Bundled Interventions, Ongoing Education Can Address Threat of Device-Related Infections

By Kelly M. Pyrek

The Centers for Disease Control and Prevention (CDC) estimates that three types of infections account for approximately two-thirds of all healthcare-associated infections (HAIs) -- central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infections (CAUTI), and ventilator-associated pneumonia (VAP). These device-related infections continue to represent a challenge to clinicians, requiring continual education, bundled interventions and evidence-based practice.

“Nurses play a key role in minimizing the occurrence of these infections,” says Elaine Foster, PhD, MSN, RN, dean of nursing and healthcare programs at American Sentinel University. “It’s important for nurses to be sure they do all they can to prevent HAIs from happening to their patients while saving their healthcare facility additional cost."

To serve as a resource for nurses to review information about prevention and interventions for HAIs, American Sentinel University created a reference guide that outlines nursing’s role in preventing these three most common HAIs. Each type of infection has specific risk factors that nurses should be aware of, as well as core strategies for prevention (defined by the CDC as those that are backed by high levels of scientific evidence and have demonstrated feasibility.) This e-book is available for download at www.americansentinel.edu/HAIebook.

Nurses are responsible for managing indwelling urinary catheters, and can effectively employ core strategies to help prevent CAUTIs. One goal is to minimize overall catheter use. Many hospitals have implemented protocols for nurse-directed removal of unnecessary catheters – these allow for nursing assessment and intervention without a physician’s order. With VAP, core prevention strategies focus on interrupting the three most common mechanisms by which it develops: the aspiration of secretions, the colonization of the aerodigestive tract, and the use of contaminated equipment. Nurses can be involved in all these strategies. To help prevent CLABSI, all nurses should be aware of the central line bundle, a group of five evidence-based strategies (described below) for the insertion and management of central lines. When implemented together, the bundled strategies result in better outcomes than when each strategy is implemented individually.
“Our e-book explains the autonomous nursing actions that can prevent the incidence of HAIs. It was developed specifically for nurses. By out-lining the nursing practices that catch potential problems before they occur, our guide supports nurses in their patient-advocacy role,” says Foster.

The central line bundle has five key components, according to American Sentinel University:
• Hand hygiene. Hands should be washed before and after palpating insertion sites or accessing, replacing or dressing a catheter. Process changes can improve compliance in this area and are easy to implement: include hand hygiene on the checklist for central lines, keep alcohol-based hygiene dispensers prominently placed, and post signs on patient rooms as reminders to staff.
• Maximal barrier precautions. One study found that the odds of developing CLABSI were six times higher when the line was placed without maximal barrier precautions. These precautions involve covering the patient with a large sterile drape, with a small opening at the insertion site. For clinicians, it means using a mask, cap, sterile gown and sterile gloves, the same as for surgical procedures. The best way to ensure compliance with this precaution is to keep all necessary equipment stocked together, to avoid the difficulty of hunting down supplies.
• Chlorhexidine skin antisepsis. Research shows that chlorhexidine provides better protection from infection than other antiseptic agents. It should be applied to the insertion site using a back-and-forth friction scrub for at least 30 seconds, and allowed to dry completely before the line is inserted. Again, it’s easy to enhance compliance by including this step on the central line checklist and keeping chlorhexidine solution handy where central line equipment is stored – note that many prepackaged central line kits include povodine-iodine solution instead, even though the IHI recommends avoiding its use at catheter insertion sites.
• Optimal catheter site selection. Evidence-based guidelines recommend avoiding the femoral vein for catheter insertion in adult patients, as studies have shown this site correlates with higher infection rates. Some research indicates that use of the subclavian site correlates with lower infection rates than does the jugular insertion site. However, the bundle approach is based solely on lowering the likelihood of CLABSI, and recognizes that other medical factors should be considered when deciding where to place the line. (A physician should conduct a risk/benefit analysis as to which insertion site is most appropriate for the individual patient, with input from care-team members.)
• Daily assessment of central line necessity. The goal here is to promptly remove lines that are no longer clearly needed for optimal care of the patient – and not to leave them in place for convenient access. The risk of infection increases over time as the line remains in place. (When central lines are placed for long-term use, as in chemotherapy, weekly review of necessity may be appropriate.)

