Picture the following scenario.
A patient arrives at your healthcare facility with an order for Ceftriaxone 1 gm BID for seven days to treat left arm cellulitis that was caused by an insect bite. The non-pitting edema extends from his hand to axilla. His peripheral venous access device (PVAD) was initiated in the emergency department, where he received the first dose of antibiotic.
What can this case study tell us about PVAD infection prevention?
On admission, the patient’s primary complaint is the IV site. Your assessment shows that a 20-gauge catheter was inserted in the antecubital fossa with an end cap on the catheter hub. No extension tube has been added. The dressing edges are loose with visible dirt, the catheter moves easily under the dressing, and there is > 2cm erythema proximal to the insertion site.
Vascular access devices (VADs) can be hazardous because they provide a direct line into the blood stream and can carry an increased risk of bloodstream infection. Regardless of the type or location, there can be the potential for harm whenever a patient has a VAD in place.1 Approximately 175 million peripheral vascular access devices (excluding midlines) are placed every year in the United States (US).2 Approximately 0.2% of these patients will experience a peripheral vascular access device (PVAD)-associated infection: a percentage that equates to over 500,000 patients each year.2 The ECRI Institute has identified infections from “peripherally inserted IV lines” as one of the Top 10 Patient Safety Concerns for 2019.3
It’s time to shift our thinking—there’s nothing ‘peripheral’ about the most common invasive procedure in healthcare.4
Common sources of PVAD site-related infections.
There are many ways bacteria and other microorganisms can cause infection. There are a few essential ways that we can try to help prevent HCAIs. They are:
- Hand hygiene: Hand hygiene is the simplest, most effective measure for helping to prevent healthcare associated infections and yet, compliance ranges 40-60% among healthcare workers.5, 6 Research shows that there are even lower rates of hand hygiene when gloves are worn.5 Inadequate hand hygiene is one of the most common causes of external (extrinsic) contamination.5
- VAD location: Site matters. A study by Moureau et al. (2018) identified that the skin’s microbial load differs depending on its moisture level and the site on the body where the VAD is inserted.7 The antecubital fossa, a common site for PVAD insertion, contains more Staphylococcus aureus than found on the forearm.8,9 The area where the infection may have started was the antecubital fossa. Patient-specific location risk factors include a site that may cause excessive pain, inability to sleep, and interfere with mobility and other activities of daily living (e.g. eating, toileting, and washing hands).
- Skin surface. The skin is composed of transient and resident microflora. Transient microflora comes from the environment. Resident microflora resides in the stratum corneum with about 80% found in the first 3-5 layers.6 The dominant species is coagulase negative staphylococci (CNS) with Staphylococcus epidermidis as the most common bacteria, colonising hair follicles and sebaceous glands.6 Therefore, skin preparation is one of the most important interventions for preventing infections. Applied improperly, inserting a VAD can introduce bacteria, viruses, or fungi into the blood stream. A common practice of palpating the potential insertion site post skin antisepsis with non-sterile gloves can help to further contaminate the area. The choice of antiseptic also matters. The traditional method of swiping an alcohol swab pre-insertion still continues despite evidence for effective and sustainable alternatives .10
- Equipment contamination: Inadequate or lack of antisepsis at all VAD touch points can allow microorganisms to enter through the contaminated access sites.6 Touch points include catheter hub, injection port, administration set, medication/infusion administration. Vigorously scrubbing of all surfaces before use, or using passive disinfectant caps, can help reduce risk.10 A compromised dressing (loose, wet, or soiled) can also put the patient at risk. Studies show that bacteria can be present under the VAD dressing, even dressings with an antimicrobial, with colony forming units 101 - 103.9 A cause of infection in this case could be an ill-fitting dressing and inadequate catheter securement.
