Reducing CLABSIs by prohibiting blood draws from line?

[fartjohnson]

In an attempt to reduce our CLABSI rate, my facility has prohibited us from drawing blood for routine blood work from central lines. We are only allowed to do so with an MD order, and the nursing supervisor on duty is supposed to be the one to do it.

Well, I looked around for research supporting this practice (ie: that reducing the number of blood draws from CVCs will reduce CLABSI rate) but I couldn't really find any literature on the matter. The only thing I found was this "project" published in the American Journal of Infection Control:

http://www.ajicjournal.org/article/S0196-6553(11)00471-8/pdf

If you're unable to access the paper, you're not missing much ... here are the last two paragraphs:

Results: CLABSIs rates decreased housewide and central line utilization ratio is trending downward. Caregiverawareness increased along with better outcomes of preserving vital central lines.Lessons Learned: There are rare cases where a patient will be a candidate for a blood draw through a central linedue to physical factors (e.g., no access, emergency, etc.). In addition we identified opportunities to cluster labdraws and reduce unnecessary and/or redundant labs. Since we are also concurrently working on other preventionissues such as education, additional interventions also affected our decreased CLABSI rates. Overall the team feltthat no blood draw from a central line without a physician's order was a huge accomplishment and is possible forthe majority of patients.

In other words, there were too many confounding factors to tell us what role--if any--this particular policy played in the reduction of their CLABSI rate. Terrific.

All of the other research I found about CLABSIs and blood draws dealt with the contamination of blood cultures drawn from CVCs. Certainly an important issue, but not what I was looking for.

Now I can see how drawing blood from a line may increase the risk of infection but I find it a bit curious that seemingly no research exists on the matter. Does anyone else know of any research on this subject? Is anybody else working at a facility that prohibits routine blood work from being drawn from CVCs? I'd love to hear about it.

[Castiela]

We are discouraged from using the central line and they prefer us to have lab poke the patient. We also need to change the cap whenever we draw blood. We circumvent this a bit by attaching a vamp line (normally used for cvps) and draw blood from the port attached to the vamp line; so we are limiting the number of times the circuit is open.

However, where I worked previously had no qualms about drawing from cvcs and preferred it to lab pokes so I'm not sure about the literature behind either practices.

[AJJKRN]

Not EBP but I truly believe that CLABSIs increase when staff are not well educated on their use and maintenance and/or take short cuts to save time. Apologies for the no-brainer;-).

[iluvivt, BSN, RN]

You will not find a specific study in regards to blood draws from CVADs.Decreasing hub manipulation is the overall goal for all CVADs to reduce the risk of BSI and you will find studies that demonstrate there is an increased risk with hub manipulations. Hopefully, you have exceptions where the benefit outweighs the risk and they will allow it.

[WestCoastSunRN, MSN, CNS]

I work in ICU. In fact, I work in a burn ICU (a very challenging place, vascularly and immunologically speaking). We have a very low rate of CLABSI. While I appreciate that CVCs need to be handled with utmost care, I cannot imagine a world in which we didn't use them for blood draws. CLABSI prevention is something my institution is very serious about and it is revisited regularly to ensure best practices. Proper scrubbing of hubs and flushing before and after blood draws, in addition to changing the microclaves every 96 hours (or before if needed), and ensuring clean and intact dressings (super challenging) that are changed per protocol are all practices that should be in place to reduce CLABSI.

[blondy2061h, MSN, RN]

My background is in BMT. We did labs sometimes q2h from lines. If I had a CVL, no way would I tolerate being stuck for labs. If you're scrubbing the hub, not constantly disconnecting and reconnecting tubing, using things like Curos caps, and keeping your blood draw equipment clean, the risk is low.

When you stick a patient for a veinapuncture there is a degree of risk of introducing bacteria there, as well.

[KelRN215, BSN, RN]

Pedi nurse here. No way would this fly. Sometimes, we've had patients who got central lines specifically because of the frequency of lab draws needed. When I worked in the hospital, we were trying to make a protocol that kids with pituitary tumors all got PICCs placed in the OR during their tumor resections because they almost inevitably developed triphasic diabetes insipidus and needed labs at least q 6hr but sometimes q 2-4 hr. Phlebotomy at this hospital would only do 1 lab draw/day- the rest were up to the nurse. And for a small child, repeated venipunctures are traumatic and they just don't have that many sites.

All my oncology patients get their routine labs from their central lines. We have kids with ports who get accessed twice/week at home for labs.

[Penelope_Pitstop, BSN, RN]

I've been out the ICU realm (and acute care in general) for a few years now, but I think a lot of times, we cut our noses off to spite our faces in these cases. CAUTI prevention is very similar - yes, we need to prevent these things, as prevention will save lives, but there are patients who need central lines and who need indwelling urinary catheters! Next, we will need two nurses present to connect any line to a CVC. I mean, after all, I've never seen a nurse utilize poor technique when drawing blood from a central line, but I have seen multiple nurses use sloppy technique when taking care of IV lines and giving IV push medications. My guess is more infections stem from this laziness than when drawing labs.

[ValeryRN]

Reducing CLABSI is a challenging process and requires proper staff education: hub scrubbing, flushing, dressing care, keeping the system closed with claves..We are constantly improving our protocol: we recently started covering the claves with an alcochol impregnated cap ( Swabcap?) That provides additional protection..

[KatieMI, BSN, MSN, RN]

Just like with many other nursing stories and lore, such as "never do anything at all on the side of mastectomy, however long time passed since surgery because it might be UNSAFE" and "never do BP on the extremity with PICC line because it might be UNSAFE", this one has no credible evidence behind it. CLABSI are proven to be reduced by proper management of the line (aka aseptic dressing changes, ports cleaning, avoiding femoral lines, timely discontinuation/change, etc). Blood draws by themselves, when done correctly, are not confirmed to increase risk.

The OP's administration simply doesn't know which rope to pull and where to run, which is its' normal modus operandi.

[ICU56]

Just like with many other nursing stories and lore, such as "never do anything at all on the side of mastectomy, however long time passed since surgery because it might be UNSAFE" and "never do BP on the extremity with PICC line because it might be UNSAFE", this one has no credible evidence behind it. CLABSI are proven to be reduced by proper management of the line (aka aseptic dressing changes, ports cleaning, avoiding demand lines, etc). Blood draws by themselves, when done correctly, are not confirmed to increase risk.

The OP's administration simply doesn't know which rope to pull and where to run, which is its' normal modus operandi.

Agreed, The way we reduced them in my previous hospital was to pull every line possible prior to the patient leaving the ICU. Laziness and poor line management produces CLABSI.

[NuGuyNurse2b]

CLABSI are proven to be reduced by proper management of the line (aka aseptic dressing changes, ports cleaning, avoiding femoral lines, timely discontinuation/change, etc).

Why do we avoid femoral lines? I had a pt with a TLC in the femoral recently so this raised my curiosity.