AACN News—October 2005—Practice

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Vol. 22, No. 10, OCTOBER 2005

Practice Alert: Preventing Catheter-Related Bloodstream Infections

The goal of the AACN Practice Alerts is to help nurses and other healthcare practitioners carry their bold voices to the bedside to directly impact patient care. Practice Alerts are directives from AACN that are supported by authoritative evidence to ensure excellence in practice and a safe and humane work environment.

Expected Practices:
• Cleanse hands with waterless cleaning solution or, if visibly soiled, with soap and water before and after patient contact.
• Disinfect clean skin utilizing friction with an appropriate antiseptic (preferably 2% chlorhexadine) before catheter insertion and during site care.
• Utilize full barrier precautions when inserting central venous access devices.
• Educate all staff who insert and care for intravascular catheters, assess competency of same at regular intervals and advocate adherence to standards of care.
• Replace peripheral intravenous sites in the adult patient population at least every 96 hours, but no more frequently than every 72 hours. Leave peripheral venous catheters in children until IV therapy is completed, unless complications (eg, phlebitis and infiltration) occur.
• Replace IV tubing at least every 96 hours, but no more frequently than every 72 hours.
• When adherence to aseptic technique during intravascular catheter insertion cannot be ensured (ie, prehospital, code situation), replace the catheter as soon as possible, but within 48 hours.

Supporting Evidence:
• A substantial proportion of hospital-acquired infections results from cross-contamination from the hands of healthcare workers. Alcohol-based hand rub, compared with traditional handwashing using unmedicated soap and water or medicated hand antiseptic agents, may offer better results because it requires less time, acts faster and is less likely to irritate skin. Thus, the Centers for Disease Control and Prevention recommends the use of alcohol-based hand rubs between patient contacts as an adjunct to traditional handwashing alone.1-3
• Chlorhexidine gluconate solutions utilized for vascular catheter site care reduce catheter-related bloodstream infections and catheter colonization more effectively than povidone-iodine solutions. Moreover, 80% of resident and transient skin flora are found in the first five epidermal layers of the skin. Clinical evidence supports the efficacy of applying antiseptics with sufficient friction to ensure that the solution reaches into the cracks and fissures of the skin. There is no evidence to support use of the traditional concentric prepping technique. Although a 2% chlorhexidine-based preparation is preferred, tincture of iodine, an iodophor, or 70% alcohol can be used. Allow these solutions to dry before inserting the catheter.1,4,5
• Compared with peripheral venous catheters, central venous catheters carry a substantially greater risk of infection; therefore, the level of barrier precautions required to prevent infection during insertion of CVCs should be more stringent. Maximal sterile barrier precautions (eg, cap, mask, sterile gown, sterile gloves, and full body sterile drapes) during the insertion of CVCs substantially reduce the incidence of CRBSI compared with standard precautions (eg, sterile gloves and small drapes).1,2,3,6,7,10 Some studies have demonstrated that infection rates are lower when the subclavian site is used. Selection of the central line insertion site, however, is based on patient risk factors.
• Healthcare workers who insert and care for intravascular devices should receive formalized education and training in indications for intravascular catheterization, proper placement, maintenance, and infection control. Educational programs focusing on central venous catheter insertion and care have led to a substantial decrease in cost, morbidity, and mortality attributable to central venous catheterization. Ongoing education and reinforcement of appropriate technique serve as a reminder of current best practices, and studies demonstrate that consistent reinforcement of aseptic technique leads to decreased CRBSI.1,8-11
• Studies of peripheral intravenous catheters show there is no substantial difference in phleblitis rates between catheters left in place 72 hours and those left in place 96 hours. No evidence exists to support that routine replacement of central venous catheters is more effective in decreasing bloodstream infections than replacing central venous catheters as needed.1,12
• Studies show that IV tubing containing crystalloids can be replaced every 72 to 96 hours. If monitoring using a transducer system, replace the transducer, tubing, flush device, and flush solution every 96 hours.1,13

What You Should Do:
• Ensure that your units have written practice documents such as a policy, procedure or standard of care that include using sterile technique with full barrier precautions when central venous access devices are inserted.
• Ensure that your units have written practice documents such as a policy, procedure or standard of care that address frequency of peripheral IV site rotation and tubing change.
• Establish a process for education and routine evaluation of all staff who insert and care for intravascular devices.
• Review your unit’s rate of catheter-related bloodstream infections and, if needed, establish an interdisciplinary team, including but not limited to a staff nurse, an advanced practice nurse, an infection control nurse (officer), and a physician.
• Develop a process for daily evaluation of the need for any central venous catheters.

Need More Information or Help?
• Call the AACN Practice Resource Network at (800) 394-5995, ext. 217. Practice Alerts are available online at www.aacn.org > Clinical Practice.

