Infusion therapy is integral to the health professional's role because most patients require some form of infusion therapy while in hospital. With this in mind, robust training and education aligned to clinical standards and evidence-based ‘best’ practice is paramount. Evidence-based guidelines provide comprehensive recommendations for preventing healthcare-associated infections (HAIs) (O'Grady et al, 2011; Loveday et al, 2014).
Recent years have seen significant practice changes in intravenous therapy with the introduction of care bundles, chlorhexidine skin and device cleansing, promotion of effective hand hygiene and aseptic technique. This standardisation of practice, training and education has equipped health professionals with appropriate evidence-based skills and knowledge, with emphasis placed on prevention of HAIs and a reduction in catheter-related bloodstream infections (CRBSIs) (Blot et al, 2014).
Peripheral vascular access is most commonly used and is associated with low levels of bloodstream infection (O'Grady, 2011). Careful consideration of the associated risks should be made when deeming central venous access (CVA) necessary.
The type of CVA will depend on individual therapy needs, duration and, where possible, patient choice. Placed in the greater central vessels, CVA has many benefits. Optimal haemodilution enables increased duration of treatment and the delivery of irritant agents that may otherwise cause extensive infiltration and extravasation injuries. Delivery of parenteral nutrition, central venous pressure monitoring and venous sampling are also achieved. However, any indwelling central venous line (CVL) has the potential to introduce a CRBSI and possible sepsis. A CVL-associated bloodstream infection is defined as a bloodstream infection in patients with a CVL 48 hours before onset of infection (O'Grady et al, 2011).
Indwelling devices are a major risk factor in the development of sepsis. The introduction of the National Institute for Health and Care Excellence (NICE) sepsis guideline (2017) has seen a huge drive in raising awareness of and education on sepsis.
Sepsis is a time-critical, life-threatening organ dysfunction caused by a dysregulated host response to infection (Singer et al, 2016). NICE guidance (2017) recommends administration of intravenous antibiotics within 1 hour, because without prompt recognition and treatment, morbidity and mortality risk increase with each passing hour.
The highest rates of CRBSIs and associated morbidity and mortality are in critical care patients where there is an increase in comorbidities, the need for multi-lumen lines and multiple access of devices (Marschall et al, 2014).
How can health professionals ensure high clinical standards are maintained? Education continues to be centred around the peripheral and CVL care bundles (Loveday et al, 2014). Surgical and standard aseptic non-touch technique (ANTT) are both now thoroughly embedded in practice and education (Rowley and Clare, 2011). There has also been widespread use of chlorhexidine-impregnated dressings and antibiotic-impregnated catheters. To maintain these high clinical standards, continuous review of integrated care bundles and formal monitoring and assessment of compliance should take place. Continuous audit and annual assessment of ANTT knowledge and clinical compliance is now recommended. A ‘challenge culture’, where poor practice is challenged by peers is a positive way of embedding knowledge and preventing HAIs.
Complete eradication of all CVL-related sepsis is challenging. However, with continued quality improvements, robust training and education and continuous assessment of clinical practice healthcare-associated CVL sepsis can be prevented.