Catheter related Infections
Submitted by Elizabeth Culvewrwell, Clinical Education CEL. Originally printed in September 2006 IVNNZ Newsletter
CATHETER RELATED HOSPITAL ACQUIRED INFECTIONS (H.A.I.)
THE PROBLEM - THE NEED - THE SOLUTION
The development and impact of technology has never been more apparent than in today's health care environment. Sophisticated procedures, techniques and risk management requirements have led to the continued development of all types of medical devices.
Infusion devices facilitate the administration of both simple and complex pharmacology regimes. The evolving complexity of these devices coupled with a need for the training in the use of such devices is recognised globally as an increasing area of risk that has to be managed.
Management of intra vascular access devices cannot be addressed in isolation from staff training and education.
Dr Leonard Mermel states ‘Intravascular catheter related infections account for considerable morbidity and prolonged hospital stay'.
Most serious infections are associated with central venous catheters.
Approximately 80,000 central line associated blood stream infections occur in US Intensive Care Units annually.
The Human & Financial Cost
To fully appreciate this 'cost', we need look no further than our own New Zealand data. In 2003, Blood Stream Infections (BSI) accounted for almost 80% in six of our large DHB's with complex services, and at a cost of around $19 million p/y in at least two large DHB's. The human cost however is very sobering. BSI comprises 5-10% of H.A.I's with a greater than 30% mortality.
Catheter infections are by no means restricted to ICU/HDU. Intravascular catheters are also an important source of infection among patients in other ‘patient care' areas of the hospital, rehabilitation facilities or those undergoing home care.
Catheter Related Infection [CRI)
Hadaway [2003] describes infection as ‘the result of a complex interaction between catheter surface and microbes and their formation of biofilm and the rich source of plasma protein'
describes infection as ‘the result of a complex interaction between catheter surface and microbes and their formation of biofilm and the rich source of plasma protein'
Intravascular catheter related infections (CRI) by their nature, Interrupt prescribed therapy, Impact on length of therapy that the patient receives and requires and Increase length of hospital stay /cost.
Risk factors can be patient related or institution related. Micro-organisms modes of transmission are skin contamination occurring in the first week of catheter dwell and catheter hub transmission which occurs after the first week.
Categories of infection can be described as follows
- Localised catheter colony
15 CFU catheter tip/hub or subcutaneous segment
- Exit site infection
2cm redness /absences of BSI /no purulence
- Tunnel infection [ Hickman/Groshong]
2cm red /tender/site induration along catheter tract, absence of concomitant BSI
- Infusate related BSI
Concordant growth from infusate & blood culture, no other identified source of infection
- Catheter related BSI
Bacteraemia /fungaemia plus positive blood culture, fever, chills, hypotension. Same organism isolated from catheter segment & blood
Implementing Preventative Strategies
Prevention of catheter-related infections should include optimal disinfection of the catheter insertion site, maximum sterile barrier[MSB] for insertion reduces infection by 2.3% - 7.3%], aseptic manipulation of catheter hubs and dressings, proper physician and nurse education and training regarding aseptic techniques, appropriate patient / nurse ratio(especially in ICU's) using non femoral devices, not inserting unnecessary devices and removing the device on completion of therapy. Adherence to hand washing and the use of alcohol hand gels has seen a reduction in HAI's by up to 90% [Pettet].
We cannot underestimate the impact of education, IV nursing teams, adherence to protocols and guidelines.[Mermel 2001].
Educational goals should present the research and evidence that underpins and facilitates best practice in caring for patients with Central Vascular Access Devices, ultimately improving patient outcomes.
This should reflect
- Best practice for infusion therapy
- The lowest risk for complications
- Support the safest course of prescribed therapy
- Provide the appropriate IV & infusion device selection for the patient
References:
Centers for Disease Control and Prevention. (2002). Guidelines for the Prevention of Intravascular Catheter-Related Infections. MMWR, 51 (No. RR-10):1-29. Available: http://www.cdc.gov/mmwr/t_blank
Darouiche R. Raad I. Prevention of catheter-related infections: The skin. Nutrition; 1997; 13(suppl):26S-29S.
Galloway, M. (2002). Using benchmarking data to determine vascular access device selection. Journal of Infusion Nursing. 25: 321-325.
Hadaway, L. (2002). Choosing the right vascular access device, part II. Nursing 2002. 32:74-76.
Hadaway, L. (2002). What you can do to reduce catheter related infections. Nursing2002. 32(9):46-48
Mermel L.A. Catheter related blood stream infection. Ann Intern Med 2000;133:395
NZ Auditor- General Report. Management of Hospital Acquired Infections. 2003 Vol: 1&2
Pittet D et al .Effectiveness of a hospital wide programme to improve compliance with hand hygiene. Lancet 2000;356:1307-9
Raad II.et al. Prevention of central venous catheter related infections by using maximum sterile barrier precautions during insertion. Infect Control hosp Epidemiol 1994;15:231-8