Unit

Background: Several collaborative studies have shown that infectious complications arising from the use of central venous catheters (CVC) in intensive care units (ICU) are preventable and that the implementation of a safety program can reduce the incidence of infection. Objective: To structure, based on the best available scientific evidence, and evaluate the results of implementation by the nursing staff of a checklist to prevent these complications. Methods: The sample analysed comprised 164 patients and was selected based on criteria of inclusion/exclusion. The accepted procedures and concepts were standardized, and both the questionnaire and the factsheets for the collection of clinical and laboratory data had been structured previously. The variables analysed in the study were: gender, age, duration of CVC maintenance, length of stay, mortality, type of condition on admission, type of dressing, chlorohexidine use, association with other concomitant venous access, anatomical region of CVC insertion, presence of consumptive disease, use of chemotherapy and awareness of the importance of professional intervention in implementing the checklist. The primary outcome measure was the presence or absence of bloodstream infection. Results: Statistical analysis showed that the test and control groups were homogeneous. The study findings revealed significant differences (p<0.05) for the presence of bloodstream infection, length of hospital stay and the duration of catheter maintenance, in both the univariate analysis and the linear regression. Conclusions: The application of the checklist used here prevents infection of the bloodstream by CVC and reduces the length of hospital stay as well as the duration of catheter maintenance, thus influencing the incidence of bloodstream complications.

Outcome of Candida Parapsilosis Complex Infections Treated with Caspofungin in Children.

BackgroundWe aimed to evaluate the correlation of caspofungin E-tests with the prognosis and response to caspofungin therapy of Candida parapsilosis complex bloodstream infections in children hospitalized in a pediatric intensive care unit.MethodsAll children who had C. parapsilosis complex bloodstream infections and who were treated with caspofungin were included in this retrospective study. For each patient, the following parameters, including all consecutive blood and central venous catheter (CVC) cultures, the duration between diagnosis and CVC removal, mortality rate, relapses of the C. parapsilosis complex infections as well as the demographic features, were recorded.ResultsThe central venous catheter survival rate was 33.3% under caspofungin treatment. In 92.4 % of the patients, the negative culture was achieved within a median duration of 12.5 days. The rate of relapses was 18.9%. The overall mortality rate was 37.7% (20 of 53 patients), and the 30-days mortality rate was 7.5% (4 of 53 patients). There was no statistically significant difference between the groups with MIC<2 mg/l and MIC =2 mg/l using CVC survival rate; rate and duration of achieving negative blood culture for C. parapsilosis complex; duration of hospital stay; rate and duration of relapses; overall mortality and 30-days mortality.ConclusionsThe beneficial effects of Caspofungin on biofilms has been shown in vivo, while its impact in children for maintenance of CVC was limited in our study but should not be underestimated in children who strongly need the presence of CVCs. The clinicians should weigh their priority for their patients and choose the optimal antifungal therapy for C. parapsilosis complex infections in children.

Impact of a Central Line Infection Prevention Bundle in Newborn Infants

OBJECTIVE To compare central line use and central line-associated bloodstream infection in newborn infants before and after the introduction of a central line infection prevention bundle in order to determine the effectiveness of the bundle and to identify areas for further improvement. DESIGN Retrospective cohort analysis of prospectively collected data. SETTING Level 5 neonatal intensive care unit in Sydney, Australia. PATIENTS Newborn infants admitted to the Royal Prince Alfred Hospital Neonatal Intensive Care Unit who had a central venous catheter (CVC) inserted. METHODS Data regarding clinical characteristics, CVC use, and infection were collected before and after the introduction of a bundle of interventions. The bundles encompassed (1) insertion of CVC, (2) maintenance of CVC, (3) an education program, and (4) ongoing surveillance and feedback. RESULTS Baseline and intervention groups were comparable in clinical characteristics. The number of CVCs inserted was reduced in the intervention group (central line utilization rate, 0.16 vs 0.2, P<.0001). Overall CVC dwell time was reduced, resulting from significant reduction in peripherally inserted CVC dwell time (6 days [95% CI, 5.0-11.8 days] vs 7.3 days [4.0-10.4 days], P=.0004). Central line-associated bloodstream infections were significantly reduced, predominantly secondary to decreased peripherally inserted CVC-related bloodstream infections (1.2/1,000 central line-days vs 11.5/1,000 central line-days, P<.0001). CONCLUSION This central line infection bundle was effective in reducing CVC use, dwell time, and central line-associated bloodstream infections. Infect Control Hosp Epidemiol 2016;37:1029-1036.

