Reducing central line-associated bloodstream infection in contaminated central venous catheters: case studies of a pediatric contamination guideline

HIGHLIGHTS

• Central venous catheter may become contaminated from patient's body fluids.
• A clinical practice guideline assists in standardizing contamination management.
• Case report to highlight importance of adhering to clinical practice guideline.

Central line-associated bloodstream infections (CLABSIs) continue to be a significant cause of morbidity, mortality, and increased costs for hospitalized adult and pediatric patients. Approximately 5 million central vascular catheters (CVCs) are placed in adult and pediatric patients in the United States every year, impacting approximately 8% of hospitalized patients.^1,2 Although CVCs are vital to deliver intravenous (IV) medications and provide medical therapies, CVCs' placement and use are associated with a risk for developing severe and life-threatening infections, which may increase the patient's risk of morbidity and mortality.^3,4 In a systematic review, Umscheid et al.⁵ reported that the cost of a CLABSI in the United States ranged from $21,400 to $110,800 per infection.

Research over the last decade has demonstrated reduction of CLABSIs by introducing standardized line insertion and maintenance bundles.^6,7,8,9 Implementing evidence-based bundles estimated prevention of 65% to 70% of CLABSIs.⁵ In addition to the use of standardized insertion and maintenance bundles described above, our hospital CLABSI Prevention Committee implemented additional practices aimed at ensuring the integrity of the CVC system, such as limiting the frequency of CVC access and limiting interruptions of the CVC system. However, further progress in reducing CLABSI rates has proved challenging, and our hospital's CLASBI reduction efforts mirrored the national trend.^6,7 Along with published recommendations from the Centers for Disease Control and Prevention, the Children's Hospital Association collaborative identified aspects of CVC care that could reduce infection risk. Such aspects were creating standard bundles for CVC insertion and CVC maintenance and practices to protect the integrity of the CVC system, such as placing occlusive CVC dressings over the insertion site and limiting the frequency of CVC access.

The 2012 year-end review of all CLABSI events identified a gap in our CVC maintenance bundle concerning CVC contamination from body fluids, stool, or other sources at the CVC insertion site and CVC access ports. To fully understand the issue, we talked with bedside nurses regarding challenges with managing contamination of a CVC. Based on this input, we recognized that the organization lacked guidance to prevent CLABSIs if a CVC contamination event occurred. A literature review on CVC contamination practices failed to yield any published recommendations. This provided an opportunity to raise awareness about the risk of CLABSI from source contamination and create a clinical practice guideline (CPG).

Due to the lack of research, a workgroup of subject matter experts was formed consisting of an infection preventionist, an infectious disease physician, pediatric intensive care unit (PICU) intensivists, a clinical nurse specialist, vascular access nurses, hospital executive leaders, and a hospital quality executive to develop a consensus-based CPG. Over a 9-month period, this group met monthly and as needed in between. The workgroup followed a basic 5-step evidence-based practice process (Figure 1). The first step was to define what constitutes a contamination event. For this guideline, contamination was defined as a situation when body fluids (emesis, gastrointestinal secretions, oral or tracheal secretions, urine, or stool) soiled the CVC dressing, CVC insertion site, catheter threads, connectors, line, or the CVC cap. Next, a literature review was conducted to identify strategies to prevent contamination. Little existing published evidence was identified; therefore, we sought expert opinion from the workgroup and others involved in current CLABSI prevention improvement work. Examples of current prevention strategies include CVC site selection, use of dressing or site protective coverings, and diverting tubing and connectors away from any potential sources of contamination.

Figure 1. Clinical practice guideline development process

Next, we recognized that a standardized approach for treatment of a known or suspected contamination event was needed. Based on the potential infection risk and pathogenesis of CLABSIs, contamination was categorized as mild, moderate, and major (gross). For example, contamination with stool was categorized as major (gross) contamination due to the higher bacterial load in the stool than other potential contamination sources, eg urine or saliva. Table 1 outlines the recommended steps for staff to take for each contamination category, including escalation to the medical team.

Case reports

All case reports were reviewed by the UT Southwestern Human Research Protection Program, which determined that it did not meet the definition of research under 45 CFR 46.102 and therefore did not require institutional review board approval or oversight.

Gross CVC contamination

A 20-month-old boy diagnosed with high-risk acute myeloid leukemia had a 5 French double-lumen tunneled CVC placed for chemotherapy administration. History included multiple episodes of Clostridium difficile enteritis, and the patient was admitted for scheduled chemotherapy. The CVC dressing was changed the day of admission utilizing a standard transparent dressing and chlorhexidine gluconate (CHG) impregnated disc.

The registered nurse (RN) documented the CVC dressing as clean, dry, and occlusive. After chemotherapy administration, the patient began having large watery bowel movements. Themother was very active at the bedside but stepped out to grab lunch while the patient slept in his crib. After chemotherapy, the patient had a large watery bowel movement that contaminated the CVC cap and external lumen and connectors. The RN immediately stopped the infusion and began cleaning the external lumen with alcohol wipes. Next, the RN attempted to clean the connectors and performed a CVC cap change per the contamination CPG. Additionally, the RN communicated the situation to the medical team and charge nurse. To preserve the tunneled CVC, the attending consulted an infectious disease physician for antimicrobial lock recommendations. The CVC was salvaged using antimicrobial locks. This patient never experienced a CLABSI.

