Running head: ANTIMICROBIAL TECHNIQUES 1

The Antimicrobial Techniques Used to Decrease Intravascular Catheter Associated

Infection

Shelby Furubayashi

Westminster College
ANTIMICROBIAL TECHNIQUES 2

An invasive line inserted into the vasculature of the body is a procedure that is

commonly performed in the hospital setting. Over 230 million intravenous lines are

placed annually in the United States (The IV Market, 2017). Intravenous lines are

implemented to provide medications, fluids, and blood products. It also can be used to

monitor pressures and bodily functions along with receiving and obtaining blood

products.

Although, placing an intravenous line is a basic skill nurses perform, it is a critical

component of patient care that needs to be practiced with aseptic technique and with

proper infection control measures (Vera, 2016). Not implementing aseptic and clean

technique upon insertion and during treatments increases the potential for healthcare-

acquired infection that could potentially be life threatening (The IV Market, 2017).

Without disinfection of the external hub, build up of bacteria on point of entrance can

occur that could potentially be put into the vascular system of the body through the

invasive line. Inserting these catheter lines directly into the body’s circulatory system can

easily spread an infection systemically throughout the body. Using antimicrobial methods

to decrease the port lines exposure to invading organisms can decrease complications of

bacteremia that could lead to a septic state and be fatal. It has been proven that

intravascular catheter infections cost a hospital $6,000 a year and can prolong a hospital

stay to an additional week (Cunha, 1998). From 2008-2013 more than 30,100 associated

central line bloodstream infections were reported in the United States (Bloodstream

Infection, 2017).
ANTIMICROBIAL TECHNIQUES 3
Today, the Institute of Safe Medicine Practice (ISMP) advises hospitals to teach

their employees adequate aseptic technique when working with intravascular catheters.

Good aseptic technique with intravascular catheters, for the ISMP, are 1) placing a new

sterile cap on the end of each port between uses, and/or 2) disinfecting the port before

each use (Grissinger, 2011). These aseptic practices are used around hospitals today, but

are they adequate antimicrobial methods implemented to cleanse the catheter hubs to

decreasing catheter-associated infection? Which one decreases infection the best? Other

techniques used today are intravascular catheters that are coated in different antimicrobial

substances such as: chlorhexidine/silver sulfadiazine and minocycline/rifampin. Ionic

silver is another technique used, that attaches to the hubs of the invasive line to provide

antimicrobial activity (Hughes, 2002). Although, these other strategies have been proven

to decrease infection – they are expensive implementation compared to the two most

common techniques used today.

Catheter associated infections through an intravenous line is a critical problem

that does not only impact hospital organizations but can be fatal to every patient that has

a intravenous catheter placed, if not properly taken care of. In the United States more

than 28,000 patient’s die from intravenous line associated blood stream infections every

year (Tools for Reducing, 2012). Patient’s that develop an infection, associated to their

intravenous line, puts them at risk of increased hospital stay, readmission, and ultimately

a fatal event. To decrease hospital acquired conditions such as, intravascular catheter

associated infections, a program called, Hospital Acquired Conditions Reduction

Program (HACRP) was established within the Patient Protection and Affordable Care Act

(ACA), that was implemented in the 2015 fiscal year (Hospital-acquired Condition,
ANTIMICROBIAL TECHNIQUES 4
2017). What the HACRP program created was an incentive well known as, ‘pay-for-

performance’ – meaning that hospitals are surveyed, typically through The Joint

Commission, and ranked on their performance across two domains that measure patient

safety and care ("Hospital-acquired Condition," 2017). If hospitals rank in the low 25

percent of each section in each domain, they are subjected to a one percent payment

reduction. The money lost by hospitals that did not perform up to standard is given to the

hospitals that meet performance standards through the program, Hospital Value Based

Purchasing (HVBP) – the money is redistributed (Haley, Zhao, & Spaulding, 2016). This

impacts the hospital organizations by depleting payments because of decreased

performance of patient safety, putting patient’s more at risk for a hospital acquired

infection such as an IV acquired infection. If hospitals fall short of standard performance

they could potentially lose their accreditation and lose Medicare and Medicaid

reimbursement.

The Center for Disease Control and Prevention (CDC) has guidelines for

preventing intravascular catheter associated infections by using chlorhexidine/silver

sulfadiazine impregnated venous catheters ("Guidelines for the Prevention," 2011).

