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García-Rivero C, Aguilar EM. Mantenimiento del catéter venoso central en la unidad de trasplante de médula ósea. Rev Enferm Inst Mex Seguro Soc. 2015;23(3):157-62.

Maintenance of central venous catheter in bone marrow transplant unit

Clementina García-Rivero,¹ Eloy Margarita Aguilar¹

¹Coordinación de Investigación en Enfermería, Departamento de Enfermería, Hospital Infantil de México “Dr. Federico Gómez”, Distrito Federal, México

 

Correspondence: Clementina García Rivero

Email: clegari57@yahoo.com.mx

Received: April 16^th 2015

Judged: June 24^th 2015

Accepted: July 22^nd 2015

Abstract

Introduction: Infection related to the use of central venous catheters (CVC) is a complication with a high prevalence. In the pediatric patient candidate for bone marrow transplant, the risk grows and increases predisposition. The safe practice of nursing interventions is crucial for the prevention of CVC infection and occlusion.

Objective: To evaluate the performance of nursing staff in the Pediatric Bone Marrow Transplant Unit (PBMTU) in the safe practice of nursing interventions and CVC maintenance techniques.

Methodology: A descriptive study was conducted with all nursing staff (20) of the PBMTU. A checklist was designed with 58 nursing interventions. Compliance was rated on a qualitative nominal scale and data analysis was done in Excel and SPSS version 9.

Results: Of the total of 58 nursing interventions, 26 interventions (hand washing) were fulfilled to 100 %, and 44 % washing catheter after taking products. 85 % of nurses carried out a total of 55 interventions. Seniority positively influenced compliance in evening shift personnel (F = 5.830, p = 0.007). Two nurses had 100 % safe practice: one from the morning shift and one from the night shift.

Conclusion: 85 % of PBMTU nurses safely practice interventions and CVC maintenance techniques in a timely and sufficient manner; therefore, their actions are appropriate.

Keywords: Catheter related infections; Bone marrow trasplantation

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Introduction

Central venous catheters (CVC) are invasive devices that can be implanted for a long time, like Hickman lines, which are indicated for the patient to receive bone marrow transplantation (BMT).^1,2 Its distal end is located in the superior or inferior vena cava. They are installed for the infusion of parenteral nutrition or chemotherapy fluids and for monitoring and diagnostic tests. They are also predisposed to complications such as infection and occlusion, among others, which have high morbidity and mortality and economic cost, so that nursing care by applying appropriate and timely maintenance techniques can influence the decrease of CVC infection and occlusion.

It is very important that nursing staff be trained in the care requirements and knowledge of CVC complications, as these are often directly related to nursing care. The nursing staff must be aware that these potential problems will disappear with the implementation of the various protocols: "It is necessary to have guidelines and protocols that give enough autonomy to nursing professionals to solve problems arising from intravenous therapy, while checking periodically the degree of compliance with them." The training and development in practical skills and consensus in care based on scientific knowledge about CVC maintenance related to the potential problems of occlusion and bacteremia is important.¹

In another CVC care guide we found that the procedures for maintenance are: sealed, blood sample, and dressing change to keep CVC permeable and aseptic.³ Specific recommendations are: to irrigate the catheter lumen with saline solution each time a medication is administered or suspended, heparinize the catheter when not in use for long periods every 24 hours with the commercial preparation in single dose, check the compatibility of the solutions if administered by the catheter lumen, discard a few centimeters blood before using catheters that have previously been sealed with heparin, and if a pathway that was sealed for several days releases no blood, do not wash with serum for risk of producing bacteremia.

