Does anyone have any references for the timeline on central line bloodstream infections caused by insertion technique vs cause by maintenance technique?
In the past, we considered that if a central line became infected in the first 4 days after insertion then the infection was related to insertion practice.
If the infection occured after the 4 day mark then it was related to maintenance issues.
Your concept of how to differentiate between insertion and maintenance CRBSI is not evidence based. Here is what is known and is repeated in numerous published studies.
Biofilm is the basis of CRBSI. There is much more biofilm on the extraluminal catheter surface within the first week of dwell time. After the first week to 10 days, there is much more biofilm on the intraluminal surfaces. So with that first week to 10 days, you can infer that the infection is most probably related to insertion, dressing intergrity/change procedures, skin surface antiseptics, hand hygiene. After that period, the cause is most probably from hub management such as changing of all IV administration sets and management of continuous vs intermittent sets; cleaning of all catheter hubs, needleless connectors and injection ports; flushing and locking catheters and where those solutions are taken from; and any procedure performed through the hub such as drawing a blood sample. Dr. Maki published a study about this several years ago. I think about a third were found to be extraluminal, about a third were intraluminal and about a third could not be determined. I may not be remembering that data correctly but this concept of extra vs intra-luminal sources is repeated in many studies.
Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
So much has changed in the last few years in maximal barriers and skin antisepsis. Our Infection Preventionist and the Infectious Disease Doctors also lean toward the 4 to 5 day cut off unless there are overt signs such as site redness or purulent drainage etc. Was Dr Maki's study before or after all the changes for insertion techniques to include maximal sterile barriers etc? Are newer studies still reflecting the same biofilm issues on the external catheter?
We haven't had an external site infection in our facility for several years and the one we had was the only external site infection in the 7 years since I started with the team before we had maximum sterile precautions and did PICCs in rooms with double occupancy. (now I can't believe we did that and with small drapes) We worked very hard to maintain our sterile field under difficult conditions. As I recall this particular site infection was actually after maximal barrier precautions. I didn't do the PICC and don't have any idea what they thought happened.
Most suspected (although many times not confirmed) infections don't occur until well after 7 - 10 days. The few that we have had in the 7 - 10 day area have still been suspect for interluminal contamination. We still are having issues with "Scrub the Hub" and documented tubing changes. I still find tubing connected back to its own y-site, the male luer end hanging open to air or in an alcohol package. Nurses not thoroughly cleaning the hub. We have a long way to go to prevent interluminal contamination. I tie a lot of knots in tubing and leave new tubing at the bedside. We have A LOT of EDUCATION yet to do. That will never stop.
I hope more studies are done to get a new idea of where infections are coming from NOW. We need pressure from studies to focus on areas that are in terrible need of improvement. Budgets won't get changed to increase education until the studies push the focus on maintance. We have managed to keep our team intact such as it is but we don't do the dressing changes any more and there is nothing in the budget to check competency for staff on dressing changes and address infection prevention issues with hubs.
Comments, Lynn?
Mary Penn RN
External cath is not the same as extra luminal. I am referring to cath wall lying in the bloodstream. More study is always needed but I don't think you will ever have all answers.
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Yes, I know the differencebetween external cath and extra luminal. I was just looking at data supporting the new chlorhexidine/silver ion catheters. The infection studies by Dr Maki listed were from 2005 and 2006. So much has changed to say that the way a facility is now detemining the source of infection is wrong science. That was the point I was trying to make with my example. Before CHG dressings and everything else we also saw much more insertion site inflammation and infection. With the added use of maximal barriers and more careful skin prep, I would not be surprised that Infection Preventionists and Infectious Disease Doctors have changed the way they look at source of infection. I find it interesting that our department agrees with what the initial writer asked. Maybe they have sources Lynn that you don't. My suggestion is that the initial writer ask the Infection Preventionist at his facility for data. Maybe you should too.
I agree that we won't ever have all the answers, but I think you should be careful in the way you present yourself when people put questions out for comment. This is almost 2013. I note you didn't repond to my question has to how old Dr Maki's studies were.
Mary Penn RN