Clinical Journal of Oncology Nursing

o understand the vulnerability of patients with cancer to central line-associated bloodstream infections related to tunneled central venous catheters (CVCs), patients were asked to describe their line care at home and in clinic and to characterize their knowledge and experience manag- ing CVCs. Forty-five adult patients with cancer were recruited to participate. Patients were inter- viewed about the type of line, duration of use, and observations of variations in line care. They also were asked about differences between line care at home and in the clinic, precautions taken when bathing, and their education regarding line care. Demographic information and primary cancer diagnosis were taken from the patients’ medical records. Patients with hematologic and gastrointestinal malignancies were heavily represented. The majority had tunneled catheters with

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subcutaneous implanted ports. Participants identified variations in practice among nurses who cared for them. Although many participants expressed confidence in their knowledge of line care, some were uncertain about what to do if the dressing became loose or wet, or how to recognize an infection. Patients seemed to be astute observers of their own care and offered insights into practice variation. Their observations show that CVC care practices should be standardized, and educational interventions should be created to address patients’ knowledge deficits.

Saul N. Weingart, MD, PhD, is the chief medical officer at Tufts Medical Center in Boston, MA; and Candace Hsieh, RN, is an infection control practitioner, Sharon Lane, RN, MPH, is the senior director of the Center for Patient Safety, and Angela M. Cleary, RN, MSN, is a program manager in the Center for Patient Safety, all at the Dana-Farber Cancer Institute in Boston. The authors take full responsibility for the content of the article. The authors did not receive honoraria for this work. The content of this article has been reviewed by independent peer reviewers to ensure that it is balanced, objective, and free from commercial bias. No financial relationships relevant to the content of this article have been disclosed by the authors, planners, independent peer reviewers, or editorial staff. Mention of specific products and opinions related to those products do not indicate or imply endorsement by the Clinical Journal of Oncology Nursing or the Oncology Nursing Society. Weingart can be reached at sweingart@tuftsmedicalcenter.org, with copy to editor at CJONEditor@ons.org. (Submitted April 2013. Revision submitted September 2013. Accepted for publication September 16, 2013.)

Key words: central venous catheter; central line-associated bloodstream infection; practice variation; patient and family engagement; quality improvement

Digital Object Identifier: 10.1188/14.CJON.321-326

n Journal Club Article

Standardizing Central Venous Catheter Care by Using Observations From Patients With Cancer

C entral line-associated bloodstream infections (CLABSIs) can cause significant avoidable morbid- ity and mortality. Estimates of the costs attributed to CLABSIs range from $5,734–$22,939 (Centers for Disease Control and Prevention [CDC], 2011; Scott,

2009). Although an established body of research exists on the prevention of CLABSIs in the intensive care unit (Pronovost et al., 2006, 2010), less data were reported about measures to prevent CLABSIs in patients with cancer treated in ambulatory settings (Laura et al., 2000; Mermel et al., 2009; O’Grady et al., 2011; Wolf et al., 2008). A guideline from the American Society of Clinical Oncology called for additional research on critical aspects of central venous catheter (CVC) care for patients with cancer (Schiffer et al., 2013).

Several factors distinguish the infection risk associated with CVCs among ambulatory patients with cancer from that of the general medicine population (Mollee et al., 2011; Tomlinson et

al., 2011). Line care in patients with cancer is usually provided in the clinic and at home, creating shared responsibility for the use of safe practices and monitoring for infections. Patients with cancer undergoing chemotherapy often experience bone marrow suppression and are susceptible to infection from trans- located intestinal flora and opportunistic organisms. Although catheter-related infections among inpatients are exquisitely sensitive to line placement technique, long-term CVCs are usu- ally placed in the operating room or an interventional radiology suite for patients with cancer. As a result, product selection and line maintenance are critical targets for preventing infection (Schiffer et al., 2013).

To understand the vulnerability of adult ambulatory patients with cancer to CLABSIs and to identify potential improvement opportunities, the authors of the current article surveyed pa- tients at a comprehensive cancer center. The authors hypoth- esized that patients were potentially astute observers; were

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322 June 2014 • Volume 18, Number 3 • Clinical Journal of Oncology Nursing

capable of describing variation in line care practice in the clinic and at home; and could articulate their understanding of proper central line care, their behavior under certain circumstances, and their ability to recognize signs of infection.

Methods Setting and Sample

Dana-Farber Cancer Institute, a Boston-based comprehensive cancer center that serves adult and pediatric patients with solid tumors and hematologic malignancies, was the study site. In 2012, more than 348,000 clinic and infusion visits occurred with 319 nurses and 407 faculty physicians. Adult patients with long-term CVCs who were treated on two chemotherapy infu- sion units from July to August 2012 were identified. A research assistant approached the clinical nurse coordinators on each unit every day for assistance identifying patients who were suitable for interview. Exclusion criteria included inability to commu- nicate in English, anxiety or emotional upset, or being asleep.

Six of 53 potential participants were excluded. Of the re- maining 47 patients, 45 agreed to participate after the research assistant described the purpose of the study and length of the interview. Although the project was conducted as an improve- ment initiative rather than a research study, the authors were careful to advise patients that participation was voluntary, that information they provided would not be shared with their care team without the patient’s permission, and that they could end the interview at any time. Interviews varied in length from 5–30 minutes. Patients’ responses were recorded manually and then entered into an electronic spreadsheet for analysis.

