So in case you wondered where I disappeared to, I just spent the last 7 of 8 days working. Such is the life of a nurse! Not to mention, Thanksgiving was my holiday this year - also the life of a nurse! But, on the bright side, working all those days has paid off and I don't have to go back to work until Thursday! (Insert happy dance here!) AND, my parents are in town for Thanksgiving so I get to spend time with them. It's the first time I've seen them in 2 months.
With that being said, I don't know how much time I'm going to have to post over the next few days. Between my parents visiting and homework looming, I won't have a ton of time. So, I am going to take this opportunity to share a research paper that I wrote for nursing school with regard to 90% Alcohol-Impregnated Port Caps used for central lines and PICC lines in the ICU. The research paper discusses their use and efficacy. It is definitely worth the read as it is something you could potentially suggest for use in your hospital unit. We just started using them in mine and I can't wait to see how it has helped to decreased Central Line-Associated Bloodstream Infections (CLABSI) in my hospital.
So, without further adieu...
I. Introduction
In
critical care units, infections continue to be a significant problem compared to
other hospital units. The amounts
of equipment required to assist the patient in recovering from their ailments
and to effectively monitor the patient to insure a speedy recovery means an
increased risk for infection as well as a need for staff vigilance. Common sources of infection in critical
care units include ventilators, Foley catheters, arterial access devices and
central venous access devices. All
of these deserve further investigation.
For the purpose of this evidence-based practice project, the focus will
be on central venous access devices (CVAD) and Central Line-Associated
Bloodstream Infections (CLABSI).
According
to Dumont and Nesselrodt (2012), “Mortality for central line-associated
bloodstream infections (CLABSIs) is 12% to 25% making them among the most
deadly of healthcare-associated infections (HAIs)” (p. 41). For this reason, continuing to seek out
and disseminate the best evidence-based practices for central line insertion
and care is of the utmost importance.
Dumont and Nesselrodt go on to report that CLABSIs in ICU’s have seen a
58% reduction over an 8-year period from 2001-2009 (2012). This is by no means an unimpressive
number. However, the goal is
always zero. And, with that being
said, why not use every resource available in an effort to reach that
goal? This is where the research
question comes in. The question
under investigation is this: In critical care unit patients, how does the use
of 70% alcohol-impregnated port caps compared to using the standard “scrub the
hub” method affect Central Line-Associated Bloodstream Infection rates within a
period of 6 months? As the
question suggests, the results of this investigation will provide information
as to whether the use of 70% alcohol-impregnated port caps in addition to
current practices will further decrease rates of CLABSI.
II. Evidence Search
Selection
criteria for research of this topic included peer-reviewed research studies and
analyses written in English from the timeframe of 2008-2013. Databases utilized for the search
included CINAHL, Cochrane, PubMed and Summon. Keywords used for the search included “central lines”,
“infection”, “catheter ports”, “catheter hubs”, “bloodstream infections”, and
“CLABSI”.
III. Evidence Summary
Dumont,
C., & Nesselrodt, D. (2012). Preventing (CLABSI) central line-associated
bloodstream infections. Nursing 2012, 42(6),
41-46.
This
article discusses the most current evidenced-based practices for reducing
CLABSI as of June 2012. It notes
that the current evidence-based interventions for central line care as
recommended and supported by the Institute of Healthcare Improvement and the
CDC makes up a Central Line Bundle which includes 1) hand hygiene, 2) maximal
sterile barrier precautions [at time of insertion], 3) chlorhexidine skin antisepsis,
4) optimal catheter site selection (avoiding the femoral vein and opting for
the subclavian vein whenever possible) and 5) daily review of line necessity
with prompt removal of unnecessary lines.
CDC
recommendations post-insertion are noted including use of a
chlorhexidine-impregnated sponge, scrubbing the hub prior to accessing the
device and the use of antimicrobial/antiseptic-impregnated catheters. From 2001 to 2009, CLABSI has seen a
58% reduction of incidence. In
ICUs, an estimated 3,000 to 6,000 lives and an estimated $414 million have been
saved in 2009 alone. This article
would be considered Level VII evidence as it is based on data from expert
authorities for infection prevention.
Parra,
A. P., Menarguez, M. C., Granda, M. J. P., Tomey, M. J., Padilla, B., &
Bouza, E. (2010). A simple educational intervention to decrease incidence of
central line-associated bloodstream infections (CLABSI) in intensive care units
with low baseline incidence of CLABSI. Infection
Control and Hospital Epidemiology, 31(9), 964-967.
