2/19/2018 Bloodstream infections from peripheral lines: An underrated risk - American Nurse Today

Bloodstream infections from peripheral lines: An underrated risk

January 2016 Vol. 11 No. 1
Author: Michelle DeVries, MPH, CIC, and Mary Jo Valentine, MSN, RN, CNS

Analytics—the study of data to reveal meaningful patterns—is remaking large swaths of our culture, from business to sports to politics. In health
care, applying analytics toward the goal of preventing bloodstream infections (BSIs) reveals a surprising truth: A hospital is likely to have nearly as
many BSIs associated with peripheral I.V. (PIV) lines as with central lines.
Yet, because we’re trained to focus on the perils of central lines (mainly central venous catheters and peripherally inserted central catheters),
we’re likely to overlook PIV perils, with potentially dangerous consequences for both patients and hospital nances. Recognizing this often-
underappreciated risk, Methodist Hospitals in Gary and Merrillville, Indiana, now mandate the same kinds of technology for PIVs that central
lines require. We take the BSI threat from PIVs seriously.

A signi cant threat, a pressing need

Several preliminary studies suggest that nearly as many BSIs are linked to PIVs as to central lines. How can that be? Certainly, the BSI risk
associated with central lines far exceeds that of PIVs. According to the Centers for Disease Control and Prevention (CDC), the pooled mean
inpatient ward rate for central line–associated BSIs was 1.14 infections per 1,000 central-line days as of 2009 (the latest year for which statistics
are available). For PIVs, the aggregate infection rate is less than half that—an estimated 0.5 per 1,000 peripheral-line days.
But far more PIVs are placed each year than central lines. In the United States, roughly 150 million PIVs are inserted annually, compared to only
about 3 million central lines. Even taking into account central lines’ much longer dwell times, you can easily see how the total number of BSIs
linked to PIVs could approach or even surpass that of central lines.
A PIV resembles a central line in one crucial respect—it’s an invasive device through which life-threatening bacteria can penetrate the
bloodstream. Then consider that 70% to 80% of hospital patients have PIVs at some time during their stay. No matter which kind of line is
involved, preventing BSIs is crucial because infected patients have a 12% to 25% chance of dying from the infection.
BSIs also can hurt a hospital’s nances, making it harder to provide the best care possible. (See the box below.)

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BSIs and the bottom line

While average treatment costs for BSIs vary, BSI prevention expert Peter Pronovost, MD, cites a gure of $45,000 per incident. And because BSIs
are considered preventable, Medicare and many other insurers don’t reimburse hospitals for those costs.
What’s more, the A ordable Care Act mandates incentives and penalties to improve healthcare quality, including nancial penalties for hospitals
with high BSI rates. Other federal penalties target only central line–associated bloodstream infections (CLABSIs), but a PIV may be involved in
those infections. Many patients have multiple lines, which may include a PIV. So an infection reported as a CLABSI per the CDC de nition may
have originated in a peripheral line.

BSIs at Methodist Hospitals

Any BSI, whether stemming from a central line or a PIV, endangers the patient’s life, is costly to treat, and can expose the hospital to nancial
penalties. For these reasons, Methodist Hospitals requires similar precautions for both types of lines.
Our two hospitals have been studying BSI distribution for more than a decade, so we were ready to act a few years ago when an alarming PIV
pattern appeared. A 6-year sample of data showed that up to 21% of our hospital-acquired, laboratory-con rmed BSIs occurred in patients with
PIVs alone. In addition, 47% of BSIs that met the federal de nition of central line–associated occurred in patients with multiple lines. In most
cases, one of those lines was a PIV.

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2/19/2018 Bloodstream infections from peripheral lines: An underrated risk - American Nurse Today
Like many healthcare organizations, Methodist had kept up with evolving guidelines for minimizing CLABSIs. During the 6-year period studied,
our CLABSI rates had dropped accordingly, but we didn’t see similar declines with PIVs. The high infection rates served as a wake-up call that we
needed to give those lines more attention.

A better PIV bundle

We used a relatively simple solution for minimizing BSI risk for patients with PIVs—implement a better bundle of preventive practices and
devices that approximate those we use for central lines. We studied recommendations from the CDC and Infusion Nurses Society (INS) to guide
us in updating our policies as needed. Here are the precautions Methodist has mandated and the rationales for each one.     

