Each year thousands of patients are
admitted to inpatient settings with various diseases requiring medical
management with use of central venous catheters (CVC). CVC are used for a
variety of reasons including administering medications frequently that may be
caustic to small vessels, administration of parenteral nutrition, needing to
administer large amounts of fluid or blood quickly, a lack of peripheral
access, hemodialysis, and hemodynamic monitoring.

            There
are three main types of CVC: tunneled catheters, non-tunneled catheters, and implanted
ports. A tunneled catheter is one that is passed under the skin having it’s own
separate exit point from the superior vena cava. Non-tunneled catheters have an
exit point close to the heart and are used in emergent or short-term situations,
whereas tunneled catheters are used for long-term and permanent use of central venous
access.  

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Information

            The skin is one of the body’s
defense mechanisms against infection-causing bacteria and once this barrier is
broken, the risk for infection increases. CVC devices provide a direct line of
access to the heart for medications as well as bacteria. According to Haddadin
and Regunath (2017), a central line associated bloodstream infection (CLABSI)
is defined as “a laboratory-confirmed bloodstream infection (not related to an
infection at another site) where a central line was in place within 48-hour
period before the development of bloodstream infection” (para. 1).

            CLABSIs are dangerous infections
with serious consequences and require fast, intense treatment. Dixon and Carver
(2010) attribute CLABSIs to increasing a patient’s morbidity and mortality,
length of hospital stay, and cost overall (pg. 817). When a CLABSI develops in
the hospital it is considered a hospital-acquired infection. The infection was
not present prior to the admission and is the result of bacteria within the
hospital causing the patient to have an infection. The Centers for Medicare and
Medicaid Services will not provide reimbursement for hospital-acquired
infections such as CLABSIs and the hospital is left to pay for the cost to
resolve the infection. Due to lack of reimbursement and wanting to provide
beneficent care for patients.

Knowledge

When a CLABSI develops the body begins to respond to
defend the body against the infection. Sepsis is the body’s overwhelming and
life-threatening response to infection, which can lead to tissue damage, organ
failure, and death. Sepsis progresses overtime and can eventually cause the
body to release endotoxins. Endotoxins damage endothelial linings of vessels
that cause hypotension, decreased systemic vascular resistance, depressed
myocardial function, lactic acidosis, thrombocytopenia, vascular leakage, and
tissue necrosis. Septic shock is the final stage of sepsis and can result in
death. Shah, Schwartz, & Cullen (2016) found that “CLABSIs are likely to
have extraordinary costs ranging anywhere between $960 million to $18.2 billion
annually.2 The expenses that occur from these preventable infections
are called contributable costs; these include inpatient-days, antibiotic costs,
and laboratory testing7…CLABSI rate is 5.3 per 1,000
catheter-days, as many as 28,000 patients die of CLABSIs annually in ICUs9″(pg.
43).

There are several precautions that are taken multiple
times a day by nurses amongst other health care workers. Some of these
precautions include hand washing, scrubbing catheter hubs with alcohol wipes
before using, checking for proper placement of peripheral intravenous devices
before use, and isolating patients with contagious diseases to private rooms.
When it comes to a patient with a CVC, implementation of the “Institute for
Healthcare Improvement Central Line (CL) Bundle,9 which consists of
5 interventions: (1) hand hygiene; (2) maximal barrier precautions during
insertion; (3) skin antisepsis with chlorhexidine gluconate (CHG); (4) optimal
catheter site selection with avoidance of the femoral vein for central venous
access in adult patients; and (5) daily review of line necessity, with prompt
removal of unnecessary lines” (Dixon & Carver, 2010, pg. 817).

Wisdom

One of the 5 interventions included in the CL Bundle that
nurses have a direct influence on is bathing patients with CHG. “CHG works by
binding to the cell wall of bacteria and has broad coverage against
gram-positive and gram-negative and anaerobic and aerobic bacteria, as well as
yeasts and viruses10” (Shah, Schwartz, & Cullen, 2016, pg. 43). Bathing
patients with CHG cloths every twenty-four hours can reduce infection rates. Several
agencies support the use of CHG cloths to prevent CLABSIs including the CDC and
AHRQ. Specifically “AHRQ CLABSI tools state that a minimum of 0.5% CHG is
necessary for skin disinfection, but greater CHG concentrations are
recommended.7 The Centers for Disease Control and Prevention also
supports the need of daily CHG bathing for patients with central lines or other
CVCs as a means to prevent CLABSI4” (Shah, Schwartz, & Cullen,
2016, pg. 43).

As
one of the most direct-care health care workers, nurses play a crucial role in
ensuring this intervention is implemented. The entire body should be bathed
with CHG. Typical packs come with either six cloths to a package of two packs
of three. Each wipe should be designated to a region of the body. These regions
should include: (1) neck, chest, and arms, (2) back, (3) right leg, (4) left
leg, (5) perineum, and (6) buttocks. This intervention should be done at a minimum
of every twenty-four with repeated CHG baths done in between a patient being
soiled. The CHG bath may also replace daily bathing required to be completed on