In 2014, SHEA and IDSA, with partner organizations AHA, APIC and the Joint Commission updated, in the journal Infection Control and Healthcare Epidemiology, the popular science-based and practical recommendations for acute-care hospitals for the prevention of common HAIs, originally published in 2008. The 2014 Compendium Updates represent practical recommendations by the leading champions in infection prevention and healthcare quality improvement, and sound instruction for the prevention of device-related infections can be found therein. Let's take a closer look at the three pertinent sets of recommendations.

Basic practices for preventing CAUTI include:
1. Provide and implement written guidelines for catheter use, insertion, and maintenance. Develop and implement facility criteria for acceptable indications for indwelling urinary catheter use.
2. Ensure that only trained, dedicated personnel insert urinary catheters.
3. Ensure that supplies necessary for aseptic technique for catheter insertion are available and conveniently located.
4. Implement a system for documenting the following in the patient record: physician order for catheter placement, indications for catheter insertion, date and time of catheter insertion, name of individual who inserted catheter, nursing documentation of placement, daily presence of a catheter and maintenance care tasks, and date and time of catheter removal. Record criteria for removal and justification for continued use.
5. Ensure that there are sufficient trained personnel and technology resources to support surveillance for catheter use and outcomes.
6. Perform surveillance for CAUTI if indicated on the basis of facility risk assessment or regulatory requirements. Identify the patient groups or units in which to conduct surveillance on the basis of risk assessment, considering frequency of catheter use and potential risk. Use standardized criteria, such as NHSN definitions, to identify patients who have a CAUTI. Collect information on catheter-days and patient-days (denominator data) and indications for catheter insertion for all patients in the patient groups or units being monitored. Calculate CAUTI rates and/or standardized infection ratio (SIR) for target populations. Use surveillance methods for case finding that are documented to be valid and appropriate for the institution. Consider providing unit-specific feedback.
7. Educate healthcare personnel involved in the insertion, care, and maintenance of urinary catheters about CAUTI prevention, including alternatives to indwelling catheters, and procedures for catheter insertion, management and removal.
8. Assess healthcare professional competency in catheter use, catheter care, and maintenance.
9. Use appropriate technique for catheter insertion. Insert urinary catheters only when necessary for patient care and leave in place only as long as indications remain. Practice hand hygiene immediately before insertion of the catheter and before and after any manipulation of the catheter site or apparatus. Insert catheters following aseptic technique and using sterile equipment.
10. Ensure appropriate management of indwelling catheters. Properly secure indwelling catheters after insertion to prevent movement and urethral traction. Maintain a sterile, continuously closed drainage system. Replace the catheter and the collecting system using aseptic technique when breaks in aseptic technique, disconnection, or leakage occur. For examination of fresh urine, collect a small sample by aspirating urine from the needleless sampling port with a sterile syringe/cannula adaptor after cleansing the port with disinfectant. Obtain larger volumes of urine for special analyses aseptically from the drainage bag. Maintain unobstructed urine flow.

