CLABSI Reduction: Make an Impact!
By Bette Case di Leonardi, PhD, RN-BC
Nurses are making an impact in reducing central line-associated bloodstream infections (CLABSI). Reducing CLABSI rates improves the quality and safety of patient care and favorably impacts the financial stability of your healthcare organization.
The Centers for Disease Control and Prevention (CDC) estimated the cost of each CLABSI at $16,550 (TJC, 2012, p. ix) while other estimates place the cost as high as $40,000. (Leapfrog Group, 2011). As many as 65% to 70% of CLABSIs may be prevented by using evidence-based strategies (Umscheid et al, 2011). The Institute for Healthcare Improvement (IHI) developed an evidence-based Central Line Bundle to assist healthcare organizations in preventing CLABSI. Organizations have established policies and procedures (P&P) that incorporate the key components of the bundle.
One key component of the bundle is hand hygiene. The CDC guideline recommends that hand hygiene be performed before and after palpating the site of catheter insertion, before and after inserting the catheter and before and after accessing, replacing, repairing, or dressing the catheter (TJC, 2012, p. 42).
Another key component of the bundle deals with Maximal Barrier Precautions Upon Insertion. The guidelines recommend that the CVC inserter wear a mask and cap, sterile gown and sterile gloves, and use a large (head-to-toe) sterile drape over the patient during the placement of a CVC or exchange of a catheter over a guidewire (TJC, 2012, p. 44).
Healthcare personnel are advised to adhere to maximal sterile barrier precautions during CVC insertion. Proper CVC maintenance includes disinfection of catheter hubs, connectors, and injection ports and limiting dressing changes. Anytime a CVC is inserted when adherence to aseptic technique cannot be ensured, as might occur during a medical emergency, it is essential that the catheter be replaced as soon as possible, preferably within 48 hours. (TJC, 2012, p. 43)
Chlorhexidine Skin Antisepsis is another key component of the bundle. Chlorhexidine gluconate preparations are recommended over both iodophors and alcohol for skin antisepsis (TJC, 2010, p. 44). The guidelines recommend that chlorhexidine is applied to clean skin, in a chlorhexidine / alcohol concentration greater than 0.5% in alcohol. If chlorhexidine is contraindicated, a tincture of iodine, an iodophor, or alcohol can be applied as an alternative. The antiseptic solution should be allowed to dry before placing the catheter (TJC, 2012, p. 45). After the antiseptic has been applied to the site, further palpation of the insertion site should be avoided, unless aseptic technique is maintained (TJC, 2012, p. 42).
Optimal Catheter Site Selection, with Avoidance of the Femoral Vein for Central Venous Access in Adult Patients is also discussed in the guidelines. Although the provider makes the decision about access sites, it is important to know that the guidelines discourage use of the femoral site due to greater infection risk. Additionally, current practice guidelines encourage the use of the subclavian rather than the jugular vein.
Daily Review of Line Necessity with Prompt Removal of Unnecessary Lines is another topic covered in the guidelines. It is recommended that the continued need for the catheter be reviewed every day, as the risk of infection increases the longer the CVC is in place. Healthcare personnel must ensure that a patient’s CVC is removed or replaced at the appropriate time and in a safe manner. It is advisable to discontinue parental nutrition at the earliest time possible, since it increases risk of CLABSI. Administration sets and add-on devices should be replaced no more frequently than every 72 hours, unless contamination occurs. Tubing used to administer blood, blood products, or lipids should be replaced within 24 hours of start of infusion, and the caps should be changed no more often than 72 hours (or according to manufacturer’s recommendations and whenever the administration set is changed) (TJC, 2012, p. 56).
By complying with your facility P&P and using the steps above, you can make an impact on CLABSI rates in your facility. To further your knowledge of central venous access devices (CVADs) and the care and maintenance associated with these devices, check out RN.com’s new 3 contact hour course: What's Your Line: Overview of Fluids, Central Lines & PICCs.
- The Joint Commission [TJC]. (2012). Preventing central line-associated bloodstream infections: A global challenge, a global perspective. Oakbrook, IL: TJC.
- The Leapfrog Group. (2011). Getting to zero: Reducing rates of CLABSI in community hospitals. Retrieved from http://www.leapfroggroup.org/media/file/Final_GettingToZero.pdf
- Umscheid, C.A., Mitchell, M.D., Doshi, J.A., Agarwal, R., Williams, K., & Brennan, P.J. (2011). Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infection Control Hospital Epidemiology, 32(2), 101–114.
- CDC’s Healthcare Infection Control Practices Advisory Committee (CDC/HIPAC) Guidelines for the Prevention of Intravascular Catheter-Related Infections (2011).
- Comprehensive Unit-based Safety Program (CUSP), an AHRQ program to promote teamwork in the use of evidence-based safety practices.
- CMS has assembled a number of resources for patients and providers related to preventing CLABSI, available at this link.
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Bette Case Di Leonardi has worked in nursing, education and healthcare administration for more than 40 years and was among the first group of nurses certified in Nursing Professional Development. Today, Di Leonardi is an independent consultant who publishes and presents on a variety of professional and educational topics.