The Hospital de Rancagua, in its CVC maintenance protocol, aims to standardize the management of CVC to minimize the risk of infection, occlusion, and displacement associated with handling; it recommends daily observing the seal of the insertion site, the characteristics of the skin surrounding the CVC, CVC attachment, and connections aligned parallel, not strained. It specifies procedures: dressing change every five days; care for the insertion site; changing the infusion system, avoiding disconnections recommended; maintaining catheter permeability, checking that there are no bends, and lumen washing after drawing blood; preventing infection through handling with aseptic technique and keeping the insertion site sealed; recording the date of healing on the attachment. The indicator applies it quarterly, and 80% compliance is expected with the protocol for managing CVC.⁴

In order for their status to be permeable and aseptic, and so to avoid complications, here we list some considerations to take into account the maintenance and care of the CVC: use transparent dressing which allows the insertion site to be evaluated, and change it once a week; use sterile gloves for dressing change, and change them between removal and repositioning; wash hands and use sterile gloves to handle equipment and connections; decrease the number of handlings. These are the indications that the nursing protocols and procedures manual dictates.⁵

The Revista de la Asociación de Enfermería (Nursing Association Journal) mentions that "in the United States, starting October 1, 2009, Medicare [health insurance] will cease to cover the costs of eight types of preventable medical errors that occur in hospitals. According to the US healthcare agency, the central venous catheter-related infections are one of eight preventable medical errors. These experts place emphasis on the training of health personnel and the need for intravenous therapy teams (ITT) in hospitals. This would be a qualitative and quantitative change. "We must be aware that the recipient of all this is the patient and that they deserve and are entitled to be treated with the professionalism demanded by new technologies".⁶ Gonzalez Perez mentioned regarding CVC maintenance: "It is very important to have nursing care protocols so that care of pathways is always carried out in the same manner".⁵

NOM-022-SSA3-2012, which establishes the conditions for the administration of infusion therapy in Mexico, provides the necessary and sufficient conditions for a homogeneous clinical practice that contributes to achieving a secure and risk-free care, establishing minimum standards for the maintenance of central venous access to contribute to improving the quality of patient care. It mentions that in Mexico between 80 and 95% of hospitalized patients receive intravenous treatment and that in the United States annually over five million central venous catheters are placed.⁷

The procedure operations manual specific to the catheter clinic of the Instituto Nacional de Rehabilitación (INR) reports that hospitals should have policies, clear procedures, and objectives for how it will perform the central and peripheral intravenous therapy, based on the implementation of policies and procedures to be used in the catheter clinic (CC) in order to standardize criteria for action. The information gathered by the CC is to be processed and reviewed in order to obtain statistics and make pertinent changes.⁸

In a study that evaluated 40 nurses from the morning shift of oncology and surgery services, who had attended a training course on insertion and maintenance of central lines, 100% answered dressing change is done with gloves but only 40% said with sterile gloves. As for monitoring the insertion point, only 25% answered correctly. 47% answered that it must be done each shift and not every 24 hours (28%), as required by the protocol. Only seven nurses (17.5%) correctly answered the question about care of the insertion site (cleaning with saline). The results from checklists and surveys regarding the insertion and maintenance of catheters are very good. However, it is worrying that only 20% of the listed items had been observed, and it would be necessary to check whether this is due to lack of adhesion, through lack of knowledge or work overload.⁹

In an investigation to determine the level of knowledge and care provided by the nurse to the patient with CVC in critical care units, the level of knowledge was fair in 73%, and the care given to CVC was fair in 70%. Level of knowledge is significantly related to care (p = 0.000).¹⁰

Another study to determine the current state of knowledge in CVC management by nurses in Culiacan, Mexico, reported that 100% know the usefulness of CVC, 79% identify the types of CVC, 22% know the effect of alcohol, 29% of chlorhexidine and 25% of the povidone iodine, and between 72 and 87% use masks and perform hand hygiene before using the CVC, and 69% do antisepsis of the lumens during procedures. 

