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Prevention of Central Venous Line-Associated Bloodstream Infections in Adult ICU Unit
The use of these catheters in ICUs is associated with the occurrence of central line-associated bloodstream infections (CLABSIs) resulting in increased morbidity and mortality rates in hospitalized patients (Perin, Erdmann, Higashi, & Sasso, 2016). Li and Bizzarro (2011) define CLABSIs as bloodstream infections that are identified and confirmed after performing appropriate laboratory investigations without other sources being identified yet the central line is in place at the time of examination or within 48 hours before the onset of the infection. In preventing the development of these lethal infections, clinicians and other people in ICUs utilize measures that include hygiene in performing diagnostic procedures and handling invasive devices that are mostly associated with nosocomial infections (Perin et al., 2016). ICU patients are at a higher risk of CLABSIs due to high prevalence rates of invasive procedures that are intended for the treatment of patients or diagnosis of different health conditions among others (Perin et al., 2016). As such, ICUs should adopt evidence-based strategies for preventing CLABSIs to mitigate the negative consequences associated with them.
CLABSIs are a common health problem in most ICU patients due to various invasive procedures. Frasca, Dahyot-Fizelier, and Mimoz (2010) explain that at least five million patients in the United States need central venous access on an annual basis. However, the venous access causes severe infections in some of the patients, since 3-8% of the inserted central line catheters result in bloodstream infections with more than 80,000 of the annually reported cases costing the country between $300 million and $2.3 billion every year (Frasca et al., 2010). Blot et al. (2014) add that these infections increase the length of hospitalization and subsequent health care costs leave alone the associated morbidity and mortality rates. Frasca et al. (2010) reiterate that additional financial costs of CLABSIs can be as high as $30,000 per patient as a result of extra weeks the patient has to stay in hospital due to complications caused by the infection; besides, 0-35% of the cases succumb to the infections depending on the extent and severity of illness. Basically, these infections are costly to patients, the country, and the world as a whole.
Despite noting the challenges associated with CLABSIs, people are still dying, as the prevalence of the infections continues ravaging the lives of ICU adult patients. Blot et al. (2014) state that although evidence-based interventions are present in clinical guidelines, CLABSIs still present a significant threat to ICU patients. Further, there is substantial concern about the prevalence of these infections, risk of infection to ICU patients, adoption of evidence-based measures when caring for patients, and the need to improve health care associated with the implantation and maintenance of central venous catheters (Perin et al., 2016). Basically, clinicians including nurses and physicians should be able to implement published evidence-based recommendations and infection prevention measures to curb the menace of CLABSIs.
As stated above, some of the effects of CLABSIs in ICU patients are increased mortality and morbidity rates as well as high costs of health care and hospitalization. In addition to determining the incidence and prevalence rates of CLABSIs in hospitalized ICU patients, this study aims to identify infection prevention measures associated with the application of central venous lines. These measures and strategies should be the ones used by nurses on a common basis. The primary objective of this study is to inform nurses and other clinicians and care providers dealing with adult ICU patients about the best evidence-based strategies that can be practiced to reduce the menace of nosocomial infections associated with venous catheters as well as other intravascular medical devices.
Incidence and Prevalence Rates of CLABSIs in ICUs
Vascular catheters are among the most frequently utilized indwelling medical devices in ICU patients since they play a vital role in the treatment of critical or chronic illnesses. Unfortunately, the placement of intravenous catheters is coupled with an immense risk of morbidity and mortality due to nosocomial bloodstream infections; mostly, these adversities outweigh the benefits of accessing the central venous system using medical devices (Patil, Patil, Ramteerthkar, & Kulkarni, 2011). As established by Frasca et al. (2010) 3-8% of patients with central venous catheters acquire CLABSIs. According to Patil et al. (2011), the rate of vascular infections attributed to the use of central venous catheters in adult ICUs stands at about 47.31 in 1000 catheter days; this fact was discovered after the examination of 54 ICU patients with intact central venous lines with 319 catheter days. Such incidence rates are high due to the increased use of these catheters in hospitalized ICU patients as well as the failure of clinicians to perform medical procedures aseptically.
