New IV Guidelines: What's Most Critical to Know

By Rita McCormick, RN, CIC and Laura Rutledge, RN, MN, CRNI

OBJECTIVES:

1. To understand why new IV guidelines from the CDC are necessary.

2. To explore maximum barrier precautions for CVC insertion.

3. To explain the recommended frequency of replacement for CVCs.

The Centers for Disease Control and Prevention (CDC) recently published new guidelines for preventing IV-related infections. With IV catheter use on the rise, harder-to-treat pathogens making their way into patient bloodstreams and the substantial cost of treating catheter-related bloodstream infections (CRBSI), these new guidelines serve as a reminder that we can never become complacent about IV infection control.

Since publication of the 1996 CDC IV guidelines, catheter use has increased significantly, especially by patients at home. As with any medical device that has widespread use, there is a tendency to handle catheters with a casual attitude. While the number of bloodstream infections (BSIs) associated with catheters hasn't increased since 1996, we're still seeing approximately 80,000 CRBSIs each year in the United States associated with central venous catheters (CVCs).1

Additionally, the type of pathogens causing CRBSI has changed -- for the worse. The three most common pathogens causing CRBSI are coagulase negative staphylococcus, Enterococcus, and Staphylococcus aureus, all of which are commonly resistant to multiple antibiotics and therefore are more difficult to treat.

The cost per infection attributable to central venous catheters (CVCs) is estimated at $34,508 to $56,000.3-4 The annual cost of caring for patients with CVC-associated infections ranges from $296 million to $2.3 billion5 -- a hefty toll on America's already-strained healthcare system.

To improve patient outcomes and reduce costs, the CDC issued new guidelines that take into account new evidence related to antiseptics, devices, dressings and replacement of devices. The most significant changes affecting healthcare professionals, administrators and patients capable of assisting in the care of their catheters are:

Maximum barrier precautions for CVC insertion
The CDC now recommends maximum sterile barrier precautions (cap, mask, sterile gown, sterile gloves and large sterile drape) during the insertion of CVCs because maximum precautions substantially reduce the incidence of CRBSI.6-7 This guideline definitely sends the message that we need to think of CVC insertion as an procedure requiring stringent asepsis, which may require a behavior change for many physicians including anesthesiologists who often fail to utilize optimal aseptic technique when inserting vascular catheters in the operating room.

Chlorhexidine is the preferred skin antiseptic
To date, povidone iodine has been the most widely used antiseptic for cleaning insertion sites prior to insertion as well as maintenance of the IV catheter, however research data indicates that 2 percent aqueous chlorhexidine gluconate significantly lowered BSI rates compared with 10 percent povidone iodine or 70 alcohol alcohol.8 It's important to note that the amount of CHG needs to be high enough. A 0.5 percent tincture is not more effective than povidone iodine, according to one study.9 Although it has been known for some time that the persistence of chlorhexidine gluconate is greater than that of povidone iodine, until recently a chlorhexidine skin antiseptic was not available for such purposes in the United States.
This change shouldn't be a problem for most healthcare practitioners. It's simply a matter of switching from a brown to a clear antiseptic.

Routine CVD replacement discouraged
Catheter replacement at scheduled time intervals was thought to reduce infections, but two trials showed no CRBSI rate reduction in patients undergoing catheter replacement every seven days compared with patients whose catheters were replaced as needed.10-11 The CDC now recommends leaving CVC catheters in as long as necessary.

Tubing and dressing change intervals extended
Replacement of CVC administration sets remains at 72 hours. For dressing change intervals, the guidelines recommend replacing CVC dressings every seven days if using transparent dressing or two days if using gauze.

Recommended materials
Catheters coated or impregnated with antimicrobial or antiseptic agents have been found to decrease the risk for CRBSI.12 Recognizing the additional cost of impregnated catheters, the CDC recommends switching to impregnated catheters only if other strategies for reducing CRBSI do not achieve your institution's set goals. The guidelines include very specific strategies that should be tried first. The comprehensive strategies should include the following components: educating persons who insert and maintain catheters, use of maximum sterile barrier precautions and 2 percent chlorhexidine preparation for skin antisepsis during CVC insertion.
Although the CDC guidelines didn't find any clinical difference in infection prevention between transparent and gauze dressing, they do recognize transparent dressings' other advantages. These include allowing for continuous visual inspection of the catheter site, permitting patients to bathe and shower without saturating the dressing, and requiring less frequent changes than standard gauze and tape -- saving healthcare personnel time.

Specialized IV teams
The CDC guidelines avoid recommending that healthcare facilities institute specialized IV teams; however, several studies cited in the guidelines have shown that specialized teams reduce the incidence of CRBSI and associated costs.13-15 For now, the guidelines focus on staff education and training, as well as adequate nursing staff levels in intensive care units.

Summary
The updated CDC IV guideline, which takes into account new research findings, as well as improvements in medical devices and supplies, provides an evidence-based blueprint for reducing catheter-related infections and reducing the high costs associated with CRBSIs. For the full CDC report, see "Guidelines for the Prevention of Intravascular Catheter-Related Infections" on the CDC Web site at http://www.cdc.gov/ncidod/hip/iv/iv.htm/.

Rita McCormick, RN, CIC, is an infection control practitioner at the University of Wisconsin Hospital and Clinics. She was a HICPAC member from 1991 to 1998 and was on the task force that developed the draft of the 2002 IV guideline. Laura Rutledge, RN, MN, CRNI, is a member of 3M's technical service team.

TEST QUESTIONS: TRUE OR FALSE T F
1. Increased catheter use, harder-to-treat pathogens making their way into patient bloodstreams and the cost of treating catheter-related bloodstream infections (CRBSIs) remind healthcare workers not to become complacent about IV infection control.    
2. While the number of bloodstream infections associated with catheters hasn't increased since 1996, approximately 80,000 CRBSIs occur each year in the United States associated with central venous catheters (CVCs).    
3. The three most common pathogens causing CRBSI are coagulase negative staphylococcus, MRSA and Staphylococcus aureus.    
4. The cost per infection attributable to central venous catheters is estimated at $34,508 to $56,000.    
5. The CDC does not recommend maximum sterile barrier precautions (cap, mask, sterile gown, sterile gloves and large sterile drape) during the insertion of CVCs.    
6. Chlorhexidine gluconate is now recommended as the preferred skin disinfectant for insertion and maintenance of IV devices.    
7. For arterial peripheral tubing, the new CDC guidelines recommend extending the replacement interval from 72 hours to 96 hours, unless infection is suspected.    
8. Catheters coated or impregnated with antimicrobial or antiseptic agents have not been found to decrease the risk for CRBSI.    
9. According to several studies cited in the guidelines, specialized IV teams have shown unequivocal effectiveness in reducing the incidence of CRBSI and associated cost.    
10. Since publication of the 1996 CDC IV guidelines, catheter use has decreased significantly.    

ANSWERS 1. T 2. T 3. F 4. T 5. F 6. T 7. T 8. F 9. T 10. F

Reprinted with permission from Infection Control Today, January 2003
2003 Virgo Publishing, Inc. All Rights Reserved.