Since nursing staff is directly responsible for the implementation of the maintenance techniques of the CVC (healing, heparinization, taking blood products, and changing infusion lines), in the Unidad de Trasplante de Médula Ósea (UTMO) it is considered important to know whether the application of this set of established techniques in the UTMO procedures manual is applied by the nursing staff adequately and properly, since in BMT patients the infusion of bone marrow is done through CVC and there is also a stage of anaplasia after the infusion, during which the likelihood of infections increases and the possibility of replacing the CVC diminishes, so blockage or infection influence the result and increase the risk of complications that lead to BMT failure.

Methodology

An observational, longitudinal, descriptive, and prospective study was conducted in the UTMO of a tertiary care hospital with a universe of 20 nurses. No selection criteria were specified, since a census was done that included 20 nurses in the three shifts, which is the total population, with different categories, years of service in the UTMO, and academic level.

An instrument was designed for data collection consisting of a checklist, called "bone marrow transplant". This list included: identification sheet, 16 interventions for taking blood products, 16 for the heparinization process, 12 for changing infusion lines, and 14 for insertion site healing, with a total of 58 interventions based on review of the literature in the field and what was established by the hospital institution, with a nominal quantitative scale (Yes, No). It was applied to 17 UTMO nurses, morning, evening and night shift on two occasions (34 surveys applied); the remaining three were not implemented for work reasons on part of the nurses.

Identification sheet data were taken from the staff data bank. The instrument was applied to general and specialist nurses trained in the care of BMT patients. The training had been either in the UTMO of Instituto Nacional de Cancerología (INC) or in the hospital where the research was conducted, and was applied by the director of research on two occasions. The average time of application of each checklist was 20 minutes (per technique) and the staff were prevented from noticing that they were observed to avoid them modifying the application of the technique.

For the data analysis a code sheet was developed and an Excel database designed, where the data were captured. A statistician was collaborating, who, supported by the software package Excel and SPSS, version 9, performed the variable analysis using the statistical alpha test. The criteria for assessing compliance with timely and sufficient CVC maintenance (healing, heparinization, taking blood products, changing infusion lines) were Good, Fair and Poor.

Results

Thirty four checklists were applied to 17 nurses, of which 39% belonged to the night shift, 32% to first shift and 29% to second shift, with an average age of 33 years and a frequency of 28 years. All were female, 74% had their degree in general nursing studies, 53% had training in BMT patient care in the INC and 47% had done it in the hospital where the research was done. 50% had three years of service. The shift to apply techniques complying with the most interventions was the evening shift, which was the one that had a higher rate of seniority, which influenced the application of appropriate and proper techniques, (F = 5.830; p = 0.007).  

The results indicated that the techniques of CVC maintenance by nurses of the pediatric UTMO were applied properly and in a timely manner when application rates were analyzed by intervention of each technique, since a high rate of compliance with these interventions was found: 100% handwashing before starting the procedure; using gown, mask, cap, sterile areas and doing aseptic technique with universal specifications; preparation of infusion lines in laminar flow hood respecting aseptic and antiseptic principles; watching for signs of infection at the insertion site; use of dressing appropriate to skin condition. The implementation of these interventions is important because it helps reduce one of the most frequent complications, local and systemic infections related to the CVC, which increase in BMT patients because of immunosuppression. 85% changed gloves after doing aseptic technique in the lumens, 97% applied three doses of Isodine solution, 91% used an applicator moistened with Isodine solution to remove material adhering to the insertion point and respected aseptic and antisepsis principles, 91% prepared the material before starting the procedures, 79% reviewed protocol of products and removed the gauze covering the lumens before starting the process of taking products. These are factors that increase the risk of infection, so its proper application reduces the risk of this complication. 

It is inferred that 100% perform aspiration of 3 ml of blood before beginning to take blood products, which increases the reliability of laboratory results, which are critical to the treatment and detection of complications in pediatric BMT patients. One thing that may reduce this reliability is that 62% do not close the CVC clamps and 44% do not "wash" with saline prior to taking blood, and that can be altered according to the solutions that are infused at that time.

