Winning the War Against Catheter-Related Infections

Waging war against nosocomial catheter-related infections in the ICU may seem a daunting task. However, the care team of the Weinberg ICU, The Johns Hopkins Hospital, Baltimore, tackles the battle against catheter-related infections with a successful strategy of empowerment, consistency, and education. With the entire staff working as a unit, the fight has gained significant ground. Since June 2003, the care team has had only two catheter-related infections, the fewest for any ICU in The Johns Hopkins Hospital.

“We have clearly raised the bar,” says Donna Prow, RN, BSN, nurse manager of the Weinberg ICU. “As of January 2006, all patient care units have adopted the checklist the Weinberg ICU instituted; it is now a hospital-wide protocol for central line insertion and management. And other hospitals across the U.S. have also adopted the guidelines The Johns Hopkins Hospital pioneered.”

Having proper equipment available is key in the prevention of catheter-related infections, according to Prow. The Weinberg ICU staff maintains a complete and mobile catheter insertion cart within the unit. The cart is restocked every four hours with everything needed to insert any type of arterial or central-venous line, including single, double, and triple-lumen catheters; dialysis catheters; Swan-Ganz lines; and sterile draping and gowning equipment. The accessibility of the catheter-insertion cart helps the staff maintain strict sterile technique.

“Everything needed is right at hand, so you do not have to interrupt the setting up of sterile fields to leave the room and get additional supplies,” says Prow. Anyone present during insertion and replacement procedures is outfitted in full barrier protection, including sterile gowns and caps. Direct, hands-on care requires wearing sterile gloves as well; others don
non-sterile gloves unless asked to directly assist in the procedure.

To reduce the risk of introducing bacteria into the field, complete sterile draping of the patient is also important. “The patient is always covered with a sterile sheet from head to toe,” says Prow.

Ensuring staff have proper protection and equipment is only a part of the strategy in the campaign against catheter-related infections. Prow also credits the success to the nurses’ consistent use of a simple procedural checklist. The checklist includes reminders to wash hands, correctly position the patient, sterilize the procedure site, properly drape the patient and maintain a sterile field, and use a sterile site dressing. Most important, there is a place to document the corrections taken when sterile technique is breached.

Initially nurses were skeptical about the effectiveness of implementing the checklist. They knew that enforcing a code of strict sterile technique without the full support and cooperation of the attending physicians would be difficult; however, the physicians were willing and have empowered nurses to carry out the standards on the checklist.

“The nurses have the authority to say, ‘Stop! Sterile technique has been broken, and we are going to start over again,’“ explains Prow.

In addition to supportive physicians, the unit boasts the advantages of a consistent RN staffing pattern and the skills of five acute-care NPs as well. The NPs perform about one third of the central-line insertion procedures, and Prow views them as an additional boon in the defense against catheter-related infections.

Maintaining consistency also means that new recruits to the unit quickly learn the catheter-insertion drill. Resident physicians, who insert catheters under the supervision of the fellow physician, arrive monthly. On their first day on the unit, an NP or nurse manager ensures their basic training and orients them to the cart, the checklist, and the procedures.

Another way to reduce catheter-related infections is the quick replacement of catheters inserted during an emergency. With these catheters, such as those inserted in the field or the ED, sterile technique may have been compromised because of the patient’s emergent condition. Education plays a major role in minimizing resistance from patients who may dread facing another major invasive procedure.

“Patients are generally willing to consent to have catheters reinserted once they understand the reasons,” says Prow. Physicians have also been very willing to reinsert these catheters.

Other important procedures include the timing and technique of tubing changes. Per protocol, tubing is changed every 96 hours and is never changed near the insertion site. Adapters keep any opening of the closed sterile system as far away from the insertion site as possible. Insertion site dressing changes are also performed as sterile procedures with the use of both sterile fields and sterile gloves.

Even prior to insertion of a catheter, careful thought is given to the possible risk of future infection. “Important decision-making happens at the time of catheter insertion,“ says Prow. “The best option is always to use a single-lumen catheter if there clearly is not a need for a multi-lumen catheter. When you add another lumen, you add another potential port of entry for bacteria.”

In addition, patients are not discharged from the ICU with central lines in place unless absolutely necessary. If continuation of a central line is deemed essential to a patient’s care, the line is not capped or locked but retains a dedicated IV fluid line.

Waging war against catheter-related infections may seem like an uphill battle; however, Prow attributes much of the success of their program to the commitment of a consistent and empowered staff who work diligently to carry out proper procedures from start to finish.

Catherine Spader, RN, is a freelance writer for Nursing Spectrum.