Although, this is the recommendation, this method is rarely used because of cost. As

mentioned above, the ISMP encourages healthcare employees to use proper aseptic

technique when handling intravascular catheters, including, establishing a new sterile

impregnated cap to the end of each port between use or disinfecting each port before use

with an alcohol pad –‘scrub the hub’ (Grissinger, 2011). ISMP does not give us

information on which of the two methods is more effective in decreasing infection

associated to catheter cleansing before use. The process for ‘scrubbing the hub’ is, using
ANTIMICROBIAL TECHNIQUES 5
clean-gloved hands to clean the port with an alcohol pad vigorously for 15 seconds and

allow to air-dry before access. A con to using this method is, that many healthcare

providers confess to not implementing the 15-second-time requirement (Moureau &

Dawson, 2010). The recommendation for impregnated alcohol caps is, that they are to be

placed on the end of a port between each use and needs to be left on for five minutes to

fully disinfect (Moureau & Dawson, 2010). A pro to using the impregnated caps is that it

protects the ports from touch contamination between each use. A con to the impregnated

caps is that they need to be left on for five minutes to effectively disinfect port (Moureau

& Dawson, 2010).

The Journal of Emergency Nursing, rules out the ‘looping’ technique, for it is not

recommended by the ISMP or by the Infusion Nurses Society (INS) as safe practice to

decrease intravascular line infections (Paparella, 2017, p. [Page 362]). ‘Looping’ is a

technique where the end of an intravascular port is connected to some part of the same

intravascular line for protection of contamination. Ruling out ‘looping’, this article

proclaims that both methods of ‘scrub the hub’ and ‘sterile capping’ are the two standard

protocols for intravascular disinfection from 2016 to current times (Paparella, 2017, p.

[Page 362]). Although, both of these two methods suggested by the ISMP are

implemented today, alcohol impregnated port protector caps have been proven to

decrease infection compared to scrubbing the ports with alcohol. In a journal article that

described the two methods suggested by ISMP showed, that not only did the impregnated

caps disinfect the ports upon use for intravascular therapy but it also implemented

continuous passive disinfection in between use (Moureau & Dawson, 2010). In the

American Journal of Infection Control journal article they showed a decrease in blood
ANTIMICROBIAL TECHNIQUES 6
culture contamination by 32 percent with alcohol disinfection caps compared to

maintenance care bundles and the ‘scrub the hub’ technique (Sams, Martin, Carraway,

Ruge, & Stettler, 2015, p. [Page S7]).

The most commonly used standard techniques, ‘scrub the hub’ and impregnated

sterile caps, have both been implemented at two of the Level 1 Trauma Centers in Utah –

Intermountain Medical Center (IMC), Murray and the University of Utah Hospital. In the

University of Utah’s, policy records for intravascular standards summation, it states hand

hygiene is to be performed before cleansing the port with alcohol for at least 15 seconds

then allow to completely air dry before access (Policy: IV Standards, 2017). An exception

is stated if the port has been protected with an alcohol impregnated cap protector for at

least three minutes ("Policy: IV Standards," 2017). During clinical experience at the

University of Utah, most of the medical surgical floors ‘scrubbing the hub’ with alcohol

is more commonly used than impregnated caps. Although, unable to obtain IMC’s

intravascular written protocols, it was observed that the facility in their Intensive Care

Units (ICU), nurses immediately look for uncapped intravascular lines; they implement

the insertion of the alcohol impregnated caps when a line is not in use or immediately

after therapy. If a line is in need of use but was not capped, ‘scrubbing the hub’ with

alcohol and letting the port dry completely before use is in protocol. Although, both

techniques are in standard protocol for both hospitals, an impregnated cap is shown to be

recommended over scrubbing the hub at IMC whereas scrubbing the hub is the first line

of disinfecting the port before the use of impregnated caps at the University of Utah

hospital. In the Utah Department of Health’s Annual Report for 2016, Intermountain

Medical Center and the University of Utah hospital both were shown to have statistically
ANTIMICROBIAL TECHNIQUES 7
fewer infections than the national baseline (Snodgrass, Gruninger, & Ward, 2017).

Although, one technique is preferred over the other at both facilities, both techniques

seem to show their ability to decrease intravascular associated bloodstream infections.