Intraluminal protection
Use PIVs with integrated extension tubing and a stabilization platform (such as Nexiva™). Lines with add-on devices have more openings
and require more manipulation; both features increase infection risk. Closed I.V. catheter systems with integrated extension sets and
stabilization platforms address this problem, which is why INS recommends them.
Use a neutral needle-free I.V. connector (such as One-Link). Multiple studies show a higher BSI risk with commonly used I.V. connector
types, such as positive and negative pressure connectors. This probably results from design features that make those connectors hard to
ush clean. The neutral connector we use addresses these issues.
Use an alcohol-impregnated disinfection cap (such as SwabCap®). This was our most e ective intervention. Originally, we implemented
these caps after a practice audit showed nurses weren’t properly disinfecting needle-free connector hubs. The standard manual method
promotes noncompliance and variance because it’s a poor t with nurses’ time pressures and workstyle. But the problem had to be
addressed, as poor manual disinfection directly increases infection risk. The alcohol-impregnated disinfection cap is quick and simple to
use, makes up for lapses in manual technique, and keeps the hub protected between line accesses (unlike manual disinfection).
 In the rst 15 months since we implemented the disinfection cap, the BSI rate associated with PIV lines dropped a statistically signi cant 66%,
compared to the 15 months before implementation. We attributed this to the cap because it was the only new intervention applied to PIVs
during that time. Cap use also was associated with a 55.7% reduction in our central-line BSI rate during that period. This result also was
statistically signi cant, although not attributable solely to the cap.

Extraluminal protection
Sterile gloves. Our policy, per both the CDC and INS, requires sta to use sterile gloves when touching the catheter site after prepping the
skin.
Updated transparent dressing (Tegaderm™ I.V. Advanced Securement Dressing). We protect the insertion site with a strongly adhesive
transparent dressing. If the dressing pulls away from the skin, we change it immediately to prevent bacteria from accessing the catheter
site.
Catheter securement. We follow the INS recommendation to leave the PIV in place until it’s no longer indicated instead of restarting it at a
de ned interval. INS adopted this guideline because studies showed regular insertion-site rotation doesn’t help prevent phlebitis or
infection. Our policy may improve patient satisfaction because it decreases extra needlesticks. Securing catheters with adhesive tape
undermines this policy because the tape can loosen and force catheter restarts. Our transparent dressing provides built-in catheter
securement, which supports extended catheter dwell times.
CHG dressing (BIOPATCH® (https://www.americannursetoday.com/goto/http://www.biopatch.com/solution) Protective disk with
chlorhexidine gluconate [CHG]). Our insertion kits include a protective disk with CHG (in addition to a transparent dressing) to safeguard
insertion sites. The dressing provides 360-degree
(https://www.americannursetoday.com/goto/http://application.aspen.edu/aspenu/rn_bsn_mr3/ANT1029) protection, releasing CHG for up
to 7 days on the skin to provide e ective antimicrobial protection. It’s the only I.V. dressing with CHG proven by multiple randomized
controlled trials to reduce CLABSIs.

Sta education
Nurses are more likely to comply with policies when they understand their importance. They’re also more likely to transition from old policies to
new ones if they know the rationale for the change. We o er bedside nurses continuing education
(https://www.americannursetoday.com/goto/http://application.aspen.edu/aspenu/rn_bsn_mr3/ANT1029) classes that cover I.V. fundamentals.
On all shifts, nurses receive education (https://www.americannursetoday.com/goto/http://application.aspen.edu/aspenu/rn_bsn_mr3/ANT1029)
(via team rounding) on the rationale for our new bundle, including its bene ts for both nurses and patients. Classes are given each quarter to
reach the greatest number of sta .
The degree (https://www.americannursetoday.com/goto/http://application.aspen.edu/aspenu/rn_bsn_mr3/ANT1029) to which PIVs threaten
patients and hospital nances may surprise many healthcare providers—but the analytics leave no doubt. Responding to this threat is clear: Use
best practices for all lines.
The authors work at Methodist Hospitals in Gary, Indiana. Michelle DeVries is a senior infection control o cer. Mary Jo Valentine is the
Magnet® Program Director and director of nursing professional development.
Selected references
Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurs. 2011;34(suppl 1):S1-S110.
Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infection in adults with di erent intravascular devices: a systematic review of 200
published prospective studies. Mayo Clin Proc. 2006;81(9):1159-71.
Mestre G, Berbel C, Tortajada P, et al. Successful multifaceted intervention aimed to reduce short peripheral venous catheter-related adverse
events: a quasiexperimental cohort study. Am J Infect Control. 2013;41(6):520-6.
O’Grady NP, Alexander M, Burns LA, et al; Healthcare Infection Control Practices Advisory Committee. Guidelines for the prevention of
intravascular catheter-related infections. Clin Infect Dis. 2011;52(9):e162-e193.
Zingg W, Pittet D. Peripheral venous catheters: an under-evaluated problem. Int J Antimicrob Agents. 2009;34(suppl 4):S38-42.

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