Healthcare associated infections
February 2006
Strategies for improvement: role of the healthcare professional
Reducing the risk of infection from the use of indwelling devices
With the body’s natural defences transiently breached, it is very common for infection to be transmitted at the site where devices such as catheters, tubes and cannulae enter the body. The impact of medical devices is highlighted by the fact that 80 per cent of urinary infections, which make up 23 per cent of all HCAIs, can be traced back to indwelling urinary catheters, while 60 per cent of bacteraemia infections are introduced by intravenous feeding lines, catheters or similar devices. [Go to note 1] In a study of the sources of bacteraemia in English hospitals between 1997 and 2002, almost two-thirds of bacteraemias were associated with an intravascular device or with device-related infections. [Go to note 18] In order to prevent infection it is important that these devices are sterilised and are used and managed in an appropriate and hygienic manner.
There is a wide variety of indwelling devices used in the healthcare setting and specific guidelines have been developed to prevent infections associated with the use of urinary catheters, central venous lines, parenteral and enteral feeding lines, peripheral intravenous cannulae and respiratory support apparatus (see boxes 6-11). The risk of infection with indwelling devices is associated with the method and duration of insertion, the quality of device care and host susceptibility. The use of indwelling devices is commonplace in hospitals and is increasing in primary and community settings. Long-term urinary catheterisation and enteral feeding are routinely used in the community for the management of elderly patients. With enteral feeding, the contamination of feeds is a key concern because it has been found that more than 30 per cent of feeds in hospital and home are contaminated with a variety of micro-organisms, largely due to the preparation or administration of feeds, and this has been linked to serious clinical infection. [Go to note 22] Patients in the community with chronic health conditions may require short- or long-term central vascular access as a necessary component of their treatment. The management of indwelling devices is an area where healthcare professionals, carers and patients in all healthcare settings have an important responsibility for the control of HCAIs.
Box 6: Care of patients with long-term urinary catheters
- Urinary catheters should only be used when there is no suitable alternative, and even then kept in place for as short a time as possible.
- Where long-term indwelling use is unavoidable, a catheter of low allergenicity will be used.
- Urinary catheter insertion, manipulation, washing out, urine sampling and removal will be undertaken by trained and competent staff using strictly aseptic techniques.
- Patients and carers will be educated in catheter maintenance with an emphasis on the techniques for reducing risk of infection.
- The date of insertion and date of removal of the device will be documented in the clinical record as a matter of routine.
Source: Winning ways – working together to reduce healthcare associated infection in England (DH, 2003)
Box 7: Care of patients with central venous catheters
- Central venous line insertion, manipulation, and removal will be undertaken by trained and competent staff using strictly aseptic techniques.
- Central venous line catheters will not be replaced over a guide wire if infection is present.
- A dedicated occlusive transparent dressing will be used to allow continuous inspection of the exit site and will be changed at no later than seven days.
- The date of insertion and date of removal of the device will be documented in the clinical record as a matter of routine.
Source: Winning ways – working together to reduce healthcare associated infection in England (DH, 2003)
Box 8: Care of patients during enteral feeding
Preparation and storage of feeds
- Wherever possible pre-packaged, ready-to-use feeds should be used in preference to feeds requiring decanting, reconstitution or dilution.
- The system selected should require minimal handling to assemble, and be compatible with the patient’s enteral feeding tube.
- Effective hand decontamination must be carried out before starting feed preparation.
- When decanting, reconstituting or diluting feeds, a clean working area should be prepared and equipment dedicated for enteral feed use only should be used.
- Feeds should be mixed using cooled boiled water or freshly opened sterile water and a no-touch technique.
- Feeds should be stored according to manufacturer’s instructions and, where applicable, food hygiene legislation.
- Where ready-to-use feeds are not available, feeds may be prepared in advance, stored in a refrigerator, and used within 24 hours.
Administration of feeds
- Minimal handling and an aseptic no-touch technique should be used to connect the administration system to the enteral feeding tube.
- Ready-to-use feeds may be given for a whole administration session, up to a maximum of 24 hours. Reconstituted feeds should be administered over a maximum four-hour period.
- Administration sets and feed containers are for single use and must be discarded after each feeding session.
Care of insertion site and enteral feeding tube
- The stoma should be washed daily with water and dried thoroughly.
- To prevent blockage, the enteral feeding tube should be flushed with fresh tap water before and after feeding or administrating medications. Enteral feeding tubes for patients who are immunosuppressed should be flushed with either cooled freshly boiled water or sterile water from a freshly opened container.
Source: Infection control – prevention of healthcare-associated infection in primary and community care (NICE, 2003)
Box 9: Care of patients during parenteral feeding
- Intravenous feeding lines will only be used when there is no suitable alternative, and even then kept in place for as short a time as possible.
- Insertion, manipulation, and removal of intravenous feeding lines will be undertaken by trained and competent staff using strictly aseptic techniques.
- A dedicated line or lumen of a multi-channel line will be used. No other infusion or injection will go via this route. Three-way taps will not be used.
- Any additives to intravenous fluid containers will be introduced aseptically in a unit or safety cabinet designed for the purpose, by trained staff using strictly aseptic techniques.
- Intravenous feeding cannulae insertion sites will be regularly inspected for signs of infection and the cannula removed if infection is suspected.
- The date of insertion and date of removal of the device will be documented in the clinical record as a matter of routine.
Source: Winning ways – working together to reduce healthcare associated infection in England (DH, 2003)
Box 10: Care of patients with peripheral intravenous cannulae
- Intravenous cannula insertion should be carried out by trained and competent staff using strictly aseptic techniques.
- The number of lines, lumens and stopcocks will be kept to the absolute minimum consistent with clinical need.
- Peripheral intravenous cannulae insertion sites will be regularly inspected for signs of infection and the cannula removed if infection is suspected.
- Peripheral intravenous cannulae will be kept in place for the minimum time necessary and changed every 72 hours irrespective of the presence of infection.
- Administration sets will be changed immediately following a blood transfusion, intravenous feed or at 24 hours (whichever is sooner). For other clear fluids, change will occur at 72 hours.
- The date of insertion and date of removal of the device will be documented in the clinical record as a matter of routine.
Source: Winning ways – working together to reduce healthcare associated infection in England (DH, 2003)
Box 11: Care of patients on respiratory support systems
- Ventilator tubing will only be changed when visibly soiled or malfunctioning.
- Gloves will be worn for handling respiratory secretions or contaminated objects.
- Gloves and appropriate personal protection will be used when aspirating respiratory secretions.
- Hands will be decontaminated after glove removal.
- The date of insertion and date of removal of the device will be documented in the clinical record as a matter of routine.
Source: Winning ways – working together to reduce healthcare associated infection in England (DH, 2003)
Further information
- More detailed information can be found in Urinary catheterisation and catheter care: best practice statement (NHS Quality Improvement Scotland, 2004), Winning ways: working together to reduce healthcare associated infection in England (Department of Health, 2003), Infection control: prevention of healthcare-associated infection in primary and community care (NICE, 2003) and The epic project – developing national evidence-based guidelines for preventing healthcare associated infections (Department of Health, 2001).
- Specific guidance for the use of arterial catheters can be found in a publication from the Royal College of Nursing (RCN), Standards for infusion therapy (RCN, 2005).