Central line BSI prevention

Double-Helix, BSN, RN · Jul 25, 2012

We follow NACHRI's recommendations for central line care.

Weekly and PRN dressing changes done in STERILE conditions using CHG swabs- 30 second scrub and 30 second dry time for all sites except the femoral (2 minute scrub). No gauze under the dressing and no bio-patches.

At least two staff members performing the change to assist with holding the patient and getting more supplies if needed. Anyone assisting at the bedside wears a mask and gloves. Person changing the dressing wears sterile gloves.

ANY time the dressing is opened, gloves and masks are to be worn. We often have to jump on our surgical residents about this, who think it's perfectly acceptable to take down a dressing with bare hands, look at the site, and slap the dressing back on. Grrr. It's a clear dressing for a reason....

Whenever the line is accessed (giving medication through a port or cap, changing syringes, drawing blood in a closed system) we use clean gloves and CHG swabs (30 second scrub, 30 second dry) on the port prior to accessing.

When the line is opened (changing caps, changing tubing, etc.) it's sterile technique- gloves, mask, sterile field under the line, and CHG scrub on all junctions before opening them.

We also use an insertion checklist when the line is being put in. The RN is responsible for insuring that sterile technique is followed by the MD's, including: scrubbing in before the procedure starts, sterile gloves, gown and mask are worn by everyone at the bedside, patient is draped head to toe with sterile drapes, all supplies are opened under sterile conditions, CHG is used with appropriate scrub/dry times prior to an access attempt.

That's all I can think of for the moment- my unit is CLABSI free for over two years.

fallinnstyle · Jul 25, 2012

we have been using curos port protectors for the last 3 months (maybe a little less). They are impregnated with 70% isopropyl alcohol, and they say as long as you place a new cap after each port access, you do not need to swab with alcohol when accessing.

I honestly do not know if it is helping, but there is also a few people who do not use them all the time, or they reuse the old cap.

Curos® Port Protector – The Green Disinfection Cap That Is Making A Difference | Curos

Does anyone else use these?

Double-Helix, BSN, RN · Jul 25, 2012

We use the brand Swab Caps on our Clearlink caps when they are unused. If they are used on peripheral lines, we just remove the cap and access. But if they are used on a central line then we still swab with CHG after removing the cap before we access the line.

meanmaryjean, DNP, RN · Jul 25, 2012

We use EffectivCaps (similar to the green one above) but I have a concern about them. Ours are orange, and to me - they are too colorful and a choking hazard, given the nature of pediatrics. Ours have too little 'screw' if you know what I mean - they only turn on the luer connector a little bit - very easy to remove.

Double-Helix, BSN, RN · Jul 25, 2012

We use EffectivCaps (similar to the green one above) but I have a concern about them. Ours are orange, and to me - they are too colorful and a choking hazard, given the nature of pediatrics. Ours have too little 'screw' if you know what I mean - they only turn on the luer connector a little bit - very easy to remove.

We are concerned about this too. So we only use them on kids when it's developmentally appropriate. I.E. They are babies who can't remove the cap, sedated/paralyzed, or an older child who understands not to remove the cap. We don't use them with toddlers or developmentally delayed kids who might put it in their mouth.

seamel · Jul 25, 2012

Thank you so much Ashley. I have been looking for the NACHRI guidelines since you posted but have been unable to find a clear cut set of recommendations. I have found some research articles related to the matter by them but have only read the abstracts- is this where I can find those guidelines?

Thanks again. I am a part of my unit's Quality Practice Committee. At our last meeting I asked if CHG wipes before accessing would be more effective but was told the friction of the alcohol wipes kills everything. I would love to learn more about CHG before accessing central lines if it could potentially decrease CLABSI at my hospital.

Double-Helix, BSN, RN · Jul 25, 2012

Glad to help. Just keep in mind that, according to our policy, CHG is not approved for use on the skin of patients less than two months of age. In that case, we use iodine when changing our dressings. We still use CHG on the ports/tubing, though, just not the skin.

NicuGal, MSN, RN · Jul 25, 2012

We do a lot of the same, as does our PICU. You can use CHG on kids under 2 months as long as they have intact skin and you wipe it off after the appopriate dry time with a sterile saline wipe. We use it on our kids over a kilo with intact skin. There is contraversy over CHG and alcohol wipes, but it is correct that it is the friction that works best...that is why you have to adhere to scrub time and dry time of 30 seconds (which is really long when you actually do it lol). We also use biopatches in our hospital, again on kids over a kilo with intact skin. We have only had 2 line infections in the past year...and those were fem lines where we were having a heck of a time keeping the dressing dry and clean as they were gut kids that dumped all the time (yeah, we pushed for a broviac, but the attendings kept telling us it would be fine...ok, now they are septic )

We found on blind audits that the biggest thing was people accessing the lines incorrectly. We had a huge rollout for all of peds and lots of re-education not only on nursing's part, but doc, RT's and anyone else that would be accessing those lines. We had inservices, power points and mandatory demonstrations. We now do blind audits once a month on each shift to make sure people are following the protocol. If they aren't, they get a private inservice with one of our education people. Sounds rough, but in the age where we are soon not going to get reimbursed for line infections and causing death to these kids, it is worth it in the long run.

iluvivt, BSN, RN · Jul 27, 2012

I'm curious about your unit's central line care to prevent blood stream infections. I have seen some posters mention their unit has not has a BSI in over a year or two. My unit is good, but not THAT good, and I would like to know what we could do different to prevent poor outcomes in our kiddos!
Currently we do daily CHG baths on kids over 2 months old with central lines, weekly and PRN CL dressing changes, scrub with alcohol swabs for 15 seconds and let dry for 15 seconds before accessing, place sterile drapes under the line each time it is accessed, and diligent hand hygiene and tubing changes.
Thanks!

Please make sure you look at the SHEA-IDSA gudelines for CA-BSIs and look at the CDC guidelines for preventing CRBSIs.

GregDennis · Nov 18, 2014

I just learned of this thread. I do consulting for a company that makes disinfection caps. I understand the concerns about young patients and these caps. It's my understanding that many hospitals have found disinfection caps to be appropriate for pediatric patients. Here are two links to brief videos from pediatric experts, summarizing their research findings in pediatric settings:

St. Mary's hospital, NYC, their infection control specialist:

http://bit.ly/1wSwEAN

Education specialist at Gillette Childrens:

http://bit.ly/11o8eqb