ENIC04-1005:
Preventing
Device-Associated Infections
Author:
Vicky Ferris, RN, CIC; Carole L. Leone, BSN, MSN, CIC; and Amy M. Hueffmeier,
RN, BSN, CIC
1.2
contact hours
Objectives
1. Discuss the adverse outcomes of positioning
2. Identify risk factors that place patients in jeopardy of developing
tissue damage during positioning
3. Compare the three most common materials used in positioning devices
4. Identify the essential components of a patient safety initiative
Advancing medical technologies have saved countless lives in the last
decades. Invasive medical devices must be evaluated to weigh the benefits
with the potential risk of adverse effects, including the risk for nosocomial
infection. The morbidity, mortality and costs associated with nosocomial
infections have been well documented by the Centers for Disease Control
and Prevention (CDC). A urinary tract infection costs an average of
$600, and the average bloodstream infection can cost up to $50,000.
This article looks at three commonly used medical devices, the infections
that can be associated with their use, and ways to prevent and/or lower
the risk for these infections. Interventions are listed that are supported
by current literature and outline methods to keep your patients safe.
Catheter-related Bloodstream Infections
Intravascular (IV) devices are indispensable in the practice of healthcare
today. They are used to administer intravenous fluids, medications and
blood products, and to supply nutrition and to monitor the hemodynamics
of critically ill patients. Healthcare institutions purchase millions
of intravascular catheters each year. As necessary as they are, they
are not without complications and can pose as a significant risk to
those they serve, your patients. Bloodstream infections are much higher
in patients with IV devices. Approximately 40 percent of primary bacteremias
occurring in intensive care unit patients are associated with IV devices.
The majority of serious catheter-related infections are associated with
central venous catheters (CVC). An estimated 250,000 cases of CVC-associated
infections occur each year in the United States. Risk factors for catheter-related
bloodstream infections (CR-BSI) include prolonged hospitalization before
central line insertion, prolonged duration of catheterization, and heavy
colonization of the insertion site and the catheter hub.
Definition
The CDC has developed a standardized definition for bloodstream infections.
Catheter-related bloodstream infection is defined as: Bacteremia/fungemia
in a patient with an intravascular catheter with at least one positive
blood culture obtained from a peripheral vein, clinical manifestations
of infection (fever, chills and/or hypotension), and no apparent source
for the bloodstream infection except the catheter.
Risk Factors for BSI
There are a number of ways that IV catheters may become contaminated.
Some of these factors are: the hands of healthcare personnel, contamination
of the catheter at the time of insertion, colonization of the catheter
hub, spread through the bloodstream from another site, auto inoculation
of the patient's own flora and/or contaminated fluid. The two most common
ways that CR-BSI occur are by:
1) migration of skin organisms at the insertion site into the cutaneous
catheter tract with subsequent colonization of the catheter tip
2) contamination of the catheter hub which contributes to colonization
of the catheter lumen, especially in long-term catheters.
Strict adherence to meticulous hand hygiene and aseptic technique are
the cornerstones for prevention of CR-BSI. Using soap and water or a
waterless hand antiseptic before any procedure in which you have contact
with the intravascular device can reduce the risk of CR-BSI. Particular
attention should be given when moving between "clean" and
"dirty" tasks. Gloves should be removed and hands washed immediately
after completing "dirty" tasks.
1. Central Line Placement
CVCs
are frequently utilized in critically ill patients. The location of
catheter placement and technique of insertion of these devices play
a critical role in the risk associated with infection.
In considering the best site for insertion, catheters inserted into
the subclavian vein have a lower risk of infection than those inserted
into the jugular or femoral veins. In adults, the femoral site is the
least preferred and should be used only in emergent situations or when
no other site is available. If the femoral site is used, the catheter
should be replaced or removed as soon as possible.
Insertion Technique
Insertion of the catheter should be completed with strict aseptic technique.
The person inserting the catheter must wear a sterile gown, sterile
gloves, cap and a mask. All other personnel in the room must also wear
a mask. If excessive hair is present at the insertion site, clipping
with scissors or clippers is recommended. Razor shaving is known to
cause micro abrasions, which may allow bacteria to enter the skin surrounding
the insertion site.