Heparin flush vs. saline flush for use in the maintenance of adult central venous and intra-arterial catheters: potential harm, too little gain?

Heparin saline use for the maintenance of invasive arterial and central lines may be associated with significant risks and has not been conclusively shown to confer additional benefits over saline flushing alone. The routine use of heparin saline flush instead of saline alone for arterial and central venous catheter maintenance should be thoughtfully considered.

Effectiveness of a programme to reduce the burden of catheter-related bloodstream infections in a tertiary hospital.

The objective of this study was to assess the effectiveness of a catheter-related bloodstream infection (CR BSI) reduction programme and healthcare workers' compliance with recommendations. A 3-year surveillance programme of CR BSIs in all hospital settings was implemented. As part of the programme, there was a direct observation of insertion and maintenance of central venous catheters (CVCs) to determine performance. A total of 38 education courses were held over the study period and feedback reports with the results of surveillance and recommendations were delivered to healthcare workers every 6 months. A total of 6722 short-term CVCs were inserted in 4982 patients for 58 763 catheter-days. Improvements of compliance with hand hygiene was verified at the insertion (87·1-100%, P < 0·001) and maintenance (51·1-72·1%, P = 0·029) of CVCs; and the use of chlorhexidine for skin disinfection was implemented at insertion (35·7-65·4%, P < 0·001) and maintenance (33·3-45·9%, P < 0·197) of CVCs. There were 266 CR BSI incidents recorded with an annual incidence density of 5·75/1000 catheter-days in the first year, 4·38 in the second year [rate ratio (RR) 0·76, 95% confidence interval (CI) 0·57-1·01] and 3·46 in the third year (RR 0·60, 95% CI 0·44-0·81). The education programme clearly improved compliance with recommendations for CVC handling, and was effective in reducing the burden of CR BSIs.

Evidence-based measures to prevent central line-associated bloodstream infections: a systematic review.

ABSTRACTObjective: to identify evidence-based care to prevent CLABSI among adult patients hospitalized in ICUs. Method: systematic review conducted in the following databases: PubMed, Scopus, Cinahl, Web of Science, Lilacs, Bdenf and Cochrane Studies addressing care and maintenance of central venous catheters, published from January 2011 to July 2014 were searched. The 34 studies identified were organized in an instrument and assessed by using the classification provided by the Joanna Briggs Institute. Results: the studies presented care bundles including elements such as hand hygiene and maximal barrier precautions; multidimensional programs and strategies such as impregnated catheters and bandages and the involvement of facilities in and commitment of staff to preventing infections. Conclusions: care bundles coupled with education and the commitment of both staff and institutions is a strategy that can contribute to decreased rates of central line-associated bloodstream infections among adult patients hospitalized in intensive care units.

Decrease in Candida bloodstream infections in veterans in Atlanta

Despite the recent focus on prevention of health care-associated infections, rates of Candida bloodstream infections in adults have remained unchanged until recently. We report a decline of Candida bloodstream infections, not explained by changes in broad-spectrum antibiotic use, but coinciding with infection control policies aimed at central venous catheter maintenance.

Decrease in Candida Bloodstream Infections in Veterans in Atlanta

Despite the recent focus on prevention of health care–associated infections, rates of Candida bloodstream infections in adults have remained unchanged until recently. We report a decline of Candida bloodstream infections, not explained by changes in broad-spectrum antibiotic use, but coinciding with infection control policies aimed at central venous catheter maintenance.

