Synopsis: Actual practice when performing intravascular site care infrequently followed written protocols. Practice varied widely between hospitals and between units in the same hospital.

Source: Roach H,. et al. Heart & Lung 1996; 25: 401-408.

Roach and colleagues directly observed staff performing site care on 86 central and 30 peripheral or arterial lines in five ICUs, three of which were located in a university teaching hospital and two in a community hospital. Their goals were to observe site care for intravascular catheters, to identify variations within and between hospitals, and to compare written protocols with actual practice. In the teaching hospital, 75 observations were made in an MICU (n = 25), SICU (n = 25) and cardiovascular ICU (n = 25). In the community hospital, 41 observations were made in an MICU (n = 25) and coronary care unit (CCU) (n = 16).

There were no significant differences between the hospitals in frequency of handwashing prior to site care, gloving practices, or maintenance of aseptic technique. However, actual practice varied significantly (P < 0.04) across individual units. Maintenance of aseptic technique ranged from a low of 60-61% in both MICUs to a high of 93% in the SICU. Significant differences were also noted for a number of other practices, including time since last site care (range, < 24 hrs to > 4 days), use of ointment (range, 0-52%) and skin adhesive (range, 0.0-93.3%). Compliance with documentation requirements, as outlined in written protocols, ranged from 53% to 86%, and was significantly different between the two hospitals with regard to recording the dressing change (P < 0.01) and whether the dressing label and chart agreed (P < 0.04). Dressings were labeled more often (P < 0.009) and the dressing label and chart agreed more often (P < 0.009) for central as compared with peripheral lines.

COMMENT BY LESLIE A. HOFFMAN, RN, PhD

Central venous catheters account for 90% of catheter-related blood stream infections, 45% of which occur in critical care units. Protocols are designed to identify standards of care and decrease infection risk by promoting optimum site care. Findings of this study suggest that site care procedures are not being consistently followed by substantial numbers of nurses.

Standards of care for central lines typically contain multiple steps and there is no consensus on the best way to accomplish this task. Thus, some differences are to be expected. However, there is no disagreement regarding the necessity to maintain aseptic technique or to glove during the procedure. In three of the five ICUs, staff maintained aseptic technique in at least 90% of observations, but in two others (both MICUs), the percentage was 60% or less. For many patients, neither the average duration of the site scrub (mean, 29 sec) nor the drying time for the antiseptic (mean, 47 sec) was sufficient to ensure maximum effectiveness. There were also a number of practices that were not appropriate, nor cost-effective, such as placing gauze under a transparent dressing. Adding to concerns, staff were appraised of the purpose of the study and knew they were being observed.

The finding that hand washing was not consistently practiced is not surprising. From direct observation of ICU practice, Kulow and Stoller (Respir Care 1996; 41:956) reported that handwashing prior to patient contact was observed for 17% of respiratory therapists, 6% of nurses, and 0% of physicians. In the present study, handwashing rates after patient contact were 43% for respiratory therapists, 26% for nurses, and 20% for physicians.

Central venous catheter-blood stream infections have been associated with an average increased hospital stay of seven days and a two- to three-fold increase in mortality. The need for improvement is clear. Today, measures to decrease costs often include fewer nurse educators and elimination of clinical nurse specialist positions. Primary prevention begins with all staff members following known procedures to reduce infection risk. Based on the findings of this study, more emphasis needs to be given to staff education, periodic surveillance, reporting of results, and reminders regarding the importance of compliance with basic infection prevention practices.