This
study utilized an educational intervention in an effort to reduce CLABSI in
ICUs. The study involved a
15-minute lecture at the start of the study to educate professionals on the 10
main points for reducing CLABSI.
The study was followed 6 months after the lecture by utilizing
questionnaires that were distributed to all participants to test their
knowledge. The questionnaires were
multiple choice and identical to the 10 main points addressed in the
lectures. No central line
equipment was changed during the timeframe of the study. Researchers found that CLABSI was
significantly reduced during the intervention period compared to the
pre-intervention period. During
the post-intervention period, CLABSI began to increase approaching the baseline
rate of the pre-intervention period.
This study would fit under Level III evidence as it appears to have been
a well-designed controlled study without the use of randomization.
Sexton,
D. J., Chen, L. F., & Anderson, D. J. (2010). Current definitions of
central line-associated bloodstream infection: Is the emperor wearing clothes? Infection Control and Hospital Epidemiology,
31(12), 1286-1289.
This
article stems from a need to address a more definitive definition of
CLABSI. The article sites that
their institution has achieved a significant reduction in their incidence of
CLABSI in ICUs from 4.4 to 0.44 cases per 1000 central-line days in 24
months. However, situations have
arisen where incidence of one isolated event of a positive blood culture in a
patient’s stay has resulted in an identification of CLABSI without
consideration for possible contamination.
In this institution, this identification was increasing their rate of
CLABSI, when in fact a true diagnosis of CLABSI could not be identified with
only one positive blood culture result.
The authors of the article call for the use of serial blood culture
draws from multiple sites revealing more than one positive result before identifying
the patient for CLABSI in an effort to better understand and identify incidence
of CLABSI in ICUs. This article
would be considered Level VII evidence as it is not taken from a study or RCT
but rather is a review of the incidence of CLABSI within the hospital and the
trends that arose throughout the examination of data.
Sweet,
M. A., Cumpston, A., Briggs, F., Craig, M., & Hamadani, M. (2012). Impact
of alcohol-impregnated port protectors and needleless neutral pressure
connectors on central line-associated bloodstream infections and contamination
of blood cultures in an inpatient oncology unit. American Journal of Infection Control 40, 931-934.
This
study focused on an initiative to trial a 70% alcohol-impregnated port cap on
all central lines and PICC lines in an oncology unit for a 6-month period to
see if the rate of CLABSI would be significantly reduced. Beginning in January 2011, units began
using the alcohol-impregnated port caps on all lines that were not currently in
use. When accessed, they were to
discard the port cap and place a new one on the port hub when they were done
using it. Staff had the option of
scrubbing the hub in addition to using the port caps.
This
study was also performed in conjunction with the use of needless neutral
pressure connectors on central lines.
The researchers found that the rate of CLABSI was reduced from 2.3/1000
central-line days in the pre-intervention period to 0.3/1000 central-line days
during the intervention period.
However, there were questions as to whether the port caps themselves
were responsible for the reduction of CLABSI or if it was in conjunction with
the neutral connectors. For that
reason, focus was also given to the rate of CLABSI associated with PICC lines
as they do not utilize the neutral connectors. Researchers found that the rate of CLABS per 1,000 PICC-days
decreased from 2.3 to 0 indicating that the use of 70% alcohol-impregnated
central line port caps does show a statistically significant decrease in the
rate of CLABSI. This evidence
would be considered Level III as it involved one well-designed controlled trial
over a period of 6 months without the use of randomization.
Wright,
M., Tropp, J., Schora, D. M., Dillon-Grant, M., Peterson, K., Boehm, S.,
Robicseck, A., & Peterson, R. (2013). Continuous passive disinfection of catheter
hubs prevents contamination and bloodstream infection. American Journal of Infection Control 40, 33-38.
This
article examines a research study conducted on the use of 70%
alcohol-impregnated port caps in their institution’s ICUs. ICUs participating in this study were
already utilizing chlorhexidine-impregnated sponges when the
alcohol-impregnated port caps were undergoing research. The researchers examined the rate of
CLABSI during the pre-intervention period, during the intervention and again
during the post-intervention period where the intervention itself was
removed. Findings include a
significant decrease in the rate of CLABSI during the intervention period and a
return to near-baseline rates during the post-intervention period when the
intervention itself was completely removed from practice. Statistical significance was obtained
with catheter hub contamination at P = .002 and recovered organisms from
catheter hubs were significantly fewer at P = .009. This study would be considered Level III evidence because it
was a well-designed controlled trial that did not include randomization.
