Patient education—a strategy for prevention of infections caused by permanent central venous catheters in patients with haematological malignancies: a randomized clinical trial

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Summary

A functioning tunnelled central venous catheter (CVC) is a crucial device for patients with haematological malignancies receiving high-dose intravenous chemotherapy. Despite the advantages, CVC infections are a major cause of sepsis and prolonged hospital stay. This study investigated the impact of patient education regarding provision of their own catheter care on the frequency of CVC-related infections (CRIs) and was conducted at a specialized haematological unit at the University Hospital of Copenhagen Rigshospitalet. From May to September 2002, 82 patients fitted with tunnelled double-lumen Hickman catheters were randomized consecutively. The intervention group (42 participants) received individualized training and supervision by a clinical nurse specialist, with the aim of becoming independently responsible for their own catheter care. The control group (40 participants) followed the standard CVC procedures carried out by nurses inside and outside the central hospital. A significant reduction in CRIs was found in the intervention group, with a >50% reduction in the incidence rate of CRIs. We conclude that systematic individualized, supervised patient education is able to reduce catheter-related infections.

Introduction

Treatment of patients with high-grade haematological malignancies usually takes six to 12 months. A well-functioning tunnelled catheter is necessary for the administration of intravenous chemotherapy and medication for associated problems related to the periodic loss of bone marrow function. Despite the advantages, infections associated with central venous catheters (CVCs) are a major cause of sepsis and prolonged hospital stay.1, 2, 3, 4 Catheter-related infections (CRIs) thus increase the morbidity and mortality rate due to septicaemia,1, 5, 6, 7 and are an economic burden to the healthcare system.8, 9 As CVCs pierce through the skin barrier, they create a potential source of and route for the spread of bacteria and fungi to the bloodstream.4, 6, 10, 11, 12 Staphylococcus epidermidis and other coagulase-negative staphylococci originating from the patient's skin flora are the most common CRIs.3, 11, 13, 14 Staphylococcus aureus, Stenotrophomonas maltophilia and Candida spp. with similar microbial adherent capabilities to, for instance, catheter surfaces are also present in serious catheter-related bloodstream infections (CRBSIs).11, 13, 14, 15 Maximum sterile precautions during catheter insertion can reduce CRBSIs at an early stage or even months after the insertion.16, 17, 18 The catheter exit site and the connection of the hub to the intraluminal surface of the catheter are the two most common sources of contamination.3 Specialized teams of physicians, technicians and nurses have been able to reduce CRBSIs six to eight fold.3, 18 Surgical and nursing strategies for the prevention of CRIs have been implemented at the University Hospital of Copenhagen Rigshospitalet. Despite these efforts, loss of hygienic quality and consistency have become recurrent problems, especially when patients fitted with these devices are discharged from the hospital in between their chemotherapy regimens.

This project explores a new type of clinical intervention. Using a randomized design, the study investigated whether patients, and/or their relatives, who were trained in catheter care could decrease the frequency of CRIs.

Section snippets

Ethics

This project was approved by the Scientific Committees of the Copenhagen and Frederiksberg Municipalities (J. no. 01-001/00) and by the Danish Data Protection Agency.

Setting

The setting for this study was a 50-bed specialized haematological unit at the University Hospital of Copenhagen Rigshospitalet with outpatient and bone marrow transplantation capacities.

Design

This was a prospective, randomized, controlled, intervention study.

Study population

From May 2000 to September 2002, adult patients with haematological malignancies, who were undergoing intravenous chemotherapy and who were fitted with tunnelled, cuffed, silicone central venous catheters (Hickman 10F), were eligible to enter the study. The patients were followed through inpatient and outpatient periods. Patients with other types of tunnelled CVCs (catheters similar to haemodialysis catheters) and those primarily admitted for allogeneic bone marrow transplantation were not

Characteristics of the population

During the study period (May 2000–September 2002), 136 patients met the inclusion criteria. A total of 21 patients were excluded, using the following exclusion criteria: acute patients with advanced progressive cancer and no or little hope of benefit from the treatment (N=8); patients who did not write or speak Danish (N=5); patients with Central Nervous System (CNS) metastasis (N=4); patients with damaged physical motor function (N=2); patients suffering from psychosis (N=1); patients with a

Discussion

This study suggests that a strategy based on a module-structured, individualized, supervised patient education programme can reduce CRIs and increase compliance with clinical procedures for catheter care. This is the first randomized study to address this issue. Patient education involving CVCs is described as an important factor in only a few non-randomized and non-controlled studies.25, 26, 27, 28, 29 In particular, one study29 described patient education as a key factor in a total quality

Conclusion

The significant results indicate that a structured, individualized, supervised patient education programme in CRIs and self-care could be a breakthrough in the reduction of CRIs. Patients providing their own catheter care show a high degree of compliance to care procedures, thus securing continuity in the healing process, as well as contributing to a reduction in the nursing care workload in the primary healthcare sector. The intervention uncovered a potential resource in preventing CRIs, and

Acknowledgements

This project was financially supported by the University Hospital of Copenhagen Rigshospitalet, the Co-operation of Copenhagen Hospitals HS and Lundbeck Foundation Denmark.

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