Patient bloodstream infection: Check the peripheral IV line
5 ways to target underestimated CABSI risk from PIVs.
Clinicians work hard to prevent central line-associated bloodstream infections (CLABSIs)—and for good reason. Central line catheter tips terminate in the superior vena cava, making them high risk. And because CLABSIs are called “never events” by the CDC—meaning they’re considered 100% preventable—when they do occur, related care is not reimbursed by Medicare or other insurers.
But many vascular access clinicians believe that infection related to peripheral IVs has long been underestimated and deserves equal attention. In fact, studies back them up showing that peripheral IVs (PIVs) may cause as many or more BSIs as central lines.1
About 200 million PIVs
are inserted annually in the United States,2 compared to about 5 million central lines.3 BSIs linked to PIVs could approach or even surpass that of central lines.1
The Infusion Nurses Society (INS) recognizes that infection risk from peripheral IVs requires more attention in its 2021 Infusion Therapy Standards of Practice. It introduced the term catheter-associated bloodstream infection (CABSI) to describe any infection stemming from peripheral intravenous catheters (PIVCs) and/or central venous catheters (CVCs). This shift expands clinician awareness beyond central lines and CLABSI risk. It recognizes that all BSIs can cause serious harm to patients4 and can come from any catheter source.
About 200 million PIVs2 are inserted annually in the United States, compared to roughly 5 million central lines.3 Given the high volume of peripherals and even accounting for central lines’ longer dwell times, the number of BSIs linked to PIVs could approach or even surpass that of central lines.1
Donna Matocha, DNP, a Medline Manager of Clinical Resources-Critical Care and former ICU nurse, says, “If you have a patient with both a central line and a PIV and that patient gets a BSI, who can say where it originated from? Bugs don’t choose one line over another. Infection occurs because there’s a break in the skin providing an opportunity for bugs to enter the body and proliferate.”
The INS CABSI terminology focuses everyone’s attention on “a risk that’s always been there,” says Matocha, adding, “You have to reduce risk around all catheters, not just central lines. PIVs aren’t benign.”
We’ve made great strides around getting central lines out as soon as we no longer need them. We’re not as good about removing PIVs when they should be removed.
Donna Matocha, DNP
Medline Manager of Clinical Resources—Critical Care
Hospitals are starting to mandate the same kinds of protocols for PIVs that central lines require to reduce cost and improve care quality. A CLABSI can cost a hospital an average of $48,000 each occurrence.5
“We’ve made great strides around getting central lines out as soon as we no longer need them,” Matocha says. “We’re not as good about removing PIVs when they should be removed. Let those veins heal. Eliminate the infection risk. Awareness and culture change, that’s how you begin.”
5 best practices to help reduce CABSIs
Matocha consults closely with healthcare leaders on discovery assessments, an opportunity to review a facility’s practices and problems and develop a plan for them to improve outcomes. Following are some key recommendations she offers to improve safety culture around catheters.
- Choose the catheter thoughtfully
Consider which catheter is least invasive to the patient as recommended by INS standards. - Remove peripheral catheters if unused
Remove unused or dormant PIVs as soon as possible. Having a PIV in for greater than three days significantly increases risk.2 And allowing the veins to heal without a PIV creates a better opportunity for successful insertion later if a catheter is needed. - Support best practices with easy-to-use kits and procedures
Every catheter insertion, line access and dressing change can open the door to microbial invaders. Training on best practices is important. And using products like insertion and maintenance bundles to help standardize procedures is key. - Practice consistent hand hygiene
It’s easy to overlook, but aseptic techniques and consistent hand hygiene go a long way toward preventing infection. Use hand sanitizer and sterile gloves when inserting a catheter and providing maintenance care. - Put a disinfection cap on every line, every time
The INS recommends using a disinfection cap on all lines, including unused lumens, to kill germs and create an infection barrier. Caps should be replaced every time the line is accessed or flushed. A syringe with an integrated cap helps standardize practice.
Key takeaway
The 2021 INS Infusion Therapy Standards of Practice uses the term catheter-associated bloodstream infection (CABSI) to recognize that harmful BSIs can come from any catheter source, not just central lines. CLABSI reduction has received much focus while the infection risks of peripheral IVs have been mostly overlooked. PIVs have lower BSI rates than central lines but are used in such high volume that bloodstream infections from peripheral IVs could match or outnumber those from central lines. PIVs and central lines should be removed as soon as they’re no longer needed to reduce CABSI risk. Use of insertion and maintenance bundles and putting disinfection caps on every line helps to reduce CABSIs.
Looking for more ways to help clinicians keep patients safe from CABSIs?
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References:
- Nickel, B. (2020). Hiding in Plain Sight: Peripheral Intravenous Catheter Infections. Critical Care Nurse, 40(5), 57–66. Available at: https://doi.org/10.4037/ccn2020439 (Accessed June 14, 2021)
- Mermel, L. A. (2017). Short-term Peripheral Venous Catheter–Related Bloodstream Infections: A Systematic Review. Clinical Infectious Diseases, 65(10), 1757–1762. Available at: https://doi.org/10.1093/cid/cix562 (Accessed June 14, 2021)
- Ruesch S, Walder B, Tramèr MR. Complications of central venous catheters: internal jugular versus subclavian access–a systematic review. Crit Care Med 2002; 30:454. Available at: https://www.uptodate.com/contents/overview-of-central-venous-access-in-adults (Accessed June 14, 2021)
- Antibiotic Research UK. Antibiotic Resistant Blood Stream Infections (BSI). https://www.antibioticresearch.org.uk/patient-support/specific-infections/blood-stream-infections-bsi/#:~:text=Blood%20stream%20infections%20(BSI)%20are,treatment%20with%20anti%2Dinfective%20medication. (Accessed January 19, 2023).
- Agency for Healthcare Research and Quality. Estimating the Additional Hospital Inpatient Cost and Mortality Associated with Selected Hospital-Acquired Conditions. Available at: https://www.ahrq.gov/professionals/quality-patient-safety/pfp/haccost2017-results.html Accessed June 14, 2021.
- Seiler, L. Rachel, Meyer, Shante, Bayshore Medical Center Case study. Improving Infection Control Compliance Using Combined Cap/Flush Syringe Technology to Reduce Central Line Associated Infections