Best practices for preventing CLABSI include:
Before insertion
1. Provide easy access to an evidence-based list of indications for CVC use to minimize unnecessary CVC placement.
2. Require education of healthcare personnel involved in insertion, care, and maintenance of CVCs about CLABSI prevention. Include the in-dications for catheter use, appropriate insertion and maintenance, the risk of CLABSI, and general infection prevention strategies. Ensure that all healthcare personnel involved in catheter insertion and maintenance complete an educational program regarding basic practices to prevent CLABSI before performing these duties. Periodic retraining with a competency assessment may be of benefit. Re-educate when an institution changes components of the infusion system that requires a change in practice. Consider using simulation training for proper catheter insertion technique.
3. Bathe ICU patients over 2 months of age with a chlorhexidine preparation on a daily basis. The role of chlorhexidine bathing in non-ICU pa-tients remains to be determined.
At insertion
1. Have a process in place to ensure adherence to infection prevention practices at the time of CVC insertion in ICU and non-ICU settings, such as a checklist. Ensure and document adherence to aseptic technique. Checklists have been suggested to ensure optimal insertion practices. If used, the documentation should be done by someone other than the inserter.
2. Perform hand hygiene prior to catheter insertion or manipulation.
3. Controversy exists regarding infectious and noninfectious complications associated with different short-term CVC access sites. The risk and benefit of different insertion sites must be considered on an individual basis with regard to infectious and noninfectious complications. Do not use peripherally inserted CVCs (PICCs) as a strategy to reduce the risk of CLABSI.
4. Use an all-inclusive catheter cart or kit. A catheter cart or kit that contains all necessary components for aseptic catheter insertion must be available and easily accessible in all units where CVCs are inserted.
5. Use maximum sterile barrier precautions during CVC insertion.
6. Use an alcoholic chlorhexidine antiseptic for skin preparation. Before catheter insertion, apply an alcoholic chlorhexidine solution containing more than 0.5% CHG to the insertion site. The antiseptic solution must be allowed to dry before making the skin puncture.
After insertion
1. Ensure appropriate nurse-to-patient ratio and limit the use of float nurses in ICUs. Observational studies suggest that there should be a nurse-to-patient ratio of at least 1 to 2 in ICUs where nurses are managing patients with CVCs and that the number of float nurses working in the ICU environment should be minimized.
2. Disinfect catheter hubs, needleless connectors, and injection ports before accessing the catheter. Before accessing catheter hubs, needle-less connectors, or injection ports, vigorously apply mechanical friction with an alcoholic chlorhexidin preparation, 70% alcohol, or povidone-iodine. Alcoholic chlorhexidine may have additional residual activity compared with alcohol for this purpose. Apply mechanical friction for no less than 5 seconds to reduce contamination.
3. Remove nonessential catheters. Assess the need for continued intravascular access on a daily basis during multidisciplinary rounds. Remove catheters not required for patient care.
4. Perform surveillance for CLABSI in ICU and non-ICU settings. Measure the unit-specific incidence of CLABSI (CLABSIs per 1,000 catheter-days) and report the data on a regular basis to the units, physician and nursing leadership, and hospital administrators overseeing the units. Compare CLABSI incidence with historical data for individual units and with national rates (NHSN). Audit surveillance as necessary to minimize variation in interobserver reliability. Surveillance for CLABSI outside the ICU setting requires additional resources; electronic surveillance is an option in these settings.
Best practices for preventing VAP in adult patients include:
1. Avoid intubation if possible. Use noninvasive positive pressure ventilation (NIPPV) whenever feasible.
2. Minimize sedation. Manage ventilated patients without sedatives whenever possible.
3. Assess readiness to extubate once a day (spontaneous breathing trials) in patients without contraindications.
4. Pair spontaneous breathing trials with spontaneous awakening trials.
5. Minimize pooling of secretions above the endotracheal tube cuff.
6. Elevate the head of the bed to 30 to 45 degrees.
7. Maintain ventilator circuits. Change the ventilator circuit only if visibly soiled or malfunctioning.
8. There are interventions that may lower VAP rates but for which there are insufficient data at present to determine their
impact on duration of mechanical ventilation, length of stay, and mortality. This includes performing oral care with chlorhexidine.

While the healthcare community has a number of guidelines and recommendations, they are only as good as the clinician putting them into practice, emphasizes Marcia Ryder, PhD, MS, RN, an independent collaborative researcher and consultant in medical biofilm/healthcare-related infections. "Unfortunately, as confirmed in a study by Pat Stone and colleagues at Columbia University, most ICUs in the U.S. have the right policies and procedures in place incorporating the CDC Guidelines, the SHEA Strategies, etc. -- but they are not actually translated into practice at the bedside.

