Preventing C-BSIs has become more than just a patient safety issue; it is now associated with reimbursement and, potentially, accreditation decisions as well.
Starting in October, under new Medicare regulations, hospitals will no longer receive higher payments for the additional costs associated with treating patients for preventable C-BSIs. Implementing best practices to prevent these infections is included among The Joint Commission's (formerly JCAHO) list of potential 2009 National Patient Safety Goals, currently under review.
The good news? Healthcare organizations can take some simple steps to prevent such infections. Consider the results at Regions Hospital, a 427-bed, full-service private hospital in St. Paul, MN: Between 2005 and 2007, the hospital reduced its C-BSI infection rate from 3.3 infections per 1,000 line days to 1.7 per 1,000 line days- a 48.5% reduction.
Regions Hospital began using a group of evidence-based recommendations to reduce C-BSI in 2004 as part of a statewide initiative, Safest in America. The organization later joined the Cambridge, MA-based Institute for Healthcare Improvement's 100,000 Lives Campaign, which was promoting the same recommendations as part of a central-line bundle. The bundle includes the following five components:
- Optimal catheter site selection, with subclavian vein as the preferred site for nontunneled catheters
- Daily review of line necessity, with prompt removal of unnecessary lines
- Hand hygiene
- Maximal barrier precautions
- Chlorhexidine skin antisepsis
The initiative involved a host of departments, including the emergency department (ED), anesthesia, nursing, respiratory therapy, IC, and critical care, says Stephanie Tismer, an ICP at Regions Hospital. Additionally, a crucial element of the program's success was strong support from hospital administration, she says.
Below are training tips that Tismer and Dede Ouren, IC manager at the hospital, recommend to other facilities looking to undertake a similar initiative:
Teach nurses to monitor compliance. It's not enough to instruct people on compliance; somebody has to be in charge of ensuring the job gets done. For this reason, audits are an important tool. Give nurses checklists to determine whether staff members are performing all recommended interventions each day. If you have an electronic medical records system, include prompts that remind nurses to follow your organization's protocols. For example, did nurses perform the daily check to see whether the line could be removed?
Ensure that staff members have the proper supplies. Create central-line carts that include two sets of all the supplies physicians need to put in a line. The duplicate set is necessary in the event that sterile technique is broken and the practitioner must start over.
Empower nursing staff members to notify you if they see a break in sterile technique. "We met with the medical directors for the critical care units and asked them to support nursing staff in identifying breaks in technique and asking physicians to start over," says Tismer. As part of the program, they developed a Stop the Line campaign, and placed Stop the Line signs in the unit's staff room that said, "The medical director supports you stopping any procedure that is not being done under maximal sterile barriers."
Standardize your definition of catheter-related infection. It's difficult to collect accurate data if practitioners do not agree on criteria for a C-BSI. "We agreed to use the CDC definition, including microbiology confirmation to classify bloodstream infections," says Tismer.
Improve ED communication. A critical goal of Regions' program was to improve communication between the ER and critical care units related to the insertion of central lines. "Our original policy stated that lines inserted emergently would be removed within 24 hours and replaced at a different site," says Tismer. "This meant a patient would undergo a second painful procedure and another expensive central-line catheter would be used when the original line may have been placed under sterile conditions using optimal sterile barriers." To improve communication and prevent an unnecessary premature line change, the facility developed a system to identify central lines that were inserted in emergent lifesaving trauma situations under duress, which may not have been placed using maximal sterile precautions. In these circumstances, Regions' ED staff members place a red sticker on the central-line dressing to immediately notify nursing staff members in other departments that this line should come out as soon as possible-within 24 hours. When staff members place a line under duress, but use maximal sterile barriers, the dressing is marked with a green sticker. This is a quick and efficient visual way for staff members to identify a line that they need to change.
Bundle ED supplies. Another effective procedure in the ED was to bundle all necessary supplies into a central-line kit. The kit includes items such as the central-catheter insertion kit, a sterile gown, sterile gloves, stickers, and a documentation form. Because there is no room for central-line carts in the ER, the central-line kits are put in a central, easily accessible location, says Tismer. The availability of these kits has significantly reduced the number of lines that require red stickers.
Get everyone on the same page. One of the most significant challenges Regions Hospital faced was standardizing procedures. For example, anesthesia physicians might be teaching residents to put a line in following one protocol, whereas interventional radiology might have a different system. Ensuring that all the units were communicating with one another and following the standard protocol was a challenge. Create standardized training programs for residents to eliminate these differences and call on department heads to model the agreed-upon protocols, says Tismer. "Physicians need to take ownership of the initiative, and nurses need to be there to reinforce the practice," she says.
Feedback is critical. It's important to report information to staff members in a timely manner. Create posters that show unit-specific rates and hang them in the patient care unit staff room. Remember, data have to be unit-specific to have an effect.
Personalize the issue. Regions Hospital performs case reviews whenever an infection occurs. IC medical directors and residents, along with critical care and nursing staff members, look at these infections to find out what went wrong, says Tismer. The key is to review the case early when staff members still remember the patient. This makes them aware of process improvement opportunities and reminds them of the adverse effect infections have on people's lives; the patients are not just an infection rate anymore.
Go beyond the recommendations. Once your infection rate drops below 3 infections per 1,000 line days, consider using new technology, such as silver-site patches and antimicrobial lines to enhance the initiative, says Tismer.