Systematic review of emergency department central venous and arterial catheter infection

Abstract

BackgroundThere is an extensive critical care literature for central venous catheter and arterial line infection, duration of catheterization, and compliance with infection control procedures. The emergency medicine literature, however, contains very little data on central venous catheters and arterial lines. As emergency medicine practice continues to incorporate greater numbers of critical care procedures such as central venous catheter placement, infection control is becoming a greater issue.AimsWe performed a systematic review of studies reporting baseline data of ED-placed central venous catheters and arterial lines using multiple search methods.MethodsTwo reviewers independently assessed included studies using explicit criteria, including the use of ED-placed invasive lines, the presence of central line-associated bloodstream infection, and excluded case reports and review articles. Finding significant heterogeneity among studies, we performed a qualitative assessment.ResultsOur search produced 504 abstracts, of which 15 studies were evaluated, and 4 studies were excluded because of quality issues leaving 11 cohort studies. Four studies calculated infection rates, ranging 0–24.1/1,000 catheter-days for central line-associated and 0–32.8/1,000 catheter-days for central line-related bloodstream infection. Average duration of catheterization was 4.9 days (range 1.6–14.1 days), and compliance with infection control procedures was 33–96.5%. The data were too poor to compare emergency department to in-hospital catheter infection rates.ConclusionsThe existing data for emergency department-placed invasive lines are poor, but suggest they are a source of infection, remain in place for a significant period of time, and that adherence to maximum barrier precautions is poor. Obtaining accurate rates of infection and comparison between emergency department and inpatient lines requires prospective study.

Simulation‐based Training for Emergency Medicine Residents in Sterile Technique During Central Venous Catheterization: Impact on Performance, Policy, and Outcomes

“…27 Other studies found higher CLABSI rates in EDs, ranging between 5.6 and 24.1 per 1,000 catheterdays. [13][14][15][16] In our study, the CLABSI rate was 1.02 per 1,000 catheter-days, which is even lower than other published studies in EDs, with the caveat that differences in ED and ICU staffing or other factors may affect such results.…”

“…12 Several studies showed high CLABSI rates in CVCs placed in the emergency department (ED), which may be due to time pressures, workload, and reliability of supervision. [13][14][15][16][17] Data from our own hospital showed a CLABSI rate exceeding 6 per 1,000 catheter-days in the years prior to this study. Published data regarding high CLABSI rates in CVCs placed in the ED, along with our own hospital data, led to the practice of routine replacement of CVCs placed in the ED within 24 hours of admission to the medical intensive care unit (MICU).…”

Infection Prevention in the Emergency Department

“…122,123 Studies examining outcomes of ED CVCs have focused more on acute mechanical complications than CLABSI, most likely due to inadequate surveillance mechanisms for tracking outcomes. [124][125][126] Prior to 2010, ED CLABSI studies suffered from imprecise definitions and lacked sufficient power. Reported CLABSI rates for ED CVCs varied from 0 to 24.1 CLABSIs per 1,000 catheter days depending on patient population and anatomical factors such as insertion site.…”

“…[127][128][129][130] Significant heterogeneity among these studies precludes pooling of their results. 126 Since 2010, only one study has described the incidence of CLABSI attributed to the ED and found that, in an academic medical center, ED CLABSI rates were similar to that of the ICU. 131 Relying primarily on administrative databases of ED patients admitted to the ICU, the rate of ED CLABSI was 1.93 per 1,000 catheter-days (95% CI 0.50-3.36).…”

“…The impact of early discontinuation of ED CVCs once they are no longer needed on ED CLABSI rates has not been evaluated. 126 Peripheral venous catheters (PVC) are a mainstay of medical therapy in the ED. While PVC infections are uncommon, bloodstream infection 140,141 and even septic thrombophlebitis may occur in rare instances.…”