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n Online Exclusive CNE Article
Strategic Patient Education Program to Prevent
Catheter-Related Bloodstream Infection
Rebecca F. DeLa Cruz, MSN, RN, CRNI, OCN®, Brenda Caillouet, MPH, RN, CRNI, and Susan S. Guerrero, MSN, RN, CRNI
Central venous catheters (CVCs) are used commonly for venous access during treatment, and
catheter-related bloodstream infection (CRBSI) is a frequent, yet highly preventable, hospitalacquired infection. One of the performance elements of the Joint Commission’s 2012 National
Patient Safety Goals addresses the education of patients and family members on CVC care and
management, as well as CRBSI prevention before a central catheter is inserted. This article presents the history and roles of the Infusion Therapy Team at the University of Texas MD Anderson
Cancer Center in CVC care and describes an organized patient education program that plays a
key part in the institution’s strategy to reduce and prevent CRBSI. Institutional standard poli© Oncology Nursing Society
cies and procedures for patient care should be in compliance with guidelines of the Centers for
Disease Control and Prevention and the Joint Commission before any patient educational initiative is implemented. Such
standards will serve as a guide to set up, organize, and implement an effective program.
Rebecca F. DeLa Cruz, MSN, RN, CRNI, OCN®, is an assistant nurse manager, Brenda Caillouet, MPH, RN, CRNI, was the associate director at the time this article
was written, and Susan S. Guerrero, MSN, RN, CRNI, is a clinical nurse, all on the Infusion Therapy Team at the University of Texas MD Anderson Cancer Center in
Houston. The authors take full responsibility for the content of the article. This research was supported, in part, by funding from the Patient Education Office of
the University of Texas MD Anderson Cancer Center. The content of this article has been reviewed by independent peer reviewers to ensure that it is balanced,
objective, and free from commercial bias. No financial relationships relevant to the content of this article have been disclosed by the independent peer reviewers or editorial staff. DeLa Cruz can be reached at rdelacru@mdanderson.org, with copy to editor at CJONEditor@ons.org. (First submission December 2010.
Revision submitted January 2011. Accepted for publication January 20, 2011.)
Digital Object Identifier:10.1188/12.CJON.E12-E17
C
entral venous catheters (CVCs) often are used to
access veins during the treatment of patients with
cancer and other chronic or critical conditions.
More than five million central line placements occur
annually in the United States (Macklin, 2007). The
use and manipulation of CVCs and associated devices create a
risk for catheter-related bloodstream infection (CRBSI) and its
subsequent burdens for patients (Shorr, Humphreys, & Helman,
2003). Meticulous care of CVC use is imperative for reducing
the incidence of CRBSI, as is collaboration among stakeholders
to develop high-quality standards of patient care. A performance
element of the Joint Commission’s (2012) National Patient Safety
Goals, which require the use of evidence-based practices that
prevent this type of infection, is to educate patients and family members on CRBSI prevention before a central catheter is
inserted; best practices and patient education should continue
even after insertion.
In this article, the authors present an overview of the history
of the Infusion Therapy Team (ITT) at the University of Texas
MD Anderson Cancer Center, a comprehensive cancer center in
Houston. The authors also briefly describe the causes of CRBSI,
review the published literature on patient education in CVC
care, and describe an organized education program that is key
to the institutional strategy to reduce the incidence of CRBSI.
Background
The ITT of the University of Texas MD Anderson Cancer Center
is believed to be the first and longest continuously operating IV
access team in the United States (Richardson & Caillouet, 2004).
The clinic began in 1975, with the world’s first peripherally
inserted central catheter (PICC) being placed by a nurse, Millie
Lawson, RN. The team currently operates with 58 RNs, 2 licensed
vocational nurses, 2 certified nursing assistants, 7 clerical support staff, 1 mid-level provider, and a surgical fellow rotating in
the department on a daily basis. The unit is responsible for the
management and care of percutaneous CVC and PICC insertions,
over-wire catheter exchanges, and removal of implanted ports.
