CRBI Literature Review
CLASS: NU 560-8
There are many articles on the subject of disinfecting and proper catheter hub cleaning techniques. This literature review was conducted using PubMed and Google Scholar to find articles related to cleaning hub site, best practices for disinfecting catheters, treatment as usual for disinfecting, complications, risks and benefits of comparisons of disinfectants, and support for the need to discover which disinfectant is best, if any. The literature supports a need for further research to discover which is best, as each of the three methods, greater than .5% chlorhexidine with alcohol, 70% alcohol, or 10% providone-iodine, are relatively similar in effectiveness (CDC, 2016; Moreau & Flynn, 2015).
Catheter-related bloodstream infections (CRBI) are common and dangerous, especially when the catheter is positioned in certain areas of the body. It is generally advised to keep the site clear of femoral access points, due to the higher risk of infection and lower cleanliness (Gahlot, Nigam, Kumar, Yadav, & Anupurba, 2014). In addition, less effective disinfectants contribute to the problem (CDC, 2016). The importance of disinfecting is proven, but there is not enough evidence from existing studies to recommend one type of disinfectant over another (CDC, 2016; Moreau & Flynn, 2015; Perin, Erdmann, Higashi, & Sasso, 2016; Curan & Rosetto, 2017).
Current best practices are outlined in several articles, including the CDC’s recommendations discussed in the first section of this paper, and findings by individual researchers (CDC, 2016; Curan ; Rosetto, 2017; Perin, Erdmann, Higashi, ; Sasso, 2016). Gahlot, Nigam, Kumar, Yadav, and Anupurba (2014) conducted research on CRBIs, aiming to develop a comprehensive summary of the elements that contribute to CRBIs, including what organisms lead to worse outcomes, pathogenesis, timeliness, and appropriateness of interventions received (Gahlot, Nigam, Kumar, Yadav, ; Anupurba, 2014). They pointed out that CRBIs are one of the most lethal and common complications, and are also the primary source of bacteremia and septicemia in hospitalized patients. The current research proposes an intervention using out-patient populations, but this evidence article is relevant due to the high risk whenever a catheter is used, in or out of the hospital. For medical-surgical ICUs, the CRBI incidence was 5.1 per 1000 catheter days (Gahlot, Nigam, Kumar, Yadav, ; Anupurba; 2014). The authors found that “Rates of CRBSI may be modified by clinical care during insertion and utilization of central venous catheters (CVCs)” (Gahlot, Nigam, Kumar, Yadav, ; Anupurba, 2014, 163). Local risk factors include poor personal hygiene, for the patient and administrator. The catheter itself can be responsible for infection in four different ways: colonization of catheter tip by skin flora, contamination of lumen, hematogenous infection from another infected site, and contamination of lumen with infusate (Gahlot, Nigam, Kumar, Yadav, and Anupurba, 2014, 164). This all leads to the support of further research on keeping the catheter clean at insertion.
Another systematic reviews of existing literature were performed by Perin, Erdmann, Higashi, and Sasso (2016) and Curan and Rosetto (2017), examining interventions to reduce CRBIs. Curan and Rosetto (2017) looked into the prevention of CRBIs in newborns, and recommended care bundles, including “hand hygiene, the use of maximal sterile barriers, cleansing skin with Chlorhexidine at 0.2% and letting air dry, keeping preassembled insertion kits, and having staff with special training” (2017, 6). Care bundles are groups of standard-use behaviors that have been proven through evidence-based research to improve patient outcomes when used in conjunction. Using only necessary catheters helps reduce infection instance (Perin, Erdmann, Higashi, ; Sasso, 2016). Most importantly, evidence shows that education, safety culture, and sanitation practices in hospitals and organizations lead to the best outcomes (Perin, Erdmann, Higashi, ; Sasso, 2016). This supports the need for research in hospitals, and a way to further standardize disinfectant processes. Finding which of the three disinfectants works best, and then creating educational information to spread the knowledge, will be in line with the recommendations of
Moreau and Flynn (2015) specifically address the integration of clinical evidence-based practices for disinfection of needleless connector hubs. Needleless connectors (NC) are used in most intravascular medical devices, and infection of the NC is related to half of post-insertion CRBIs. The authors found that the primary cause of colonization of the NC is due to insufficient cleaning when switching catheters, and that the flora can invade the needle and other parts of the catheter (Moreau ; Flynn, 2015). Some studies have shown compliance with post-insertion disinfectant procedures to be as low as 10% (Moreau ; Flynn, 2015). This shows that there is a need for the care bundles and education recommended in the various studies reviewed. Since education and organizational culture of attention to disinfecting are considered primary predictors for decreased CRBI rates, Moreau and Flynn’s study reinforces the need for a single, standard effective disinfecting solution. These authors recommend scrubbing with 70% alcohol as the disinfectant choice, but this evidence is contradicted by the recommendations of Camacho-Ortiz and Roman-Mancha (2016).
The authors Camacho-Ortiz & Roman-Mancha (2016) explored and discussed the importance of disinfectant over method of disinfecting, such as scrubbing, twisting, etc.. Chlorhexidine was compared to providone-iodine in a recent study known as the CLEAN study (Oliver-Mimoz et al., 2015). In that study, there was a clear reduction in infection when Chlorhexidine was used. At the same time, the authors of both papers acknowledged that there was not enough evidence to support Chlorhexidine over all disinfectants, and that little research has been done to find which is best. However, since they found a difference between two of the three recommended procedures, this proposed study may also find a difference, or add to the body of data on the subject.
The style of application in disinfecting a catheter hub is not as important as the constant and reliable use of an effective solution. Standard behaviors lead to uniform application (Sochet, Siems, Godiwala, Herbert, & Corriveau, 2016). By creating educational, EBP standards, patients receive the same quality care regardless of who sees them and where. The intervention and experiment proposed for this study is based on the need for finding which of the three standard disinfectants are best at cleaning a catheter hub. In the proposed research, style of disinfecting will be ignored, and the medical professional can use scrubbing, twisting, or whatever style they want. This procedure is supported by Camacho-Ortiz & Roman-Mancha (2016), and the use of evidence-based research recommending care bundles is also supported (Perin, Erdmann, Higashi, & Sasso, 2016). Education, sanitation attention, and hospital standard policies contribute to reduced cases of CRBIs, so finding one disinfectant that is proven to be optimal, or better than the other two, will inform future research and also inform hospital practices and policies aimed at ensuring good handwashing, insertion cleanliness, and location guidelines are followed.