Healthcare-associated infections are considered an area "ripe" for quality improvement in all settings, including home healthcare (National Quality Forum, 2008). Although the overall risk of infection in patients receiving home infusion therapy is low when compared with inpatient settings (Gorski et al., 2010), all patients are at risk for infection primarily due to the presence of a vascular access device (VAD). Most of these infections are considered preventable. With implementation of the "central line bundle" in acute care hospitals, organizations have been able to markedly decrease the rate of central vascular access device related infections (Berenholtz et al., 2004; Berriel-Cass et al., 2006; Pronovost et al., 2006; Venkatram et al., 2007). The central line bundle is a group of evidence-based interventions that, when implemented together, result in better outcomes than when implemented individually and include the key components of hand hygiene, maximal barrier precautions upon insertion, chlorhexidine skin antisepsis, optimal catheter site selection, and prompt removal of unnecessary lines (Institute for Healthcare Improvement, 2009).
Although we need more research about the risk, incidence, and the cost of infusion-related infections in home care, we must develop a zero tolerance for infections and home care agencies must develop processes for infection surveillance (Association for Professionals in Infection Control and Epidemiology [APIC], 2008; Gorski, 2009). As a nurse who on occasion serves as an expert witness in malpractice cases, I have reviewed the records of home care patients who died as a result of preventable central line infections. Although fortunately such cases are rare, even an infection that is managed and resolved demands an investigation. "Getting an infection during the course of receiving home care should not be acceptable, even when the home care providers are not the only ones providing the patient's care; every infection should be investigated closely to determine why it happened so that measures can be taken to prevent it from happening again—for any patient" (McGoldrick, 2008, p. 67).
The risk of infectious complications is decreased when hand hygiene is practiced, infusion access devices are appropriately assessed and cared for, infusion therapy is carefully administered, and patients and their caregivers are well educated. Most patients receiving home infusion therapy have CVADs, essential for administration of irritating I.V. solutions and medications for short- and long-term infusion therapy. In this article, a review of the etiology, identification, and best practices related to central vascular access devices (CVAD) is presented.
Etiology of CVAD-Associated Infection
Potential routes of catheter-associated infection include the skin—either organisms on the patient's skin or organisms from the healthcare provider placing/caring for the CVAD, the catheter hub/needleless connector, contaminated infusate, and hematogenous seeding of the CVAD from another source. The most common sources of infection—skin and catheter hub contamination—will be addressed in the following sections. Nursing activities aimed at reducing the risk of contaminated infusate are summarized in Table 1.
It is recognized that all indwelling VADs form a biofilm on the device shortly after insertion. A biofilm is a community of microorganisms surrounded by a slime matrix that protects the bacteria from antibiotics (Talsma, 2007). Bacteria from the biofilm that detach from either the external or internal catheter surface can lead to catheter-associated bloodstream infection.
During catheter insertion, organisms attach to the tip and external surface as the catheter passes through the epidermis. The source of organisms includes the healthcare provider's hands and/or bacteria from the patient's skin. The patient's skin is considered the primary source of contamination of the external surface of the catheter (extraluminal). Attention to skin antisepsis before placement is likely the most important intervention in prevention of catheter-associated infection (Ryder, 2006). Extraluminal catheter-associated infections typically occur early, within the first week after placement (Ryder, 2006).
Microorganisms can enter the internal catheter surface anytime the infusion system is manipulated, such as during intravenous administration, CVAD flushing, and administration set changes. Intraluminal-associated infection typically occurs after 1 week (Ryder, 2006). Although attention to central line insertion procedures, including the components of the central line bundle, is reducing the incidence of infection in short-term catheters, optimal care and management of the long-term catheter is less well-researched. Hand hygiene, attention to the catheter hub, including adequacy of disinfection, and the optimal type of needleless connector to reduce infection risk are important aspects of care.
Assessment of the patient with a CVAD includes ongoing evaluation of the insertion site, catheter tract, adjacent skin, and assessment for systemic changes indicative of infection, including fever. The site is to be assessed with every home visit, and patients should be taught to inspect their site at least every day (Gorski, 2005). The insertion site should be assessed for the integrity of the dressing, any signs of infection including erythema, drainage, swelling, or induration, and any other complications such as catheter migration. For patients with tunneled catheters (e.g., Hickman), the tunnel is also assessed for any pain, swelling, drainage, or erythema. The portal pocket for implanted ports is assessed for the same. Because catheter-associated infection can occur without any evidence of site complications, attention should also be paid to elevations in temperature and any complaints of chills, weakness, and/or malaise.