Most of the catheters have dwell times ranging from months to
years. For the MD Anderson Cancer Center, the longest continuous use is seven years for a silicone PICC and 10 years for a silicone
subclavian CVC. The ITT clinic includes the implanted port clinic,
which comprises a dedicated surgeon, physician assistants, an
Clinical Journal of Oncology Nursing • Volume 16, Number 1 • A Program to Prevent Catheter-Related Bloodstream Infection
E9
RN, and clerical staff; that team performs most implanted port
insertions at the institution. The ITT clinic places an average
of 600 percutaneous CVCs and PICCs and 100 implanted ports
every month.
The ITT nurses function in a variety of roles, including insertion of PICCs; assisting surgeons and mid-level providers with
percutaneous, nontunneled central catheter insertions; and
removal of implanted ports. Specialty-trained and -competent
ITT nurses also perform overwire exchanges to reposition
malpositioned catheters or when an existing catheter needs to
be salvaged because of rupture, lumen occlusion, or need for a
different type of catheter for treatment or suspected infection.
In addition, the ITT team educates patients and family members
on CVC preventative care and maintenance before and after
a catheter is placed. The role of the ITT nurse as educator is
invaluable and critical to reducing the incidence of complications. Patient safety and caregiver education has been included
in ITT practice since the 1970s, long before the emergence of
published literature demonstrating that patient education helps
prevent CRBSI.
In the mid-1970s, options for health care at home were scarce.
Few home healthcare agencies existed for referral that had the
equipment or knowledge to care for patients with CVCs. To
ensure patient safety at home, the ITT team at MD Anderson
Cancer Center created a
Although catheter-related CVC care kit and taught
patients and family membloodstream infection is highly bers to perform ongoing
avoidable, it is the most common maintenance and care.
type of hospital-acquired infection The program originally
used one-on-one teaching
and can cost more than $1.4 (Richardson & Caillouet,
billion per year to treat. 2004). Later, a more formal
education program was
developed to assist and promote self-reliance among patients and
their family members in maintaining CVCs. Classes were held
weekly and later daily; to date, they are held twice each weekday
and once on Saturdays and Sundays.
In 1981, a video on catheter care was developed to facilitate the
educational process and maximize the efficiency of ITT nursing
staff (Richardson & Caillouet, 2004). The CVC care video has
been revised numerous times to reflect changes in practice as
set forth by the professional and national regulatory standards of
the Centers for Disease Control and Prevention (2010), Infusion
Nurses Society (Gorski, Perucca, & Hunter, 2010; Infusion Nurses
Society, 2011), and Oncology Nursing Society (Camp-Sorrell,
2011); the latest revision was completed in 2009. Changes in CVC
care have included the conversion to chlorhexidine-based antiseptic solution and dressings, adaptation of zero reflux connector
caps, and educational emphasis on aseptic techniques geared
toward preventing CRBSI. In 2010, the film won the National
Health Information Merit Award for Patient Education (National
Health Information Awards, 2010).
Catheter-Related Bloodstream Infection
Because the use of CVCs for venous access is essential in
treating patients with cancer, the risk of CRBSI is imminent.
In the United States, an estimated 80,000 cases of CRBSI occur
E10
in intensive care units and 250,000 cases occur in all hospitals
(O’Grady et al., 2011); 12%–25% of those cases result in death
(Harnage, 2008; O’Grady et al., 2002). Although CRBSI is highly
avoidable, it is the most common type of hospital-acquired infection (Stone et al., 2010) and can cost more than $1.4 billion
per year to treat (Ryder, 2010). In 2008, the Centers for Medicare and Medicaid Services issued a regulation on nonpayment
for conditions such as hospital-acquired infections, including
CRBSIs that occur during the hospital stay and are not present
on admission (Stone et al., 2010). Because of the high medical
costs and mortality, the Centers for Disease Control and Prevention recommend the use of standardized practices to decrease
the occurrence of CRBSI (O’Grady et al., 2002).
