Managing Central Venous Catheters

Over 5 million central venous catheters are inserted annually in the United States. Yet the ‘ideal’ access device does not exist. A host of issues preclude optimizing central line care. They include the lack of:

• Evidence-based guidelines;
• Randomized controlled clinical trials;
• Formal assessment strategies for appropriate patient selection by type of device;
• Patient knowledge;
• Insurance coverage for catheter supplies.

Mikaela Olsen, MS, RN, AOCNS, an oncology/hematology clinical nurse specialist at the Sidney Kimmel Comprehensive Cancer Center at the Johns Hopkins Hospital, Baltimore, discussed these topics during her presentation, “Evidence-Based Practice Strategies for the Management of Vascular Access Devices,” at Scripps Cancer Center’s 32nd annual Oncology Nurses Symposium, held last October, in San Diego. Of special note was the speaker’s analogy with pharmaceuticals. The FDA requires evidence of outcomes associated with new drugs, whereas there is no such comparable oversight required of companies who manufacture central venous catheters.

Central lines are distinguished by their design. There are six characteristics:

• Distal lumen variables (ie, open-ended, valved, termination point);
• Presence of clamps;
• Flushed with heparin or saline;
• Large bore (for pheresis, dialysis);
• Power-injectable capability;
• Presence of coating or impregnation.

The oncology nurse must be aware of these characteristics to ensure proper use and maintenance of select catheters.

Catheter selection, insertion, and maintenance are critical to the prevention of complications. The femoral site should always be avoided due to the high likelihood of mechanical, infectious, and thrombotic events. The appropriate location of the catheter tip of a central line is the most important factor in the catheter’s longevity. The ideal location is at the superior vena cava/right atrial junction, and it should only minimally be in the distal third of the superior vena cava.

Hub care is another important variable within the context of central line care. Several points were emphasized emanating from the CDC Guidelines (2011):

• The needleless connector/hub should be cleaned before every access;
• Scrub in a motion similar to juicing an orange for 30 seconds;
• Needleless connectors should be replaced with tubing changes, if occlusion is noted or visible blood or debris is seen in the connector, and prior to drawing blood cultures;
• Chlorhexidine is the skin prep of choice.

Central line-associated bloodstream infection (CLABSI) is the most costly and life-threatening of all hospital-acquired infections. There are over a quarter million cases of CLABSI diagnosed annually, with an attributable mortality of 12% to 25%. CLABSI prolongs hospital stays by 7 days and can cost up to $50,000 per case. Currently, CMS does not reimburse a hospital for hospital-acquired CLABSIs.

The prevention of CLABSI is a nurse-sensitive phenomenon and is an indicator of the quality of nursing care. The prevention of CLABSI constitutes a national effort based on the utilization of five evidence-based strategies, which include:

1. Good hand hygiene;
2. Use of maximal barrier precautions for line insertion;
3. Use of chlorhexidine to prepare skin;
4. Optimal catheter site selection with avoidance of the femoral vein for central venous access in adult patients;
5. Daily review of line necessity with prompt removal of unnecessary lines.

Of note is that the Infectious Diseases Society of America (IDSA) has guidelines for the appropriate removal of central lines (2009).

Optimum central line care can be facilitated by numerous interventions. Ms. Olsen suggested the following be considered:

• Encourage ownership and teamwork of the process to improve care;
• Reward units and staff when improvements are actualized;
• Ensure that reporting rates are visible and addressed;
• Evaluate staff clinical competency routinely (vs “see one do one”) by peers;
• Share best practices when change efforts are effective.