Potential barriers that could be an issue for complete disinfection to prevent

intravascular associated bloodstream infections is time dependent factors for both

techniques. Time is of the essence for both techniques commonly used today to prevent

intravascular line associated bloodstream infections. An observational design was

performed and was published in the American Journal of Infection Control, that

compared the time caregivers scrub the hub before any interventions occurred, to the time

scrubbing with education intervention, and lastly the time when using a timing device

such as a timer or music (Caspari, Epstein, Blackman, Jin, & Kaufman, 2017, p. 648-

651). Through observation this study showed that caregivers were spending less than the

15-second-time protocol (10 plus or minus 5 seconds) of scrubbing without any

interventions compared to after interventions (23 plus or minus 12 seconds) and using a

timer (31 plus or minus 8 seconds). This article proved that without interventions or using

a timing device ‘scrubbing the hub’ could potentially be hazardous to the time dependent

protocol of ‘scrubbing the hub’ for at least 15 seconds. No articles were found about the

safety of keeping the impregnated caps on for a certain amount of time but Merit Medical

Systems informs that if the cap is on for at least 30 seconds disinfection occurs

("Bringing Disinfection," 2017). Healthcare providers have confessed to not

implementing the time dependent rule to both techniques that could potentially increase

the rate of intravascular associated bloodstream infections. Although, the two methods
ANTIMICROBIAL TECHNIQUES 8
are used, if they are not performed to protocol standards, especially the time dependency,

infection rates could increase.

Despite the availability of newer and more sophisticated methods, ‘scrubbing the

hub’ and the use of impregnated sterile caps are more commonly used throughout the

clinical setting today. Both methods have been shown to decrease infections associated

with intravascular lines, but the use of impregnated sterile caps has the additional benefit

of keeping the lines sterile between uses. Noncompliance to proper protocol could

potentially result in decreased sterility because both methods are time dependent for

efficacy. In conclusion, according the evidence based research both ‘scrubbing the hub’

and impregnated alcohol caps have been shown to be effective. Although, using

impregnated caps further decreases intravascular line associated bloodstream infections

because of the delivery of continuous sterility.

ANTIMICROBIAL TECHNIQUES 9
References

Bloodstream infection event (Central line-associated bloodstream infection and non-

central line-associated bloodstream infection). (2017). Retrieved from CDC

website: https://www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf

Bringing disinfection & protection together. (2017). Retrieved from Merit Medical

Systems website: https://www.merit.com/cardiac-intervention/solutions/infection-

control/dualcap/

Caspari, L., Epstein, E., Blackman, A., Jin, L., & Kaufman, D. A. (2017). Human factors

related to time-dependent infection control measures: “Scrub the hub” for venous

catheters and feeding tubes. American Journal of Infection Control, 45(6).

Guidelines for the prevention of intravascular catheter-related infections. (2011).

Retrieved from Centers for Disease Control and Prevention website:

https://www.cdc.gov/infectioncontrol/guidelines/bsi/recommendations.html

Haley, R. D., Zhao, M., & Spaulding, A. (2016). Hospital value-based purchasing and 30

day readmissions: Are hospitals ready? Retrieved from CNE Series website:

https://www.nursingeconomics.net/ce/2018/article3403110.pdf

Hospital-acquired condition reduction program (HACRP). (2017). Retrieved from

Centers for Medicare and Medicaid Services website:

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/AcuteInpatientPPS/HAC-Reduction-Program.html

Hughes, J. M. (2002). Guidelines for the prevention of intravascular catheter-related

infections. Retrieved from National Center for Infectious Diseases website:

https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5110a1.htm
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The IV market is large and growing. (2017). Retrieved from Lineus Medical website:

http://lineusmed.com/clinical-info/

Moureau, N. L., & Dawson, R. B. (2010). Keeping needleless connectors clean, part 2.

Retrieved from Nursing 2017 website:

http://journals.lww.com/nursing/Citation/2010/06000/Keeping_needleless_connec

tors_clean,_part_2.19.aspx

Paparella, S. F. (2017). The devil is in the details: Failure to cap or scrub the hub can lead

to infection control risks. Journal of Emergency Nursing, 43(4).

Policy: IV standards summation. (2017).

Sams, K., Martin, S., Carraway, S., Ruge, D., & Stettler, J. (2015). Alcohol impregnated

cap implementation significantly reduces blood culture contamination rates in an

oncology population. American Journal of Infection Control, 43(6).

Snodgrass, L., Gruninger, R., & Ward, R. (2017). Healthcare-associated infections in utah

2016.

Tools for reducing central line-associated blood stream infections. (2012). Retrieved from

Agency for Healthcare Research and Quality website:

https://www.ahrq.gov/professionals/education/curriculum-

tools/clabsitools/index.html

Vera, M. (2016). 50 IV therapy tips and tricks: How to hit the vein in one shot. Retrieved

from Nurseslabs website: https://nurseslabs.com/50-intravenous-therapy-iv-tips-

tricks/