Preparation of the skin prior to insertion should include at least 10
cm surrounding the insertion site. An appropriate antiseptic should
be utilized at insertion and at the time of dressing change. The preferred
antiseptic is a 2 percent chlorhexidine-based preparation. Some alternative
preparations are tincture of iodine, an iodophor or 70 percent alcohol.
It is necessary to allow the antiseptics to remain at the insertion
site and dry completely before inserting the catheter. If povidone-iodine
is utilized, it must remain on the skin at least 2 minutes, or longer
if it is not dry prior to insertion. CDC recommendations include the
use of a large sterile sheet or drape. A sterile drape that is large
enough to prevent accidental contamination during insertion and allows
good visualization of the insertion site is ideal.
Guidewire Exchange
Lines may be changed over a guidewire only to replace a malfunctioning
non-tunneled catheter and when there are no signs or symptoms of infection
and the risk of inserting a new site are unacceptably high (e.g., obesity,
coagulopathy). Strict adherence to aseptic technique and the procedure
for preparation of the insertion site should be the same as if inserting
a new catheter.
Catheter Site Care
Routine care of the catheter is critical in the prevention of bloodstream
infection. The dressing of choice is a transparent membrane dressing.
Change from transparent to sterile gauze or vice versa if sensitivity
to the dressing materials occurs.
Catheter site dressings should be replaced:
- When the intravascular device is removed or replaced.
- When the dressing becomes damp, loosened, or soiled. Dressings may
need to be changed frequently in diaphoretic patients or when catheter
placement is made at a site where it is difficult to maintain an occlusive
dressing (e.g., jugular and groin placement)
- Change transparent dressings according to your facility's policy.
CDC recommends that dressings be changed at least weekly for adult and
adolescent patients.
- Gauze dressings should be changed according to your facility's policy.
Gauze dressings should be replaced when the site is visually inspected.
It
is essential that routine dressing change procedures begin with meticulous
hand hygiene with soap and water or a waterless hand antiseptic.
The old dressing may be removed with clean gloves. The insertion site
should be observed for erythema, exudates and catheter placement, including
the integrity of the suture or other devices used to maintain the placement
of the catheter. At this time a change to sterile technique should occur
for the remainder of the dressing change procedure. Topical antimicrobial
ointments should not be applied to the insertion site because of their
potential to promote fungal infections and antimicrobial resistance.
Signs/Symptoms of CR-BSI
:Despite meticulous care some patients may acquire CR-BSI. To detect
potential problems in patients with central lines you should: 1) palpate
the catheter insertion site for tenderness on a regular basis 2) visually
inspect the insertion site according to your hospital policy and if
the patient develops any symptoms of bloodstream infection. Symptoms
to watch for may include the following: tenderness at the insertion
site, fever without an obvious source, chills or shaking rigors, hyperventilation,
confusion, seizures, erythema at the site of insertion, hypotension,
shock, abdominal pain, vomiting, diarrhea and any drainage including
blood at the insertion site. 3) Record the date and time of catheter
insertion in an obvious location near the catheter-insertion site.
Conclusion
Central venous access can be an asset or a liability for your patient.
Many risk factors are not under the control of the healthcare provider.
However, how well we care for this medical device can certainly make
a difference in the outcome of this healthcare episode.
2. Catheter-associated Urinary Tract Infections
Healthcare providers have been using urinary catheters for patients
for over seven decades. The benefit to using urinary catheters is well
known, especially for postoperative patients and for patients with urinary
retention. Not unlike many medical interventions, however, urinary catheter
use comes with some risk of adverse effects. Urinary tract infection
(UTI) is one of these risks, and is one of the most common nosocomial
infections. Hospital-acquired UTIs account for approximately 40 percent
of all nosocomial infections annually. Most nosocomial UTIs are associated
with some type of urinary tract instrumentation. Indwelling catheters
are associated with about 80 percent of nosocomial UTIs.
