Central line-associated bloodstream infection (CLABSI) is an insidious and ubiquitous issue in healthcare settings. Despite greater awareness of the issue, CLABSI events continue to be one of the most prominent but preventable events related to hospital-acquired infection, with potentially severe complications and implications. According to the Centers for Disease Control and Prevention, CLABSI results in thousands of deaths per year and adds billions of dollars in cost to the US Healthcare System.
At the institutional level, such events may lead to reduced reimbursement. Perhaps most important to our patients, bloodstream infections are associated with more extended hospital stays and increased morbidity. While the concern for CLABSI is universal across hospital units, it may be especially important in the NICU, where patients with compromised immune systems are often treated with invasive life support systems. This combination makes these patients particularly susceptible to overwhelming infection.
A Multipronged Approach to Reducing CLABSI Risk Factors
Several risk factors for CLABSI have been identified. Risks include whether the site is dressed; the quality and type of dressing utilized; and whether or not the dressing is clean, dry, and occlusive. Another common risk factor is accessing the site that has not been properly disinfected. Much research has been dedicated to discovering and describing best practices for the manual disinfection of access sites. Two fundamental principles of manual disinfection are encapsulated by mantras frequently used by health care practitioners: “Scrub the hub” and “If it’s not dry, the bugs didn’t die.” The former underscores the importance of the physical process of disinfecting the port. The latter refers to the fact that it is necessary to wait for the port to dry after “scrubbing the hub” and before accessing the line.
However, manual disinfection alone is less than ideal for preventing CLABSI, in part because full compliance with “scrub the hub” protocols is suboptimal. Studies suggest that as much as 43% of needle-free valves are scrubbed inadequately, and 23% of needle-free valves are never scrubbed. To counteract this, we have adopted a multipronged approach to reducing the potential for CLABSI events at our institution that starts with a daily discussion regarding the necessity of the central venous access device for each patient. When they are needed, we aim to limit the number of times that lines are accessed, including keeping the fluid lines connected whenever possible. The use of gloves during any manipulation of the line is essential. When there is a need to disconnect the line, manual disinfection with an alcohol-based cleansing product, including vigorous scrubbing and waiting for it to dry, are essential steps.
The Additive Value of Alcohol-Impregnated Caps
To help further reduce contamination due to human factors, we also adopted the use of alcohol-impregnated caps, both at the site of the needle-free valve (or injection cap) and on the male Luer connection whenever the fluid line is disconnected, or a new fluid line is primed. While there is strong evidence that antiseptic barrier caps reduce the risk for CLABSI, this practice is considered somewhat controversial in pediatric settings, as the caps introduce a potential choking hazard. Specifically, some of the options on the market are manufactured with bright colors, which aids in visualization, but which also makes them look like candy to younger patients. Other options, such as the DualCap Disinfection & Protection System (Merit Medical), are constructed with a blue cap, which may be less attractive to younger patients, and therefore may be less likely to be ingested.
We have also found that because of the longer threading, the DualCap system feels more secure than other similar products, thus providing a layer of barrier protection against contamination. We also appreciate the fact that they are available with caps for the valve and male Luer. Both caps are designed with medical-grade sponges saturated with 70% isopropyl alcohol, thereby providing disinfection and protection for IV connectors between uses. It is important to note that we continue to “scrub the hub” after removing the alcohol-impregnated cap. We had a strong practice that we did not want to change with the introduction of the Dual Caps.
Conclusion
Our adoption of alcohol-impregnated caps is certainly not universal; indeed, if we think there is any risk of choking or misuse with a specific patient, we avoid them altogether. Nor are alcohol-impregnated caps intended to be a panacea against CLABSI events. As our multipronged “maintenance bundle” protocol suggests, reducing central line-associated bloodstream infections requires several steps and continued vigilance from each member of the staff and medical team. Adding alcohol-impregnated caps to our approach to reducing CLABSI adds one more weapon in the fight against potentially deadly infections, one that is complementary to and synergistic with other approaches we already use.
Selected Sources
- Centers for Disease Control and Prevention. Central Line-associated Bloodstream Infections: Resources for Patients and Healthcare Providers. Available at:
https://www.cdc.gov/hai/bsi/clabsi-resources.html. Accessed April 23, 2019. - Kaufman D, Fairchild KD. Clinical microbiology of bacterial and fungal sepsis in very-low-birth-weight infants. Clin Microbiol Rev. 2004 Jul;17(3):638-80
- Helder OK, Kornelisse RF, Reiss IK, Ista E. Disinfection practices in intravenous drug administration. Am J Infect Control. 2016;44(6);721-723.
- Drews FA. An Evaluation of Methods to Reduce IV Catheter-Related Bloodstream Infections (Program No. 9-369, APIC 2013 Annual Meeting Scientific Abstracts).
- Voor In ‘t Holt AF, Helder OK, Vos MC, Schafthuizen L, Sülz S, van den Hoogen A, Ista E. Antiseptic barrier cap effective in reducing central line-associated bloodstream infections: A systematic review and meta-analysis. Int J Nurs Stud. 2017;69:34-40.
- Tawfik KO, Myer CM 4th, Shikary T, Goldschneider KR. The catheter hub disinfection cap as esophageal foreign body. Laryngoscope. 2015 Dec;125(12):2820-2822.
About the Author: Linda S. Strain BSN, RN is Imaging Manager of the Quality, Education, Research and Central Access Team at Children’s Wisconsin. She has been in the Imaging Department for 15 years, and has more than 33 years of healthcare experience. Her recently expanded role encompasses the department’s education, quality, safety and research initiatives.