Evaluating an Educational Intervention of Central Venous Catheter Maintenance among Oncology Nurses

Evaluating an Educational Intervention of Central Venous Catheter Maintenance among Oncology Nurses

A community collaborative to develop consensus guidelines to standardize out-of-hospital maintenance care of central venous catheters.

Central venous catheter (CVC) maintenance is integral to preventing complications and improving outcomes. This process is made more challenging when patients transition from hospital to home care or to an outpatient infusion setting, because different CVC maintenance practices and care parameters confuse patients and care providers alike. Through collaboration and consensus building, a group of metropolitan home health and home infusion agencies developed a standardized approach to CVC maintenance care. This article discusses the multiagency collaborative and resulting guideline and other educational materials that better enable providers, patients, and families to maintain CVC integrity and achieve optimal outcomes.

Management of central venous catheters in intensive care units: Comparative study of guidelines versus practice.

Sir, An observational study was conducted on 100 nurses with minimum 6 months of experience in various intensive care units (trauma, swine flu, medical, and renal) of the hospital to assess their knowledge and clinical practice. A two-part questionnaire [Table 1] was filled by the nurses after every central venous catheter (CVC) insertion for a period of 2 months. Each correct response was scored 1; incorrect 0. Total number of catheter insertions was 148. Mean score for the study was 53%. Table 1 Questionnaire Results from Part A: Standardized equipment set, barrier precaution, filling of the checklist, and an assistant was available in 96%, 95%, 86%, and 98% of the insertions. Two-third were done on monitored beds with head low; only 1% on unmonitored beds. Povidone iodine, 70% alcohol, 2% chlorhexidine-based preparations were preferred in decreasing order for disinfection of skin (60%, 21%, and 19%, respectively). Eighty percent preferred sutures for catheter fixation and transparent bio-occlusive dressing. Results from Part B: Subclavian, internal jugular and femoral vein were preferred by 66.6%, 25%, and 9%. One-fifth were not aware of use of ultrasound. 98% managed unintended arterial puncture by removal of needle/catheter and application of pressure. 90% opined that chest X-ray confirmed placement of CVC. 96% preferred heparin based solution; 4% used normal saline. Two inspections of CVC/day were made by 50%; one/day were made by 40%. One-fifth wiped access ports with antiseptic before drug administration. Removal of infected CVC was considered by 60%; 25% believed in giving an antibiotic and observing. Three-fourth marked 4 h as maximum infusion time for blood products; 24 h for change of intravascular catheters/sets. Tubings for blood products and lipid emulsions were changed by 80% 12 hourly. Three-fourth believed in no fixed duration for changing CVC; one-fourth believed in the weekly change. Half believed in administration of antibiotics for central lines inserted in emergency. Only 25% considered a replacement of the catheter within 48 h. The remaining 25% considered replacement only on signs of infection. Routine prophylactic antibiotics was advocated by 36%. Results show that awareness on the use of chlorhexidine, ultrasound, correct management of arterial punctures and protocol for CVC inserted in emergency departments needs to be increased. Regular training programs with the nursing staff on bundles of care related to insertion and maintenance of CVC are needed.[1,2,3] American Society of Anesthesiologists guidelines[4] are focused on elective insertions of CVC's performed by anesthesiologists, but the Centers for Disease Control and Prevention guidelines[5] also address emergency placements, peripherally inserted central catheters, pulmonary artery catheter and tunneled central lines. Safety or efficacy of chlorhexidine in neonates and infants aged <2 months remains an unresolved issue. Fluid administration sets need to be changed at 96 h intervals and tubings for blood products and lipid emulsions every 24 h. Routine replacement of CVCs on the basis of fever alone and prophylactic administration of systemic antimicrobial agents is discouraged. Mandatory replacement is to be done within 48 h for all catheters inserted in an emergency without aseptic precautions.