A patient is considered to have a nosocomial UTI when he/she acquires
significant bacteriuria (> or = 100,000 colony forming units/ml)
while in the hospital. The patient may or may not have clinical symptoms.
Most patients with catheter-associated bacteriuria do not have clinical
symptoms. In a catheterized patient who is unable to experience urinary
symptoms, fever is sometimes the only clinical symptom.
The CDC's
definition of UTIs includes the following categories:
- Symptomatic urinary tract infection
- Asymptomatic urinary tract infection
- Other infection of the urinary tract (includes kidney or bladder
infection and infections of urethra, ureter, or tissues surrounding
retroperitoneal or perinephric spaces)
A urinary catheter must be present for a UTI to be considered catheter-associated.
There are several ways bacteria can gain entry to the catheterized patient's
urinary tract and potentially cause a urinary tract infection. If the
patient or equipment is contaminated during catheter insertion, bacteria
can enter the bladder and bacteriuria can develop. Bacteria can also travel
from the periurethral space along the outside of the catheter, or it can
travel from the drainage system along the inside of the catheter up to
the bladder if the catheter system has been contaminated or broken.
Risk factors for catheter-associated UTIs include duration of catheterization,
breaks in catheter care technique, absence of systemic antibiotics, female
gender, and older age.
Ways to Prevent Catheter-associated UTIs
- Limit
Catheter Use/Use Catheters Wisely
One obvious
way to reduce catheter-associated infection rates is not to use indwelling
catheters, or at least use them only when absolutely necessary. As logical
as this seems, studies have shown that at least 31 percent of catheter
use is inappropriate and that healthcare providers are sometimes unaware
that patients have indwelling catheters.
Consider other methods of urinary diversion if appropriate, such as
condom catheters, suprapubic catheters, or intermittent catheterization.
The use of an alternative method may be dependent upon factors such
as the need for short vs. long-term catheterization, ability of patient
or caretakers to perform the procedure, likelihood of patient to manipulate
catheter, and potential for other adverse effects. Be sure to allow
time and privacy for patients using bedpans or urinals to void. If a
patient does need a urinary catheter, be sure to remove the catheter
as soon as the patient no longer needs it. Do not perform routine catheter
changes.
- Educate
Education
is a key factor in UTI prevention. Ensure that anyone catheterizing
a patient (including healthcare workers, family members/caretakers and
patients) are educated on the proper technique for catheter insertion
and care. Review of proper technique should occur periodically and should
include the concepts discussed in this article.
- Use
Good Hand Hygiene
Hand hygiene
must be performed before and after catheter insertion, specimen collection,
and/or any contact or manipulation of the catheter system. Ensure that
handwashing/hand hygiene policies are in place and that hand hygiene
products are available and readily accessible for working with patients
and catheters.
- Use
Good Catheter Insertion Technique
Only sterile
equipment may be used for catheter insertion. Aseptic technique must
be used when inserting a urinary catheter. Sterile supplies include
drapes, gloves, antiseptic solution, single use lubricant, and sponges.
Ensure that these items are all readily available for personnel responsible
for catheter insertion. If your facility uses a prepackaged kit, be
sure that it contains all of the proper supplies. It is best to avoid
trauma by choosing the smallest catheter possible while still large
enough to ensure unobstructed urine flow.
Maintain
a Closed System
The benefits
of a closed system for urinary catheters may appear obvious and the
likelihood of opening the present day urinary catheter systems may
seem rare. The benefits of the closed system can be appreciated when
considering how UTIs began decreasing in the 1960s. This is when catheter
technology changed from urinary catheters consisting of open tubing
draining into a bucket and developed into models closer to today's
catheters. The importance of keeping this system closed should be
emphasized. Take care not to disconnect the catheter setup. Many catheter
systems are now designed to have sealed connections, using tape or
plastic shrinkwrap. These systems may be beneficial to decrease infection
rates, but more studies are needed to confirm their effectiveness.
-
Keep
Urine Flow Unobstructed and Free Flowing
Ensure that urinary flow in the catheter is not obstructed or compromised
in any way.