The external length of the catheter should also be documented during the admission visit to monitor catheter migration. If leakage of parenteral solution from the catheter insertion site is noted, catheter integrity should be evaluated immediately. If the patient develops symptoms of an infection, notify the physician. Site and/or blood cultures from the CVAD and via venipuncture need to be completed. Depending on patient's condition, antibiotics may be initiated, the CVAD may be removed, and/or the patient may require hospitalization. The CDC (O'Grady et al., 2002) recommends that catheters not be removed on the basis of fever alone as the infection could be related to another location or due to noninfectious causes.
Site Care and Dressing Changes
Site care consists of cleansing the site using an antiseptic and replacement of the dressing. The goal is to minimize the number of microorganisms at the insertion site and surrounding skin. Site care is always done following aseptic technique and while wearing a mask (Infusion Nurses Society [INS], 2006). The preferred antiseptic for site preparation before CVAD placement and for site care is chlorhexidine (O'Grady et al., 2002; Chaiyakunapruk et al., 2002). When using chlorhexidine, a back and forth scrubbing method using friction for 30 seconds is recommended by the manufacturer (Chloraprep, 2009). Dressing choices include the transparent semipermeable membrane dressing or a simple gauze dressing. The research supporting the choice of dressing is limited, and the evidence does not support one choice over another (Gillies et al., 2003). Choose the dressing based on patient preference and needs. The INS (2006) standards and the CDC (O'Grady et al., 2002) recommendations address changing the transparent dressing at least every 7 days and changing gauze dressings every 48 hours. If there are signs of infection or loss of dressing integrity, the dressing is also changed, allowing the opportunity to closely assess, cleanse, and disinfect the site. A transparent dressing is preferred in most cases, allowing the patient and the nurse to easily visualize the insertion site, and it is a cost-effective choice due to less frequent changes.
Gauze dressings may be used for patients with site drainage, excessive perspiration, or sensitivity reactions to transparent dressings. Use of gauze under a TSM dressing is not an uncommon practice. If gauze is used under a transparent dressing, it is considered a gauze dressing and is changed every 48 hours. Another potential misunderstanding about dressing change frequency may result when a gauze dressing is used under the wings or extension tubing of a noncoring needle inserted into a port that is then covered with a transparent dressing, a common practice. In this case, as long as the gauze does not obscure or cover the catheter-skin insertion site, it is not considered a gauze dressing (INS, 2006).
Finally, antiseptic dressings are being used more often as research supports their benefits in short-term CVADs in hospitalized patients (Ho & Litton, 2006). There is no current research addressing the benefits in terms of reduced infection with long-term catheters; their use with home care patients should be based on individual agency infection data and practice issues.
Catheter stabilization is increasingly recognized as an important intervention in reducing the risk for phlebitis, infection, catheter migration, and catheter dislodgment (Gorski, 2007). When the catheter is stabilized, there is less movement of the catheter in and out of the insertion site, which can lead to infection/phlebitis, and the catheter is less likely to be dislodged. Alternatives to suturing should be considered due to the risk of needlestick injuries by healthcare workers (Occupational Safety and Health Administration [OSHA], n.d.). Sutures are associated with increased risk for infection (Yamamoto et al., 2002). The INS standards recommend the use of manufactured catheter stabilization or securement devices as preferred over other methods, such as sterile tapes and surgical strips. Such devices consist of an adhesive pad and a mechanism to hold the catheter and administration tubing to the pad. There are several commercially available stabilization devices. It is essential that the home care nurse understands the specific manufacturer's directions for use and frequency of device replacement, in most cases, at least weekly. Nursing activities aimed at reducing skin flora as a contributor to infection are summarized in Table 1.
Because microorganisms potentially have access to the internal catheter surface with each use, attention to aseptic technique is necessary with every procedure used with infusion administration including needleless connector and administration set changes, catheter flushing, drug/fluid administration, and blood withdrawal for laboratory testing. Hand hygiene, practiced by both home care nurses, and patients/caregivers who perform infusion-related procedures, is an essential and critical action in infection prevention.
The needleless connector on the end of the CVAD is routinely changed. INS standards recommend that it be changed with each administration set change, at least every 7 days for catheter maintenance, if residual blood is present, and whenever the integrity is compromised. CDC guidelines (O'Grady et al., 2002) recommend changing it no more frequently than every 72 hours and at least as frequently as the administration set.
