Nursing Guidelines and its Effect on Reducing Central Line Related Infection among Traumatic Patients

Introduction

Central venous catheter (CVC) is the most important procedure at intensive care unit (ICU). Although there are many benefits of (CVC) as medication administration, blood sampling, and measurement of the central venous pressure (CVP) (Aloush et al. 2018). It is associated with numerous complications such as infection, bleeding, thrombosis, and mortality. Infections are the most common complications that can be developed. Incidence of infections varies according to the patient`s health status, duration of insertion time and localization, as well as with the type of catheter and asepsis precautions (Drašković et al., 2019).

Trauma  patients  account  for  one  third  of  all  ICU  admissions  as the  improvement  in  surgical techniques  and   life   support   management   of   critically   injured  patients  increased  survival  after  the  injury.  (Djuric et al. 2018). Because of the multitude of lines required in trauma patients especially CVC, central line related infections are very common. They are one of the major contributors of bacteraemia (Sartelli & Tranà 2019).

Central line-related infections in critically ill trauma patients are potentially fatal infections and are associated with a substantial increase in long hospital stay and total hospital cost. Nosocomial infections are preventable by adherence to procedures and policies designed to limit spread of infection between patients and between ICU staffs and patients (Sartelli and Tranà 2019).

The ICU staff must take the lead in establishing infection control protocols, including procedures for aseptic technique for catheter insertion, standards for universal precautions, duration of catheter placement, appropriate use of antibiotics, procedures in the event of finding antibiotic-resistant microorganisms, and the need for isolation of patients (AbouZied. 2018).

Nurses play an important role in providing care for patients connected with central venous catheters. They assist in central line insertion, care of its dressing, withdrawing a venous blood sample, and delivery of drugs. As well as, they teach the patients if oriented and their family about the specialized care of central venous catheters. Therefore, they contribute to reducing the risk of infection (Khalil 2018).

Significance of The Study

Central line related infection is an important cause of mortality in ICU patients. The infection rate is considerably higher than that in recent studies from developed counties, but it is still lower than the rates reported in comparable published studies in Egypt. Strict adherence to the standard infection prevention practices for critically ill patients is highly recommended. In Egypt, a study was conducted in the ICUs of 3 hospitals at Cairo University, and central line related infection rates varied widely, from 2.9 to 14.3 per 1,000 central line-days, with an overall rate of 9.1/1,000 central line-days (Malek et al. 2018).

Although there were various studies focusing on estimating the incidence rates of CVC-related infections among critically ill patients; there was little researches focus on implantation and nursing interventions for reducing this infection especially in our geographical area. Furthermore, from the researcher's clinical experience, it was found that there was a high incidence of central-line related infection among traumatic ill patients in Qena university hospital without any previous conducted educational intervention in this setting. So study was to evaluate the effect of nursing guidelines on reducing central line related infection among traumatic patients.

Aim of the study

The current study aimed to:

To evaluate the effect of nursing guidelines on reducing central line related infection among traumatic patients.

Research hypothesis

Traumatic patients who received nursing guidelines about central-line care will have reduced central line-related infections than those who not received.

III- Study Procedure

Preparatory phase

Research Design:

This study was conducted using a quasi-experimental research design.

Setting:

The current study was conducted at traumatic intensive care unit of Qena university hospital, Qena governorate, Egypt. The ICU locates on the first floor of the hospital and contains about 12 beds.

Sample:

The study included a purposive sample of 60 newly admitted adult patients of both sexes, selected from ICU patients, with central venous catheter. The selected patients of the study were meeting the inclusion criteria and classified into two equal groups (study and control groups, thirty cases for each group).

Sample equation:

The study sample was collected according to the following formula:-

N =  60 patients

Description:

N = required sample size.

t = confidence level at 95 % (standard value of 1.960).

p = estimated prevalence of patient with central venous catheter at ICU in Qena University Hospital 2017 (0.040).

m = margin of error at 5 % (standard value of 0.050).

Both groups of the study selected according to the following inclusion and exclusion criteria:

Inclusion criteria:

Both groups of the study selected according to the following inclusion and exclusion criteria:

-          Newly admitted patients (no more than 48 hrs).

-          Newly inserted central venous catheter.

-          Traumatic patients (head, chest, and abdominal trauma).

Exclusion Criteria:

-          Immuno-compromised patients.

-          Patients with systemic infections.

-          Patients receiving corticosteroid or chemo-radiotherapy.

Study Duration:

Data collection of the present study was done over a period of twelve (12) months, which started from beginning of January to the end of December, 2019.

