Understanding evidence-based strategies for the management and administration of central venous catheters is crucial to the prevention of associated complications, MiKaela Olsen, DNP, APRN-CNS, AOCNS®, FAAN, said in a presentation for the inaugural ONS Bridge™ virtual conference. Oncology nurses need to be knowledgeable about vascular access to prevent complications and ensure optimal outcomes for patients.
Best practice begins with catheter selection and should consider:
- What type of drug is being used?
- How long does the patient need IV therapy?
- What is the condition of the patient’s vessels?
- What is the diagnosis or anatomical/risk considerations?
- What is the best vascular access device for the patient currently?
Central Line–Associated Bloodstream Infections
To prevent central line–associated bloodstream infections (CLABIs) and other complications, Olsen said that an evidence-based central line checklist is a key tool for oncology nurses.
“Checklists should be completed by an observer who is trained and not part of the insertion process,” she said. “This person should be empowered to speak up if any step of the procedure is compromised or not completed.”
Before inserting a central line, Olsen said to prep the skin with chlorhexidine (CHG), which is more effective in preventing CLABSI than povidone-iodine. And catheter tip location is critical and a major factor in reducing complications.
“Optimal placement of a central venous catheter can lead to catheter longevity and decrease complications such as thrombus, malposition, and dislodgment,” Olsen said.
Central lines are exclusively placed in the superior vena cava, ideally at the superior vena cava–right atrial junction. Midline catheters are placed in the middle of the arm and not in the subclavian. After insertion, confirm tip location by chest x-ray or electrocardiogram. Never connect used IV tubing to new central line.
Daily Care Prevents CLABSI
Use CHG daily to prevent pathogens and as an alternative to bathing with soap and water, Olsen said. Needleless connectors and hubs should be scrubbed clean before every access. Change the connectors with each tubing change, every 96 hours when not accessed, or if they contain visible blood or debris. Alcohol swabs are important for passive continuous disinfection but are not a substitute for frictional scrubbing, she cautioned.
Dressings that are transparent, dry, clean, and intact reduce the risk for CLABSI. Olsen said that a highly permeable dressing with appropriate skin prep (CHG as the first choice) helps to prevent dressing disruptions. When dressing, any sign of blood should be met with zero tolerance and can be prevented or mitigated with best practice techniques.
IV tubing contamination leads to CLABSIs, Olsen explained. Effective IV tubing strategies include minimizing add-on devices, maintaining a closed system, utilizing back priming, and never looping tubing back into another port. Strict sterile technique must also be used when obtaining blood cultures.
“A blood culture policy should be in place to guide ordering and procurement of blood culture,” Olsen said. “A competency for obtaining both peripheral and central blood cultures should be in place for staff training to avoid contamination.”
Frequent flushing of a catheter keeps it free from blood and debris and reduces the chance for CLABSI. Occlusions are caused by inadequate flushing after incompatible medications, blood draws, and blood product administration. Occluded lines can lead to delayed therapies, increased length of hospital stay, and other related issues.
The healthcare team should evaluate the need for a central line catheter daily, asking:
- What is it being used for?
- Can it be removed?
- Can IV meds be converted to oral administration?
- Can labs be drawn peripherally?
CLABSIs are the costliest and most threatening of hospital infections. With proper implementation of the basics using evidence-based practice, a team approach, cutting-edge training methods, and a patient-centered focus, CLABSI occurrence and attributable mortality will decline.