Device-associated Prevention

Central line-associated bloodstream infections (CLABSIs) result in thousands of deaths each year and billions of dollars in added costs, according to the CDC.

CDC guidelines for central line-associated bloodstream infection prevention >

Definitions

Central line: An intravascular catheter that terminates at or close to the heart, or in one of the great vessels that is used for infusion, withdrawal of blood, or hemodynamic monitoring. 

Infusion: The administration of any solution through the lumen of a catheter into a blood vessel. Infusions include continuous infusions (e.g., nutritional fluids or medications), intermittent infusions (e.g., IV flush), IV antimicrobial administration, and blood transfusion or hemodialysis treatment.  

Line Access: Entering a line with a needle or needleless device for infusion or withdrawal of blood. 

General Guidelines

• Assess the need to continue central line use daily. Call the provider and have the catheter removed when no longer necessary
• Perform hand hygiene prior to accessing or handling catheter hubs, needleless connectors, injection ports, IV tubing and central line dressings
• Gloves should be worn prior to accessing or handling catheter hubs, needleless connectors, injection ports and IV tubing
• “Scrub the Hub” - Disinfect catheter hubs, needleless connectors, and injection ports with friction for 10-15 seconds with chlorhexidine, povidone iodine, an iodophor, or 70% alcohol prior to each use
• Only single sterile devices should be used to access catheters  
• Antimicrobial ointments for hemodialysis catheter-insertion sites should be used with the dressing
• A chlorhexidine impregnated dressing should be used for all central lines except dialysis catheters
• Central line dressing changes should occur using aseptic technique  
• Immediately replace dressings that are wet, soiled, or dislodged  
• Gauze dressings should be changed every two days  
• Semipermeable dressings should be changed every seven days 
• All localized infections at the catheter entrance site should be reported to the provider for treatment  
• Localized infection signs and symptoms include pus, redness and swelling.
• Catheter administrations sets for continuous infusions should be changed every four days 
• Catheter administrations sets for intermittent infusions should be changed every 24 hours 
• If blood or blood products or fat emulsions are administered the tubing should be changed every 24 hours 
• All catheter dressings and administration sets should be labeled with the expiration date 
• CLABSI surveillance should be performed using the Centers for Disease Control and Prevention National Healthcare Safety Network’s criteria 
• CLABSIs should be reported in raw numbers and if appropriate by 1000 catheter days

CDC: Frequently Asked Questions about Catheters >

CDC: Checklist for Prevention of Central Line-associated Bloodstream Infections >

A urinary tract infection is an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidneys. UTIs are the most common type of health care-associated infections and urinary catheters are the main sources of these infections.

CDC guidelines for catheter-associated urinary tract infection prevention >

Definitions

External Catheter: A device that is adhered to or placed near the external genitalia or pubic area to collect urinary output. 

Indwelling Catheter: Often referred to as a Foley, a sterile closed system with a catheter and retention balloon that is inserted into the bladder. The catheter may be inserted through the abdominal wall, referred to as a suprapubic catheter or through the urethra. A Foley is connected to an external device to collect urine.

Intermittent Catheter: Often referred to as a straight catheterization. A catheter is inserted into the bladder, or other surgically created channels, to drain urine. The catheter is promptly removed once the bladder is empty.

Proper techniques for urinary catheter insertion

All indwelling urinary catheters should be placed with a physician’s order and meet Centers for Disease Control and Prevention (CDC) guidelines for appropriate use

CDC indicators for indwelling urethral urinary catheters:

• Acute urinary retention or bladder outlet obstruction
• Accurate measurements of urinary output or strict Q1-2 hour I&Os in critically ill patients (I&Os should to be recorded every 1-2 hours)
• Perioperative use for selected surgical procedures: Patients undergoing urologic surgery or other surgeries on contiguous structures of the genitourinary tract 
• To assist in healing of open sacral or perineal wounds stage 3 or 4 in incontinent patients
• A resident requiring prolonged immobilization (e.g., potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures)
• To improve comfort for end-of-life care.

Examples of Inappropriate Uses of Indwelling Catheters:

• As a substitute for nursing care of the resident with incontinence
• As a means of obtaining urine for culture or other diagnostic tests when the residents can voluntarily void

External catheters should be considered as an alternative to indwelling urethral catheters whenever possible 

Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction

Only properly trained persons who know the correct aseptic technique for insertion and catheter maintenance should be given these responsibilities.

General Guidelines for Insertion:

• Perform hand hygiene immediately before and after inserting the catheter
• Insert urinary catheters with only sterile equipment
• Use sterile gloves, drape, sponges, an appropriate antiseptic as needed
• Sterile solution for periurethral cleaning should be used, along with a single-use packet of lubricant jelly for insertion
• Use the smallest possible catheter to ensure proper drainage and to minimize urethral/bladder neck trauma
• Properly secure indwelling catheters after insertion to prevent movement and urethral traction.

Proper Technique for Urinary Catheter Maintenance:

• Assessment of the catheter should occur daily with documentation in the resident's medical record
• Perform hand hygiene immediately before and after any manipulation of the catheter
• Use Standard Precautions, including the use of gloves and a gown as appropriate, during any manipulation of the catheter or collection system
• Following aseptic insertion of the urinary catheter, maintain a closed drainage system
• If breaks in aseptic technique, disconnection, or leakage occurs, replace the catheter and collection system using aseptic technique and sterile equipment, if not a chronic Foley
• Use urinary catheter systems with preconnected, sealed catheter-tubing junctions.
• Maintain unobstructed urine flow:
  • Keep the catheter and collection tubing free from kinking
  • Keep the collection bag below the level of the bladder at all times
  • Do not rest the bag on the floor or the bed.
• If obstruction occurs and it is likely that the catheter material is contributing to obstruction, change the catheter
• If obstruction is anticipated, closed continuous irrigation is suggested to prevent obstruction
• Empty the collection bag regularly using a separate, clean collection container for each resident; avoid splashing and prevent contact of the drainage spigot with the non-sterile collecting container
• Do not clean the periurethral area with antiseptics while the catheter is in place
• Clean the meatal surface during daily bathing and when soiled
• Clamping indwelling catheters prior to removal is not necessary
• Do not change indwelling catheters or bag at arbitrary fixed intervals. Unless the resident has a long-term catheter.

Urinary Catheter Specimen Collection:

Urinary cultures for asymptomatic residents should be limited to individuals with signs and/or symptoms of a urinary catheter infection

Sign/symptoms of infection while urinary catheter is in include:

• A new-onset or worsening of fever (>38.0)
• Rigors
• Altered mental status or lethargy with no other identified cause
• Acute hematuria
• Costovertebral angle pain without other recognized causes: e.g., left or right lower back or flank pain. Lower back pain is too generalized as a symptom
• Suprapubic tenderness without other recognized causes: e.g., lower abdominal pain or bladder or pelvic discomfort. Abdominal pain is too generalized as a symptom.

Sign/symptoms of a urinary tract infection with a urinary catheter recently removed:

• Dysuria
• Urinary urgency or frequency.

Urinary cultures should not be sent for:

• Pyuria
• Odoriferous urine
• Changes in urine color
• Sediment
• Turbidity urine
• To test for a cure.

Obtaining an aseptic urine sample

• If a small volume of fresh urine is needed for examination (e.g., urinalysis or culture), aspirate the urine from the needleless sampling port with a sterile syringe/cannula adapter after cleansing the port with a disinfectant
• If a large volume of urine is needed for special analyses (not cultures) obtain an aseptic sample from the drainage bag.

SHEA/IDSA Practice Recommendation: Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals: 2014 Update >