Care bundle to reduce central venous catheter-related bloodstream infection: an integrative review

Abstracts

Trata-se de uma revisão integrativa da literatura, que objetivou identificar intervenções baseadas em evidência que compõem o método bundle, designados à redução de infecção de corrente sanguínea relacionada ou associada a cateter intravenoso central. Para a coleta de dados online, em bases nacionais e internacionais, foram utilizados a palavra-chave bundle e os descritores catheter-related infection, infection control e central venous catheterization, resultando, após aplicação dos critérios de inclusão, amostra de quinze artigos. Este trabalho evidenciou cinco intervenções como as mais frequentemente empregadas na construção dos bundles: higienização das mãos, gluconato de clorexidina como antisséptico para pele, uso de barreira máxima de precaução durante a inserção cateter, evitar acessar veia femoral e verificar necessidade diária de permanência do cateter, com sua remoção imediata quando não mais indicado. A maioria dos estudos demonstrou resultados estatisticamente significantes na redução de infecção de corrente sanguínea relacionada ou associada a cateter intravenoso central.

Infecções relacionadas a cateter; Controle de infecções; Cateterismo venoso central; Segurança do paciente; Enfermagem pediátrica

REVIEW ARTICLE

Care bundle to reduce central venous catheter-related bloodstream infection: an integrative review

Método bundle en la redución de infecciones relacionadas a catéteres centrales: una revisión integrativa

Juliana Dane Pereira Brachine^I; Maria Angélica Sorgini Peterlini^II; Mavilde da Luz Gonçalves Pedreira^III

^IA Master's student in Sciences at the Federal University of São Paulo (UNIFESP). São Paulo, São Paulo, Brazil

^IIShe holds a Doctorate, she is an Adjunct Professor at the Escola Paulista de Enfermagem (School of Nursing of São Paulo) – Federal University of São Paulo (UNIFESP). São Paulo, São Paulo, Brazil

^IIIShe holds a Doctorate, she is a CNPq (National Council for Scientific and Technological Development) Researcher, an Associate Professor at the Escola Paulista de Enfermagem (School of Nursing of São Paulo) – Federal University of São Paulo (UNIFESP). São Paulo, São Paulo, Brazil

^{Author's address}

ABSTRACT

This is an integrative review of literature aimed to identify evidence-based interventions which make up care bundles to reduce central venous catheter-related or associated bloodstream infections. To collect data in Brazilian and international databases were used the key word bundle and the descriptors catheter-related infection, infection control and central venous catheterization, resulting in fifteen articles, after inclusion criteria application. This work showed five interventions as those commonly employed in the bundles methods: hand hygiene, chlorhexidine gluconate for skin antisepsis, use of maximal sterile barrier precaution during the catheter insertion, avoid the femoral access and daily review of catheter necessity with prompt removal as no longer essential. The majority of the studies showed a significant reduction in bloodstream infection related to or associated with central venous catheters.

Descriptors: Catheter-related infection. Infection control. Central venous catheterization. Patient safety. Pediatric nursing.

RESUMEN

Esta es una revisión integradora tuvo como objetivo identificar intervenciones basadas en evidencias que componen método bundle de reducción de infección sanguínea relacionadas o asociadas con catéter intravenoso central. Para recopilar los datos en las bases brasileñas e internacionales, utilizando la palabra clave bundle y los descriptores infecciones relacionadas con catéteres, control de infecciones y cateterización venosa central, identificando, con los criterios de inclusión, muestra de quince artículo. Este estudio muestra cinco intervenciones como comúnmente empleadas en los métodos bundles: higiene de las manos, clorhexidina como antiséptico para la piel, uso de precaución de barrera máxima durante la inserción del catéter, evitar el acceso de la vena femoral y comprobar la necesidad diaria del catéter con su retirada inmediata cuando posible. La mayoría de los estudios analizados mostraron una reducción significante de infección sanguínea relacionadas o asociadas con catéteres intravenosos centrales.

Descriptores: Infecciones relacionadas con catéteres. Control de infecciones. Cateterismo venoso central. Seguridad del paciente. Enfermería pediátrica.