Heparinization was done with heparin 700U (as dictated by procedure) prior to "washing" with 10 ml of saline solution in 94%, 82% "washed" the CVC with saline solution at the end of taking products, 76% held the CVC clamps closed before and after heparinizing, 97% affixed the CVC to the skin. Failure to follow these interventions predisposes occlusion by fibrin clots or angles that prevent the flow of solutions.

It is noteworthy that in taking blood products and changing infusion lines 100% made notations on the nursing sheet, in heparinization 94% did and in healing 41% did, with nurse’s name and the date. If the date of heparinization or how it was done is unknown, this complicates decisions regarding the cause of occlusion if it were to happen. Knowing who did the healing (and when they did it) is important because it defines the responsibilities of the nurse.

Of the 58 interventions comprising the techniques for CVC maintenance, 26 were fulfilled by 100%, 44 by 85%, 8 in over 60%, 1-44% washing CVC before taking products, 1-41% recording date and name of the nurse who did the healing. This represents a total of 17 nurses who carry out over 55 interventions of the 58 techniques. Those performed in a low percentage have little influence on infection and occlusion. Two apply 100% of the operations located in the first and third shift, so it is found that the application of maintenance technique is timely and sufficient.  

Discussion

The study was longitudinal, descriptive and prospective in the UTMO in a tertiary care hospital. It had a universe of 20 nurses, three of which were left out. To determine if the techniques of CVC maintenance were conducted by nursing staff adequately and properly, a checklist was applied with a total of 58 interventions. Care was taken not to let the nurse know she was observed. We believe that the results can be disseminated throughout the hospital to make nurses aware of the importance that their interventions be carried out properly and adequately.

In the results it emerged that 100% apply the interventions of hand washing, using sterile areas and performing aseptic technique with universal specifications, preparation of infusion lines in the laminar flow hood, respecting the aseptic and antiseptic principles, watching for signs of infection at the insertion site, and using dressing appropriate to the skin condition. This contrasts with what was found in a study conducted the Hospital Clinico San Carlos in 192 intensive care units. The results obtained from the maintenance checklists reported 57% gauze dressing, 15% dirty or detached, 40% changed dressing with sterile gloves, and 17.5% cared for the insertion area according to protocol.

An important factor of these contrasting results is probably the service in which it was conducted, as in the UTMO the use of surgical uniform, boots, hat, and mask is required, as well as the constant monitoring of handwashing technique. The equipment to do the maintenance procedures has the material necessary for this purpose according to the technique to be done.

In an investigation to determine the level of knowledge and care provided by the nurse to the CVC in critical care units, the level of knowledge was fair in 73%, the care given to CVC was fair in 70%, a checklist of maintenance techniques was applied; knowledge level was significantly related to care (p = 0.000).⁹ This research found that the results differ even though they are applied in the same service and knowledge was measured in both. The results are related to those obtained in the study, since the application of CVC maintenance is good.

Another study to determine the current state of knowledge of CVC management in nurses in Culiacan, Mexico, reported that 100% know the usefulness of CVC, 79% identify the types of CVC, between 72 and 87% use masks and perform handwashing before using the CVC, and 69% do antisepsis of the lumens during procedures.¹¹ These results are different from the current study, since 100% used masks and washed hands, and 97% used asepsis techniques on infusion lines.

Conclusion

We can conclude that we found an application of CVC maintenance procedures (healing, heparinization, taking blood products, changing infusion lines) that was timely and sufficient, which results in reducing the risk of CVC complications, such as infection and occlusion. Probably the results were different from those of other studies because the pediatric UTMOs have specific characteristics of construction and insulation, as well as nursing staff trained in patient care.

The recommendations are that whenever a procedure for the maintenance of CVC is applied, that it be done with the technique of procedure specified in protocols, emphasizing that it should be done with sterile technique, using masks, sterile gloves and gown, constant and ongoing supervision and training of nursing staff, that hospital units should have material and equipment sufficient for each technique, and that assessments of the implementation of the procedures should be done periodically to make changes.

References

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