To do this, verify:
- that the tubing does not become kinked
- that collection bags are kept below the level of the bladder
- that malfunctioning or obstructed catheters are irrigated or changed
if necessary
- that collection bags are emptied on a regular basis
- Empty
Collection Bags Aseptically
When emptying urine collection bags, prevent contamination of the urinary
collection system by:
- keeping a separate collection container for each patient
- emptying the collection bag into a container aseptically without touching
the drain spigot to the collection container
- Avoid
Irrigation
Do not routinely
irrigate urinary catheters. However, if you must irrigate, choose the
proper method. If irrigating to prevent a likely obstruction, such as
from heavy bleeding, use closed continuous irrigation. If irrigating to
alleviate a minor obstruction that has developed, such as a blood clot,
use an intermittent irrigation method. Disinfect the connection between
the catheter and tubing. Use only sterile syringes and irrigants for irrigation,
and use aseptic technique. Discard both after using.
- Secure
the Catheter
To prevent
movement of the catheter while in place, the catheter tubing should
be secured to the patient after insertion.
- Keep
the Perineal Area Clean
Although
studies have not been conclusive to recommend a specific meatal cleansing
regimen for UTI prevention, it is logical to keep the perineal area
clean to prevent bacteria from migrating along the catheter. Diarrhea
may be a contributing factor for urinary tract infections, so take extra
care in cleaning patients incontinent of stool.
- Obtain
Urine Samples Aseptically
To obtain
a urine sample, use the urine sampling port as recommended by the manufacturer.
Be sure to wipe the port with an appropriate antiseptic prior to obtaining
the sample. If a large volume of urine is needed, obtain the sample
aseptically from the collection bag.
- Developing
Technologies
Newer
ways to prevent catheter-associated urinary tract infections, such as
antimicrobial prophylaxis, antibiotic coated catheters, and silver alloy/hydrogel
catheters, are being researched, but further studies are needed. While
some studies have shown benefit to antimicrobial prophylaxis for patients
with urinary catheters, the development of adverse effects and antimicrobial
resistance must be considered. When considering the use of antibiotic
coated catheters or silver alloy/hydrogel catheters, healthcare institutions
should review the studies and also evaluate cost effectiveness.
3. Ventilator-associated
Pneumonia
According
to the National Nosocomial Infections Surveillance system (NNIS), pneumonia
is the second most common infection in hospitals. Ventilator-Associated
Pneumonia (VAP) is the most common nosocomial infection in intensive care
units and is responsible for 60 percent of all deaths attributable to
nosocomial infections. The devastating consequences of even one case of
VAP make it necessary to define "best practices" and develop
procedures designed to decrease risks in our patients.
Definition
A standardized definition and denominator must be used to identify infections
and calculate rates. The CDC's definition for nosocomial pneumonia can
be applied; however, their definition does not help to distinguish a VAP
from nosocomial pneumonia in non-ventilated patients. Mayhall defines
VAP as a pneumonia "diagnosed in an intubated, mechanically ventilated
patient after more than 48 hours of ventilation". Hospitals planning
to benchmark their data with NNIS must use the same definition and calculate
their rates using ventilator days as a denominator.
Causes
of VAP
The CDC reports that mechanical ventilation puts patients at highest risk
for developing a nosocomial pneumonia. This is likely due to the artificial
airway increasing the opportunity for aspiration of colonizing bacteria
from the oropharynx and GI tract of patients. Transmission of bacteria
from contaminated equipment and healthcare workers' hands to the patient
has also been implicated in outbreaks. Consequently, interventions are
aimed at preventing bacterial colonization of the aero-digestive tract
and reducing the risk for aspiration. Unfortunately, many practices proposed
in the literature designed to prevent VAP have not been well studied or
the studies have had equivocal results.
Preventing
Bacterial Colonization
Ventilated patients have altered host defenses and require more intensive
care, making preventing bacterial colonization all the more difficult.
