Small Steps to Big Benefits at the Bedside

Hospital-acquired infections (HAIs) represent an ever-growing concern that not only impacts families but the financial health of every medical institution in the nation. As best practices have improved and technology continues to evolve we are more equipped than ever to win the war over these potentially devastating and costly patient outcomes. Yet, despite these advancements, we are still faced with a high incidence of HAIs about 2 million annually a number too high to ignore.

The Institute for Healthcare Improvement (IHI) has taken a bold initiative to rally the support of hospitals across the country to do no harm. The 24-month campaign, Protecting 5 Million Lives from Harm, by Dec. 9, 2008, encourages hospitals to participate, at a level higher than ever before, to join forces and commit their efforts in improving patient outcomes for the better. This voluntary improvement plan asks hospitals to respond aggressively to the need of protecting their patients from the incidence of medical injury. One focus area of the IHIs campaign is in the prevention of central line infections which are a major cause of patient morbidity and mortality every year. The Centers for Disease Control and Prevention (CDC) estimates a cost of $34,000 to $56,000 per infection and can add up to billions in healthcare costs annually.

As hospitals recognize the need to get up to speed with requirements to improve patient outcomes, many seem confused or uncertain where to look for help. Who has the answers and how can we trust they will work in our situation? Fortunately, many hospitals have already demonstrated successful reductions in catheter related bloodstream infections (CRBSIs) and now serve as role models providing evidence of which direction to take. This can prove to be comforting for the healthcare team who is attempting to make a difference in the field.

The purpose of this article is to identify the common denominators found among these successful hospitals and how they impact the reduction of CR-BSIs. The goal in exposing these denominators is to help provide an avenue for the healthcare team to strategically develop and administer a plan of action in their own hospital setting. Phone calls were made to a variety of hospitals across the United States, some known to have lower CR-BSIs rates and others were unknown. The hospitals that verbally confirmed a low CR-BSI rate or a significant decrease in the past 12 months to 24 months were asked to participate in a survey. A questionnaire was utilized and 27 hospitals agreed to participate anonymously in the survey. Each facility was questioned extensively as to what measures contributed to their success in reducing the incidence of hospital- acquired CRBSIs. Best practices, awareness, bundles, education, products, protocols, standards, barriers, guidelines, tools, technology and staffing where all evaluated. The data was compiled and analyzed searching for trends and consistencies in practice.

The denominators in common materialized quickly and appeared all to familiar to an experienced nurse. All 27 hospitals surveyed had three common denominators: education, best practices and new technology. The strong correlation discovered between these denominators suggests they are interdependent and have the ability to produce dramatic improvement. Let us take a closer look at each variable and the role each one plays in the big picture.

Education

The hospitals all agreed that bringing awareness of the problem to the healthcare team was the first step in their education process. Acknowledging their current rates as they compare to national standards was pivotal in providing a starting point for the healthcare team to develop an appropriate plan of action. Then each hospital looked specifically at their potential modes of infection transmission to determine areas of weakness. Familiarization of evidence-based practices and review of the most current guidelines for prevention of CR-BSI provided an additional measuring tool for further comparison and planning. Once the target areas were identified and studied an educational program was launched to address those areas of needed change. Several methods were used to reinforce best practices including in-service programs, staff education, audits, competencies, skill evaluations, posters, handouts, updated protocols and incentives as needed. More than half the hospitals surveyed claimed surprisingly low hand hygiene compliance rate among their healthcare workers. Because hand hygiene is the most significant factor in reducing cross-contamination of microorganisms the need to increase compliancy rates was crucial if they were to bring their CR-BSI rates down.