The place of insertion of a central venous catheter has some influence on the incidence rates of CLABSIs in adult ICU patients. In their study, Patil et al. (2011) established that the incidence rates of catheter bloodstream infections in ICU patients are 25%, 23.81%, and 33.33% in the jugular, femoral, and subclavian catheters respectively. From these statistical findings, it is evident that jugular and subclavian intravenous catheters are related to a high risk of nosocomial infections. The site of catheter insertion significantly influences the risk for associated bloodstream nosocomial infections as a result of vital differences in the density of normal skin flora as well as the risks of thrombophlebitis (Frasca et al., 2010). Further, Blot et al. (2014) explain that CLABSIs still present a significant threat to hospitalized patients since their incidence rates stand at 4.4 per 100 devices that are inserted per 1,000 catheter days. As such, duration of catheterization and the site of insertion are primary determinants of the incidence and prevalence rates of CLABSIs. Besides, the way nurses and other clinicians handle the site of insertion or the level of asepsis during the execution of medical procedures has a significant influence on the risk for these infections.
Infection Prevention Interventions for Nurses and Other Clinicians
First, optimal site selection is a critical measure towards the mitigation of CLABSIs in ICU patients since the site of infection is associated with the variation of prevalence of bloodstream infections. According to Ling et al. (2016), nurses and other clinicians caring for hospitalized patients should avoid femoral catheters since they are associated with a higher bloodstream infection risk, and use subclavian and jugular ones instead. Subclavian sites are mostly chosen as insertion sites in adult patients; further, such factors as the risk associated with subclavian vein stenosis and potential mechanical complications should be assessed before choosing this location (Ling et al., 2016). Frasca et al. (2010) reiterate that subclavian sites are a priority as they are associated with reduced infection risk in adult patients; however, insertion skills of a clinician, the risk of subclavian vein stenosis, and most importantly, the possibility of mechanical ventilation should be considered. Moreover, the risk of thrombophlebitis should be considered when using the femoral site (Frasca et al., 2010). Therefore, choosing an appropriate insertion site that is associated with a reduced risk of infection is one of the main steps towards the prevention of catheter-associated infections in ICU patients.
Hand hygiene when touching or performing any manipulations at the insertion site or during central venous catheter insertion is one of the measures a clinician should take to prevent the occurrence of CLABSIs in hospitalized ICU patients. Ling et al. (2016) explain that hand hygiene should be upheld before the insertion or maintenance of the catheter combined with appropriate aseptic techniques during any catheter manipulation and care. For instance, nurses and other ICU clinicians should uphold hand hygiene practices before and after palpating catheter insertion sites as well as before and after inserting, replacing, accessing, and repairing the catheter or dressing the location of insertion (Ling et al., 2016). Therefore, clinicians should uphold such hand hygiene practices as hand washing and wearing appropriate medical gloves when dealing with catheters and insertion sites.
Further, clinicians should ensure that the skin is cleaned before central venous catheters are inserted or manipulated to avoid the introduction of microbes into the bloodstream. Frasca et al. (2010) state that since the density of microbes at the insertion sites poses a massive risk to the development of catheter infections, skin antisepsis is equally important to prevent the colonization of the site with pathogens that later find their way into the bloodstream. According to Ling et al. (2016), alcohol-based skin preparation fluids containing chlorhexidine have proven to be the most common and effective antiseptic agents to clean and eliminate skin bacteria at the either peripheral or central venous catheter insertion site. Frasca et al. (2010) reiterate that in addition to povidone-iodine, chlorhexidine is the most used antiseptic with high efficacy in the prevention of catheter colonization as well as bloodstream infections as compared to other skin aseptic solutions. Since chlorhexidine tends to cause skin reactions and other anaphylactic effects in some patients, alternatives are recommended in some cases (Ling et al., 2016; Frasca et al., 2010). Therefore, clinicians can mitigate the risk of CLABSIs using antiseptic preparations to clean the site of catheter insertion as a way of preventing the introduction of infections from the skin into the bloodstream.
Other Infection Prevention Strategies
Other strategies that can be adopted by nurses and other healthcare professionals caring for hospitalized patients are proper dressing of the catheter insertion site and regular review and replacement of the inserted lines. According to Ling et al. (2016), clinicians should use transparent semipermeable dressings instead of the gaze ones since they permit continuous visual inspection of the catheter site. Conversely, gauze dressings may be chosen in case of sweating, oozing, or bleeding at the insertion site. In all cases, these dressings should be clean and applied in an aseptic manner to prevent the introduction of nosocomial bloodstream infections (Frasca et al., 2010). Further, central venous catheters and dressings should be checked daily, and replacements are done when necessary since the risk of CLABSIs increase with the time the insertions are in situ (Ling et al., 2016). The inspections and regular changing of these catheters mitigate the risk of infection; moreover, clinicians should remove intravenous catheters once they are no longer required.