CRBSI has four common sources (Hadaway, 2006; O’Grady,
2002; Richardson, 2007). A break in the skin during catheter
insertion allows microorganisms normally present on the skin
to gain access to the circulatory system and potentially cause infection. For catheters used long term, the frequent manipulation
of catheter connector end caps and their potential for contamination is the usual cause of CRBSI (Hadaway, 2006). Another
source is contaminated infusates, which permit pathogens to
enter the catheter and bloodstream. Finally, hematogenous
seeding, which occurs when microorganisms from another
infectious site travels to and invades the CVC (e.g., bladder
infection), also can lead to CRBSI.
Literature Review
Limited published information is available about detailed
educational programs geared toward patients and caregivers
in the care of CVCs. The authors conducted a literature review
using the electronic databases PubMed, CINAHL®, and Scopus
and the keywords patient education, central venous catheter
care, home care, and CRBSI. Cole (1999) asserted that initiatives
to involve patients and family members in CVC care promote
patient satisfaction and reduce the incidence of CRBSI. In addition, three articles were identified that focused on the benefit of
patient education in preventing and reducing CRBSI (Møller &
Adamsen, 2010; Møller, Borregaard, Tvede, & Adamsen, 2005;
Santarpia et al., 2002).
The study by Santarpia et al. (2002) showed that formal
and detailed instruction on the use and care of CVCs, with
meticulous attention to aseptic techniques given by a specially
trained team to patients and caregivers, reduced the incidence
of CRBSI. Santarpia et al. (2002) compared group A, which
received written and oral instructions on CVC care, to group
B, which received more detailed instructions and training sessions on CVC care with central focus on aseptic technique and
identification of complications. Results showed that group A
had a CRBSI incidence of 6 per 1,000 catheter days, whereas
group B had 3 per 1,000 catheter days (p < 0.001) (Santarpia
et al., 2002).
Møller et al. (2005) showed that “systematic individualized,
supervised patient education is able to reduce catheter-related
infections” (p. 330). A control group that received inpatient and
outpatient CVC care coordinated by nurses was compared to the
intervention group, which was taught to perform self CVC care.
In that study, the education program provided to the intervention
group was focused on the theory and practice of CVC care, such
February 2012 • Volume 16, Number 1 • Clinical Journal of Oncology Nursing
as cleanliness, sterile techniques in performing the procedure,
uses for the catheter, and the risks involved. The result showed
the incidence of CRBSI was 4.22 per 1,000 catheter days in the
control group and 1.92 per 1,000 catheter days in the intervention
group (p < 0.05) (Møller et al., 2005).
Finally, Møller and Adamsen (2010) found that patients who
received an in-depth, individualized instructional CVC care
program felt more self-reliant and accountable for their own
care compared with patients who received nursing care. The
self-care group also believed that their self-confidence increased
their autonomy and decreased their reliance on nurses. Although
Møller and Adamsen’s (2010) study explored patients’ clinical and
psychological responses to CVC care, it also showed that patients’
feeling of efficiency in performing CVC care and their knowledge
of aseptic techniques possibly helped prevent CRBSI, based on
the results of a previous study that showed a decrease of CRBSI
by 50% (Møller et al., 2005).
Historically, patients and their caregivers did not commonly
participate in CVC care (Cole, 1999). MD Anderson Cancer Center
is an exception in that the patient education program has been in
place since the 1970s. Because of the time span, reviewing patient
outcomes and determining whether the education has been an
effective means of preventing CRBSI would be difficult, as creating a control group would require withholding the complete
educational program from some patients. However, the authors
presumed that the evolving education program has contributed
to the historically low CRBSI rate at the institution in inpatient
and outpatient areas, which also was supported by the other
published study results in the literature review. To date, the institution’s annual infection control report shows a steady decline in
its CRBSI rate per 1,000 catheter days (0.42 in 2006, 0.28 in 2007,
0.28 in 2008, 0.18 in 2009, and 0.12 in 2010).
develop patient education materials that would be readable and
understandable by most patients.
