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.
While there are other such caps available, the cap we chose has several advantages including:
- A thread cover design that helps seal in the alcohol that bathes both the valve surface and threads, disinfecting and protecting the valve between accesses;
- Aseptic "touch-free" packaging that's easy to use.
- Softer material makes it comfortable for patient
The cap answered the questions Moore Regional was addressing. Notably, because applying the cap provides the same thorough disinfection every time it is used, variation in technique was not a concern. The cap provided compliance with a valve disinfection protocol that was simple to verify. The bright orange color makes it easy to spot, and when the cap is attached to the valve, compliance is confirmed.
The cap was implemented at Moore Regional in January 2010. As part of the hospitals policy on central lines, nurses can choose between using the device or swabbing with a alcohol pad. Which approach do nurses prefer? A survey conducted in spring 2010 shows that 87 percent of nurses use the disinfection cap instead of using the wipe method with an alcohol pad.
Coral Springs Story
Coral Springs is a 200-bed community based hospital with a Level 2 NICU and PICU. Before implementing the cap, the hospital relied on the same valve disinfection policy that Moore Regional did. Although there was no formal review of compliance, Coral Springs' infection preventionist understood intuitively that technique variation and noncompliance were both highly likely. Coral Springs was also concerned about whether the Joint Commission would view their valve-scrubbing technique as an appropriate standardized protocol.
The device was trialed at Coral Springs during the second quarter (April through June) of 2010. During that time, no CRBSI occurred. This result was startling compared to the hospital's CRBSI rate of 4.75 infections/1,000 patient days over the previous three quarters (roughly 2.2 CRBSI per month).
Despite these results, some members of the Broward Health system's Value Analysis Committee, which had to approve new devices, remained skeptical about the device because they believed it added cost to patient care. The financial analysis, which showed a half-million dollars in savings per quarter, convinced them otherwise and the device was implemented immediately after the trial's conclusion. The zero rate of CRBSI has continued.
The cap appears to be responsible for this dramatic improvement because no other changes in policy or procedure have occurred during this time. Coral Springs is also confident that the cap has addressed the issue with the Joint Commission requirement. The disinfection cap is now in use at three of four hospitals in the Broward Health system.
Discussion and Conclusion
Are disinfection caps by themselves the answer to the CRBSI issue? Of course not. Combating CRBSI requires a comprehensive set of evidence-based practices and technologies so that every opportunity for bacterial contamination is addressed. But at hospitals that already have good preventive policies and are still experiencing high CRBSI rates, better valve disinfection may be the difference that pushes their CRBSI rate to zero. Needleless connectors play a critical role in prevention because they guard the intraluminal pathway. If they are not properly disinfected before each line access, bacteria can gain entry to the pathway and create the conditions for an infection.
The problem is exacerbated by the fact that many of the most widely used valves are poorly designed from an infection prevention standpoint, as a recent action by the FDA alert about positive-displacement connectors makes clear. Among other problems, some connectors have uneven septum surfaces that make them hard to disinfect even with meticulous scrubbing and are hard to flush thoroughly, creating an environment in which infection-causing biofilm can grow.
The disinfection cap can mitigate these design problems by virtually eliminating bacteria at the entry point. Any facility concerned about the effectiveness of its approach to valve/injection port disinfection should consider this potential solution.
Ava Dobin, RN, BSN, CIC is regional manager of epidemiology for Broward Health Coral Springs Medical Center in Coral Springs, Fla.
Jayne Lee, BSN, MPH, CIC is director of infection control and patient safety at FirstHealth of the Carolinas. FirstHealth Moore Regional Hospital in Pinehurst, N.C. is the flagship hospital for the FirstHealth of the Carolinas healthcare network.