By Ava Dobin, BSN, RN, CIC and Jayne Lee, BSN, MPH, CIC
For several years now, healthcare facilities have faced intense pressure to minimize catheter-related bloodstream infections (CRBSI). In recent months, the pressure has grown. Here are just two examples:
- A recent CDC report that gained media attention said CRBSI have dropped only 18 percent, while an earlier study from the Agency for Healthcare Quality and Research said these infections may not have dropped at all.
- The Centers for Medicare and Medicaid Services (CMS), which stopped reimbursing for CRBSI some time ago, has upped the ante. In 2011, it will start requiring that all Medicare-eligible hospitals report certain hospital-acquired infections to get full payment in its "pay for reporting" program. The required reporting includes CRBSI, which CMS believes are completely preventable.
Government agencies and infection control experts aren't the only ones chagrined about the lack of progress in CRBSI prevention. Many institutions plagued with high CRBSI rates are just as frustrated with their failure to make headway because they feel that they've "tried everything." That is, they've implemented practices and devices recommended by such stellar sources as the CDC, the Society for Healthcare Epidemiology of America (SHEA), and the Keystone Initiative, and often have only modest gains to show for it.
Our experience at two hospitals in the southeastern U.S. may offer some insight into the solution. At Broward Health Coral Springs Medical Center in Coral Springs, Fla., use of a well designed twist-on cap for disinfecting luer access valves has completely eliminated CRBSI since the beginning of April 2010 (as of this writing in mid-September 2010). Financial analysis shows that Coral Springs saved an estimated $504,000 through the disinfection cap in just the first quarter of use. (The cost analysis is based on a conservative estimate of eight CRBSI that the hospital could have expected without the cap and the costs of treatment [average = $42,000] and length-of-stay [average = 30.4 days] that were avoided.
As at Coral Springs, the disinfection cap has solved a major problem regarding compliance with disinfection protocols at the second institution, FirstHealth Moore Regional Hospital in Pinehurst, N.C. We discuss the process that led both hospitals to trial and then adopt the cap and why this has relevance for other facilities struggling to reduce their own CRBSI rates.
Conventional Luer Access Valve Disinfection
The disinfection cap used between line accesses at Coral Springs and Moore Regional is SwabCap™ from Excelsior Medical. Somewhat similar devices are available from other manufacturers. To understand why a disinfection cap makes such a difference, you have to first understand the conventional means used to disinfect luer access valves.
Most hospitals use a method that involves vigorously swabbing the valve/injection port (also known as a needleless connector) with an alcohol wipe for 10-15 seconds and then waiting for the port to dry before accessing the line. It takes up to 30 seconds for the port to dry so the total process takes up to 45 seconds.
This process is recommended by experts and is a widely accepted practice because in vitro studies show it to be an effective disinfection technique. But the studies don't take into account the actual conditions at hospitals where the process is intended to be used. The recommended process has three potential drawbacks:
- When nurses are pressed for time (and is there ever a time when they're not?), they are likely to just give the port a light, quick wipe before accessing the line rather than spend the full 45 seconds to perform the procedure correctly. If they cut the time short or don't wipe with the appropriate pressure, the port will not be completely disinfected. This increases the risk that bacteria will enter the catheter during the line access and cause a CRBSI.
- With this process, non-compliance is almost impossible to monitor unless a supervisor follows every nurse on her rounds, which of course is a practical impossibility. Therefore the policy is very challenging to enforce.
- A relatively new Joint Commission requirement states that hospitals implement "a standardized protocol to disinfect catheter hubs and injection ports before accessing the ports." While the conventional swabbing procedure might qualify as a standardized protocol, is it really wise to show the commission a process that is prone to variance and non-compliance?
The problems with the conventional protocol are widely recognized. Not as well recognized, however, is the positive impact that an alternative such as a disinfection cap can have – not just on solving the above problems but also on lowering CRBSI rates.
Use of the Disinfection Cap at Moore Regional
Because the problems with the standard valve disinfection protocol are so widespread, we feel our experiences at Coral Springs and Moore Regional have great relevance for other institutions. We'll tell the Moore Regional story first.
Moore Regional Hospital is a 372-bed community-based hospital with four adult ICUs and a Level 2 NICU. Like many institutions that are conscientious about patient safety, it was intent on minimizing CRBSI. Along with other members of the North Carolina Hospital Association, the hospital joined the Michigan Keystone ICU Project and set a goal of zero CLABSI. The Keystone Project is based on the notion that CRBSI can be predictably minimized if a facility institutes a set of meticulous preventive practices and diligently enforces compliance with their use. One example of a compliance enforcement step taken at Moore Regional was use of a checklist for our catheter insertion practices.
Of course, as we've just shown, there is no way to guarantee compliance with an alcohol-scrub policy for luer access valves. Sure enough, an internal review showed that few of Moore Regional's nurses were complying with the hospital's valve-scrubbing protocol.
While searching for a solution to the dilemma, the hospital's director of infection control and patient safety became aware of the valve disinfection cap. The device is a bright orange plastic cap with a foam pad inside saturated with 70 percent isopropyl alcohol. The act of twisting the cap onto the male threads of the valve top compresses the pad, releasing the alcohol onto the valve top and threads. In vitro research shows that after five minutes of attachment, the valve top is disinfected.