IV. Expert Evidence
As
stated previously, according to the CDC (2010), the standard of care for
preventing CLABSI is appropriate hand hygiene, appropriate skin antiseptic,
sterile procedure for central line insertion, recommended central line
maintenance practices, proper hand hygiene when accessing the central line
ports for use and removing a central line as early as possible. Very little specific detail is provided
for standards of care post-insertion.
In a March 2011 article entitled, “Making Healthcare Safer: Reducing
Bloodstream Infections,” the CDC encourages the government to promote further
research towards identifying other methods to reduce CLABSI.
The
U.S. Department of Health and Human Services (2013) has an action plan on their
website entitled, “National Action Plan to Prevent Healthcare-Associated
Infections: Roadmap to Elimination.”
This action plan addresses the need for more research and clinical
trials to develop new strategies to preventing the acquisition of
hospital-acquired infections including CLABSI. The HHS also seeks to determine if antimicrobial lock
solutions would help to increase prevention.
Most
of the patients encountered are post-operative and feeling at their worst. Many of them have multiple
co-morbidities and an infection could be potentially fatal. Many are unaware of the risks that come
with a large surgery such as Open Heart involving multiple central lines and
other necessary equipment. All
point to the potential for a serious infection, which would further complicate
the possibility of recovery. Given
the choice, patients would want whatever protection from infection was
available to them.
VI. Critical Analysis
The
evidence available for this evidence-based practice project was rather
limited. If one thing is clear,
it’s that more studies need to be conducted in an effort to obtain more
information about the efficacy of 70% alcohol-impregnated port caps and their
ability to decrease CLABSI. Both
articles specifically related to these special port caps involved studies that
were performed in healthcare facilities.
In both cases, the use of 70% alcohol-impregnated port caps seemed to
reduce the rate of CLABSI on the respective units. Most notable was the study conducted by Wright et al
(2013). During Phase 2 of the
study when the port caps were being used with all ICU patients, the rate of
CLABSI was reduced by more than half.
When the intervention was discontinued and patient care returned to
baseline, the rate of CLABSI was near baseline.
Almost
equally as impressive is the study conducted by Sweet, Cumpston, Briggs, Craig
& Hamadani (2012). The results
of this study were very similar to the results of the aforementioned
study. Infection rates decreased
with the use of the alcohol-impregnated port caps. However, one limitation to this study is that the
researchers allowed caregivers to continue to scrub the hub if they chose to do
so. This is a drawback to the
study because it is hard to detect if the improvement in CLABSI rate came from
the port cap itself or from the port cap in conjunction with scrubbing the
hub. It would have been more
reliable if they requested that everyone did not scrub the hub or if they
requested that everyone did scrub the hub. Either way, you will still have
caregivers who forget to do one or the other. However, the reliability of the results would have been more
conclusive.
In
addition, they combined this study with a secondary study regarding needless
neutral pressure connectors. The
researchers admitted that results obtained from central lines were inconclusive
because the port caps and neutral connectors were used in conjunction. However, the PICC lines did not use the
neutral connectors so the results that were obtained from PICC line studies
were attributed only to the port caps.
In this case, the study was worthwhile because the results gleaned from
the port caps used with PICC lines showed a significantly decreased rate in
CLABSI.
One
aspect of both studies is that infection rates were not observed to increase
with the use of the port protectors.
Therefore, while there is not a significant amount of evidence to
support their use for a dramatic decrease in CLABSI, there is information to
support that their use does not have a negative impact on rates of CLABSI.
Finally,
as Sexton, Chen & Anderson (2011) state in their article, it is important
that each facility has a protocol in place for identifying CLABSI. One positive blood culture does not
define CLABSI. The fact that an
institution does not have a concrete definition and protocol for identifying
CLABSI makes it increasingly difficult to prevent. Even the best of standard precautions and sterile technique
can lead to an inadvertent contaminated blood culture. It is important to have a
well-established procedure in place so that true cases of CLABSI are being
identified.
VII. Application of
Evidence
Logically,
the addition of 70% alcohol-impregnated port caps to standard central line care
cannot hurt the chances of reducing CLABSI. The port cap acts as a physical and chemical barrier between
central line hubs and the environment.
The use of central line port caps was estimated to be an additional $2
per day per patient (Dumont & Nesselrodt, 2012). This, in no way, equals the cost of treating a patient who
has been infected with CLABSI. My
recommendations would be as follows:
·
Replicate
the study performed by Wright et al (2013).
o Review CLABSI rates from the previous
year.
o Provide proper staff education starting
with only ICU caregivers.
o Trial the 70% alcohol-impregnated port
caps for 6 months. Review CLABSI
rates during the 6-month timeframe.
o Remove the intervention after the 6-month
period and re-evaluate CLABSI rates.