INTRODUTION

Central venous catheters are essential devices for health care nowadays ^(1-2). According to the Centre for Disease Control and Prevention (CDC), half of the patients in Intensive Care Units (ICU) in the United States of America (USA) use some kind of Central Venous Catheter (CVC) resulting in an amount of 15 million catheters / day every year ^(3-4).

This kind of device is used in a variety of therapeutic applications such as hemodynamic monitoring, application of fluids, medicines, blood derivatives and parenteral nutrition ^(1,5-6).

Despite the advantages of its use, there are risks associated with it, among them the colonization and the bloodstream infection ^(3,5,7-9). Catheter-Related Bloodstream Infection (CRBSI) stands out as the main complication resulting from the use of this kind of device according to lab tests confirmation. If the association between catheter and bloodstream infection is not confirmed by lab tests, but CVC is the most probable cause of the infection, it is characterized as Central Line-Associated Bloodstream Infection (CLABSI) ⁽¹⁰⁾.

The majority of CRBSIs is caused by microorganisms of cutaneous microbiota through the contamination of the catheter insertion site, through the infusion of contaminated IV solutions, through the device's connections, through hematogenous dissemination and through the staff's hands. Authors relate the risk of acquiring CRBSI with the kind of infused solution, the catheter's on-call time, the professional experience in the patient care, among others ^(11-14).

CRBSI repercussion is so relevant that American Institute for Healthcare Improvement (IHI) listed it as one of the six main initiatives in campaigns directed to save a hundred thousand lives and, later, five million lives, attempting to improve patient care, preventing death by adopting simple and effective measures of easy implementation ⁽¹³⁾.

Defining bundle

Nowadays there are plenty of strategies developed in order to reduce the risk of CRBSI. Such strategies are described in CDC as guidelines (Guidelines for the Prevention of Intravascular Catheter-Related Infections) ^(4,6) and they have been applied in clinical practice as a pack or set of interventions formed by a small group of specific care called bundle. These care are essential to the patient safety and when they are applied together they generate significantly better results ^{(15-16 )}.

Bundle can include constant surveillance, health staff education, training of catheter- inserting / handling staff and prevention strategies against bloodstream infection ^(9,14,16-24).

It is important to emphasize that, in order to guarantee better results, it is necessary to have a high adhesion to bundle and the proposed guidelines must be jointly and uniformly applied to all patients, becoming a powerful tool for the safety culture ⁽²⁵⁾.

It's important to observe that the translation of the term bundle as a pack does not seem to be culturally appropriate to the Portuguese Language because it does not mirror the concept entwined with the conduct. In our practice, we initially tried to use the term set of good practices; however, it does not mirror the need of implementation of the set in its entirety. This way, this term has been used in national health system and a synonym must be culturally defined for the methodology application

Thus, the guiding question of this investigation is: What guidelines have been used as bundle elements in order to reduce catheter-related bloodstream infection?

In the face of the aforementioned considerations and of the large number of CVCs used in clinical practice nowadays, the current study aims to verify scientific researches referring to the use of bundle guidelines in order to reduce CRBSI and to analyze the results of such researches.

MATERIAL AND METHOD

In order to investigate the contribution of the conducted researches on the use of bundle as a strategy to reduce CRBSI, we opted for an integrative review of the literature which is the research method that allows us to bring scientific evidences to clinical practice, in addition to enable the inclusion of studies with different designs ^(26-27).

The stages that guided this integrative review were: subject identification and hypothesis selection or issues for review; establishment of criteria for the inclusion and exclusion of the articles composing the research sample; definition of the characteristics of the primary researches composing the review sample; evaluation on the included articles; interpretation of the results and review presentation, providing a critical review on the findings ⁽²⁶⁾.

The criteria for inclusion were: texts in English, Spanish or Portuguese, with abstract, title and/or content in which the term bundle was present and texts that indicated the use of this strategy to prevent or to reduce CRBSI.

The object of study identification was carried out by searching the data base on Virtual Health Library (Biblioteca Virtual em Saúde – BIREME) and National Library of Medicine (Pubmed) through combinations of the key-word bundle and the descriptors catheter-related infection, infection control, central venous catheterization.

In the search through BIREME, we used data base from Latin-American Literature on Health Sciences (Lilacs), Medical Literature Analysis and Retrieval System on Line (Medline) and Scientific Electronic Library Online (Scielo).

