Q&A: How COVID-19 Changed Vascular Access Methods

The entire health care system has been subjected to incredible change over the last 14 months as it tries to turn back the coronavirus disease 2019 (COVID-19) pandemic. Vascular access is no exception, Kelly Cawcutt, MD, MS, FACP, FIDSA, tells Infection Control Today®. Cawcutt, the associate medical director of infection control and epidemiology at the University of Nebraska Medical Center, says that she’s “seen a much longer length of stay in the ICU than we historically have had. [And] the longer that line is in, the more potential there is for an adverse event, including something like a central-line associated bloodstream infection.” A crisis often invites innovation and Cawcutt says that “at our organization, we have tried to bring our vascular access team and infection prevention team together into a CLABSI steering committee.”

Infection Control Today®: Infections involving vascular access procedures have been a problem for a long time. Has it gotten worse because of COVID-19? Now, this beat reporter assumes that there’s not enough data yet to make that determination. Is that a correct assumption?

Kelly Cawcutt, MD, MS, FACP, FIDSA: Partially correct. What we’re actually seeing is that with the increasing number of patients from the COVID-19 pandemic, we’re seeing increased numbers of subsequent vascular access. Venous access, ranging from a peripheral IV, all the way to a central venous catheter, is the most common invasive procedure done in the hospital. When it comes down to the data related to reportable infections, such as central-line associated bloodstream infections, we are starting to see a tip up and some early publications showing some associations with increasing HAIs; specifically thinking about CLABSI that are likely due to the COVID-19 pandemic and are more prominent in COVID-19 patients.

ICT®: There’s a recent study in the journal the Lancet Infectious Diseases about CLEAN3. Can you tell us what that study was about and what your interpretations of the results might be?

Cawcutt: Sure. So, this is a study that was recently published, as you noted, and it’s really looking at two major changes in what is considered a standard of care for peripheral IVs. Peripheral IVs are again, as I mentioned, incredibly common in the hospital. And you can absolutely get complications from those peripheral IVs, including early failure, meaning the IV doesn’t last as long as we’d like, or other complications like infections to the skin locally, or even a bloodstream infection. This can have huge impacts on our patients. But we don’t have a lot of data on how to best optimize peripheral IVs in our patients to minimize those risks. The CLEAN3 study is a single center randomized control trial comparing two different aspects of peripheral IVs. The first part is how we clean the skin. Taking kind of the standard of care from central lines

Kelly Cawcutt, MD, MS, FACP, FIDSA

with 2% CHG with alcohol combination, compared with our iodine alcohol combinations for skin antiseptics. And then, in addition, in that CHG we are using more recent technology for peripheral IVs to minimize the risk of IV contamination and number of access points to the IV compared to some more standard IV mechanical parts that we’ve had historically. And in this study, they randomized patients that are coming in through the emergency room really only looking at adults and assess the differences in patient satisfaction, in local infections, in complications, in rates of failure. Now, what they saw was with the improved structure of the IVs and the change to CHG alcohol, they did see a lower number of local skin infections and a lower number of complications, including a longer time in which that IV would stay in place. This again, compared to that more standard arm of therapy. What they didn’t have a lot of data for is bloodstream infections, specifically associated to that peripheral IV. And that’s because when you look at the overall number of peripheral IVs, you would need thousands and thousands of patients to really be able to tell a statistically significant difference, or clinically significant difference. Even though they enrolled about a thousand patients, they didn’t have enough patients to show a difference in that particular outcome. But with the outcomes they have, they did show decreased colonization. And like I said, some of these other adverse events. So really giving us some evidence that we can do better. And we can look toward potential other skin antiseptics and technology to improve our peripheral IV complication rates. Now, we really need to expand that study to more sites and more patients, to really look at how we evolved that to a standard of care and really understand the impact on things like bloodstream infections.

