Preventing Central Line

Associated Bloodstream
Infections (CLABSIs)
What Clinical Staff Should Know
Prepared by
Ann Bailey RNC-NIC, BSN, MBA, CIC
Joanne Dixon MN, RN, CIC
Gwen Irwin, RN, CRNI
Judy Smith, RN, BSN, CRNI
December 18, 2009

Objectives
Upon completion of this module, the learner will be
able to:

Summarize the Joint Commission 2010

National Patient Safety Goal 07.04.01
related to Central Line Associated
Bloodstream Infections (CLABSIs),
effective 01/01/10
Includes using Bundle with respect to
preventing CLABSIs

Define Bundle
Name 2 ways patients get CLABSIs
List 4 evidence-based practices that
have been shown to help prevent
CLABSIs

The Joint Commission

2010 National Patient Safety Goal
(NPSG)
NPSG 07.04.01 focuses on the prevention of
CLABSIs.
All those who manage central lines MUST have education
about the importance of preventing CLABSIs.
Includes staff, doctors, APNs or other licensed providers

Patients and families MUST be educated about CLABSI

prevention before any central line insertion.
CLABSI surveillance will be hospital wide, not targeted to
ICUs.
For adults, NO femoral catheters, unless other sites arent
available.

Patient and Family Education

Before Central Line Insertion
FAQ Catheter Associated
Bloodstream Infections from Joint
Commission covers:
Providers doing hand hygiene
Steps for maximum barrier CVL
insertion
Clean hands before using CVL
Clean connectors with antiseptic
solution before using CVL
Decide every day if CVL is
needed.
Ask providers to clean hands if
patient doesnt see them.
Tell nurse if dressing comes off or
wet or dirty.
And more

The Joint Commission

2010 National Patient Safety Goal
(NPSG)
NPSG 07.04.01 focuses on the prevention of
CLABSIs.
Also includes the CVL insertion bundle.
We have had in place for almost 5 years.
Also includes part of the CVL maintenance
bundle.
We have had in place for about 2 years.

What is a Bundle?
A grouping of evidence-based best practices
that individually improve care, but when applied
together result in substantially greater
improvement.
Science behind the bundle elements is well
established the standard of care.
Bundle element compliance can be measured
as yes/no.
All or none approach.

The CVL Insertion Bundle

1.

2.

3.
4.

Hand hygiene immediately prior to insertion

-wash hands or
-use alcohol-based hand gel/foam
Maximal barrier precautions
-full body sterile drape
-clinician and assistant wear cap, mask, sterile gown, gloves
-persons within 6 feet wear hat and mask
Skin antisepsis with chlorhexidine 2% / 70% isopropyl alcohol.
Subclavian site considered 1st choice; avoid IJ & femoral.
Exceptions: Should be rare for adults
- Hemodialysis catheters
- When high risk for pneumothorax
- When high risk for noncompressible hematoma

The CVL Maintenance Bundle

1. Perform good hand hygiene, prior to handling line
-Hand washing or
-Use alcohol-based hand gel/foam
2. Assess dressing/site with routine assessment
3. Scrub connector vigorously with alcohol x 15
seconds
-Allow to dry before accessing
4. Assess line patency for brisk return and easy
flushing
5. Assess to determine if patient meets criteria for line
necessity

Why Prevent CLABSIs?

Nationally and annually:
80,000 central line associated bloodstream infections occur in
ICUs
250,000 hospital-wide, including ICUs

Seton Family of Hospitals

The majority of CLABSIs occur outside of the critical care units
Check your units CLABSIs with your infection preventionist, if you
are interested in more information

Increases the patients risk of death significantly

CLABSIs lead to longer length of stay (LOS)
National estimates show the cost of a BSI can be as high as
$25,000 per episode
(MMWR, August 9, 2002 Vol. 51, No. RR-10)

How do CLABSIs happen?

Introduction of pathogens into
the bloodstream from the skin
around insertion site
Introduction of pathogens into
the bloodstream from the hub or
connector of the catheter.
Most frequent cause nationally
Also true at Seton

Factors That Increase Risk of BSIs

CVLs in areas that have increased colonization
of organisms
such as the internal jugular or femoral sites

Multiple lumens: More manipulation and

contamination.
Use of stopcocks
Contamination of IV tubing or connectors (caps)
(MMWR, August 9, 2002 Vol. 51, No. RR-10)

(MMWR, August 9, 2002 Vol. 51, No. RR-10)

Longer dwell time of CVC

Factors That Lower Risk of BSIs

Select subclavian site over internal jugular or
femoral sites, if PICC not used
Perform hand hygiene
Use maximum barrier precautions
Skin prep with chlorhexidine rather than
povidone-iodine
Skin prep on clean skin

Maintain patency of all lumens

Free of sluggishness or occlusion; brisk blood return

Remove line when no longer necessary

CVL Insertion Bundle Component:

CVL Site Choices

Femoral Vein
Last choice

Subclavian Vein
First Choice

Internal Jugular
Second choice

Hand Hygiene The Most Important Way to

Prevent Any Infection

Alcohol-based hand gel/foam - apply

product to palm of one hand and rub
hands together, covering all surfaces
of hands and fingers until hands are
dry

Handwashing - 10-15 seconds of

soap and friction, rinse, dry and
turn off faucet with clean paper
towel

Im
acc medi
ess
a
ing tely b
e
the
cen fore
tral
line

CVL Insertion Bundle Component:

Maximum Sterile Barrier Precautions

Sterile gown

Hat and mask

Sterile gloves
Persons within 6 feet also
wear hat and mask

CVL Insertion Bundle Component:

Chloraprep

Gross debris or dirt should be

removed
with an alcohol pad, prior to using
the skin prep.
by washing with soap and water,
prior to using the skin prep.

