I attended a round table discussion last evening lead by a well known hospital consultant and several nurse leaders in our area. The discussion was about struggles with CAUTI, CLABSI, Falls and Wounds. We shared our processes to help keep these hospital infections at zero with great collaboration tips and processes being shared.
I was surprised to hear that a burn unit in our area had a zero central line infection rate. Curious, I asked what the maintenance bundle included. The response was unexpected. The normal routine is that all central lines on the burn unit are overwired at day 3, 6, 10 of insertion with removal by day 14. When I asked for the science behind this practice there was no immediate response except that burn units manage central lines differently and literature to support this practice would be emailed to me later.
My question is:
Can anyone shed light on this practice? Is this an "older" practice that has resurfaced?
Very Curious-
Lois Long Rajcan, MSN, RN, CRNI
I have been reviewing the literature on crbsi for several projects recently. I have not seen anything about a scheduled overwire exchange as a means for infection prevention. So it sounds like something that this burn unit has decided works for them. I would require more hard data and not just their anecdotal comments. 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
In my experience as a clinical specialist for a vascular access company, I have run into the same practice in the last few years at many hosptials. It seems the practice of overwire exchange for central lines every 3 days has never left these areas (burn units specifically, but I have also seen it in Trauma ICUs). The MDs in these units do not care that the CDC guidelines recommend against this practice, that antimicrobial central lines exist and are perfect for this population (some of these hospitals even used these lines and still exchanged them every 3 days) or that the current literature shows these patients at higher risk for complications. If the infection rate on thier unit is zero, that is all that matters to them, because especially in burn patients, any infection could mortally effect the outcome for these patients. The MDs were very resistant to change--"if it works why change it?"
Costly, yes, but hard to argue with the results if their patients do not have other complications from this practice.
Chris Cavanaugh, RN, BSN, CRNI, VA-BC
I have done a non comprehensive literature search and found many references to exchanging central venous catheters routinely in burn patients as a means of reducing central line infections in the burn population.
As I continue to "Nancy Drew Sleuth" this topic I will be more than happy to post my findings.
Lois Rajcan MSN, RN, CRNI
Intravenous literature: Sheridan, R.L., Neely, A.N., Castillo, M.A., Shankowsky, H.A., Fagan, S.P., Chung, K.K. and Weber, J.M. (2012) A survey of invasive catheter practices in u.s. Burn centers. Journal of Burn Care Research. 33(6), p.741-6.
Abstract:
Burn-specific guidelines for optimal catheter rotation, catheter type, insertion methods, and catheter site care do not exist, and practices vary widely from one burn unit to another. The purpose of this study was to define current practices and identify areas of practice variation for future clinical investigation. An online survey was sent to the directors of 123 U.S. burn centers. The survey consisted of 23 questions related to specific practices in placement and maintenance of central venous catheters (CVCs), arterial catheters, and peripherally inserted central catheters (PICCs). The overall response rate was 36%; response rate from verified centers was 52%. Geographic representation was wide. CVC and arterial catheter replacement varied from every 3 days (24% of sites) to only for overt infection (24% of sites); 23% of sites did not use the femoral position for CVC placement. Nearly 60% of units used some kind of antiseptic catheter. Physicians inserted the majority of catheters, and 22% of sites used nonphysicians for at least some insertions. Ultrasound was routinely used by less than 50% of units. A wide variety of post-insertion dressing protocols were followed. PICCs were used in some critically injured patients in 37% of units; the majority of these users did not rotate PICCs. Thus, it can be surmised that wide practice variation exists among burn centers with regard to insertion and maintenance of invasive catheters. Areas with particular variability that would be appropriate targets of clinical investigation are line rotation protocols, catheter site care protocols, and use of PICCs in acute burns.
Robbin George RN VA-BC
this is against all regulatins and no past studies have shown benefit for this practice
CDC 2011, IDSA 2008 and 2009 do not suggest this preactice
Kathy kokotis RN BS MBA
BAS
this is against all regulatins and no past studies have shown benefit for this practice
CDC 2011, IDSA 2008 and 2009 do not suggest this preactice
Kathy kokotis RN BS MBA
BAS
Extremely interesting! Kathy is correct that no set of guidelines or standards have recommended any type of routine change of any CVAD in burn patients. Then that new study shows such a wide variation in practice, it seems obvious that these burn centers are not accepting these recommendations for CVAD management. We must have good evidence to use for any clinical decision. So those burn centers who are doing these routine changes must publish their evidence. In China, I will also be giving several presentations on Standards and how to achieve a level of compiance with Standards and Gudielines. This presentation emphasizes that knowledge learned from data collected must be shared internally and externally to improve clinical practice. So if these centers have knowledge that this routine change is working, they have a professional responsibility to share this through publications. 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
Below is the reference from a burn unit. This is used as a reference to continue the practice of overwire exchange in burn patients. I find the findings intriguing.
Lois Long Rajcan, MSN, RN, CRNI
Timing of Central Venous Catheter Exchange and Frequency of Bacteremia in Burn PatientsKing, Booker MD*; Schulman, Carl I. MD, MSPH*; Pepe, Antonio MD*; Pappas, Peter MD†; Varas, Robin ARNP*; Namias, Nicholas MD*
Journal of Burn Care & Research:
November/December 2007 - Volume 28 - Issue 6 - pp 859-860
doi: 10.1097/BCR.0b013e318159a40b
Abstract:
We evaluated the impact of increasing the interval between routine central venous catheter exchanges from every 3 days to every 4 days on the rate of catheter infections and catheter-related bacteremia. Computer records of catheter tip and blood culture results in burn patients were reviewed. The change to every 4 day catheter exchange occurred in November 2000 and data were collected until June 2001. One hundred and ninety-six guidewire exchanges were performed in the every 3 day (q3day) group, and 164 guidewire exchanges were performed in the every 4 day (q4day) group. The rate of catheter infections (>15 colony forming units) was 11% in the q3day group and 28% in the q4day group. Catheter-related blood stream infection occurred in 4% of patients in q3day group and 12% of patients in q4day group. A prospective review of this change in practice revealed that there was a significantly greater risk of infections in the q4day group. The increase in infected central venous catheter segments was associated with an increase in blood stream infections.
(C) 2007 The American Burn Association