At MD Anderson Cancer Center, all patients needing CVC care
are required to receive specific education on their catheter before
the central line is placed. Patients and their at-home caregivers
receive the written information handout Prevention of Central
Venous Catheter–Related Infections (see Figure 1). The full handout provides an overall review of CRBSI and its prevention, as well
as information regarding the risks, preventive measures, and signs
of CRBSI; changing the CVC dressing; and the change procedures
for the connector injection cap. If a patient or caregiver expresses
that he or she is not ready to assume this responsibility, their
The purpose of this document is to point out certain steps in the care
of your central venous catheter that are important in decreasing your
risk of getting a catheter infection.
What is a catheter-related bloodstream infection (CRBSI)?
uA CRBSI happens when bacteria
gets in the catheter and then enters
your blood stream.
uThe two most common sites that
often contribute to the development
of a CRBSI are the catheter insertion site and the catheter hub.
uCleaning the catheter site and hub
as you have been taught is very
important.
What puts me at risk for getting a CRBSI?
u Low white blood cell counts, as white blood cells help fight infection
u Not washing your hands before and after changing your dressing
u Improper changing of your catheter dressing and cleaning of your
Developing a Patient Education Program
In developing a patient education program, comprehension
level, language barriers, literacy, communication disabilities,
and preferred learning methods must be considered. Nurses
should be attentive to signs of those issues. According to
Vandeveer (2009), “Adults are not content oriented; adults are
self-directed and problem centered, and they need and want
information that can be readily adapted” (p. 207). According
to the National Work Group on Literacy and Health (1998) report, education materials for patients with inadequate literacy
should be written at the fifth-grade level. The average reading
level of an adult is between eighth and ninth grade, and one
of every five individuals can read only at the fifth-grade level
(Doak, Doak, & Root, 1996). Because most illiterate people will
not acknowledge that they are unable to read, write, or comprehend information beyond a fourth-grade level (Bastable,
2008; Cole, 1999), literacy must be considered in the presentation of the instruction. Adult learners, particularly those with
hearing and visual deficits, tend to opt for printed instruction
for reference (Hainsworth, 2008). The use of audiovisual
technology increases retention because the learners are able
to relate printed information and the actual performance of
a task (Hainsworth, 2008). In consideration of the patient
population at MD Anderson Cancer Center, the patient education department chose a sixth-to-eight-grade reading level to
catheter
u Not changing your dressing routinely or when it is wet or soiled
u Not cleaning the injection caps with alcohol before flushing your
catheter
What can I do to decrease my chance of getting a catheter
infection?
u Wash
your hands thoroughly with
soap and warm running water for
at least 15 seconds using friction.
Do this before and after changing
your dressing.
u Change your dressing if it is wet or
dirty.
u Always cover your dressing and all catheter parts with plastic and
tape to protect them while showering.
u Clean the injection cap with an alcohol prep pad just before flushing
your catheter.
u Flush your catheter at least three times a week up to once a day
when you are not getting medicines.
u Don’t change your dressing in the bathroom or kitchen. Use a clean
and quiet place, such as the dining table or bedroom.
FIGURE 1. Prevention of Central Venous Catheter–
Related Infections
Note. Copyright 2006, 2010 by the University of Texas MD Anderson
Cancer Center. Reprinted with permission.
Clinical Journal of Oncology Nursing • Volume 16, Number 1 • A Program to Prevent Catheter-Related Bloodstream Infection
E11
options are visiting the outpatient ITT clinic for routine care or
receiving a referral to a home health agency.