Tools of the study:

Two tools were designed and tested after extensive literature review by the researcher for data collection to detect presence of central line related infection among traumatic patients

First Tool: General patient assessment sheet: A structured interview questionnaire sheet: It was used one time for each patient of both groups. It was divided into 3 parts:

1^st Part: Demographic data that includes (Patient’s name, Age, sex, marital status, place of residence, etc.).

2^nd Part: Medical data profile that includes (date of admission, medical diagnosis, past medical history, Drug used, etc.).

3^rd Part: Central Venous Catheter assessment sheet included the following items as (date of insertion, catheter type, catheter size, number of lumens, and the site of insertion).

Second Tool: Central line related-infection assessment sheet: It used to determine the generalized and localized manifestation of central line related infection among traumatic patients and included two parts:

1^st Part: the general and localized signs and symptoms of central line related infection: Fever, malaise, insertion site color change, drainage, swelling, pain, palpable tenderness and catheter occlusion etc.

-         These items rated on a rating scale of (Yes, No)

-         Scores for each item assigned as follows:

Yes = score one

No = score zero

1^stpart of the 2^nd tool was used daily from the first day of the study to the sixth day for both study and control group.

2^nd Part: Bacterial colonization indicator used to detect the presence of central line related infection, this part was included three laboratory investigation as following: skin swab analysis normally negative (Lemuel. 2021), white blood cells count normally 4,500 to 11,000 WBCs per microliter (4.5 to 11.0 × 10⁹/L)( Chernecky & Berger. 2013), and blood culture normally negative (Robinson. 2020).

The 2^nd part of 2^nd tool was assessed twice (one at the 1^st day to provide base line data and to ensure that the patient is free from infection and the second time after the 6^th day to compare the effect of applying the nursing guidelines on reducing the central line related infections among both studied groups).

Procedure

Validity and Reliability:

The tool was tested for content validity by a jury of five experts in the field of the study (medical surgical nursing) and necessary modifications were done. The tool was tested for internal consistency.

Reliability of the tools was performed to confirm its consistency by using Cronbach's alpha test. The reliability scores of the second tool (1^st part) as above 0.87, which indicates the tool internal consistency of the used tool.

Pilot study

A pilot study was conducted on 6patients (10% of the total sample) to test clarity, completeness and to determine the time involvement. Results of the pilot study illustrated that no any refinements and modifications needed so the subjects were included to the actual sample.

Ethical Considerations:

A written initial approval was obtained from the research ethical committee of the faculty of nursing, Minia University. The purpose of this study was explained for every patient except unconscious patients and each patient has the right to accept or refuse participation in the study. Oral informed consent was obtained from patients who participated in this study. They also informed that the information obtained will be confidential and will be used only for the purpose of the study. Each assessment sheet was coded and patients' names did not appear on the sheets for the purpose of anonymity and confidentiality.

An official permission to conduct the proposed study was obtained by the researcher from the manager of Qena University Hospital. Also, the official approval for data collection was obtained from the medical consultant and the head nurse of the study setting after explanation of the purpose of the study. Also, verbal consent was obtained from each patients participated in the study. Clarification of the nature and purpose of the study was done on initial interview with each patient. The researcher emphasized that the participation was absolutely voluntary and confidentiality of each patient will be assured throughout the whole study.

Implementation phase:

Once the permission was obtained to conduct the study, the researcher initiated data collection. The researcher started data collection by collecting the control group firstly which receive routine nursing care that took about 5 months, started at January and end at May. After completion of control group, data were collected from the study group which receives nursing guidelines adopted from (Marschall et al.2014) that took about 7 months started at June and end at December.

The nursing guidelines which applied for study group include: 1- Comply with hand hygiene requirements using antiseptic soap or gell. 2- Bathe intensive care unit patients with a chlorhexidine preparation on a daily basis. 3- Scrub the access port or hub with friction immediately prior to each use with an appropriate antiseptic (chlorhexidine). 4- Use only sterile devices to access catheters. 5- Immediately replace dressings that are wet, soiled, or dislodged. 6- Perform routine dressing changes using aseptic technique with clean or sterile gloves. A- Change gauze dressings daily. B- Disinfect the insertion site using chlorhexidine solution or Use a chlorhexidine impregnated dressing for the six continuous days of the study. 7- Change administrations sets for continuous infusions no more frequently than every 4 days, but at least every 7 days. A- If blood or blood products or fat emulsions are administered change tubing every 24 hours. B- If propofol drug is administered, change tubing every 6-12 hours or when the vial is changed (Marschall et al.2014).

Both groups (control and study) were assessed firstly using first tool (first part + second part) once only on the patients admission.

Evaluation phase

Both group of the study were assessed and evaluated at the first day of the study for signs and symptoms of central line related infection using 1^st part of second tool and daily continued till the sixth day.

