BSI Bundle: A Best Practice

Intravascular catheters are indispensable in modern-day medical practice, particularly in intensive care units (ICUs). Although such catheters provide necessary vascular access, their use puts patients at risk for local and systemic infectious complications, including local site infection, catheter-related bloodstream infections (CRBSIs), septic thrombophlebitis, endocarditis and other infections (Centers for Disease Control and Prevention [CDC] 2002).
It has been estimated that approximately 80,000 central venous catheter-related BSIs occur in ICUs each year in the United States (CDC, 2002). The incidence of CRBSIs varies considerably by type of catheter, frequency of catheter use and other patient-related factors. Peripheral venous catheters are the devices most frequently used for vascular access (CDC, 2002).

However, according to reports from the CDC, the majority of serious catheter-related infections are associated with central venous catheters (CVCs), especially those that are placed in patients in ICUs. In the ICU, patients are more likely to be immunocomprimised; central venous access is usually needed for extended periods of time; patients can be colonized with hospital-acquired organisms; and the catheter can be manipulated multiple times per day for the administration of fluids, drugs and blood products. In addition, some catheters may be inserted in urgent situations, during which optimal attention to aseptic technique might not be feasible. Certain catheters, such as pulmonary artery catheters, are accessed multiple times per day for hemodynamic monitoring or to access samples for laboratory analysis, augmenting the potential for contamination and infection.

To improve patient outcomes and reduce health care costs, the CDC promotes the development of strategies to reduce the incidence of these infections. This effort should be multidisciplinary, involving health care professionals who insert and maintain intravascular catheters, health care managers who allocate resources, and patients who are capable of assisting in the care of their catheters (CDC, 2000).

The Joint Commission has attempted to reduce the incidence of CRBSIs by identifying evidence-based practices that will prevent central line-associated bloodstream infections. The seventh National Patient Safety goal identifies 13 elements of performance to achieve this goal. These elements include staff and patient education, the implementation of policies, procedures and periodic risk assessments to reduce the risk of CRBSIs, and the measurement of key outcomes.

Two extremely significant recommendations for nurses include the use of a catheter checklist and standard protocol for central line insertions and maintenance. Hand hygiene and use of a standardized supply cart / kit that contains all necessary equipment required for insertion and maintenance of the line are best nursing practices that will help prevent CRBSIs.

The use of a chlorhexadine-based antiseptic for skin preparation and the use of a standardized protocol for disinfecting catheter hubs and injection ports prior to use are two additional elements of performance that have been proven to minimize CRBSIs.

In addition, the Institute for Healthcare Improvement ([IHI], 2010), recommends the use of “care bundles,” which are groupings of the best nursing practices that pertain to a specific disease process. Implementing all practices in a single bundle has shown to produce better outcomes than using the practices individually. The science supporting the bundle components is sufficiently established to be considered the standard of care.

The key components of the Central Line Bundle are:

  • Hand hygiene
  • Maximal barrier precautions upon insertion
  • Chlorhexidine skin antisepsis
  • Optimal catheter site selection, with avoidance of the femoral vein for central venous access in adult patients
  • Daily review of line necessity with prompt removal of unnecessary lines

To learn more about central line care bundles, visit the Institute for Health Improvement website