What is the protocol for preventing central line-associated bloodstream infections (CLABSIs)?

CLABSI Prevention Protocol

The most effective approach to preventing Central Line-Associated Bloodstream Infections (CLABSI) is implementing a comprehensive multidimensional strategy that includes care bundles, education, surveillance, compliance monitoring, and performance feedback. 1

Pre-Insertion Preparation

• Mandate education and competency assessments for all healthcare professionals involved in central line insertion and maintenance 2
• Evaluate the necessity of central line placement versus alternative options
• Select optimal insertion site (avoid femoral sites in adults except for hemodialysis; consider PICCs which have lower CLABSI risk) 1
• Prepare all necessary supplies using a central line insertion cart or kit

Insertion Bundle

1. Hand hygiene before any central line procedure
2. Maximum barrier precautions:
   • Provider: Cap, mask, sterile gown, and sterile gloves
   • Patient: Cover with large sterile drape
3. Skin antisepsis:
   • For patients >2 months: Use alcoholic chlorhexidine solution (minimum 2% CHG)
   • For neonates <2 months: Use povidone-iodine with 2-minute dry time
   • Allow antiseptic to completely dry before skin puncture
4. Use ultrasound guidance when available to decrease complications 1
5. Document insertion procedure and any complications

Maintenance Bundle

1. Daily necessity evaluation: Assess ongoing need for central line 1
2. Dressing management:
   • Apply chlorhexidine-containing dressings for patients >2 months of age 2
   • Replace transparent dressings every 7 days with CHG-based antiseptic
   • Replace gauze dressings every 2 days
   • Replace immediately if soiled, loose, or damp
   • Use gauze instead of transparent dressings for sites with bleeding/drainage
3. Access port management:
   • Disinfect catheter hubs, needleless connectors (NCs), and injection ports before each access
   • Use passive disinfection with 70% alcohol-impregnated caps or
   • Perform mechanical disinfection with friction for 5-15 seconds 2
4. Consider daily chlorhexidine bathing for ICU patients >2 months of age 1

Staffing and Organizational Factors

• Maintain appropriate nurse-to-patient ratios in ICUs 2
• Restrict use of float nurses in ICUs 2
• Implement a nurse-led multidisciplinary team approach 1

Surveillance and Monitoring

1. Use standardized CDC/NHSN surveillance methods and definitions 2
2. Calculate and track metrics:
   • CLABSI rate: (Number of CLABSIs ÷ Total central line-days) × 1,000
   • Device utilization ratio: observed CL days ÷ observed patient days
3. Stratify rates by patient-care unit type
4. Perform root cause analysis for all CLABSI events
5. Provide regular performance feedback to staff 1

Resource-Limited Settings Recommendations

• Use collapsible closed-system IV fluid containers instead of open-system rigid containers 2
• Use needleless connectors instead of three-way stopcocks 2
• Prefer positive displacement NCs over negative or neutral displacement NCs 2

Practices to Avoid

• Do not use antimicrobial prophylaxis during short-term tunneled catheter insertion 2
• Do not routinely replace central lines or arterial catheters 2
• Avoid CHG bathing and dressings for infants under two months due to risk of severe skin reactions 2, 1

Common Pitfalls and Caveats

1. Inadequate staff training: Ensure all staff are properly educated and assessed
2. Poor compliance monitoring: Track bundle compliance using objective measures
3. Inconsistent documentation: Standardize documentation of insertion and maintenance
4. Delayed catheter removal: Remove central lines as soon as they are no longer necessary
5. Skin reactions to CHG: Monitor for contact dermatitis, particularly in neonates and pediatric populations 2

Implementation of these evidence-based practices has been shown to dramatically reduce CLABSI rates, even in settings with initially low infection rates 2, 1.