ICT®: One of our Editorial Advisory Board members is a vascular access nurse. During the course of interviewing her once, she said that the longer you can keep an IV in the better. The fewer times you have to change it, the better. Do you agree with that assumption? This study seems to show positive results in this area.

Cawcutt: This study is a little unique they have a standard where they change their peripheral IVs every four days. They don’t necessarily take that dogma of “if you can keep it in longer, it’s better.” But they did show longer longevity interval times of those peripheral IVs. In general, there are definite benefits to keeping an IV in place under the assumption that the IV is working. And it is secured appropriately with a good dressing in place. And that the health care team is accessing that IV in a clean way that really meets the standard of care to minimize risk of infection. If the IV is moving in the arm, kind of pistoning in and out of the skin, or starts to develop more redness and inflammation around it, then keeping it in with those kinds of changes is not ideal. If everything is done right, yes, keeping it in as long as we can versus putting in more lines or new lines is a good choice. But if once we start to have any problems with the integrity of the line or the skin surrounding it, then we need to be much more cautious about getting that line out before we have more complications, such as an infection.

ICT®: As I mentioned, some of our readers are members of vascular access teams. Another core readership comprises infection preventionists. Do they work closely together enough?

Cawcutt: I think that each organization is a little different with how well these teams are collaborating. In a perfect world, vascular access teams and infection prevention teams really should be working very tightly together to optimize the practice of putting our vascular access in place, but also the technology and procedures around that. What are we choosing to use? Are we moving our organization collaboratively up to the standard of care, or even evolving new standards with new technology, like we’re talking about with CLEAN3. I also think it’s really important that the vascular access team gets feedback on CLABSI rates and complication rates so they know if they’re seeing an increase of CLABSI or failure rates or any other complications related to lines they put in. But again, every organization is a little different. I think they do need to be tightly married. And personally, I always think there’s more room for improving our communication and our collaboration and things like this.

ICT®: Do you know of a hospital system or a hospital itself that does this really well? That can be held up as an example?

Cawcutt: I don’t know that it’s easy for me to say that there is one particular exemplar. I think different organizations do different aspects of this really well. I think at our organization, we have tried to bring our vascular access team and infection prevention team together into a CLABSI steering committee, and have collaboratively made decisions related to how we access our new data, our CLABSI rates and technology innovations that need to be brought in. But I think every organization that I’ve been at or that I’ve talked to…. I don’t know that I can say with full certainty, especially not having been intricately involved with all those organizations, that there’s one that does all of these things really well. And certainly, this year, when we are all stretched really, really thin, I am not sure how we’ve all done in 2020.

ICT®: What organization are you affiliated with now?

Cawcutt: I work at University of Nebraska in the medical center there. I’m the associate director for our infection control and hospital epidemiology program for Nebraska Medicine, and that is affiliated with our academic center, the University of Nebraska Medical Center.

ICT®: What’s the main thing that you see changing in your area of interest, which is vascular access, because of COVID-19?

Cawcutt: Oh, that’s a great question. And I should have put a caveat in here. I’m an infectious disease physician, but I’m also a critical care medicine physician. I work as a primary ICU doctor in our COVID units. And we’ve actually seen some huge changes in what happens in the ICU, especially to our patients with vascular access, as it pertains to COVID-19. So, a few things. One, we have seen a much longer length of stay in the ICU than we historically have had. So again, the longer that line is in, the more potential there is for an adverse event, including something like a central-line associated bloodstream infection. We’ve also seen changes in the way ICU patients are positioned. And most significantly, the idea of proning our patients. Flipping a patient who may have a vascular access device on the front of their body, but having them laying on their stomach for 16 hours a day, impacts the number of times we can assess the dressing or change the dressing. It may impact just gravitationally what happens with the pull of the dressing. And I think that can really impact things. And a lot of our treatments for COVID-19 have some immunosuppressive impact. And although the data is evolving, and very early there, we are seeing some early data signaling that certain medications may have an association with increased collapses. But that’s not borne out yet to say that that’s the cause.

This interview has been edited for clarity and length.