Strictly Clinical

Bloodstream infections from peripheral lines: An underrated risk

PIV

Analytics—the study of data to reveal meaningful patterns—is remaking large swaths of our culture, from business to sports to politics. In health care, applying analytics toward the goal of preventing bloodstream infections (BSIs) reveals a surprising truth: A hospital is likely to have nearly as many BSIs associated with peripheral I.V. (PIV) lines as with central lines.

Yet, because we’re trained to focus on the perils of central lines (mainly central venous catheters and peripherally inserted central catheters), we’re likely to overlook PIV perils, with potentially dangerous consequences for both patients and hospital finances. Recognizing this often-underappreciated risk, Methodist Hospitals in Gary and Merrillville, Indiana, now mandate the same kinds of technology for PIVs that central lines require. We take the BSI threat from PIVs seriously.

A significant threat, a pressing need

Several preliminary studies suggest that nearly as many BSIs are linked to PIVs as to central lines. How can that be? Certainly, the BSI risk associated with central lines far exceeds that of PIVs. According to the Centers for Disease Control and Prevention (CDC), the pooled mean inpatient ward rate for central line–associated BSIs was 1.14 infections per 1,000 central-line days as of 2009 (the latest year for which statistics are available). For PIVs, the aggregate infection rate is less than half that—an estimated 0.5 per 1,000 peripheral-line days.

But far more PIVs are placed each year than central lines. In the United States, roughly 150 million PIVs are inserted annually, compared to only about 3 million central lines. Even taking into account central lines’ much longer dwell times, you can easily see how the total number of BSIs linked to PIVs could approach or even surpass that of central lines.

A PIV resembles a central line in one crucial respect—it’s an invasive device through which life-threatening bacteria can penetrate the bloodstream. Then consider that 70% to 80% of hospital patients have PIVs at some time during their stay. No matter which kind of line is involved, preventing BSIs is crucial because infected patients have a 12% to 25% chance of dying from the infection.

BSIs also can hurt a hospital’s finances, making it harder to provide the best care possible. (See the box below.)


BSIs and the bottom line

While average treatment costs for BSIs vary, BSI prevention expert Peter Pronovost, MD, cites a figure of $45,000 per incident. And because BSIs are considered preventable, Medicare and many other insurers don’t reimburse hospitals for those costs.

What’s more, the Affordable Care Act mandates incentives and penalties to improve healthcare quality, including financial penalties for hospitals with high BSI rates. Other federal penalties target only central line–associated bloodstream infections (CLABSIs), but a PIV may be involved in those infections. Many patients have multiple lines, which may include a PIV. So an infection reported as a CLABSI per the CDC definition may have originated in a peripheral line.

BSIs at Methodist Hospitals

Any BSI, whether stemming from a central line or a PIV, endangers the patient’s life, is costly to treat, and can expose the hospital to financial penalties. For these reasons, Methodist Hospitals requires similar precautions for both types of lines.

Our two hospitals have been studying BSI distribution for more than a decade, so we were ready to act a few years ago when an alarming PIV pattern appeared. A 6-year sample of data showed that up to 21% of our hospital-acquired, laboratory-confirmed BSIs occurred in patients with PIVs alone. In addition, 47% of BSIs that met the federal definition of central line–associated occurred in patients with multiple lines. In most cases, one of those lines was a PIV.

Like many healthcare organizations, Methodist had kept up with evolving guidelines for minimizing CLABSIs. During the 6-year period studied, our CLABSI rates had dropped accordingly, but we didn’t see similar declines with PIVs. The high infection rates served as a wake-up call that we needed to give those lines more attention.

A better PIV bundle

We used a relatively simple solution for minimizing BSI risk for patients with PIVs—implement a better bundle of preventive practices and devices that approximate those we use for central lines. We studied recommendations from the CDC and Infusion Nurses Society (INS) to guide us in updating our policies as needed. Here are the precautions Methodist has mandated and the rationales for each one.     