These patients often receive enteral feedings and/or ulcer prophylaxis
(antacids, H2 antagonists or adenosine triphosphatase inhibitors), which
can cause a change in gastric acidity, creating an optimal environment
for bacterial growth. Some studies have suggested that the drug sucralfate
may be an alternative to antacids or H2 blockers for ulcer prophylaxis
because of its minimal effect on gastric pH and possible bactericidal
properties. Selective decontamination of the digestive tract by administering
antibiotics and antifungals via the nasogastric tube, intravenously or
orally, has also been mentioned in the literature. However, due to the
associated high costs and the lack of available data to support it, the
CDC does not recommend this practice. Recently oral care has been a topic
of discussion in the literature.
It is theorized that inadequate oral care leads to increased risk of colonization.
One study found that the mouth, sputum and suctioning equipment were all
colonized with similar bacteria and note that oral suction devices have
been "overlooked as a potential contributor to the development of
VAP." Another study showed that the use of a chlorhexidine gluconate
(CHG) mouth rinse decreased respiratory infections from 9 percent to 3
percent. As a result of these and other studies, manufacturers have designed
oral care systems complete with CHG impregnated mouth swabs and self-sheathing
oral suction devices. Yet Mayhall warns that the long-term effects on
oral mucosa and the risk of bacterial resistance to CHG is unclear.
Special precautions should be taken when suctioning a patient to prevent
contamination.
Gloves should be worn when using single-use catheters or in-line suctioning.
Whether or not the gloves should be clean or sterile is an undecided issue.
Oral suction devices must be kept covered in a non-sealed paper or plastic
bag when not in use and should not be left to lie in the patient's bed,
under his pillow or on the floor. Suction catheters and other equipment
must also be stored in a manner that protects against contamination. Suctioning
should be performed on an as-needed basis; routine suctioning may provide
unnecessary opportunities for the introduction of organisms. Suction containers
and tubing must be changed after each patient except in short-term care
areas.
As mentioned previously, bacterial colonization can also take place due
to contaminated hands of healthcare workers or contaminated equipment.
It is of utmost importance that healthcare workers practice hand hygiene
before and after patient or ventilator contact as well as when they are
moving from a "dirty" to a "clean" procedure. In addition
to hand hygiene, steps should be taken to decrease the contamination of
the ventilator circuit. This can be accomplished in several ways. Ventilator
circuits, in-line suction catheters, and humidifiers should not be routinely
changed unless they are visibly soiled or malfunctioning. Heat moisture
exchangers (HME) should not be used for patients with excessive secretions
or hemoptysis. When HMEs are used, they must be changed according to the
manufacturer's recommendations or when visibly soiled. Sterile fluids
must be used for nebulization and must be administered aseptically. Additional
precautions include wearing clean gloves when handling respiratory equipment
or anything contaminated with respiratory secretions and assuring non-disposable
respiratory equipment is adequately cleaned and sterilized or disinfected
after use.
Preventing
Aspiration
To reduce the risk of aspiration of contaminated secretions, the CDC recommends
several interventions. First is to elevate the patient's head of bed at
least 30 degrees, if tolerated. Next, ventilator condensate should be
drained periodically to avoid condensate from draining toward the patient.
Care should be taken not to contaminate the circuit when disconnecting
ventilator tubing to drain condensate. In addition, gastric distention
should be avoided by monitoring residual volumes, assessing intestinal
motility and removing nasogastric tubes as soon as possible. Enteral feedings
increase pressure on the stomach, creating the opportunity for reflux
and aspiration.
It has been suggested that intermittent feedings will help prevent aspiration
by lowering the intragasatric pressure; however, this is also an unresolved
issue according to the CDC. Lastly, adequate endotracheal tube cuff pressure
should be maintained and subglottic secretions should be removed prior
to extubation to prevent aspiration.
With the ventilated patient's risk of developing a VAP increasing by 1%
per day, it is important to wean the patient as soon as possible and implement
practices to prevent aspiration and reduce bacterial contamination. Although
the practices mentioned above are not exhaustive of the CDC guidelines,
implementing evidence-based interventions will help to increase staff
awareness and hopefully decrease the incidence of VAP.
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