Ryder continues, "Frequently, I see clinicians struggle with the ability to accurately evaluate the literature for applicability in change of practice" "So much of this depends upon their level of academic preparation and critical thinking skills. While we have multiple documents that provide assimilation of that evidence in the form of guidelines and recommendations, they are not perfect and sometimes in conflict. I sometimes observe that those who have evaluated the evidence in those documents may not be as prepared as they should be either, but it's the best that we have and we certainly need to take the guidelines and recommendations into account as we evolve practice. Another challenge is the timeliness of these documents that are almost outdated by the time they appear in publication. Clinicians must be aware of that fact as part of their clinical decision-making and be sure to review the literature since the time of publication."

 Variance in practice has been an ongoing barrier to best practice. Bundled interventions are designed to take much of the guesswork out of the equation. However, they are not perfect from a human-factors perspective.  "We know that bundles are very effective but the challenge can be putting that bundle together and determining the most effective components," Ryder says. "This becomes highly problematic if for no other reason than a majority of the interventions are technology-based. Differences in technologies do affect patient safety. Decisions need to be made every day on the selection of the most effective technology for the best outcome. We still, in the clinical community, have this aversion to talking about technologies and evaluating the effectiveness and safety of them. Choices must be made for the lowest risk connectors, catheters, dressings, etc. but how can this be done unless there can be an open dialogue about product differences and evaluation of the data? Even today, in publications or presentations at organizations' events, speakers are restricted from stating the names of the manufacturers or their product names, you must identify the technology generically. Where does the money come from to evaluate technology? It's not coming from the government and it's not coming from schools of nursing, but it's coming from industry. There's this stigma that if you accept funding from industry to perform research, the research is automatically discounted without assessing the merit of the work. How can we put together an effective bundle if we approach it in this way?"

Another barrier Ryder identifies is the lack of appreciation by the C-suite and purchasing managers about the value of evidence-based, cost effective bundles. "How can you expect clinicians to produce the best outcomes when inferior products or technologies are forced by contract restrictions?  Even though there may be solid science behind a certain product or technology, clinicians can't get it because it's outside of their hospital's contract.  Clinicians are often frustrated by not having access to the products they need to effectively care for their patients while they are pressured to achieve better outcomes. The world of vascular access is for the most part, technology-driven. The identification and selection of the best products is a major element but the failure to use the technology in a consistent and effective manner by the clinician is also a major gap in results. For even the best of products, improper use voids the benefit of the technology. Infection preventionists are expected to be involved in technology assessment, but I see infection preventionists so burdened by surveillance and reporting that they have limited time to educate themselves, let alone educate, monitor and evaluate competency and compliance of the clinicians."
Ryder adds, "A solution lies in creating and supporting formal multidisciplinary vascular access teams in all healthcare institutions." Do I believe vascular access is a specialty? Absolutely, unequivocally, yes. Do we need to establish and formalize vascular access teams? Yes indeed, It is a critical patient safety matter but unfortunately so many hospital C-suites are blind to it."
She says that in addition to vascular access teams in hospitals, there is a great need for nursing schools to integrate topics such as the pathogenesis of medical device biofilm–related infections into their programs.  “I have no idea how many nursing schools are even teaching the science behind biofilm infections and antimicrobial resistance, but I fear that they are not. Unfortunately, we can't see bacteria – let alone know if they are resistant organisms; we are fighting an invisible enemy of which there is little understanding at the bedside. Given that most bedside clinicians are not knowledgeable in the pathogenesis and prevention of biofilm infections, they are instead often focused on simply trying to get the work done. Revising curriculum and changing behavior takes considerable time and effort and clearly has not happened as we have sat by and watched the problem of antibiotic resistance escalate. Vascular catheters are a significant part of the problem for which they are used to treat. But now the price is too high, so we must acknowledge vascular access as a specialty and formalize multidisciplinary vascular access teams to be a part of the antimicrobial stewardship effort. Specialties enhance practice and improve outcomes; we need that specialization as part of a paradigm shift. We must think out of the box, because otherwise it isn't going to happen and we will continue to do the same things over and over with the same results over and over."