Best Practices

Taking the information and putting it into practice was the next task in order to accomplish the desired results. Although, there were many practices and tools used, the following list represents only those practices that were implemented and consistently performed by all 27 hospitals with the exception of one hospital that occasionally used heparin to flush intravenous (IV) lines:

• Following CDCs Guidelines for Prevention of Intravascular Catheter Related Infections 

• Implementing IHIs central line bundle including the maximal sterile barrier precautions 

• Holding healthcare team accountable for aseptic techniques 

• Handwashing protocol 

• Flush protocol with saline 

• Swab protocol 

• Method for data collection and reporting 

None of the hospitals surveyed were utilizing the entire central line bundle and/or maximal barrier precautions or even all of the rest of the practices mentioned prior to deciding to reduce their incidence of CR-BSI rates. However, after the education process was initiated and best practices coupled with new technology implemented, all hospitals reported a reduction in CR-BSIs within one quarter. This is significant when looking at the impact of the denominators on reducing CR-BSIs.

New Technology

The last denominator that impacted positive outcomes was the use of new technology. Several new technology products are indicated and are recommended under the CDCs Guidelines for Prevention of Intravascular Catheter Related Infections (listed under best practices above) such as antimicrobial impregnated catheters, chlorhexidine skin prep, sutureless securement devices, etc. However, two other products used by all the hospitals were noticed through the survey. The first was pre-filled saline syringes used when flushing the IV catheter lines. The reasons for using the pre-filled saline syringe are given: saves time, easy to use, and eliminates the risk of cross-contamination with multiuse vials. The next product was the introduction of a positive pressure access device with a swabable design. Several indicators were mentioned as to why a conversion to this new needless access device occurred: Easy to use; the hub is swabable-free from grooves and indentations; removes confusion by using this same device on all lines; effective flush system with only 5ccs of saline; heparin not required; less occlusions due to the positive displacement feature; and compliments best practices.

Obstacles

It should be mentioned that many of the hospitals experienced barriers that required a great deal of effort to overcome. A few hospitals stated they are still in the process of working through those barriers. Here is a list of obstacles that were disclosed during the survey process: 

• Resistance of healthcare team to comply resulting in delays and added healthcare costs.

• Poor compliance with aseptic technique among nursing and medical staff contributing to overall incidence of CR-BSIs 

• Resisting change until industry speakers have given stamp of approval often delaying decisions to move forward with new and better technology 

• Ability to access new technology is frequently limited and/or cost prohibitive due to threats of increased costs on other product lines. One manager verbalized frustration in her inability to utilize products that have proven effective in the reduction of bloodstream infections in all departments with all patients due to contract restrictions. She was told that she could not change products without affecting a price increase for an entire group of related products.

• Healthcare team frustration and confusion related to non-standardization of care within the hospital.

The most compelling story regarding the importance of best practice with best technology at the bedside was told by a manager of a neonatal intensive care unit (NICU). She shared the success story of a three year effort to eliminate bloodstream infections in infants. On year one, their infection rate was statistically significant to cause the deaths of as many as 4.5 infants. Year two, after implementing all possible techniques to decrease infection they still had twelve bloodstream infections. After changing to a swabable needleless connector called the MaxPlus they just completed year three with no bloodstream infections.

This survey was helpful in identifying the common denominators that are integral in successfully reducing the incidence of CR-BSIs. It is no coincidence that these same three denominators are the cornerstone for all effective healthcare practices both past and present.

Education, best practices and compatible technology, hold the keys to lowering CR-BSI rates, while at the same time providing a framework for duplication. The findings in this survey confirm the legitimacy of following already established best practices and previously published guidelines from the CDC and the IHI on the prevention of CR-BSIs. Prevention is still the best protection and should continue to be our main focus in the fight against all HAIs.

Survey findings also found that the pre-filled saline syringe and the swabable design positive pressure needless access device were recognized by all the hospitals as having contributed favorably to reducing their risk of CR-BSIs. This clearly demonstrates the benefits of adapting new technologies that prove to compliment and streamline best practices at the bedside. One final note worth mentioning is the urgency to investigate and eliminate any obstacles that may pose a threat to the healthcare workers ability to deliver safe and effective healthcare.

Cynthia Grube, RN, BSN, PHN, a graduate of Loma Linda University, has been practicing nursing in a variety of clinical areas for 20- plus years. As co-owner and educator of a professional education service in Corona, Calif., her focus is on education and prevention with emphasis on culture change.