Cleansing the needleless connector with an antiseptic before accessing the CVAD for flushing or medication administration is an important intervention. The Institute for Safe Medication Practices (ISMP ) highlighted infection control problems including failure to disinfect the needleless connector when accessing the infusion for flushing or medication administration, increasing the risk for contamination and potential catheter-associated bloodstream infection. INS and ISMP clearly recommend that the injection or access port be aseptically cleansed with an approved antiseptic before use. Although there are no specific evidence-based guidelines documenting the optimal disinfectant or duration of connector disinfection, the "scrub the hub" mantra is frequently cited. In an in-vitro study, a 15-second scrub using either a 70% alcohol or 3.15% chlorhexidine/70% alcohol solution was effective in eradicating microbes from four different types of injection access caps that were inoculated with bacteria (Kaler & Chinn, 2007).
The 2002 CDC guidelines recommend administration set (i.e., tubing) changes to be no more often than every 72 hours. The INS standards makes an additional, separate, and distinct recommendation for administration set changes to be done every 24 hours for the intermittent infusions. It is important to recognize that when an intermittent infusion is repeatedly disconnected and reconnected for the infusion, there is much more manipulation of the tubing and of the needleless connector (Gorski, 2008). This increases the risk of contamination and potential catheter-related bloodstream infection. The ISMP also documented the problem of failure to place a sterile cap on the end of the reused I.V. tubing for intermittent infusions as well as poor compliance rates with hand hygiene, failure to maintain aseptic technique during preparation and administration of infusions, and reports of unlicensed staff disconnecting IV tubing when an intermittent infusion is completed. Although this was discussed in relation to acute care settings, the same risks also exist in the home setting. A sterile cover must be placed on the exposed end of the I.V. tubing between uses.
The INS standards (2006) state that the catheter should be removed immediately upon discontinuation of infusion therapy, if contamination is suspected, or if a complication is unresolved. Daily review of central line necessity with prompt removal of unnecessary lines is one of the components of the central line bundle with this recommendation also cited by others including the National Quality Forum (2008) and the Infectious Diseases Society of America/Society for Healthcare Epidemiology in America (Marschall et al., 2008). Although some home care patients require venous access with devices intended for long term, such as tunneled catheters or implanted ports, many others have peripherally inserted central catheters (PICCs) in place for shorter courses of therapy. When the PICC is no longer being used for active treatment, the nurse should collaborate with the physician regarding removal. The reality is that in most cases, the physician or healthcare provider who placed the catheter is not the physician managing the infusion therapy. The home care nurse plays an important role in communicating to all involved healthcare providers to ensure that the catheter is removed when no longer needed. Additional nursing activities aimed at reducing transmission at the catheter hub/needleless connector can be found in Table 1.
Effective patient education is an important component of effective home infusion therapy and in risk reduction of infusion-related complications including infection. Although the home care nurse provides expert assessment and impeccable care to the CVAD while in the home setting, the patient is responsible for living day to day with the CVAD and is likely to be participating in self-infusion of prescribed medications. Therefore, patient education becomes a most critical intervention. The patient's readiness to learn and any potential factors affecting readiness must be assessed. The patient's physical condition, such as weakness, fatigue, or anxiety over being at home with an IV catheter and medications, will impact ability to learn. Functional limitations may also be a concern, such as the patient's manual dexterity or poor memory. Enlisting family or other caregivers is necessary if the patient exhibits limitations or is just not ready to learn. It is important to periodically reevaluate the patient's infusion technique, even after they have been independent. Some patients become more confident and sometimes skip steps, especially if they have not experienced any problems. It is important to give patients clear instructions about what to report in simple terms, for example: "Call your home care nurse right away if you have pain, redness or swelling where the PICC enters your skin or if you have a temperature above 100 °F, chills, or weakness." Suggestions for optimizing the patient education process are listed in Table 1.
Infections related to CVADs in the home care patient are preventable. As home care nurses, we must be knowledgeable about infection transmission and we must hold the highest standards in following infection prevention interventions including hand hygiene, aseptic technique, and infusion administration. We must recognize that we are role models to our patients and families as we demonstrate infusion-related care. We must also educate our patients well and alert them to the risks and signs of infection without causing undue fear or anxiety. As stated earlier, any occurrence of infection must be investigated to determine why it happened so that measures can be taken to prevent it from happening again.
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