Instrument Development

Because the authors were unable to identify a suitable survey tool, an instrument was developed for eliciting information about CVC care from the patient’s perspective. The instrument was informed by a review of the literature and meetings with frontline nurses, infection control practitioners, and patient safety experts. Infection control practitioners and patient safety experts reviewed the instrument for face validity and pilot tested it on the study units. It used a semistructured format with follow-up prompts.

The survey queried patients about the type of line, duration of use, problems encountered, and observations about variations in line care. It asked patients to characterize differences between line care at home and in the clinic, and precautions taken when showering or bathing at home. It also asked patients to describe how they were educated about the care of their central line and to assess its adequacy. The patients rated their confidence in car- ing for the line and their knowledge about what to do if the dress- ing became loose or wet, and they were asked to describe signs of infection. The authors also abstracted information from medical records (e.g., age, gender, insurance, primary cancer diagnosis).

Data Analysis

The authors tabulated social, demographic, and clinical char- acteristics. Members of the project team reviewed the survey responses and categorized them thematically. Certain questions

were inapplicable to particular patients, depending on the type of line they used. Patients’ responses were tabulated, and illus- trative, verbatim comments were selected by category.

Results Patient Characteristics

The median age of the participants was 50–59 years (see Table 1). More men than women participated in the study, and the majority had private insurance. The cohort consisted primarily of patients with hematologic and gastrointestinal malignancies, reflecting the composition of the clinical unit where the project was conducted. Thirty-six patients had surgically implanted catheters with subcutaneous implanted ports (i.e., port-a-cath), including 13 whose catheters were ac- cessed for home treatment or supportive care. The remainder (n = 9) had either surgically implanted cuffed tunneled CVCs (i.e., Hickman line) or peripherally inserted central catheters (PICC). Fourteen patients had a previous central line for can- cer treatment.

TABLE 1. Sample Characteristics (N = 45)

Characteristic n

Age (years) Less than 40 8 40–49 7 50–59 11 60–69 14 70 or greater 5

Gender Male 26 Female 19

Insurance type Private 32 Medicare 10 Medicaid or self-pay 2 Government 1

Disease type Lymphoma 14 Colorectal 9 Leukemia 6 Pancreatic 5 Myeloma 5 Gastric, esophageal, or biliary tract 3 Brain tumor 1 Myelodysplasia 1 Other 1

Type of central venous catheter Port-a-cath with no home access 23 Port-a-cath with home access 13 Hickman 6 Peripherally inserted central catheter 3

Number of months since line placement 0–2 12 3–6 12 7–12 9 13–24 4 25 or greater 8

Previous central line No 31 Yes 14

Clinical Journal of Oncology Nursing

Clinical Journal of Oncology Nursing • Volume 18, Number 3 • Standardizing Central Venous Catheter Care 323

Practice Variation and Concerns

Most patients observed more similarities than differences in the way that clinicians cared for their central line. A patient with a port-a-cath said, “I wouldn’t say that they were all identi- cal to each other, but ultimately they all cover the same require- ments: flushing it, cleaning it, putting the needle in.” Another patient with a port-a-cath said, “I’ve only had it done a couple of times, but it seems pretty much the same. One [provider] might be a bit slower and another one a bit faster.”

However, 13 of the 45 respondents noted differences in how the clinician cleaned the hub, their familiarity with the device, their care in checking the location of the catheter, the use of dated labels on the line, the degree of care used to avoid hurt- ing the patient, and staff members’ occasional frustration when the line did not work properly (see Table 2). One patient with a Hickman line said,

There are different techniques in the lab around how they clean it. Some people are very particular about keeping it clean, and others wipe it off very quickly. Other than how people clean and prepare it, everyone else sets it up the same.

A patient who had a port-a-cath with a home infusion pump said,

Today I had someone who cleaned it really well. She really got right in there. She put this sticker [with initials on it, placed just below the clamp] on too. See, [the neighboring patient with a port-a-cath] doesn’t have the sticker. Other times, people don’t clean it so well.

A minority of patients said that clinic or homecare staff cared for the line in a way that concerned them. Seven respondents noted a concern, including failure to clean or flush the line ap- propriately, failure to allow alcohol to dry, failure to use ethyl chloride topical anesthetic, pain, or concern about staff members’ ability to get the catheter to work. A patient with a Hickman line said,

It’s just some nurses that I’m not used to don’t scrub the cap properly, or [use mask and glove] when changing the dressing. Some scrub it hard, but others just give it a quick wipe. I like it scrubbed hard. I mean, it goes straight to my heart. Probably, like, a quarter don’t do it properly.

A patient with a port-a-cath said,

This was early on, maybe six months into it, the nurse for- got to flush it and I picked up on it. I usually get the smell and taste of it in my mouth, and that time I didn’t have it, so I asked her if she’d flushed it and she said she hadn’t. She fixed it up. That was one incident early on.

Another patient with a port-a-cath said,

One time I didn’t have the [ethyl chloride] spray. He said he didn’t do it that way. He had his reasons, and others have theirs. He said “I don’t use the spray.” I think it was because it exposes everyone in the room; it stays in the air for a while.

A patient with a port-a-cath said, “Oddly enough, there’s one person in the lab that never seems to be able to get it to work. I don’t know their name, and even if I did I wouldn’t tell you. It could just be chance.” Clinical Journal of Oncology Nursing