Patients or their caregivers are required to attend the CVC
care class, which addresses catheter flushing, connector cap
change, and the sterile dressing change competency. The class
requirement was added to the written consent form for the
catheter insertion procedure. The standard is to attend the
class twice to be able to obtain competency for all three procedures. The program currently incorporates all the methods
by which adults learn: audiovisual techniques, written handouts, provider demonstration, hands-on practice, and patient
or caregiver return demonstration (Bastable, 2008). Although
the ITT does not formally assess the literacy level of patients
and family members, the CVC care video and the written handouts were created in consideration of literacy level and were
reviewed and finalized by the educator specialists of the
When to Change Dressings
patient education department at MD Anderson Cancer CenMost dressings are changed once or twice a week, depending on the type of
ter. Performing a CVC care return demonstration validates
dressing that you use. In addition, you should change the dressing promptly if
any issues with educational level, listening comprehension,
u The dressing is wet from sweating or bathing.
physical impairments, age differences, and cultural implicau The dressing is coming off or is dirty.
tions. In addition, confirmation of actual learning occurs
u There is new discomfort under the dressing.
during the demonstration. A Spanish version of the video is
available, as are handouts in Spanish, Turkish, Arabic, and
Getting Started
other languages.
u Find a clean, quiet place to work (living room, dining room, or bedroom
The CVC care class begins with a 30-minute film of
is best).
step-by-step instructions. Written handouts with graphic
u Gather all your supplies.
illustrations are distributed at the beginning of the class for
u Wash your hands thoroughly with soap and running water, scrubbing hands
learners to follow along with, record notes and questions on,
for at least 15 seconds, and dry with a clean towel.
or use as a resource (see Figure 2). The video Care of Your
u Place a clean towel under the arm or under the shoulder where the cathCentral Venous Catheter describes a systematic process
eter is inserted.
for safely caring for a CVC. The video presents information
Remove Old Dressing
on the different types of catheters, sites of insertion, parts
of the catheter, and uses for the catheters. Weekly connec! Never use scissors near your
catheter.
tor cap change, routine flushing of the CVC, and changing
u Wear nonsterile gloves. CareCVC sterile dressing are highlighted. Emphasis is placed
fully, using adhesive remover,
on proper hand-washing technique before and after the
remove the old dressing and
care procedures, the importance of maintaining sterile
throw away.
technique, and the difference between clean and sterile. In
u Look for redness, swelling, pain,
addition, frequently asked questions, signs and symptoms
discharge, or loose sutures.
of complications, protection of the catheter during showeru If you see any of these
ing, when and how to report problems or issues, and the
problems, finish the dresshours and contact telephone numbers of the ITT clinic are
ing change and call infusion
reviewed. A voiceover verbalizing the step-by-step instructherapy or your doctor.
u Take off your gloves.
tions and written text added to still shots also draw attention to salient points and details.
Open Dressing Kit
The remainder of the CVC care class consists of a 30-minute
u Open the package and remove
didactic lecture, nurse demonstration of caring for a locking
the kit.
flush and implementing a connector cap change, hands-on
u Remove the glove package and
practice by the learners, and instructions about the return
hand gel. Use the hand gel first.
demonstration requirements. Information is given on the
u Then place the gloves in an
availability of the MD Anderson Patient Learning Center,
area away from the dressing kit.
where patients can go to view the CVC care class video, access
u Before putting on gloves, carefully open the paper wrapping of the
it online via myMDAnderson (a secure Web site), or purchase
dressing kit.
a copy of the video in DVD format for home reference. The
u Then carefully open the glove package. First, pick up a glove by the cuff
film also is available on demand on all hospital network televiand place it on the hand you normally use. Then with the gloved hand,
sions at MD Anderson Cancer Center.
pick up the remaining glove by placing your gloved fingers under the cuff.
Slip glove on other hand.
Class attendance is documented, with about 750 students
u Now, be careful not to touch anything that is not sterile (skin, clothing,
attending the CVC care class each month. Patients and caretable top) with your gloved hands.
givers can choose to repeat classes as often as they like. After
u If you accidentally touch something unsterile with a gloved hand, change
fulfillment of the class requirements and when a patient
gloves right away.
or caregiver feels confident about performing CVC care, a
one-on-one return demonstration is scheduled with an ITT
FIGURE 2. Preparation for Central Venous Catheter
nurse to validate the knowledge and skills learned. During
Dressing Change
the demonstration, the ITT nurse evaluates for readiness
Note. Copyright 1994, 2009 by the University of Texas MD Anderson Cancer
and competence in CVC care. A certificate of completion
Center. Reprinted with permission.
