Adherence to the central line bundle in intensive care 

BACKGROUND :

Central line-associated bloodstream infections (CLABSI) occurring in intensive care units are associated with increased morbidity and mortality.These infections increase the length of hospital stay for an affected patient, as well as the cost of care associated with treating CLABSI. The Centers for Disease Control and Prevention (CDC) published guidelines for intravascular device infections in 1983, with subsequent updates in 1996, 2002, and 2011. These guidelines are intended to provide evidence-based recommendations for the prevention of CLABSI . Based on these guidelines, the CDC provides a bundle checklist which includes proper insertion practices, appropriate maintenance and handling recommendations, and prompt removal of unnecessary central lines to prevent CLABSI. The guidelines and checklist bundle have been extensively promoted and implemented internationally The use of proven guidelines to prevent infection of the blood from central lines is required of all hospitals accredited by The Joint Commission as part of the National Patient Safety Goals.  Although most hospitals in the United States report adopting the central line bundle recommendations, the CDC estimates 30,000 CLABSI still occur in intensive care units and acute care units each year. Despite the promotion of central line bundle policies, wide variability exists in compliance and infection rates in intensive care units across the United States.  Although there is interest and awareness for CLABSI prevention, the need for improved practices and collaboration to decrease the occurrence of CLABSI still exist.

Adapted checklist for prevention of CLABSI :

Follow proper insertion practices :

1. Perform hand hygiene before insertion .

2. Adhere to aseptic technique. 

3. Use maximal sterile barrier precautions 

f) Mask g) Cap h) Gown i) Sterile gloves j) Sterile full body drape.

4. Choose the best insertion site to minimize infections and noninfectious complications c) Base on individual patient characteristics d) Avoid femoral site in obese adult patients .

5. Prepare the insertion site with >0.5% chlorhexidine with alcohol .

6. Place a sterile gauze dressing or a sterile, transparent, semipermeable dressing over the insertion site.

Handle and maintain central lines appropriately :

1. Comply with hand hygiene requirements .

 2. Bathe intensive care unit patients over 2 months of age with a chlorhexidine preparation daily.

3. Scrub the access port or hub with friction immediately prior to each use with an appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70% alcohol)  .

4. Use only sterile devised to access catheters .

 5. Immediately replace dressings that are wet, soiled, or dislodged  .

6. Perform routine dressing changes using aseptic technique with clean or sterile gloves d) Change gauze dressings at least every 2 days e) Change semipermeable dressings at least every  ./7 days f) For patients ≥ 18 years of age, use chlorhexidine impregnated dressing with a Food and Drug Administration cleared label that specifies a clinical indication for reducing CLABSI for short-term non-CLABSI with baseline prevention practices .

7. Change administration sets d) For continuous infusions: no more frequently than every 4 days, but at least every 7 days e) For blood or blood products or fat emulsions: every 24 hours f) For propofol: every 6 to 24 hours or when vial is changed  

Promptly remove un-necessary central lines 1. Perform daily audits to assess whether each central line is still needed .