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As central-line infections rise, providers look for best practices

1 month ago 15
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As health systems grappled with staffing and supply challenges during the pandemic, they also saw a surge in central-line associated bloodstream infections.

Centers for Disease Control and Prevention data showed a 28% jump in the standardized infection ratio for central-line-associated bloodstream infections between the second quarters of 2019 and 2020. From 2015 to 2019, a 31% decline occurred in the standardized infection ratio for central-line infections.

The analysis of CDC data calculated the number of observed central-line associated bloodstream infections over the number of predicted infections at 936 facilities and more than 13,000 inpatient units.

Increasing infections correlated with escalating disease severity in hospital intensive care units as the pandemic surged. Patients with more serious illnesses require critical support like central lines for a longer period of time, said Dr. Richard Beers, chair of American Society of Anesthesiologists' committee on occupational health.

Healthcare workers have been placing the infusion devices connected to central lines outside of patients' rooms during the pandemic so they can make adjustments without entering the environment. While this lowers the risk for contracting COVID-19, longer lines mean more potential for contamination of the ports and connections between lines, Beers said.

Preventing central-line infections requires significant monitoring. Clinicians need to keep track of central venous catheters, their condition and how long they've been in, said Marie Moss, a member of the Association for Professionals in Infection Control and Epidemiology's communications committee.

"We have to ensure that patients have these central lines only for as long as is necessary," she said.

In general, health systems are attempting to minimize workers' exposure to COVID-19 patients, which can make it harder for clinicians to follow sterile procedures, said Dr. Jim Williams, clinical professor at Texas Tech University and a research director at Meritus Medical Center in Hagerstown, Maryland. A nurse might opt to save time by using an antiseptic to cleanse an area, but not wait long enough for the substance to kill bacteria before inserting the central line, Williams said.

Staff turnover has also overburdened workers and forced them to take on increased high-acuity patient loads as new personnel, including recent graduates, enter the field, said Dr. Lisa Maragakis, senior director for infection prevention at Johns Hopkins Medicine.

Central line maintenance is typically the responsibility of nurses, but lack of expertise or staff can make it more difficult to change dressings constantly, she said. It is also harder to clean central lines when patients with severe COVID-19 symptoms are being cared for in the prone position, lying on their stomach to assist with respiratory symptoms and avoid ventilators.

In 2020, critical care locations saw a 39% increase in their standardized infection ratio, with 1,911 adverse events taking place in the year's second quarter. Pediatric medical-surgical wards had a 118% increase in their standardized infection ratio. Medical-surgical critical care units had a 59% increase.

At the same time, data reporting on central-line–associated bloodstream infections decreased by 17% nationwide, with 609 fewer hospitals reporting in 2020 than in 2019. While northeastern states did not seem to experience significant increases in standardized infection ratios, reporting in the area decreased by 48% since 2019.

At Johns Hopkins, Maragakis said there is a heavy focus on using skin antisepsis products like chlorhexidine and scrubbing the hub, so the line can be accessed in the most clean way possible.

To avoid infections, physician assistants and providers are encouraged to work together to decide whether a patient needs a central line placed at all, or if they can use another, lower risk alternative, she said. They also ensure the catheter is removed as soon as possible.

Providers need to educate nurses and physicians on evidence-based practices, review protocols and provide positive feedback so staff can care for central lines better, Beers said.

Additionally, health systems should develop devices that allow for safer injection practices and monitor worker progress in reducing infections, he said.

Institutions can use surveillance data to audit their central line process steps and find areas for improvement, said Bert Thurlo-Walsh, chief quality officer and vice president of clinical transformation and medical staff services at Milford Regional Medical Center in Massachusetts.

Milford regularly tracks and reports its central-line–associated bloodstream infections to ensure staff are following infection control policies with the correct use of equipment, antiseptic wipes, hand hygiene, masking and other personal protective equipment, Thurlo-Walsh said. The medical center reported no central line infections in its most recent Leapfrog hospital safety grade.

Although hospitals seek to have zero infections, they're focused on returning or improving their previous standardized infection ratio while meeting national targets for central-line associated bloodstream infections.

"These are already the sickest of the sick patients," Williams said. "We got to do whatever we can to minimize complications [using] our interventions."

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