Central Line Associated Blood Stream Infections (CLABSI) and Catheter Associated Urinary Tract Infection (CAUTI)

Central Line Associated Blood Stream Infections (CLABSI)
Catheter Associated Urinary Trace Infection (CAUTI) 

Central Line Associated Blood Stream Infections (CLABSI)

The insertion of central lines in the EC must be considered carefully as the risk of infection is high and the definite indications for central line insertion probably limited to inotropic support, total parenteral nutrition (TPN) and very limited cases difficult IV access.

1. Hand hygiene
   • Hand washing with line placement as well as all patient contact including central line access and repair decreases nosocomial infections.
2. Maximal barrier precautions
   • During central line insertion compliance to: strict hand hygiene, wearing a cap (covering all hair), mask (cover nose & mouth), sterile gown and sterile gloves. Barrier precautions for the patient include covering with sterile drapes (preferably head to toe) leaving only a small area for access during placement.
3. Chlorhexidine cleansing of skin.
   • Chlorhexidine is superior to other antiseptics (incl. povidone-iodine.)  Use “to & fro” motion for 30 at least seconds then allow to dry (2 minutes) pre insertion of central line.
4. Optimal catheter site selection
   • Subclavian Vein showed reduced likelihood of infection (femoral access highest infection rate.) Optimal site selection requires various factors to be considered: operator experience and skill level, ultrasound guided insertion should be standard (where available), patient coagulation status, potential mechanical complications, risk of subclavian vein thrombosis, anatomical variation and injuries.  
5. Review of central line necessity & removal of unnecessary lines
   • Removal of central line as soon as line not required and peripheral access can be utilised
6. Dressing clean & intact
   • Use of transparent dressings frequently reviewed for inflammation of insertion site
7. Central Line Lumen Care
   • Lumen access by aseptic technique → cleaning the hub pre-access.      Allocation of dedicated lumen for TPN reducing contamination.

Catheter Associated Urinary Tract Infection (CAUTI)

The aim of this intervention is to reduce unnecessary urinary catheter days and prevent catheter related urinary tract infections with associated complications.

Avoid unnecessary urinary catheters

Catheterisation cause pain, discomfort and impairs the mobility of patients (ass. increased risk of thrombo-embolic events and pressure ulceration)

Definite indications for catheterisation in the EC should be decided on for each institution. Suggested indications include:

• Urine output / fluid balance monitoring in critically ill patients (incl burns)
• Acute urinary retention or urethral obstruction
• Incontinent / Chronically ill / Bedridden patients to prevent or assist pressure ulcer management
• On patient request to improve comfort (exception only)
• Comfort during Palliative care / End-of-life care in EC

Consider alternatives to catheterisation where appropriate

Insert urinary catheters using strict aseptic technique

Trained staff only to perform the procedure using sterile technique including hand hygiene, sterile gloves, sterile drapes, antiseptic cleaning solution, single use lubricant packaging (including local anaesthetic) and catheter size to minimise urethral injury (smallest)

Routine catheter care based on recommended guidelines

Routine catheter care must be part of daily practise for all patients according institution protocol. Hand hygiene should be a basic intervention with every patient care interaction.

Routine catheter care includes:

• Maintenance of a sterile, continuously closed drainage system                                
• Appropriate catheter securing to minimise injury                                                       
• Maintaining catheter bag positioning below bladder                                                       
• Regular collection bag emptying into an individual collecting container for every patient

Avoid following during catheter care:

• No irrigation of catheters (except if obstructed)                                                    
• Disconnecting catheter from drainage bag / tubing                                                       
• Catheter replacement as routine                                                                                     
• Aseptic technique if collecting system requires replacement

Daily review of catheter necessity & prompt removal.

In the EC length of patient stay may not require this intervention but still aim to remove catheters as soon as possible to prevent infection. The duration of catheterisation is directly proportional to the risk of developing infection.

References

• Wood S, Winters ME. Care of the intubated Emergency Department patient. J Emerg Med 2011;40(4): 419-427.
• Best Care Always Initiative - http://www.bestcare.org.za/