Intraluminal protection

  • Use PIVs with integrated extension tubing and a stabilization platform (such as Nexiva™). Lines with add-on devices have more openings and require more manipulation; both features increase infection risk. Closed I.V. catheter systems with integrated extension sets and stabilization platforms address this problem, which is why INS recommends them.
  • Use a neutral needle-free I.V. connector (such as One-Link). Multiple studies show a higher BSI risk with commonly used I.V. connector types, such as positive and negative pressure connectors. This probably results from design features that make those connectors hard to flush clean. The neutral connector we use addresses these issues.
  • Use an alcohol-impregnated disinfection cap (such as SwabCap®). This was our most effective intervention. Originally, we implemented these caps after a practice audit showed nurses weren’t properly disinfecting needle-free connector hubs. The standard manual method promotes noncompliance and variance because it’s a poor fit with nurses’ time pressures and workstyle. But the problem had to be addressed, as poor manual disinfection directly increases infection risk. The alcohol-impregnated disinfection cap is quick and simple to use, makes up for lapses in manual technique, and keeps the hub protected between line accesses (unlike manual disinfection).

 In the first 15 months since we implemented the disinfection cap, the BSI rate associated with PIV lines dropped a statistically significant 66%, compared to the 15 months before implementation. We attributed this to the cap because it was the only new intervention applied to PIVs during that time. Cap use also was associated with a 55.7% reduction in our central-line BSI rate during that period. This result also was statistically significant, although not attributable solely to the cap.

Extraluminal protection

  • Sterile gloves. Our policy, per both the CDC and INS, requires staff to use sterile gloves when touching the catheter site after prepping the skin.
  • Updated transparent dressing (Tegaderm™ I.V. Advanced Securement Dressing). We protect the insertion site with a strongly adhesive transparent dressing. If the dressing pulls away from the skin, we change it immediately to prevent bacteria from accessing the catheter site.
  • Catheter securement. We follow the INS recommendation to leave the PIV in place until it’s no longer indicated instead of restarting it at a defined interval. INS adopted this guideline because studies showed regular insertion-site rotation doesn’t help prevent phlebitis or infection. Our policy may improve patient satisfaction because it decreases extra needlesticks. Securing catheters with adhesive tape undermines this policy because the tape can loosen and force catheter restarts. Our transparent dressing provides built-in catheter securement, which supports extended catheter dwell times.
  • CHG dressing (BIOPATCH® Protective disk with chlorhexidine gluconate [CHG]). Our insertion kits include a protective disk with CHG (in addition to a transparent dressing) to safeguard insertion sites. The dressing provides 360-degree protection, releasing CHG for up to 7 days on the skin to provide effective antimicrobial protection. It’s the only I.V. dressing with CHG proven by multiple randomized controlled trials to reduce CLABSIs.

Staff education

Nurses are more likely to comply with policies when they understand their importance. They’re also more likely to transition from old policies to new ones if they know the rationale for the change. We offer bedside nurses continuing education classes that cover I.V. fundamentals. On all shifts, nurses receive education (via team rounding) on the rationale for our new bundle, including its benefits for both nurses and patients. Classes are given each quarter to reach the greatest number of staff.

The degree to which PIVs threaten patients and hospital finances may surprise many healthcare providers—but the analytics leave no doubt. Responding to this threat is clear: Use best practices for all lines.

The authors work at Methodist Hospitals in Gary, Indiana. Michelle DeVries is a senior infection control officer. Mary Jo Valentine is the Magnet® Program Director and director of nursing professional development.

Selected references

Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurs. 2011;34(suppl 1):S1-S110.

Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc. 2006;81(9):1159-71.

Mestre G, Berbel C, Tortajada P, et al. Successful multifaceted intervention aimed to reduce short peripheral venous catheter-related adverse events: a quasiexperimental cohort study. Am J Infect Control. 2013;41(6):520-6.

O’Grady NP, Alexander M, Burns LA, et al; Healthcare Infection Control Practices Advisory Committee. Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis. 2011;52(9):e162-e193.

Zingg W, Pittet D. Peripheral venous catheters: an under-evaluated problem. Int J Antimicrob Agents. 2009;34(suppl 4):S38-42.

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