Central venous catheters, also known as central venous access devices, are used to administer large amounts of intravenous (IV) fluids, medications that can be irritating to smaller veins, and blood products (Infusion Nurses Society, 2006). Central venous catheters were once used only in patients in the intensive care unit, or other high-acuity areas. Now, nurses in all areas of healthcare, including home health and other less acute areas are taking care of patients with central venous catheters. Central venous catheters are inserted through a large central vein, such as the subclavian vein and terminate at the junction of the superior vena cava and the right atrium. In some instances, the catheter may be inserted through the femoral vein and terminate in the inferior vena cava. Because central venous catheters terminate in large veins, there is rapid blood flow around the tip of the catheter. This allows the fluids and medications infused through the catheter to be rapidly diluted and quickly moved into the patient’s circulation.
The easy and rapid access of central venous catheters to the patient’s bloodstream increases the patient’s risk for developing a catheter related bloodstream infections. Infections related to central venous catheters are more likely to occur in patients who are immunocompromised or seriously ill, such as patients in the intensive care unit. The organisms most likely to cause a central venous catheter related bloodstream infection are Staphylococcus epidermidis, Staphylococcus aureus, Candida albicans and Klebsiella pneumonia (Tilton, 2006). According to the Centers for Disease Control and Prevention (CDC), approximately 250,000 central venous catheter related bloodstream infections occur each year, at a cost of $25,000 per infection (Hadaway, 2006). The mortality rate for central venous catheter related bloodstream infections is estimated between 4% and 20% (Hadaway, 2006). These statistics make preventing central venous catheter related bloodstream infections extremely important. Preventing these infections is so important The Joint Commission has dedicated one of their National Patient Safety Goals to the prevention of catheter related bloodstream infections (The Joint Commission, 2009).
Also, effective October 1, 2008, the Centers for Medicare and Medicaid Services have stopped reimbursing hospitals for conditions that have evidence-based prevention guidelines, which includes catheter-related bloodstream infections. Now, hospitals have additional incentive for preventing infection in patients with central venous catheters, as it has become directly tied to their payment.
The Institute for Healthcare Improvement (IHI) also recognizes the importance of decreasing central venous catheter related bloodstream infections. They have implemented a 5 Million Lives campaign that is aimed at protecting patients from incidents of medical harm, including catheter infections. To help healthcare professionals accomplish this, the IHI has developed a care bundle aimed at preventing central venous catheter infections. A care bundle is a group of practices that together result in improved outcomes than if the practices were implemented separately. The central line bundle developed by the IHI has five key components:
- Hand Hygiene
- Maximal Barrier Precautions Upon Insertion
- Chlorhexidine Skin Antisepsis
- Optimal Catheter Site Selection, with Avoidance of the Femoral Vein for Central Venous Access in Adult Patients
- Daily Review of Line Necessity with Prompt Removal of Unnecessary Lines
Early studies indicate that implementing the IHI central line bundle helps significantly decrease central venous catheter related bloodstream infections (Galpern, Guerrero, Tu, Fahoum, & Wise, 2008).
A central venous catheter may be inserted by an advance practice nurse, physician’s assistant, physician, or other health care professional, depending on each state’s practice act. Choices that the healthcare professional makes during insertion of the catheter, such as the type of catheter inserted and where the catheter is inserted, can affect the patient’s risk of infection. When caring for a patient with a central venous catheter, the nurse should be aware of how these factors can influence a patient’s risk for developing a catheter related bloodstream infection.
Central venous catheters may be made out of either polyvinyl chloride or polyurethane material. Studies have indicated that catheters made out of polyurethane have a lower infection rate than catheters made out of polyvinyl chloride (Centers for Disease Control and Prevention, 2002). Some manufacturers also make catheters that have been impregnated with different antimicrobial and antiseptic agents. The science behind these catheters is that if the organism cannot attach to and move along the catheter, the less chance the patient has of developing a central venous catheter related blood stream infection. The most common types of impregnated catheters are chlorhexidine/silver sulfadiazine, minocycline/rifampin, and platinum/silver. Because of the increased cost associated with impregnated catheters, current guidelines recommended using them only if the catheter is expected to stay in place for longer than five days. These catheters are also used primarily in patients who are at a greater risk of infection, such as those with burns and severe neutropenia. If caring for a patient with one of these special catheters in place, the nurse should make sure she is familiar with the manufacturer’s recommendations for caring for the catheter.
The site where the central venous catheter is inserted can affect the patient’s risk of developing a bloodstream infection. The common sites of central venous catheter insertion are the subclavian vein, the internal jugular vein, and the femoral vein. The subclavian vein allows for easy access and a short, direct route to the superior vena cava. The internal jugular also allows for easy access and a direct route to the superior vena cava, especially on the right side. However, the internal jugular is also very close to the common carotid artery, which increases the chance of complications. The femoral veins are used when the other veins are unsuitable for use. Insertion of the catheter into the femoral veins is more difficult that insertion into upper extremity vein, and there is an increased risk of puncturing the patient’s lymph nodes.