- Idle catheters11: Catheters can be a nidus for infection due to the continuing buildup of fibrin—a protein-rich source that bacteria thrive on. For this reason alone, they should be removed when no longer medically needed (Refer to V.E.I.N.S.S Part 2 for more details). As long as the device is in place, there may be an increased risk of contamination each time it is accessed. Is the device still the best option for this patient? We’ll discover more clues regarding this in the next parts of this series.
- Aseptic no-touch technique (ANTT®): Asepsis is defined as a process for keeping away disease-producing organisms in sufficient quantity to cause infection.12 Regardless of whether the procedure is simple or complex, the goal for healthcare professionals is to prevent the transfer of pathogens. ANTT® is a procedural technique used to maintain asepsis for non-sterile procedures. Due to the wide variation of understanding and practice for no-touch technique, Part 4 of the VEINSS series is devoted to learning more about ANTT®.
Implement evidence-based prevention strategies.
Healthcare professionals can apply their knowledge of evidence-based guidelines and prevention strategies into their practice by following recognized guidelines and standards, like CVAA and INS, to address the following:
- Use single-use items and ANNT® for PVAD dressing changes.
- Choose suitable veins in the forearm. Do not use areas of flexion (wrist, ACF) unless in emergency situations.
- Use a systematic and patient-centric process for VAD insertion including site location.11
- Consider developing and implementing PVAD Insertion and maintenance bundles to help improve consistency of practice and standardization of products.
- Hand hygiene.11
- Use the same antiseptic skin preparation and sterile precautions as for CVAD.
- Skin antisepsis.11
- Prevent touch contamination by using disinfecting caps for all hubs and ports.12
- Review clinical need for the PVAD daily.
PVADs are ubiquitous in healthcare. These steps can help healthcare professionals prevent infection and improve patient outcomes.
Part 4 of our series will be a refresh on aseptic non-touch technique and its critical role in infection prevention strategies.
For more information on infection control with PVAD devices, contact a representative by filling out the form below.
- Gabriel J. 2008. “Infusion therapy part two: prevention and management of complications,” Nursing Standard 22(32): 41-48.
- Helm, R.E., Klausner, J.D., Klemperer, J.D., Flint, L.M., and Huang, E. (2015). “Accepted but not accepted peripheral IV catheter failure,” J Infus Nurs. 38(3): 189-203.
ECRI Institute. 2019. 2019 Top 10 Patient Safety Concerns. Available: https://assets.ecri.org/PDF/White-Papers-and-Reports/2019-Top10-Patient-Safety-Concerns-Exec-Summary.pdf
- Smith S. 2019. “Re-examining the risks for peripheral vascular access device infection,” Prevention Strategist 12(3): 38-39.
- Baloh, J. et al. 2019. “Hand hygiene before donning nonsterile gloves: healthcare workers’ beliefs and practices,” Am J Infection Control 47(5): 492-497.
- Ryder M. 2006. “Evidence-based practice in the management of vascular access devices for home parenteral nutrition,” J or Parenteral Enteral Nut. 30(1): S82-93.
- Moureau, N. et al. 2018. “Evaluation of skin colonisation and placement of vascular access device exit sites (ESCAPE Study),” J Inf Prev. 20(1): 51-59.
- Ryder M. 2019. “Peripheral Vascular Access Device Infection: An urgent patient safety issue.” Presentation, APIC Annual Conference (personal notes).
- Moureau N. 2018. “Does exit site matter in terms of bacterial load and risk?” Presentation, AVA.
- Canadian Vascular Access Association. 2019. Canadian Vascular Access and Infusion Therapy Guidelines. Pembroke, ON: Pappin Communications.
- Becerra, M.B., Shirley, D., Safdar, N. 2016. “Prevalence, risk factors, and outcomes of idle catheters: an integrative review,” Am J Inf Control 44: e167-e172.
- Iwamoto, P. et al. 2014. “Aseptic technique,” in APIC Text of infection Control and Epidemiology (4th ed). Open source: APIC Textbook 4th Ed online
Disclaimer: Karen Laforet is a 3M-sponsored blogger. The opinions expressed in this article are those of the individual.