is awarded when the return demonstration is performed
E12
February 2012 • Volume 16, Number 1 • Clinical Journal of Oncology Nursing
Implications for Practice
u
An organized and systematic patient educational program on
central venous catheter care that focuses on sterile technique
is a significant strategy to prevent catheter-related bloodstream infection.
u
The role of nurses as educators is essential to achieve safe and
high-quality standards of patient care.
u
An educational program using detailed written instructions,
audiovisual presentation, instructor-led discussion, hands-on
practice, and one-on-one return demonstration to validate
knowledge and skills learned can empower patients and caregivers to participate in their own care.
Conclusions
Complying with the Joint Commission’s national safety goal
to use evidence-based practices that prevent CRBSI and implementing those measures requires a strategic and organized
education program to directly target and reduce the incidence
of CRBSI, a highly preventable adverse event. The use and incorporation of evidence-based products and the implementation of
best practices to improve health care and promote safety can be
accomplished most effectively through the development of educational initiatives and standard guidelines. In addition, nurses
and their institutions should keep abreast of current available
healthcare trends and evidence-based medicine.
The authors gratefully acknowledge Judy K. Payne, PhD, RN,
AOCN®, for her editorial contributions.
successfully; only then will any supplies be released to the
patient for home care. However, if the nurse determines that
the patient or caregiver is unable to follow and perform the
procedure safely, more class time is suggested or the patient is
instructed to visit the ITT clinic for routine CVC care. Another
option is for the patient’s primary clinic to arrange a home
healthcare referral. About 95% of the patients and their caregivers perform their own CVC home maintenance.
A patient satisfaction survey conducted quarterly by the ITT
includes a question focused on the perceived confidence of
patients or caregivers in performing CVC care and their knowledge of where to seek help if needed. Of 861 returned voluntary
surveys for 2009, 97% responded positively to that question.
Implications for Nursing Practice
Regulatory standards for improved healthcare delivery are
changing constantly to meet demands for safe, cost-effective,
and evidence-based care. An annual safety goal of the Joint Commission is CRBSI prevention. For patients who receive CVC care
at home, the goal can be accomplished with standardized education that accounts for differing levels and means of learning and
communication.
Patient safety is a systemwide opportunity (Murdaugh & Jordin, 2008). For an education program to be effective, a collaborative, sustained effort and accountability are required among
all stakeholders (e.g., leaders of health institutions, healthcare
providers, patients and their families) to comply with and meet
federal and professional standards. At MD Anderson Cancer
Center, institution-wide standard policies and procedures for
patient care must be set before any educational program is
implemented; the ITT ensured the policies and procedures
were in place for the patient education program on CVC care
to reduce the incidence of CRBSI. The standards are a valuable
guide for setting up, organizing, and implementing an education initiative.
As educators, nurses are on the front line of the healthcare delivery process and are responsible for catalyzing change, whether
in the clinical or academic setting. For that reason, the nursing
profession holds a great responsibility for improving patient
safety and standards of patient care. Those changes can improve
patient outcomes and satisfaction, nursing career fulfillment,
and healthcare costs.
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For Exploration on the Go
Learn more about catheter-related infections in Access Device Guidelines: Recommendations for Nursing Practice and Education
by Dawn Camp-Sorrell by opening a barcode scanner on your smartphone. Point your phone at the code and take a photo. Your
phone will link to the content automatically. Or, access this content at http://esource.ons.org/ProductDetails.aspx?SKU=INPU0600.
Receive Continuing Nursing Education Credits
Receive free continuing nursing education credit* for reading this article and taking a brief quiz online. To access the test for this and
other articles, visit http://evaluationcenter.ons.org/Login.aspx. After entering your Oncology Nursing Society profile username and
password, select CNE Tests and Evals from the left-hand menu. Scroll down to Clinical Journal of Oncology Nursing and choose the
test(s) you would like to take.
* The Oncology Nursing Society is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s COA.
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February 2012 • Volume 16, Number 1 • Clinical Journal of Oncology Nursing
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