Reducing central venous catheterassociated infections in critical care

Introduction

Central venous catheters (CVCs) are required for nearly all patients in critical care to facilitate treatment (Aitken et al, 2019). However, they pose a safety risk during insertion, care and removal; the main risks include bleeding, thrombus, pneumothorax, inadvertent placement and infection. This complicates patients’ critical illness (Blot et al, 2022; Walsh and Fitzsimons, 2023). Despite well-established, evidence-based care bundles (Loveday et al, 2014; Bion et al, 2013), CVC-associated bloodstream infections continue to be a significant issue for critical care units both nationally and globally (Gerver et al, 2020). Such infections are well documented as a multifactorial issue spanning medical and nursing care (Bodenham et al, 2016).

Our adult intensive care unit experienced a high rate of CVC-associated bacteraemia infections. There were also regular safety incidents, such as the correct procedures not being followed to remove or access a CVC. The problem had been discussed regularly and needed a solution.

To address this, we successfully applied for the trust’s Chief Nurse Excellence in Care Fellowship Programme, which gives nurses eight hours a week of protected, non-clinical time to implement an improvement project. This initiative has been running successfully for several years to develop junior clinical staff, progressing their academic and leadership skills in response to dedicated support from clinical academic and research staff (Bramley et al, 2018). The programme is now offered to allied health professionals and midwives; it is also now run in other hospitals in the UK.

Delivering the project

Our project aimed to examine existing practice and measure adherence to the care bundle, policies and procedures in the clinical setting. Where non-adherence or problems arose, we planned to trial improvement ideas using a plan, do, study, act (PDSA) cycle.

Over nine months, we audited compliance with our existing CVC care bundle and associated trust policies, such as intravenous drug administration and aseptic non-touch technique (ANTT).

Outcomes

Through the audit, we collected and analysed a total of 183 entries. The results highlighted areas that needed to be addressed. This is demonstrated by the following statistics, all of which increased the risk of potential infection:

• 88% of staff members wore the correct personal protective equipment when accessing a CVC;
• 87% of staff followed correct ANTT procedure;
• 69% of CVC lumens were flushed and/or clamped after previous use;
• 58% of dressings were changed using the correct aseptic technique;
• 83% of CVCs had clean, dry, intact dressings.

To improve these areas, we used informational posters and bedside teaching to refresh and reinforce key knowledge. We sourced pre-made sterile saline flushes, ordered additional IV trays and created custom-made dressing packs to provide solutions for time-stretched nurses.

During initial audit analysis, the main issue highlighted was the need for new dressings. Discussion with the nurses revealed that the existing dressings were not fit for purpose and often peeled off.

A clean, dry, intact dressing is a key feature in CVC care and preventing associated infection (Loveday et al, 2014). The National Institute of Health and Care Excellence (2020) recommends that dressings are clear and semi-permeable so the insertion site can be routinely inspected; however, a range of chlorhexidine gel pad dressings can be used to reduce infection. Following a trial, nursing staff found chlorhexidine gel pad dressings to be of higher quality, more adherent and more occlusive than the existing film dressings. Using these meant that, during the subsequent audits, the number of CVCs that were clean and dry with an intact dressing upon inspection was greatly increased.

The variation in staff knowledge and lack of specific guidance for nursing staff led to us creating a standard operating procedure and a new guideline for the nursing care of CVCs. Both medical and nursing staff have agreed these are highly beneficial.

At the end of the project, final audit results showed overall staff compliance with the care bundle improved from 84% to 92%. We undertook a follow-up questionnaire, which showed 95% of nursing staff felt the project improved CVC care.

“The winner inspired the judges with her enthusiasm, passion and perseverance.
We were impressed by the way she sought to understand the human factors that affect practice and looked for ways to make positive changes” Judges’ comments

Challenges

Critical care units are busy, stressful environments, in which nurses must have a high level of clinical knowledge about a variety of medical devices (Credland et al, 2021). Critical care was also hugely affected by the Covid-19 pandemic, through both burnout and an increase in hospital-acquired infections due to:

• Reduced staffing;
• Increased bed capacity;
• Longer patient stay;
• Increased duration of venous access device use (Weiner-Lastinger et al, 2022).

In our service, a unit expansion, recent staff turnover and a large unit size posed additional considerable challenges to improving adherence to practice for a nursing team of over 150.

There were also challenges of implementing changes to nurses individually. It is often difficult to challenge practice without causing negativity. It was important, therefore, to encourage change through motivation and by using good communication.

We also observed a large variation in practice, for example where a general concept was understood (such as ANTT or sterile dressing change) but individual components needed clarification.

Conclusion and future plans

The improvement project discovered a key issue in the critical care unit was contributing to increased infections and associated incidents for patients. By using a continuous audit and PDSA cycle, we developed short-, medium- and long-term solutions, resulting in increased adherence, improved staff knowledge and a clear decrease in CVC-associated bloodstream infections.

The clinical, academic and research aspects of the project have been thoroughly enjoyable, allowing a balance of working clinically and improving the service. We are currently planning to begin a qualitative study into infection control behaviours in critical care nurses; this will be facilitated by Health Education England’s integrated clinical academic internship.