have become a ubiquitous feature of modern-day patient care; current estimates suggest that as many as 2 million persons in the U.S. have an intravascular device that is used daily or intermittently.1 These devices fulfill a variety of clinical needs, including monitoring acutely ill patients and the administration of critical medications, in a variety of settings, including ICUs, medical and surgical units, and the outpatient setting.
This important therapeutic role comes with associated risks, including the possibility of bloodstream infection, which leads to an increase in morbidity, length of stay, and cost. Each year in the ICU alone, 80,000 catheter-related bloodstream infections (CRBSIs) occur. This figure increases to 250,000 to 500,000 infections per year when all hospitalized patients are considered.1,2
Infections related to intravascular catheters have been targeted by numerous quality-improvement (QI) initiatives, uncovering a number of clinical actions that can impact their rates. Studies have shown that these infections can be avoided and nearly eliminated entirely with close adherence to several evidence-based, infection-control measures.3 Furthermore, these results can be sustained across multiple ICUs over extended periods.4
The majority of data that describe the epidemiology of CRBSIs and the interventions needed to prevent these infections have been generated in the ICU. However, the pervasiveness of these devices in other care settings dictates the need for heightened awareness by the entire care team. As such, it is important for hospitalists to understand and be aware of guidelines outlining the standard of care not only in personal practice, but also in order to ensure that all members of the team are playing their part in preventing this serious complication.
In May 2011, the Society of Critical Care Medicine (SCCM), in collaboration with 14 other professional organizations, published new guidelines for the prevention of intravascular catheter-related infections.5 These guidelines are a revision of guidelines published in 2002 and provide recommendations that apply to all intravascular catheters, as well as specific comments based on the type of device in use.6
Specific recommendations include:
- Responsible staff should be well-versed and assessed on the proper procedures for the care of all intravascular catheters with designated personnel responsible for central venous catheters (CVCs)
- and peripherally inserted central catheters (PICCs).
- Prior to CVC and arterial catheter insertion and during dressing changes, an antiseptic solution containing more than 0.5% chlorhexidine with alcohol should be used to prepare the skin.
- Nontunneled CVCs should be preferentially placed in a subclavian site rather than a jugular or a femoral site, except in hemodialysis or advanced kidney disease patients, for which this may cause subclavian stenosis, with the understanding that the risks of placing a CVC at a site be weighed against its benefits.
- Skilled personnel should use ultrasound guidance during CVC placement, and the minimal essential number of ports or lumens on the CVC should be present. Avoidance of routine placement of CVCs and prompt removal of any nonessential intravascular catheter is recommended.
- Maximal sterile barrier precautions should be taken during the placement of CVCs and PICCs or guidewire exchange, which includes a sterile full-body drape for the patient and use of cap, mask, sterile gown, and gloves for personnel. After the catheter has been placed, it should be secured with a sutureless securement device. In addition, patients with these intravascular catheters should bathe with 2% chlorhexidine daily.
- If rates of CLABSI remain high despite adherence to education/training, appropriate antisepsis, and maximal sterile barrier precautions, the use of antiseptic- or antibiotic-impregnated, short-term CVCs and chlorhexadine-impregnanted sponge dressings might help to further decrease rates.5