Finally, clinicians should not only disinfect catheter hubs but also change medical devices or access lumens in addition to implementing barrier precautions as an infection prevention strategy in ICU patients. Ling et al. (2016) explain that the catheter hubs are one of the most frequent sources of bacterial colonization since they serve as an immediate portal of entry of pathogens to intraluminal surfaces of medical devices. Fundamentally, the disinfection of catheter hub surfaces should be a priority every time clinicians use them when performing medical procedures. Further, Ling et al. (2016) assert that clinicians, especially nurses, should utilize full-body sterile drapes in addition to wearing face masks, gowns, and sterile gloves to cover body parts during the procedures of catheter insertion to prevent the transfer of potential microbial pathogens to patients. This strategy prevents the transfer of microbial pathogens from clinicians to critically ill ICU patients.
This study will use secondary sources of data to search for scientific information concerning the prevention of CLABSIs in ICUs as well as the incidence and prevalence rates of these health problems. The use of secondary sources of data is common since it is attributed to time wastage mitigation as compared to many other conventional methods. Further, computers and credible databases will be used to search for scientific sources of data related to the issue. Similarly, the use of computer-based search strategies will significantly save substantial amounts of time compared to manual search through traditional resources in libraries. Some of the databases that will be used when searching for the data include Medline, Google Scholar, PubMed, ProQuest, and CINAHL among many others. These databases will provide a sizeable number of scholarly sources of reliable and objective information to address the research topic.
The search strategy will involve using the entire topic and the key terms that will aid in finding articles and other scholarly sources that present objective information on the prevention of CLABSIs in ICU adult patients. Some of the keywords, which will be searched either singly or in combination, include "catheter-related infections," "central venous line infections," "infection control strategies in ICU patients," "catheterization and infection control," and "CLABSI" among others. Among all the scholarly sources it will be important to find peer-reviewed nursing and non-nursing journal articles and articles or guidelines posted on the reliable websites of such organizations like the Center for Disease Prevention and Control and the World Health Organization as well as government sources. The sources eligible for inclusion into the study will be those published in English with the date of publication ranging from 2007 to 2017. Besides, they should be of a high level of validity and reliability. To fulfill the research goals and objectives, the researcher will read all the relevant information regarding the research topic before compiling a report, containing comprehensive answers to the topic of the study.
Implications for Nursing Practice
This study will present the implication for nursing practice, especially for nurses working in ICUs as well as those caring for other hospitalized patients with not only central venous catheters but also those with peripheral ones. In ICUs, it is no secret that CLABSIs present a significant threat to the lives of patients and one of the primary aims of nurses is to reduce nosocomial infections including those attributed to the utilization of central venous catheters. Therefore, providing information on how these healthcare professionals can curb the menace of CLABSIs through the adoption of effective infection control strategies will improve their practice. For instance, nurses will adopt the recommendations of this study into practice by practicing evidence-based interventions. Some of the possible interventions will include an aseptic technique when not only managing central venous lines but also inserting and removing them. Moreover, other interventions will contain an appropriate selection of insertion sites and frequent dressing among others. Eventually, the risk of CLABSIs will be significantly reduced resulting in better treatment outcomes and reduced length of ICU hospitalization in adult patients.
Patients in ICUs require critical care with central venous lines and other intravascular medical devices being used to access the vascular system for assessment, diagnostic and treatment purposes. Unfortunately, nosocomial pathogens can use these routes to find their way into the bloodstream resulting in CLABSIs. Since these devices cannot be avoided in critically ill patients, the only way is to prevent the development of these infections through the adoption and execution of appropriate interventions. Besides, clinicians have no option other than to reduce healthcare costs associated with the treatment of illnesses and complications related to them. In this case, reduction of the costs of critical care in adult ICU patients involves the prevention of CLABSIs. Therefore, nurses should be informed about the appropriate strategies and interventions to mitigate the occurrence of CLABSIs.