·
As
evidenced above, there are very few studies to support the use of 90%
alcohol-impregnated port caps.
Therefore, more research is necessary for their use to become an
evidence-based practice.
VIII. Stakeholders/Change
Agents
Persons
interested in this intervention would be patients/families, nurses, physicians,
hospital administration and insurance companies. The benefit to patients and families is that, already in its
limited use, 70% alcohol-impregnated port caps have been shown to reduce CLABSI
and infectious organisms that linger on central line catheter hubs. This reduction means that patients who
are already at an increased risk of obtaining a hospital-acquired infection
will be less likely to obtain a CLABSI than if the port caps were not in use.
In
addition, nurses and physicians will find the port caps helpful as they will be
an additional barrier for prevention of CLABSI. Thus far, the port caps have only been proven to help
prevent CLABSI, not hinder its prevention. In emergent situations when thoughts of scrubbing the hub go
out the window, the port caps will already be in place to help protect the
patient from infection. In
addition, the decreased risk for infection means the patient is more likely to
have a quicker recovery and a shorter hospital stay.
Currently,
CLABSI is considered by Medicare to be a “Never Event.” This means that should a CLABSI event
occur with a patient, Medicare will not reimburse for the treatment. According to Medicare.gov (2013), “By
law, hospitals cannot receive payment from Medicare or charge Medicare patients
for treating these conditions.”
This costs hospitals millions of dollars each year. According to Dumont & Nesselrodt
(2012), the average cost per case is upwards of $26,000. A cost of $2 per patient per day seems
menial in comparison.
IX. Summary
In
summary, there is currently a lack of evidence on the use of 70%
alcohol-impregnated port caps and their use with patients. Additional research is necessary for
the use of these port caps to be considered an evidence-based practice. However, based on the limited evidence
available, 70% alcohol-impregnated port caps assist in significantly reducing
the incidence of CLABSI for patients with central lines. Neither study mentioned an increase in
CLABSI or no change between the pre-intervention and intervention stage.
Caregivers
can advocate for their patients by suggesting the use of these port caps. They can suggest to management and
hospital administrators that the use of the port caps cost significantly less
than the incidence of CLABSI. As
stated above, more research is needed and this would be a perfect opportunity
for caregivers to suggest a research study to test these special port caps in
their facility. It is likely
hospital administrators will take this recommendation seriously because CLABSI
is considered a “never event” for Medicare reimbursement and it is expensive to
treat. Most importantly, it is
detrimental to the health and safety of the patient. When it comes to CLABSI, the goal is always zero.
Resources
Centers
for Disease Control and Prevention. (2010). Central-line associated bloodstream
infections: Resources for patients and healthcare providers. Retried from http://www.cdc.gov/HAI/bsi/CLABSI-resources.html.
Dumont,
C., & Nesselrodt, D. (2012). Preventing (CLABSI) central line-associated
bloodstream infections. Nursing 2012, 42(6),
41-46.
Medicare.gov.
(n.d.) Hospital-acquired conditions.
Retrieved from http://www.medicare.gov/hospitalcompare/Data/RCD/Hospital-Acquired-Conditions.aspx.
Parra,
A. P., Menarguez, M. C., Granda, M. J. P., Tomey, M. J., Padilla, B., &
Bouza, E. (2010). A simple educational intervention to decrease incidence of
central line-associated bloodstream infections (CLABSI) in intensive care units
with low baseline incidence of CLABSI. Infection
Control and Hospital Epidemiology, 31(9), 964-967.
Sexton,
D. J., Chen, L. F., & Anderson, D. J. (2010). Current definitions of
central line-associated bloodstream infection: Is the emperor wearing clothes? Infection Control and Hospital Epidemiology,
31(12), 1286-1289.
Sweet,
M. A., Cumpston, A., Briggs, F., Craig, M., & Hamadani, M. (2012). Impact
of alcohol-impregnated port protectors and needleless neutral pressure
connectors on central line-associated bloodstream infections and contamination
of blood cultures in an inpatient oncology unit. American Journal of Infection Control 40, 931-934.
Wright,
M., Tropp, J., Schora, D. M., Dillon-Grant, M., Peterson, K., Boehm, S.,
Robicseck, A., & Peterson, R. (2013). Continuous passive disinfection of
catheter hubs prevents contamination and bloodstream infection. American Journal of Infection Control 40,
33-38.
U.S.
Department of Health and Human Services. (n.d.) National action plan to prevent
healthcare-associated infections: Roadmap to elimination. Retrieved from http://www.hhs.gov/ash/initiatives/hai/acute_care_hospitals.html.