Moderate CVC contamination

A 12-year-old boy admitted to the PICU with Guillain-Barré syndrome was intubated and had a 4 French peripherally inserted central catheter (PICC) in his upper right arm. During CVC rounds, the patient's head was near his right arm, and the PICC dressing was contaminated with oral secretions. Upon further assessment, the PICC dressing was occlusive with a CHG impregnated disc in place at the CVC insertion site. The IV tubing and caps were secured away from possible contamination.

Following the contamination CPG, the RN relocated all IV medications infusing via the PICC to another access point.

Next, the area surrounding the PICC was dried with a towel, the PICC dressing and the surrounding skin was cleaned using CHG wipes, and the PICC dressing was removed and replaced.

Once the CPG steps were implemented, the nurse reconnected the IV medications to the PICC. The contamination event was documented in the CVC flowsheet as part of the patient's electronic health record as the PICC dressing change indication and discussed by the medical team during rounds. The PICC was salvaged, and a CLABSI was prevented. A week later, the PICC was removed because it was no longer needed for therapy.

Unwitnessed CVC contamination

A 19-week-old infant with a complex medical history, including prematurity and tracheostomy dependence, was admitted to the PICU status post a Nissen fundoplication procedure with gastrostomy tube placement. The patient remained hospitalized due to drainage from the new gastrostomy tube.

The patient had a 1.9 French right brachial CVC in place. The patient exhibited symptoms concerning for sepsis, and blood, tracheal aspirate, and urine cultures were obtained. Before the onset of symptoms, the patient was noted to have increased tracheal secretions. The patient's blood and tracheal cultures were positive for Enterobacter cloacae complex and Klebsiella pneumoniae. In this case, CVC contamination risk factors included increased tracheostomy secretions and gastrointestinal tube feeds. During review of the event, it was noted that protective overlays were not used for the CVC in the days preceding the event. With the known risk factors and the culture results, the CLABSI was attributed to contamination from tracheal and gastric secretions. The CLABSI prevention bundle includes the use of protective coverings to mitigate the risk of CVC contamination.

This case report shows the opportunity for improvement of the utilization of a protective CVC covering.

Challenges and considerations

CPG implementation encountered several barriers. Gaining consensus on practice standards from multiple units and providers throughout the hospital proved challenging. A subcommittee of CVC key stakeholders created the CPG and obtained the hospital wide CLABSI committee approval of the final CPG. All staff within our hospital received education on the CPG. All employees had access to the CPG via the organization's electronic system, which allows easy access to all employees. Adherence to the CPG was not universal once a CVC contamination occurred, especially on low-volume CVC units. Low-volume units had to retrieve the CPG to utilize it.

Over time, we have improved consistency through reeducation, newsletters, and system-wide quality communications. Also, to prevent any delay once contamination occurs, we have empowered nurses to perform immediate interventions.

Another challenge we observed was the ability to track CPG utilization and assess its effectiveness accurately. Since approval in 2013, the CPG has been viewed 1736 times by 881 different users. However, we do not know if, once viewed, the CPG was followed or was used to prevent a CLABSI related to CVC contamination.

The year-end 2012 CLABSI rate decreased from 1.8 infections per 1000 central line days to 0.8 in 2020. Implementation of the contamination CPG was one of several CLABSI prevention interventions simultaneously occurred at our institution, making our CLABSI rate reduction difficult to show attributable to any one improvement. Through apparent cause analysis for CLABSI events, we track and monitor instances of CVC contamination as a potential contributor to the event, including utilization of the contamination CPG. Therefore, our data are limited. Data are only tracked when the contamination event resulted in a CLABSI and not when the CPG was used to prevent one. An area for future research would be to develop strategies to track and assess the effectiveness of the introduction of CPGs for CVC contamination events in CLABSI reduction efforts.

Conclusions

Efforts to reduce CLABSIs are ongoing and require consistent reinforcement, training, monitoring, and education. Establishing standardized practices for CLABSI insertion and maintenance is the cornerstone of a hospital's CLABSI reduction efforts but may not encompass all available effective strategies.

Creation and implementation of the contamination CPG is one example of how a multidisciplinary approach to an identified gap in care results in a solution. Although we cannot attribute a reduction in our CLABSI rate solely to the CVC contamination CPG implementation, we have demonstrated expert consensus for standardization of CVC contamination management across the hospital using a CPG.

Preventing hospital-acquired conditions, such as CLABSI, remains a focus for every clinician. Besides following industry guidelines and known evidence-based practices, additional research and guidance are needed to decrease the mortality and morbidity rates associated with CLABSIs.

There continues to be very little published research on practices for suspected or known CVC contamination. More research on this topic is needed to provide evidence for effectiveness.