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Question: My mother is being treated for cancer. The doctors installed an IV tube near her collarbone where they inject her chemotherapy drugs. It’s called a central line and I’ve heard that this type of IV can become infected. I recently got into an argument with a nurse who I felt didn’t properly disinfect the IV before injecting the medication. She gave it just one quick swipe. Was that good enough?
Answer: You are right. The use of certain types of intravenous (IV) lines can significantly increase the risk of a patient getting a serious and potentially life-threatening infection.
Health care workers should follow specific procedures to reduce the chances of a patient becoming infected. When one of these infections does happen at an Ontario hospital, it must be reported to the provincial Ministry of Health and Long-Term Care.
So, you are certainly justified in asking about the infection prevention practices at the medical centre where your mother is being treated.
To put these risks into context, it’s worthwhile providing some more background information.
As you undoubtedly know, some medications are injected directly into a patient’s bloodstream – usually through an IV that is put into a vein near the surface of the skin such as in a hand or arm. This is a standard and necessary procedure for many patients who are in a hospital.
However, certain medications – particularly some cancer drugs and antibiotics – can be extremely harsh and may damage the small blood vessels in the arm. Furthermore, some patients require many drug injections over a prolonged period of time. And still others may need to have liquid nourishment injected directly into the bloodstream because they have trouble swallowing or eating.
In these cases, doctors often insert a Central Venous Access Device – or “central line” – in a large vein in the neck, upper chest or groin. This flexible plastic tube (catheter) is threaded into the vein until it reaches a spot close to the heart.
A so-called “hub” or “port” at the top of catheter provides an easy access point that can be used over and over to inject medications or fluids, which are then drawn into the heart and rapidly dispersed throughout the body. The device may remain in place for several days to many months at a time.
But there is a downside to this convenience. The central line can serve as a gateway for germs to get inside the body.
For this reason, extra precautions are taken for inserting and maintaining a central line says Grace Walter, a clinical educator for the critical-care unit at Sunnybrook Health Sciences Centre.
For instance, doctors and nurses are expected to wear sterile gloves, gowns, caps and masks when a central line is put into a patient. “We have a checklist to make sure everyone is taking the proper precautions to prevent an infection during the insertion procedure,” says Walter.
The dressing – a clear adhesive plastic – is changed only on an as-needed basis to reduce the number of times the injection site is exposed to the air. And, whenever the hub or port is accessed, it must first be properly sterilized.
With this background in mind, let’s now get back to your question. You mentioned that you felt a nurse didn’t spend enough time cleaning your mother’s IV tubing (or central line). So, what’s the appropriate time needed to do a thorough job?
Walter says that protocols may vary slightly from one hospital to the next depending, in part, on the antiseptics and equipment used in patient care.
Hospitals rely on a variety of different antiseptics, including chlorhexidine, providone iodine, iodophor or 70 per cent alcohol, according to the Canadian Patient Safety Institute (CPSI).
When chlorhexidine is used as a disinfectant, the port should be swabbed for 15 to 30 seconds and allowed to fully dry before using it, says the CPSI.
The exact scrubbing time may differ with the other disinfectants. But Walter notes that it’s a fairly standard procedure to wait until it is dry – and that depends on environmental factors such as humidity of the surrounding air.
If you’re uncertain about what is being done, “you should definitely ask questions,” says Walter. “It’s always better to be informed.”
That sentiment is echoed by Michelle Stasiuk, a patient advocate who serves on an advisory committee of the South Health Campus, a Calgary hospital.
Stasiuk has lived with a central line for the past 18 years. She developed dangerous blood clots when she was pregnant. Doctors had to remove a large part of her bowel, which makes it impossible for her to absorb a sufficient amount of nutrients through food alone. A central line was installed to provide liquid nourishment directly into her bloodstream.
“My central line is my life line,” she says. “If I get an infection, it could be life threatening for me.”
Not surprisingly, Stasiuk is extremely protective of her central line. “At times, I’ve been in hospital and a health care worker has done a swipe with an alcohol swab and I have said ‘that’s not enough infection-control prevention in my opinion’,” she recalls.
“I would really advocate for patients standing up for the way they want their lines treated.”
Others agree that patients – as well as their family members – do have an important role to play in reducing infections.
The U.S. Centers for Disease Control and Prevention (CDC) put together the following list of ways in which patients (or their advocates) can help protect themselves while they are in a health-care facility:
- Research the hospital, if possible, to learn about its Central Line-associated Bloodstream Infection (CLABSI) rate. (You can find the infection rates of Ontario hospitals by going to the website ofOntario Ministry of Health and Long-term Care.)
- Speak up about any concerns so that health care workers are reminded to follow the best infection-prevention practices.
- Ask your health-care providers if the central line is absolutely necessary. If so, ask them to help you understand the need for it and how long it will be in place.
- Pay attention to the bandage and the area around it. If the bandage comes off or if the bandage or area around it is wet or dirty, tell a health care worker right away.
- Don’t get the central line or the central line’s insertion site wet.
- Do not let any visitors touch the catheter or tubing.
- Avoid touching the tubing as much as possible.
- Everyone visiting you must wash (or sanitize) their hands — before and after their visit.
What’s more, you should be on the lookout for any signs of an infection, which may include redness or soreness around the site of the catheter as well as a fever or chills, says the CDC.
“If you think you have an infection in your central line, then you should definitely talk to your health-care professionals as soon as possible,” advises Walter.
Paul Taylor, Sunnybrook’s Patient Navigation Advisor, provides advice and answers questions from patients and their families. His blog, Personal Health Navigator, is reprinted on Healthy Debate with the kind permission of Sunnybrook Health Sciences Centre. Follow Paul on Twitter @epaultaylor.