vascular access infection prevention
By Nancy Moureau , RN , PhD , CRNI , CPUI , VA-BC
Peripheral Vision : Looking Beyond CLABSI to Improve Vascular Access Patient Safety
Nearly two years after COVID-19 first up-ended the world , we continue to learn more about the far-ranging impact the pandemic has had on our healthcare system . After a decade of progress in reducing healthcare-acquired infections ( HAIs ), recently published reports from the Centers for Disease Control ( CDC ) show a dramatic increase in HAIs in the latter half of 2020 . The most significant change was reported for central line-associated bloodstream infections ( CLABSIs ), which increased by more than 40 percent in both Q3 and Q4 2020 . 1
As we continue our progression to a post-COVID “ new normal ,” it ’ s essential that we refocus infection prevention efforts and take a more robust approach to patient safety to reverse this trend . As the only bloodstream infection ( BSI ) category with mandatory reporting requirements , central-line associated infections tend to get the most attention — yet these represent just a fraction of all catheter-related bloodstream infections ( CRBSIs ). The true picture of national CRBSI events is unknown , thanks to the narrow surveillance mandates . When it comes to improving infection prevention with catheters and vascular access , part of this new normal may also require looking at infections related to all intravenous ( IV ) devices — not just central lines . Fortunately , there is a growing awareness among clinicians regarding that it may be time to broaden our focus to reduce infections to include peripheral IV catheters ( PIVC ).
Why All Lines Matter
PIVC catheters are the most commonly used type of vascular access device , with nearly 90 percent of hospitalized patients requiring one at some point during their stay . In the U . S ., there are approximately 350 million PIVC devices sold each year , and each catheter placement representing an inherent risk of infection or other complications . 2 Most PIVC infections are caused by microorganisms from the skin such as methicillin-resistant Staphylococcus aureus ( MRSA ) and can cause significant morbidity . Yet there is currently no mandated reporting system for infections related to PIVCs , making it one of the most underreported types of infection .
But with several studies linking PIVC catheters to significant rates of bloodstream infections , evidence is mounting that these catheter related infections are more prevalent than previously thought . In one study , 20.4 percent of all non-CLABSI events were directly tied to the PIVCs . For peripheral catheter usage that outnumbers central lines 35-to-1 , the sheer quantity of PIVCs has led to an absolute infection rate similar to that of central catheters . 3
Earlier this year , ECRI named peripheral vascular harm to its list of Top 10 Patient Safety Concerns for 2021 . The report notes that up to 69 percent of PIVC catheters are removed prematurely due to failure or infection , and severe cases of PIVC infection require intensive care or long-term care , and can lead to extended
hospital stays , antibiotic treatments and even death . 4 In fact , this is the second time ECRI has identified PIVC infections as a major patient safety issue in recent years , noting in their 2019 report that “ increased awareness of PIV-catheter-related infections , coupled with routine active surveillance and follow-up reporting , can help reduce the risk .”
An Added Layer of Safety
Consistent education is the foundation of patient safety and reducing catheter-related infections is no exception . Skin protection is a critical component of preventing infections that can originate at IV sites , so education topics must include proper skin preparation and aseptic non-touch technique ( ANTT ) to avoid touch contamination during insertion and post insertion with PIVC usage . Insertions by skilled clinicians has been shown to reduce the number of catheter placement attempts , which can also lower infection rates . 5 Application of ANTT during care and maintenance establishes the safety necessary to avoid contamination of the catheter and hub where bacteria attach and grow .
Yet even the best training cannot completely eliminate human error . Practice variations can lead to breaks in technique and touch contamination . Certain levels of protection can be added such as use of antimicrobial dressings enhancing antisepsis at the insertion site for up to seven days . Antimicrobial devices serve as a powerful tool in the fight to reduce catheter-related bloodstream infections ( CRBSI ), providing an added layer of safety . Over the years , IV dressing technology has evolved from basic gauze and tape to flat transparent dressings , and now dressings with antiseptic-impregnated coatings using the antimicrobial power of chlorhexidine .
The introduction of chlorhexidine-impregnation into transparent dressings was a significant advancement in IV site protection . Chlorhexidine is a well-known , broad-spectrum antiseptic that is widely used in healthcare settings , and it has been shown to prevent transmission of organisms commonly linked to CRBSIs , including MRSA . 6 Most dressings utilize salt-based chlorhexidine formulations . Early on , pure chlorhexidine was shown to have poor solubility , creating a challenge for its use as an antiseptic . The solution was found within various salt formulations that improve solubility for chlorhexidine gluconate ( CHG ) and chlorhexidine acetate ( CHA ). Multiple studies confirmed efficacy of these dressings in reducing the incidence of catheter colonization and CRBSI . 7-10
Back to Basics
Reversing the pandemic increase in HAIs requires a restart of efforts to evaluate , educate and revisit the basics of infection prevention to ensure consistent hand hygiene , skin antisepsis , access disinfection and removal of unnecessary catheters . Institution of education forms the foundation for teaching the essentials of infection prevention . Identification of gap areas ,