Minimize Risk of CLABSI

The public health burden associated with hospital-acquired infections is substantial and includes increased morbidity and mortality, increased length of hospital stay, and increased costs. It is well known that CRBSIs are associated with increased morbidity and mortality.

Raad et al published an attributable mortality rate of 12% to 25% in the critical care patient population that experiences catheter-related bacteremia,2 and the CDC has estimated approximately 71,900 CLABSIs occur in the US each year.1 The excess costs associated with each incidence of CLABSI ranges up to $46,685.3 Additional estimates place the total economic burden of CLABSIs in the US at approximately $2 billion.10

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Common CLABSI-Related Questions

How often do CLABSIs occur?

  • The CDC has estimated that approximately 71,900 CLABSIs occur in the US each year1
  • 12 – 25% of CRBSIs will result in infection-attributable death2

What is the cost of CLABSI?

  • Incremental cost per episode of CRBSI ranges up to $46,6853

How do Catheter-Related Bloodstream Infections Develop?

  • The development of CRBSI takes place by contamination of the catheter in 1 of 4 separate ways either intraluminally or extraluminally, with the majority being extraluminal. 4
    • “Migration of skin organisms at the insertion site into the cutaneous catheter tract and along the surface of the catheter with colonization of the tip
    • Direct contamination of the catheter or hub by hand contact or contaminated fluids/devices
    • Hematogenous seeding from another focus of infection
    • Infusate contamination (rare)”

What are the risk factors for CLABSI?

  • Dressing Disruptions Happen Frequently and Contribute to Increased CRBSI
    • Evidence indicates that 67% of CVC dressing changes were performed prematurely, before the planned date.5
    • Risk of CRBSI increased by more than 3-fold after the second dressing disruption and more than 12-fold after the final dressing disruption.5
    • A study found that 4 commercially available central venous catheter dressings had surprisingly limited durability. A total of 75% of the dressings lasted less than 48 hours, and only 3% of dressings lasted a full 7 days.6

What evidence-based recommendations exist to provide guidance on the care and maintenance of vascular catheters to prevent infections?

  • Clinical best practices guidelines from the CDC recommend:7
    • Replacement of catheter site dressing if the dressing becomes damp, loosened, or visibly soiled
    • Replacement of dressings used on short-term CVC sites at least every 7 days
    • Use a sutureless securement device to reduce the risk of infection for intravascular catheters
  • The Infusion Therapy Standards of Practice list the following dressing change recommendations:8
  • Vascular Access Device Post-Insertion Care
    • Change transparent semipermeable membrane (TSM) dressings at least every 7 days (except neonatal patients) or immediately if dressing integrity is dis­rupted (eg, lifted/detached on any border edge or within transparent portion of dressing; visibly soiled; presence of moisture, drainage, or blood) or evidence of compromised skin integrity under the dressing, and following manufacturer’s instruction for use. (Level III)
    • Change sterile gauze dressings every 2 days or earli­er if dressing integrity is disrupted (eg, if damp, loose, or visibly soiled). (Level III)
    • Consider the beneficial use of gum mastic liquid adhesive on adult patients when enhanced adhesive dressing adherence is needed (eg, diaphoresis). (Level III)
    • Select the type of sterile dressing considering factors such as the type of VAD, risk of bleeding or infection, skin condition, known allergies or sensitivities, patient size, patient preference, cost, sterility, wear time, and ease of use of dressing, with the goal of selecting and applying a dressing that will have minimal dressing disruptions, as multiple dress­ing changes increase the risk of infection. (Level I)
    • Use a securement method to stabilize and secure VADs, considering a bundled approach. (Level I)
    • Use a dressing change kit to standardize the procedure and improve efficiency. (Level V)
  •  Vascular Access Device Securement
    • Use a securement method, such as adhesive securement device (ASD), integrated securement device (ISD), subcutaneous anchor securement system (SASS), or tissue adhesive (TA), in addition to the primary dressing, to stabilize and secure VADs. Inadequate securement can cause dislodgement and complications requiring premature removal. (Level I)
    • Avoid the use of sutures, as they are not an effective alternative to a securement method; sutures are associated with needlestick injury, support the growth of biofilm, and increase the risk of catheter-associated bloodstream infection (CABSI). (Level III)
    • Evaluate the potential for clinical and fiscal efficacy of SASS for PICCs and CVADs, including both tunneled, cuffed and tunneled, noncuffed catheters in adult and pediatric patients. (Level III)
    • Assess the integrity of VAD securement with each dressing change and change the securement device according to the manufacturers’ directions for use. Remove ASDs with each dressing change to allow for appropriate skin antisepsis and apply a new ASD. TA should be reapplied at each dressing change. A securement device designed to remain in place for the life of the VAD (eg, SASS) does not need to be removed and replaced regularly with each dressing change; however, it should be assessed during catheter care and management to ensure its integrity. (Level I)
  • Catheter Associated Skin Injury
    • Change the VAD dressing promptly if soiled, not intact, or upon initial signs/symptoms of skin impairment. (Level III) Follow manufacturers’ instructions for use.
    • Consider use of gum mastic liquid adhesive that is compatible with antiseptic and dressing products when enhanced dressing adherence is needed. (Level IV)
    • Use medical adhesive remover per manufacturer instructions and adhering to Aseptic Non Touch Technique (ANTT®). Use additional precautions with dressing and securement removal for patients at high risk for skin injury. (Level III)
    • Employ quality improvement measures to monitor and address incidence of CASI. Monitor current evidence to explore options. (Level IV)

What can be done to minimize risk of vascular access device (VAD) dressing disruption?