Clean with friction for minimum of

30 seconds.
Allow Chloraprep to completely
dry, before procedure for best
results.
DO NOT REMOVE Chloraprep
after the procedure is completed.
Exception: neonates <2 months.

CVL Maintenance Bundle Component:

Assess line patency for brisk return
and easy flushing

Research studies indicate a direct correlation with

occlusions, fibrin sheaths, and risk of CLABSIs

No blood return? Flushes easily?

Probable fibrin sheath or fibrin
tail
Treat as soon as possible
Treat with Alteplase per
declotting protocol
Infusing
around sheath
Fibrin
sheath

Catheter

Attempting to
withdraw blood

CVL Maintenance Bundle Component:

Daily Review for Line Necessity
Remove when No Longer Indicated
Indications for a CVL
Hemodynamic monitoring
Administration of certain medications that require central
administration, e.g. vasopressors, chemotherapy, TPN
Long term IV therapy, e.g. antibiotics or inotropes
Plasmapheresis, apheresis, hemodialysis, or continuous renal
replacement therapy
Poor peripheral venous access, when IV treatment is still needed

CVL Maintenance Bundle Component:

Scrub the Hub with Alcohol for 15 seconds,
prior to accessing

Vigorous scrubbing is
necessary to remove
pathogens
Research shows that 5
seconds is not enough.

67% of pathogens are still

transferred.

Research shows that 15

seconds with friction is 100%
effective in disinfection.
If this step is skipped,
the patient is inoculated
with the organisms of his
surroundings.

CVL Maintenance Bundle Component:

Assess dressing/site with routine assessment

Keep dressing clean dry and intact

Loose and wet
dressings are sites of
potential infection.
CHANGE THEM!

Cover the site

dressing and the
connectors during
showers.
Aquaguard is available:
7x7 Lawson number 080204

Potential ways of contamination

The top of the
medication vial is not
sterile.
The top is a dust
cover.
Clean vigorously
with alcohol before
accessing the vial
with the blunt fill
needle.

Disconnecting tubing
Sterile end cap in place

Not recommended by
manufacturer. Off-label use.
How do you know if the tubing
tip is still sterile?

Indicates tip sterility maintained

Some Prefilled Saline Syringes

Are for Flushing ONLY
The saline flush syringes in the clear cellophane
package is ONLY for flushing
According to the manufacturer, DO NOT use
for medication dilution.
The inside of the barrel & the fluid pathway is all
that is sterile on these syringes.
When you push out saline, the outer side of the
plunger contaminates the inside of the barrel.
Then, when you draw back into the syringe, you are
pulling the plunger over areas that were just
contaminated.
If you do this, you could be pushing pathogens into
the patients bloodstreams.

The saline flush syringes in the sterile peel pack

may be used for medication dilution.

Your Role
Follow the bundle components specific to your role in the
patients care
Provide appropriate/indicated patient teaching regarding
these bundle component and other recommended
practices
Document patient education related to the goal of CLABSI
prevention
Patient education materials related to CLABSI prevention
can be found on the Intranet:

http://intranet.seton.org/polandproc/infectcontrol/docs/clabsi.pdf
http://intranet.seton.org/polandproc/infectcontrol/docs/clabsi_largertext.pdf
http://intranet.seton.org/polandproc/infectcontrol/docs/clabsi_spanish.pdf
http://intranet.seton.org/polandproc/infectcontrol/docs/clabsi_span_lg_txt.pdf

Remind peers of the importance of following the bundle

components and other recommended practices if they are
observed to be non-compliant

Policies
Central line insertion and dressing policies:

Caring for Central Venous Catheters (CVC), (adult patients)

Caring for Central Venous Catheters (CVC), e.g. Brovia
c, Hickman, Groshong, Hohn, Peripherally Inserted Cent
ral Catheter (PICC) (pediatric patients)
Caring for Peripherally Inserted Central Catheter (PICC
) in Neonatal Patients
Caring for Temporary and Permanent Hemodialysis Cat
heters, e.g. Quinton or Perm Cath
Declotting Central Venous Catheters with Alteplase,

References
http://www.cdc.gov/ncidod/dhqp/gl_intravascular.html
http://www.ihi.org/ihi/search/searchresults.aspx?searchterm=clabsi&searchtype=basic
http://www.jointcommission.org/NR/rdonlyres/868C9E07-037F-433D-88580D5FAA4322F2/0/RevisedChapter_HAP_NPSG_20090924.pdf
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