As the final result search through national and international data base detected a limited number of articles on CRBSI, we also took into consideration articles that approached CLABSI, considering that the elements composing bundle are common to the studies of CRBSI.

In Medline data base, the combinations between bundle, catheter-related infection, infection control and central venous catheterization resulted in nine publications, one of them being excluded for not contemplating the inclusion criteria. In Pubmed data base, sixteen publications were found, eight of them were also found in Medline and three of them were excluded for not falling within this study's purpose.

In the search in Lilacs and Scielo data base, terms such as bundle, central venous catheterization and infection control were used, resulting in three identical articles in each data base. Only two of them fit inclusion criteria. After analyzing these different data bases we ended up with fifteen articles.

RESULTS AND DISCUSSION

Figure 1

Table 1 presents an overview of the studies identified and included in the current integrative review, according to the guidelines adopted in bundle method and the main results.

Data are presented upon the analysis of the fifteen articles, fourteen in English and one in Spanish, which refer to the use of bundle to prevent CRBSI and CLABSI, particularly focused on the study of CVC.

Eight of all selected articles referred to the use of bundle to prevent CLABSI and seven of them focused on CRBSI.

We observed that nine studies (60%) had adult population as their target audience ^{(9,17-18,22-23,25)}, two of them (13,3%) were carried out with children^{(5, 24)}, three of them (20%) with newborns ^{(15-16, 20)}, and one of them (6,7%) with both populations, in pediatric and neonatology units⁽¹⁴⁾. Eight of them (53,3%) were developed in the USA ^{(6,9,15-16,18,22-23,25)} and only three (20%) were developed in Latin America, two of them in Brazil ^(20-21) and one in Colombia ⁽¹⁴⁾.

The initial objective of many studies was staff education, so they all could know the project purpose, besides training for the proper application of protocols and procedures checking-list.

One of the analyzed articles describes the updating on different types of catheters available, infection risks related to their use and it establishes prevention measures regarding infection⁽⁶⁾.

The use of Peripherally Inserted Central Catheter (PICC) was mentioned in four studies ^{(14-15,21-22)} and only one of them describes infection rates per catheter type⁽¹⁴⁾.

Articles analysis regarding the type of bundle methodology described showed that they were composed of at least three and at most six interventions and the majority of the prospective studies presented statistically significant results regarding CRBSI and CLABSI reduction, being CLABSI the object of study in most of the articles ^{(9,15-16,19-22,25)}.

Table 1 presents the summary of the interventions described as bundle elements and the number of times that each strategy was listed in the fifteen analyzed articles.

Hands hygiene, a practice universally known as one the main prevention measures against nosocominal infection was mentioned in most of the studies ^{(5-6,9,14-17,19-20,22-25).} Staff education on the need of proper hand sanitation at the moment of inserting, handling or checking CVC was one of the strategies mentioned in order to increase professional adhesion.

In order to obtain a more detailed assessment on the studies, discussion on results was divided in two thematic categories: bundle and CVC insertion care; bundle and CVC maintenance care.

Bundle and CVC insertion care

In addition to hand hygiene, the most mentioned interventions were: the use of chlorhexidine gluconate as skin antiseptic, the use of maximal barrier precautions (cap, mask, sterile apron, sterile field on patient and sterile gloves) and avoidance of accessing femoral vein when possible.

Treating the skin using ≥ 0.5% alcoholic solution of chlorhexidine gluconate as antiseptic before CVC insertion is an IA-level-of-evidence recommendation ⁽²⁸⁾, i.e., a strongly recommended measure for implanting and based on well designed randomized clinical studies, however, 70% alcohol and tincture of iodine may be used as antiseptic alternatives in the case of contraindication for the use of chlorhexidine gluconate⁽²⁸⁾.

Only one study described the use of tincture of iodine as antiseptic for children's skin, however, it did not show statistically significant results ⁽²⁴⁾.

The use o maximal barrier precautions for CVC insertion is an IB recommendation ⁽²⁸⁾ and it was described in thirteen articles ^{(5-6,14-19,21-25)}.

Catheter insertion site is one of the main factors that lead to CRBSI because it is directly related to the site's microbiota skin density and to the risk of thrombophlebitis ⁽⁴⁾.

