This paper reviews Hadaway's (2006) practice guidance for nurses on preventing catheter-related bloodstream infections (CR-BSIs), with particular emphasis on central venous catheters (CVCs). Drawing on Institute for Healthcare Improvement (IHI) guidelines and CDC recommendations, the paper examines five key prevention areas: hand hygiene, maximum barrier precautions, antiseptic selection, insertion site choice, and catheter management techniques. It also discusses program implementation strategies, device-related risk factors, and the ethical imperative for nurses to follow established protocols. The paper concludes that because the primary sources of CR-BSIs are patient skin and CVC technique, most infections are theoretically preventable through relatively simple and inexpensive interventions.
Hadaway (2006) sought to provide practice guidance to nurses for catheter-related bloodstream infections (CR-BSIs). The points of emphasis included short peripheral catheters, but the main focus was infections associated with central venous catheters (CVCs), because these occur more often and result in more severe adverse outcomes. To support these practice recommendations, Hadaway relied on CVC best practice guidelines published by the Institute for Healthcare Improvement (IHI). The information provided is designed to assist nurses in implementing best practices in the area of CR-BSI prevention. In addition, infection rate statistics and recommendations from the Centers for Disease Control and Prevention (CDC) were presented to demonstrate why this issue is critically important.
Hadaway (2006) discusses the five IHI guidelines for reducing the incidence of CR-BSIs. The argument is that best practice involves improving hand hygiene, barrier precautions, antiseptic use, insertion site selection, and catheter insertion and removal techniques.
A primary goal of this guidance is to educate nurses on how to prevent their hands from becoming contaminated. This is a significant concern because it is easy for nurses to contaminate their hands while caring for patients and transitioning from one procedure to another (Hadaway, 2006). For this reason, the IHI recommends that infusion procedures be performed before all other patient care tasks.
Alcohol-based hand cleaners are appropriate for most routine tasks; however, if hands have been visibly contaminated with bodily fluids, a thorough scrubbing with antimicrobial soap is indicated. Hand care is also important because damaged skin can more easily harbor microbes, and the use of emollients is recommended to promote a healthy skin barrier. Gloves should be changed and hands decontaminated before a catheter is inserted or removed and before administering an infusion.
Fingernail condition is another important consideration. Long nails, artificial nails, or fingernail polish can harbor dangerous microbes. Nurses who place peripherally inserted central catheters (PICCs) or who work with CVCs in an ICU should maintain short, natural nails only.
Maximum barrier precautions are recommended for the insertion of CVCs, including those inserted peripherally (Hadaway, 2006). A sterile gown, gloves, face mask, and cap should be worn. In addition, the patient should be completely covered during the procedure except at the insertion location. The recommended antiseptic is 2% or 3.15% chlorhexidine gluconate in 70% isopropyl alcohol, as this combination reduces both the incidence of CR-BSIs and skin problems compared to other common antiseptics.
With respect to insertion site selection, the IHI recommends the subclavian site over jugular or femoral sites due to concerns about neck movement and hair growth. Hadaway (2006), however, notes that the studies investigating insertion site choice were published over 20 years ago and produced no clear winner. The CDC recommended the subclavian site for nontunneled, noncuffed catheters in 2002 but acknowledged that all site choices pose risks for infections and other adverse events.
Catheter replacement should be based on the emergence of local or systemic complications observed during daily monitoring, and unused catheters should always be removed immediately. Because the skin is a primary source of infection, replacing catheters at the same insertion site is not recommended.
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