  • Gum mastic liquid medical adhesive can help caregivers adhere to best-practice recommendations by preventing the loosening of dressings for up to 7 days, which may prevent catheter insertion-site exposure and catheter dislodgement.
  • A dressing bundle with gum mastic and adhesive remover was implemented at a Methodist facility to improve dressing integrity. Over 30,000 intravenous sites were assessed. The authors report dressing integrity was improved, with less than 96% of dressings fully intact at the time of visual assessment. There was no reported increase in medical adhesive related skin injury (MARSI).9

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Does choice of catheter securement impact CLABSI?

Use of Subcutaneous Anchor Securement Systems (SASS) significantly reduces risk of CLABSI.11

  • University of Arkansas for Medical Sciences (UAMS) analyzed 7,779 patients over four years of Central Line Associated Bloodstream Infection (CLABSI) data
  • Analysis compared outcomes of patients whose PICCs were secured with a the SASS to those secured with an adhesive device
  • Analysis showed those who had an adhesive device had a 288% increase in risk of CLABSI compared to those who had a SASS

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Does choice of catheter securement impact risk of catheter migration and dislodgement?

Subcutaneous anchor securement systems (SASS) are shown to be more effective at keeping central catheters in place, compared to suture-based (SBS) or adhesive device-based securement (ASD) methods.12

  • A systematic review of more than 8,000 studies was performed to examine safety and efficacy outcomes related to CVAD securement
  • The median incidence of migration and dislodgement for SASS was 1.76%, compared to 6.77% for SBS, and 9.69% for ASD

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How can I find out the rate of dressing adherence at my facility and to ensure compliance with evidence-based guidelines for dressing care and maintenance?

  • The loss of vascular access device dressing adherence exposing the insertion site is an often overlooked and unattended occurrence, which increases the risk of CRBSI.5
  • Request a Vascular Access Dressing Adherence Point Prevalence Assessment from Eloquest Healthcare here.

References

  1. Magill SS, Edwards JR, Bamberg W, et al. Emerging Infections Program Healthcare-Associated Infections and Antimicrobial Use Prevalence Survey Team. Multistate point-prevalence survey of health care-associated infections. N Engl J Med. 2014; 370(13): 1198-208.
  2. Raad I, Hanna H, Maki D. Intravascular catheter-related infections: advances in diagnosis, prevention, and management. Lancet Infect Dis. 2007 Oct; 7(10):645-57. PMID: 17897607.
  3. Nelson RE, Angelovic AW, Nelson SD, Gleed JR, Drews FA. An economic analysis of adherence engineering to improve use of best practices during central line maintenance procedures. Infect Control Hosp Epidemiol. 2015 May; 36(5): 550-6.
  4. Safdar N, Maki DG. The Pathogenesis of Catheter-Related Bloodstream Infection with Noncuffed Short-term Central Venous Catheters. Int Care Med. 2004; 30:62-7.
  5. Timsit J, et al. Dressing disruption is a major risk factor for catheter-related infections.  Crit Care Med.  2012; 40(6): 1707-1714.
  6. Richardson A, et al. Central venous catheter dressing durability: an evaluation. Journal of Infection Prevention.  2015; 16(6):  256–261.
  7. O’Grady NP, et al. Healthcare Infection Control Practices Advisory Committee: Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011.
  8. Nickel B, Gorski L, Kleidon T, Kyes A, DeVries M, Keogh S, Meyer B, Sarver MJ, Crickman R, Ong J, Clare S, Hagle ME. Infusion Therapy Standards of Practice, 9th Edition. J Infus Nurs. 2024 Jan-Feb 01;47(1S Suppl 1): S1-S285. doi: 10.1097/NAN.0000000000000532.
  9. DeVries, Michelle; Sarbenoff, Jill; Scott, Nancy; Wickert, Margaret; Hayes, Lisa Marie. Improving Vascular Access Dressing Integrity in the Acute Care Setting: A Quality Improvement Project. Journal of Wound, Ostomy and Continence Nursing 48(5):p 383-388, September/October 2021. | DOI: 10.1097/WON.0000000000000787
  10. Herzer KR, Niessen L, Constenla DO, Ward WJ Jr, Pronovost PJ. Cost-effectiveness of a quality improvement programme to reduce central line associated bloodstream infections in intensive care units in the USA. BMJ Open. 2014 Sep; 4(9): e006065. doi: 10.1136/bmjopen-2014-006065.
  11. Rowe, et al, “Catheter Securement Impact on PICC-related CLABSI: A University Hospital Perspective” American Journal of Infection Control, Open Access, June 17, 2020. Available at: https://securacath.com/wp-content/uploads/2020/12/Rowe-AJIC-Dec-2020.pdf.
  12. Jon A. Bell, Michelle Hawes, Emily Diloreto, S. Matthew Gibson; Systematic Review of the Safety and Efficacy of Central Vascular Access Device Securement. Journal of the Association for Vascular Access 1 September 2022; 27 (3): 15–35. doi: https://doi.org/10.2309/JAVA-D-22-00013 – https://meridian.allenpress.com/java/article/27/3/15/486486/Systematic-Review-of-the-Safety-and-Efficacy-of