Central lines (CLs) are a basic tool of the nursing trade. They are used for a variety of functions, including “allowing for the administration of intravenous fluids, blood, products, chemotherapeutic medications, and parenteral nutrition,” as well as for “hemodialysis and hemodynamic monitoring” (Truscott, 2013, p. 22). CLs have changed the way health care providers view treatment, deliver care, and have improved patient outcomes (Truscott, 2013). Nevertheless, CLs are not without problems and complications. Truscott (2013) reports that though many of these complications “have been addressed,” several of these problems continue to “occur with unacceptable frequency and consequences” (p. 22). One of these complications which continues to occur in the context of CL use is central line associated bloodstream infections, or CLABSI. CLABSI continue to occur frequently in hospital and long-term care environments despite protocols and policies in place intended to reduce or prevent CLABSI.
CLABSI continue to be such a problem that they are specifically addressed by 2014 National Patient Safety Goals (NPSG) for hospital accreditation. NPSG.07.04.01 directs hospitals to “implement evidence-based practices to prevent central line-associated bloodstream infections” (The Joint Commission, 2013, p. 9). This goal “covers short- and long-term central venous catheters [CVCs] and peripherally inserted central catheter (PICC) lines” (The Joint Commission, 2013, p. 9). The goal contains 13 elements which are intended to support the education of both staff and patients on CVCs; the implementation of policies and procedures which are intended to reduce the likelihood of CLABSI; the direction to regularly perform risk assessment and effectiveness studies; the provision of CLABSI-related data to stakeholders; the creation a checklist and protocol for CVC insertion and use; the emphasis on hand hygiene in CVC contexts; the implementation of protocols for sterile barriers and skin preparation; the implementation of disinfectant protocols for catheters and injection hubs; and the routine evaluation of CVCs and the discard of nonessential CVCs (The Joint Commission, 2013). Many of the elements in the NPSG focus on importance of protocols, policies, and procedures, all three of which are critical to the prevention of CLABSI.
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It is often the failure of protocols and procedures and the non-enforcement of policies which result in the circumstances which promote CLABSI. Truscott (2013) reports that “an estimated 5 million CLs are placed annually” in the United States which result in “approximately 250,000 CLABSIs, with an attributable mortality of 12-25%” (p. 24). In other words, the failures to observe protocols and procedures and to enforce policies have the potential to result in death. This suggests that that meaningful solutions to the prevention and/or reduction of CLABSI rest in understanding how protocols, procedures, and policies may be more effectively observed and enforced, as well as observing how failures may occur.
In that vein, Pak-On, Hsin-Lan, Yu-Hsiu, & Chih-Cheng (2014) sought to examine how staff factors – specifically physician factors – might influence compliance with a CVC insertion bundle in the ICU at a regional teaching hospital. The ICU contained 63 adults ICU beds: 26 for surgical ICU, 23 for medical ICU, and 14 for cardiac care. The ICU featured 8 intensivists (that is, health care providers specializing in intensive care). Pak-On et al. (2014) report that most of the CVC insertions are performed by the intensivists; however, cardiologists, surgeons, and trained residents are also authorized to perform CVC insertions by themselves. The CVC insertion bundle was implemented in all of the ICU units in March 2013; the bundle is composed of four components: “hand hygiene, maximal sterile barriers upon insertion, use of chlorhexidine gluconate (CHG) for skin preparation, and avoiding the use of the femoral vein as an access site” (Pak-On et al., 2014, p. 602).
The authors defined “compliance” as “the number of actions performed divided by the number of CVC insertions” which were observed between March 1 and October 30, 2013” (Pak-On et al., 2014, p. 602). The authors reported observing a total of 456 CVC insertions; 413 (90.6%) were performed by the intensivists, while the remaining were performed by cardiologists (26, or 5.7%), surgeons (13, or 2.8%), and trained residents (3, or 0.7%) (Pak-On et al., 2014). The authors reported that overall compliance for the complete bundle was 60.7%; compliance with individual elements is as follows: “100% for hand hygiene, 78.2% for maximal sterile barrier precaution, 99.8% for the use of CHG, and 73.4% for optimal site selection” (Pak-On et al., 2014, p. 602). The authors also found that compliance was significantly higher for the intensivists versus the nonintensivists (Pak-On et al., 2014). These findings suggest that staff experience and training (that is, intensivists versus nonintensivists) was a significant factor in compliance.
The authors’ findings also suggest that noncompliance with the sterile barrier precaution and optimal site selection may be significant contributors to CLABSI. To that end, the implementation of protocols and procedures which emphasis the importance of all steps in CVC insertion would be recommended for hospital environments. In other words, while hand hygiene and skin preparation are important, as evidenced by compliance with those steps in the study, compliance with taking barrier precautions and selecting ideal sites for insertion are also important steps. While compliance with those two elements was lower than hygiene and skin prep, compliance was still significant. The implementation of a CVC bundle which equally emphasizes all four components would clearly be a recommended and evidence-based practice that perhaps should be universally adopted. Such a bundle clearly reflects all of the elements outlined in the NPSG pertaining to CLABSI and can evidently support and encourage practices which help mitigate the development of CLABSI.