Studies have shown that central venous catheters inserted into the femoral vein have a higher risk of infection than catheters placed in the subclavian veins (Muto, Herbert, Edwards, Horan, Andrus, Jernigan, & Kutty, 2006). This is due to the increased density of the skin flora at the femoral site compared to sites located in the upper extremity. The CDC recommends placing a catheter in the subclavian vein to decrease the risk of infection (Hadaway, 2006). When caring for a patient who has a central venous catheter that is inserted in a vein other than the subclavian vein, be aware of the patient’s increased risk for infection and report any signs of infection to the practitioner.
Nurses perform much of the daily care of central venous catheters. Therefore, nurses play an integral role in preventing bloodstream infections. There are four activities that nurse perform related to central venous catheters on a regular basis that can help prevent catheter related bloodstream infections. These activities are:
- handwashing
- performing skin asepsis
- accessing the catheter hub
- changing the insertion site dressing.
The best way nurses can help decrease the risk for a central venous catheter related bloodstream infection is by using meticulous hand hygiene. Proper hand hygiene before performing central venous catheter care can involve either the use of a waterless alcohol-based product, or using an antibacterial soap with water and adequate rinsing (Hadaway, 2006). A waterless alcohol-based product is sufficient if the hands are not visibly soiled. If hands are visibly soiled, or if the healthcare professional has been caring for a patient with C. difficile, hands should be washed with soap and water (Hadaway, 2006). Hand hygiene should be performed before any central venous catheter care, even if a dressing change or accessing the catheter is not being performed. This helps decrease the number of bacteria that come in contact with catheter, and therefore helps decrease the patient’s risk of developing an infection.
Skin antisepsis, or cleaning the skin, is another important way to help prevent central venous catheter related bloodstream infections. Chlorhexidine gluconate is the preferred antiseptic to use at the insertion site (Muto, Herbert, Edwards, Horan, Andrus, Jernigan, & Kutty, 2006). Studies have shown that chlorhexidine has a better rate of infection prevention than povidone-iodine (Muto, Herbert, Edwards, Horan, Andrus, Jernigan, & Kutty, 2006). Chlorhexidine should be used prior to insertion of the catheter to remove microorganisms at the insertion site (Infusion Nurses Society, 2006). It should also be used to clean the insertion site at every dressing change. When cleaning with chlorhexidine, use a back and forth scrubbing motion for at least 30 seconds. Then, let the site air dry in order to ensure asepsis (Infusion Nurses Society, 2006).
Some chlorhexidine preparations may contain isopropyl alcohol, which can be damaging to central venous catheters made of polyurethane (Hadaway, 2008). When preparing to clean the catheter insertion site, check the facility’s policy to make sure that it supports the use of chlorhexidine with central venous catheters.
When the catheter hub is accessed, such as during a blood draw or to infuse a medication, the patient is at an increased risk for microorganisms entering the bloodstream. Microorganisms can be transferred into the catheter and bloodstream for the surface of the catheter hub as well as the syringes or needleless connectors that are attached to the hub (Hadaway, 2008). Blood and drug particulates, and tape residue also provide a prime environment for organisms to multiply. Each time the hub is accessed, clean the hub with a new alcohol pad before accessing it (Infusion Nurses Society, 2006). This helps decrease the number of organisms on the hub hat that could potentially be transferred into the patient’s bloodstream.
Never draw blood through an access cap at the end of a central venous catheter. When drawing blood from the catheter, include the following steps: remove the access cap before drawing blood, clean the catheter hub with alcohol, and attach the syringe directly to the catheter hub. When finished, replace the access cap with a new, sterile cap. Every time the access cap is removed, or if it becomes contaminated with blood or other fluid, replace the cap with a new, sterile cap (Infusion Nurses Society, 2006).
Changing the central venous catheter dressing is one of the most common nursing functions related to central venous catheter care. Although each facility has its own policy and procedures related to central venous catheter dressing changes, there are some factors that have been proven to help decrease the patient’s risk of a central venous catheter bloodstream infection when changing a dressing.
The recommended dressing type to use on a central venous catheter is a semipermeable transparent dressing. A transparent dressing allows visualization of the insertion site to help monitor the patient for signs of infections. Signs of infection that may be visible at the insertion site include redness, drainage, and pain. Assess the insertion site through the dressing at least once a shift (Infusion Nurses Society). If the patient has a transparent dressing, it should be changed at least every seven days. If the dressing is loose, soiled, or damp, or if the dressing must be removed to examine the site closely, then the entire dressing should be replaced (Infusion Nurses Society, 2006).
In some instances, the dressing used may be a combination of gauze and transparent dressings. This is often the case in newly inserted central venous catheters, where a slight amount of drainage is normal at the insertion site. When gauze is used as a dressing for central venous catheter, the dressing should be changed at least every two days, or if the integrity of the dressing is compromised (Infusion Nurses Society, 2006).
Some facilities are now using a round chlorhexidine impregnated dressing at the insertion site. Although studies with these dressings show promise in decreasing catheter related bloodstream infections, there have been no formal guidelines issued regarding the use of these dressings (Maki, Mermel, & Kluger, 2000).
