By John Palmer
A new study by researchers from Mercy Hospital in St. Louis has found that the use of maintenance bundles with peripheral intravenous catheters (PIV) can significantly decrease the incidence of bloodstream infections (BSI) in patients who receive them.
The study, “A Bundled Approach to Decrease the Rate of Primary Bloodstream Infections Related to Peripheral Intravenous Catheters,” was published in the March 2018 issue of The Journal of the Association for Vascular Access and found that implementing a PIV maintenance bundle using disinfecting caps and tips successfully decreased primary BSIs from 0.57 to 0.11 per 1,000 patient days (p < 0.001).
That might seem like it should be a commonsense finding, as catheters are inserted into patients every day. But apparently, they are not always maintained in the same way. According to Pat Parks, MD, PhD, medical director of 3M Healthcare’s Critical and Chronic Care Solutions Division, PIVs, commonly referred to as “standard lines,” are placed into veins typically in the hand, arm, or scalp, as well as the foot when necessary. They are primarily used for the administration of medications and fluids, and for blood draws. In contrast, central lines are placed into a large vein and used on patients who require longer-term care, including administration of chemotherapy drugs, various medications, or other fluids.
Both types of catheters present a potential entry site for bacteria and the foundation for a BSI. But historically, PIVs have been considered lower-risk as they are inserted into smaller veins for shorter periods of time. “Nevertheless, PIVs should not be overlooked due to the high frequency at which they are placed in patients,” says Parks. “In a study published by the British Journal of Medicine, there are an estimated 200 million PIVs inserted annually in the United States compared to only 5 million central lines, potentially posing a greater risk for PIV-associated complications.”
Primary BSIs are common hospital-acquired infections that can lead to substantial patient morbidity and significant increases in healthcare costs, researchers say, as well as longer treatments and hospital stays. In fact, estimates place the treatment costs for a BSI around $10,000–$20,000; in an ICU, the cost may be closer to $40,000.
Over the past decade, more research and standardization around central line care and maintenance have led to a significant reduction in central line–associated BSIs (CLABSI). Researchers have said that when it comes to PIVs, though, there hasn’t been much standardization in clinical practice.
“PIV catheter maintenance bundles are important to ensure that all patient IV lines are handled in the same manner using the latest industry best practices to help minimize the risks associated with BSIs,” Parks says. “Standard maintenance bundles for PIVs tend to be less common than central lines because they are not frequently monitored for infection reporting purposes.”
The study authors said that research in the field is limited regarding numbers of primary BSIs related to peripheral lines and prevention of peripheral line–associated bloodstream infections (PLABSI). With this in mind, they designed a study that would create a new PIV maintenance bundle using disinfecting caps and tips (provided by 3M), monitor compliance with the bundle, and assess whether the bundle would lead to a decrease in PLABSI rates.
The study took place at Mercy Hospital, a 900-bed Level I trauma care center, from November 2, 2015, to June 5, 2016, and resulted in the audits of 1,977 peripheral and 378 central lines.
The bundle included proper assessment of PIV sites and removal of IV catheters when there was an indication of phlebitis, with staff assessing that the dressing was dry, occlusive, and intact. It called for changing the dressing if it was nonocclusive or blood was present, using alcohol-impregnated disinfecting caps on all needleless connectors, minimizing IV tubing disconnections, and using alcohol-impregnated disinfecting tip protectors on all disconnected IV tubing. All nursing staff members on the included units were educated on the new PIV maintenance bundle, and an online learning module was instituted along with discussions at daily nursing huddles.
Weekly audits using a new audit tool were conducted to measure compliance with the new PIV bundle and the existing CLABSI bundle. Also audited were the disconnection methods used for IV line tubing (peripheral and central lines) before and during the study intervention period.
“A compliance rate of close to 90% with the use of the disinfecting caps and tips was attained,” the authors concluded. “Using a PLABSI bundle successfully decreased primary bloodstream infections due to PIVs (from 0.57 infections per 1000 patient-days preintervention to 0.11 infections per 1000 patient-days; p < 0.001). We confirmed that improving care for PIVs would decrease primary bloodstream infections associated with these devices.”
According to the researchers, various products are available to protect critical components inserted into patients from contamination. Disinfecting caps can be placed over needleless connectors during disconnection to keep them clean. Disinfecting tips are intended to keep the male connections clean and covered during the disconnection and until the next use.
“The purpose of this study was to test whether a PIV maintenance bundle that includes use of disinfecting products (caps and tips) could lower the rate of primary BSIs due to peripheral lines at our institution,” the researchers wrote. “We also wanted to show that it is safe to change intermittent tubing every 96 hours if the tubing is properly protected. Specifically, the study intervention consisted in using a disinfecting cap on all peripheral IV needleless connectors, and a disinfecting tip on all disconnected IV tubing. Since our institution had already been using the disinfecting cap on central lines for five years, we also added as an intervention in this study the use of the disinfecting tip to the IV tubing disconnected from the central lines. We monitored both peripheral and central lines for a side-by-side comparison of compliance with disinfecting caps and tips and infection rates.”
According to Parks, 3M™ Curos™ Disinfecting Caps for Needleless Connectors provide passive disinfection and act as a physical barrier to contamination for the most common needleless connectors. They contain 70% isopropyl alcohol (IPA), which can disinfect in less than a minute. The caps are active against a number of microorganisms commonly associated with BSIs and provide protection for up to seven days if left in place.
The 3M™ Curos Tips™ Disinfecting Cap Strip for Male Luers also contains 70% IPA and easily twists onto male luer devices to help reduce the risk of contaminants entering the IV line. Parks says the unique design keeps excess alcohol from entering the lumen while ensuring the exterior surface is adequately exposed to alcohol.
“Curos disinfecting port protectors offer many advantages over manual “scrub the hub” practices, including: can save clinicians valuable time, provides a physical barrier to contamination, removes user technique variation, and provides visual confirmation at a glance that a port is clean,” says Parks.
Researchers say the new intervention showed that these caps and disinfecting tips can significantly reduce the rate of PIV infections to a level similar to that of central lines when part of a peripheral maintenance bundle. Along with fewer infections, they say they observed a reduction in pain, redness, and swelling at the insertion sites.
“This likely led to improved practice in general, and with catheters being consistently removed when there is an indication of phlebitis and dressings being changed when they were no longer intact, this improvement in practice most likely contributed to reducing skin complications overall,” they wrote.
According to Parks, whose company has an obvious interest in the results of the study given that its products were used, the study found an 81% reduction, reported in infections per patient days, in PLABSIs from the pre-intervention period. The results represented a dramatic change in direction in clinical thought to focus on PIVs. Parks says implementation of a comprehensive PIV maintenance bundle, including consistent disinfection of needleless connectors and male luers, reduced microbial contamination of IV access points.
“The greatest battle health systems currently have in implementing a maintenance bundle is recognizing the significance of this real-world study, how it applies to them, and the necessary changes that are needed to accommodate the new policy at their institution to improve infection prevention outcomes,” says Parks. “We are confident that we will see an uptick in hospitals wanting to try these methods and products when they are aware that implementation of a comprehensive PIV maintenance bundle can not only help improve patient outcomes, but may save nurses and clinicians time and boost the facility’s bottom line.”
About the author
John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at firstname.lastname@example.org.