Both group of the study were assessed and evaluated for presence of site and blood stream infection using 2^ndpart of second tool which started at the first day of study and repeated again at the sixth day of the study.

Statistical analysis data

The statistical analysis was done using SPSS–20 statistical software package. Data were collected, revised, coded, analyzed, and tabulated using number and percentage distribution. Data were presented using descriptive statistics in the form of frequency and percentages for quantitative continuous data which were compared by using student T–test in case of comparisons between the mean scores of the two groups. For multiple groups F–test or (ANOVA) was used. Person correlation analysis was used for assessment of the interrelationships between Infection total score and numbers of manipulations. Statistical significance was used at p. value < 0.05.

Results:

Table (1) Frequency distribution of the studied groups according to their Demographic characteristics (study and control groups)(n 60)

N.S= Not significant                  * p = ≤.05 (statistical significance)

Table (1) illustrate that more than half of both group are men with the mean age of 41.3 ± 12.30 and 41.60 ± 12.05for the study and control group respectively. As regards marital status it was found that (56.6% & 66.6 %) of the study and control group were married respectively. Concerning place of residence (46.6% & 60.0%) of study group and control group respectively living in rural area and (53.3% & 40%) of study and control group living in urban area respectively.

Table (2) Frequency distribution of the study subjects according to the central venous catheter data

Chi-Square Tests,   N.S = Non significant difference P˃0.05, Significant difference P≤0.05     highly significant p˂0.01.

Table (2) clarifies frequency distribution of the study subjects according to the insertion sites. It is revealing that (53.3% & 46.6%) of study & control group had subclavian veins inserted catheter respectively. As regards the catheter exchange, it was found that 90% for study group has no catheter exchange. But, 36.6% of control group there catheter were changed. The number of manipulation was lower in the study group than the control groups which had its effect on the catheter related infection presence. There were statistical significance difference between the study and control groups regarding the (number of manipulation and catheter exchange) presented by P value (0.000** & 0.01) respectively.

Table (3) Comparison between the study and control groups regarding presence of the localized signs of infection (n 60)

Chi-Square Tests,   N.S = Non significant difference P˃0.05, Significant difference P≤0.05     highly significant p˂0.01.

Table (3): illustrates regarding to pain that (10% & 26.6%) of study and control group had pain at the first day of the study. There were no statistical significance difference between them p-value =0.90. On the other hand (30%) of the study group had pain at the sixth day but (86%) of the control group had it also. p-value =0.000. Regarding the swelling it was found that (0.00% & 6%) of study and control group had swelling at the first day p-value =0.24 comparing to (20% & 100%) of study and control group at the sixth day. there was a highly statistical significant difference between the study and control groups concerning the presence of the localized signs of infection at the sixth day reflected by p-value =0.000.

Table (4) Comparison between the study and control groups regarding the catheter related signs of infection (n 60)

Chi-Square Tests,   N.S = Non significant difference P˃0.05, Significant difference P≤0.05     highly significant p˂0.01.

Table (4) represents regarding fever that (0.00% & 6%) of study and control group respectively had fever at the first day comparing to (30% & 70%) of study and control group respectively at the sixth day. There was a statistical significant difference between the study and control groups concerning the presence of fever at the sixth day reflected by p-value =0.002.

Regarding the purulent drainage it was found that (0.00% & 0.00%) of study and control group had purulent drainage respectively at the first day comparing to (20% & 83.3%) of study and control group at the sixth day respectively.  Also it was highly statistical significant difference between the study and control groups concerning the presence of chills and purulent drainage at the sixth day reflected by p-value =0.000. But there is no statistical significant difference between the study and control groups concerning the catheter occlusion reflected by p-value =0.500.

Table (5): Comparison between the study subjects according to their total infection score at the first, third and the six days of the study

T-Test,   Ns= Non significant differenceP˃0.05    significant P≤0.05     highly significant p˂0.01.

Table (5) presents that there is a highly statistically significance difference between study and control group concerning their total infection score revealed by p-value = 0.000 at the sixth day.

Table (6) Comparison between the groups of the study about the laboratory infection indicators

Chi-Square Tests, T- test,   Ns= Non significant differenceP˃0.05    significant P≤0.05     highly significant p˂0.01.

Table (6) illustrates that there is a highly statistically significance difference between study and control group concerning the skin swab and WBCs presented by p-value = 0.000. Also it was statistically significance difference between study and control group concerning the blood culture revealed by p-value = 0.032 at the 6^th day of the study.

Figure (1) Frequency distribution between the studied groups of the study regarding the type of organism

Figure (1) illustrates that 16.6% &56.6% of the study and control group was gram negative respectively. Whereas, 16.6% & 23.3% of the study and control group was gram positive respectively. There is a highly statistically significance difference between study and control group presented by p-value = 0.000.