CMS SOM App. H, Tag V147

Recommendations for Placement of Intravascular Catheters in Adults and Children

I. Health care worker education and training

1. Educate health-care workers regarding the … appropriate infection control

measures to prevent intravascular catheter-related infections.

2. Assess knowledge of and adherence to guidelines periodically for all persons

who … manage intravascular catheters.

II. Surveillance

• Monitor the catheter sites visually or by palpation … of individual patients. If

patients have tenderness at the insertion site, fever without obvious source, or

Page 30 of 420

other manifestations suggesting local or BSI [blood stream infection], the

dressing should be removed to allow thorough examination of the site.

Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery

Catheters in Adult and Pediatric Patients.

VI. Catheter and catheter-site care

• Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to

prevent CRBSI (catheter related blood stream infections).

Interpretive Guidance § 494.30(a)(2)

According to the CDC, intravascular catheters solve the problem of attaining vascular access

quickly when there is insufficient time for development of a longer-term internal access: ideally a

fistula, or secondarily, a graft. Catheters also provide a solution of last resort when internal

access site opportunities have been exhausted.

However, despite their expedience, these catheters pose a threat of infection with the potential

for immediate and long-term morbidity and mortality consequences for the patient.

The use of catheters for hemodialysis is the most common factor contributing to bacteremia in

dialysis patients and the relative risk for bacteremia in patients with dialysis catheters is seven

times the risk for patients with primary arteriovenous fistulas. Staff must maintain aseptic

technique for the care of all vascular accesses, including intravascular catheters.

The CDC lists the two most common routes of catheter infection as:

• Migration of skin organisms through the insertion site and into the cutaneous

catheter tract, resulting in colonization of the catheter tip; and,

• Contamination of the hub, resulting in intraluminal colonization of the catheter. The

initiation and termination of the dialysis process, as well as manipulation and tension

on the catheter, provide frequent opportunities for such contamination. Minimizing

the use of intravascular catheters and protecting the insertion site and catheter hub

from contamination through education and training on rigorous care is crucial in

reducing catheter-related infections.

Catheter insertion sites should be routinely assessed by staff at each treatment. Most catheter

sites are covered with either transparent dressings or gauze. Patients with catheters should be

instructed to replace the dressing if a catheter site has sufficient bleeding or drainage to dampen

or soil the dressing between treatments.

The CDC advises that prophylactic antibiotic lock solutions be reserved for use only in special

circumstances, e.g. in units where the rate of catheter-related bloodstream infection (CRBSI) has

not decreased despite optimal maximal adherence to aseptic technique.

In addition to CDC recommendations for education, training, and infection control surveillance

of intravascular catheters, dialysis facilities should adhere to current standards of practice for

Page 31 of 420

vascular access care. The National Kidney Foundation Kidney Disease Outcomes Quality

Initiative (NKF KDOQI) has provided evidence-based clinical practice guidelines for a number

of topics, including Clinical Practice Guideline for Vascular Access. As of 2019, NKF’s KDOQI

guidelines continue to recommend the use of aseptic technique and masks for patients and staff

performing catheter connection and disconnection procedures to minimize the risk for infection.

Manufacturers’ directions should be adhered to for the types of antiseptics recommended for

safe cleaning of the skin and catheter.

The facility should have an initial and ongoing training program for infection control practices,

which includes information on the prevention of intravascular catheter-related infections.

Facility policies should address the training and qualifications of staff who may access

catheters, in accordance with any State licensure requirements, as well as the frequency for

periodic practice audits, to verify staff knowledge and adherence to infection control guidelines

for intravascular catheters.