Recommendation, IA category ⁽²⁸⁾, is to avoid femoral vein for central venous catheterization in adult patients, being subclavian vein the most appropriate place. In children, femoral vein catheterization is related to low rate of mechanical complications ⁽²⁸⁾.

Eleven studies described the contraindication for the use of femoral vein ^(6,14,17-25), seven of them were developed with adult population ^{(17-19,21-23,25)}.

Although femoral vein catheterization in children is related to low rate of mechanical complications, as previously mentioned, three publications referred to this intervention as elements of bundle ^(14,20,24).

Multidisciplinary clinical visit for the discussion of venous device use (category IB) was described in only one study ⁽²³⁾.

Bundle and CVC maintenance care

In this group of interventions the use of the following recommendations was more often described: daily review of the catheter necessity with its removal as soon as possible; scrub of central catheter ports and hubs and bandage care.

Daily review of the catheter necessity of CVC permanence with its removal as soon as possible is a disseminated theme as an efficient intervention on infection rate reduction. It was observed in eleven studies ^{(5,14-21,24-25)}.

Scrub of central catheter's ports and hubs on each handling besides the cleanliness of the device's insertion site during dressing changes were described in four studies ^(6,9,16,22)..

Semi-permeable, sterile, transparent dressing has been used as it allows the visualization of catheter insertion site and it enables a lower number of bandage changes. The use of this kind of protective covering and its changing routine were described in five studies ^{(5-6,15-16,22)}.

Some articles described the use of chlorhexidine gluconate-impregnated dressing for catheter's insertion sites ⁽²²⁾, the use of antibiotic/antiseptic-impregnated catheters ^(6,17,22), the use of ultrasound equipment to guide CVC's insertion ⁽¹⁸⁾ or connectors and sets' changing routine depending on the infusion solution ⁽⁶⁾.

Strategies for increasing staff's trust, guaranteeing implementation and evaluate bundle adhesion were also described: creating a staff responsible for catheters insertion ⁽²³⁾; auditing during CVC insertion and bandage in order to verify and guarantee that all interventions proposed in this activity will be carried out by the use of tools such as procedure checking-list ^{(16,18,21-24)}; staff empowerment allowing procedure interruption in case of noncompliance with bundle; elaboration of a set of materials ^{(16,18,21,23)} composed by all devices required to CVC insertion and dressing; feedback on the staff's results ^(18,20-21) with monthly information on bundle adhesion and unit infection rates.

CONCLUSION

Bundle use is a current theme directly related to patient's safety besides being emphasized by specialists and by international organizations as an efficient method to prevent and to reduce bloodstream infection.

Based on the analyzed studies it is possible to see the lack of articles that describe the use of such tool in CRBSI prevention in children and, specially, in newborns.

However, it was possible to identify important aspects on clinical practice. Evidence-based interventions used in bundles can be applied in any kind of population or central device and, because they are jointly implemented, they generate significant results on bloodstream infection reduction rates.

Described guidelines include: hand hygiene before catheter handling; chlorhexidine gluconate used as skin antiseptic; maximal barrier precaution for central catheter insertion; sterile transparent semipermeable dressing for covering the device, with its replacement every time it gets dirty, wet or unattached; the use of antibiotic/antiseptic-impregnated catheters; daily review of the catheter necessity with its immediate removal when it's no longer essential; staff education; procedure checking-list for procedure auditing, among others.

We recognized the fact that the main and more frequent composing elements of bundles presented were: hand hygiene, alcoholic solution of chlorhexidine as skin antiseptic, the use of maximal barrier precautions, avoidance of femoral vein and daily review of the catheter necessity with its immediate removal when no longer essential.

Findings presented by the studies highlight the need of further research on this issue, with the intention of focusing clinical practice on how to apply and verify bundle use results in preventing PICC-related bloodstream infection, as it is a relevant line of research for nursing for the fact that these professionals are responsible for this kind of device's installation and maintenance.

REFERENCES

Received: 23.07.2012

Approved: 05.10.2012

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Publication Dates

• Publication in this collection
  27 Mar 2013
• Date of issue
  Dec 2012

History

• Received
  23 July 2012
• Accepted
  05 Oct 2012