1. O’Grady NP, Alexander M, Dellinger EP, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control. 2002;30(8):476-489.
2. Rosenthal K. Guarding against vascular site infection: arm yourself with the latest knowledge on equipment and technique to protect patients from catheter-related bloodstream infections. Nur Management. 2004;35(suppl):4-9.
3. Pittet D, Hugonnet S, Harbath S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet. 2000;356:1307-1309.
4. Clemence MA, Walker D, Farr BM. Central venous catheter practices: results of a survey. Am J Infect Control. 1995;23:5-12.
5. Chaiyakunapruk N, Veenstra DL, Lipsky BA, et al. Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: a meta-analysis. Ann Intern Med. 2002;136:792-801.
6. Mermel LA, McCormick RD, Springman SR, Maki DG. The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters: a prospective study utilizing molecular subtyping. Am J Med. 1991;91(suppl):197-205.
7. Raad II, Hohn DC, Gilbreath BJ, et al. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infect Control Hosp Epidemiol. 1994;15:231-238.
8. Gnass SA, Barboza L, Bilicich D, et al. Prevention of central venous catheter-related bloodstream infections using non-technologic strategies. Infect Control Hosp Epidemiol. 2004;25(8):675-677.
9. Sherertz RJ, Ely EW, Westbrook DM, et al. Education of physicians-in-training can decrease the risk for vascular catheter infection. Ann Intern Med. 2000;132:641-648.
10. Coopersmith CM, Rebmann TL, Zack JE, et al. Effect of an education program on decreasing catheter-related bloodstream infections in the surgical intensive care unit. Crit Care Med. 2002;30(1):59-64.
11. Berenholitz SM, Pronovoist PJ, Lipsett PA, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004;32(10):201-220.
12. Josephson A, Gombert ME, Sierra MF, Karanfil LV, Tansino GF. The relationship between intravenous fluid contamination and the frequency of tubing replacement. Infect Control. 1985;258:177-181.
13. Gillies D, O’Riordan L, Wallen M, Rankin K, Morrison A, Nagy S. Timing of intravenous administration set changes: a systemic review. Infect Control Hosp Epidemiol. 2004;25(3):240-50.

Other Articles of Interest:
Henna H., Raad I, Darouiche R. New approaches for prevention of intravascular catheter-related infections. Infect Med. 2001;18(1):38-48.
Kline A. Pediatric catheter-related bloodstream infections—latest strategies to decrease risk. AACN Clin Issues. 2005;16(2):185-198.
McGee D, Gould M. Preventing complications of central venous catheterization. N Engl J Med. 2003;348(12):1123-1133.

ANA Code of Ethics: Provision 6 Emphasizes Healthy Work Environments

Editor’s note: The American Nurses Association’s Code of Ethics for Nurses contains nine provisions that are the foundation of nursing care. The purpose of the code is to provide concise statements of ethical obligations and duties to all nursing professionals.1 It is the profession’s ethical standard and commitment to society, and all acute and critical care nurses should practice in accordance with this code. Following is the third in a series of articles applying the provisions of the ANA Code of Ethics to critical care nursing practice. This article highlights the sixth provision and its underlying principles.

By Nancy Blake, RN, MN, CCRN, CNAA
Treasurer, AACN Board of Directors

Provision 6 of the ANA Code of Ethics says:

The nurse participates in establishing, maintaining and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action.1

It was just two years ago when then AACN President Connie Barden, RN, MN, CCRN, CCNS, called on us to “use our bold voice” to make our work environments safer. Since that time, thousands of nurses have taken on Barden’s challenge to make a public statement committing to healthy work environments. Her challenge was for nurses to:

• Identify the most pressing challenge in their work environment
• Initiate discussions with their colleagues to find solutions to this challenge
• Remain actively involved in the solutions until they are working.2

AACN’s Mission Statement and Vision are consistent with this philosophy. The Mission Statement, in part, says:

Building on decades of clinical excellence, the American Association of Critical-Care Nurses provides and inspires leadership to establish work and care environments that are respectful, healing and humane.

AACN’s Vision is:

AACN is dedicated to creating a healthcare system driven by the needs of patients and families where critical care nurses make their optimal contribution.

Without a healthy work environment, nurses cannot make their optimal contribution to the care of patients and families.
In January, the AACN Standards for Establishing and Sustaining Healthy Work Environments3 were unveiled and the essentials of a healthy work environment were defined. These six essential standards align directly with the core competencies of health professionals recommended by the Institute of Medicine. The standards for establishing and maintaining healthy work environments are:

1. Skilled Communication: Nurses must be as proficient in communication skills as they are in clinical skills.
2. True Collaboration: Nurses must be relentless in pursuing and fostering true collaboration.
3. Effective Decision Making: Nurses must be valued and committed partners in making policy, directing and evaluating clinical care and leading organizational operations.
4. Appropriate Staffing: Staffing must ensure the effective match between patient needs and nurse competencies.
5. Meaningful Recognition: Nurses must be recognized and must recognize others for the value each brings to the work of the organization.
6. Authentic Leadership: Nurse leaders must fully embrace the imperative of a healthy work environment, authentically live it and engage others in its achievement.

The Healthy Work Environment Standards support Provision 6 of the ANA Code of Ethics by establishing and sustaining healthy work environments. Properly implemented, the standards will ensure that acute and critical care nurses have the skills, resources and accountability to make decisions that result in excellent professional nursing practice and optimal care for patients and their families.

1. ANA Code of Ethics With Interpretive Statements. Washington, DC: American Nurses Publishing. 2001.
2. Barden C. Bold voices: fearless and essential. Presented at: AACN National Teaching Institute; May 19, 2003; Atlanta, Ga.
3. American Association of Critical-Care Nurses. AACN Standards For Establishing and Sustaining Healthy Work Environments: A Journey to Excellence. 2005.

Public Policy Update

Guidance for Reopening Shuttered Hospitals
Information to help public health officials and emergency response teams reopen shuttered hospitals to care for survivors of Hurricane Katrina is available from the Agency for Healthcare Research and Quality. Included is a list of supplies and medications needed by stable medical-surgical patients and checklists to assess facility readiness, staffing needs and levels, and patient transport readiness.

The information comes from a new AHRQ report titled “Use of Former (Shuttered) Hospitals to Expand Surge Capacity,” which gives emergency responders and public health officials useful, practical tools for opening shuttered hospitals when an emergency is under way. The report also gives surrounding communities not immediately affected by the hurricane a way to assess their existing facilities to meet future needs.

The report includes fill-in-the-blank facility evaluation checklists for chief administrators, facilities experts, medical personnel, security experts, equipment and supply experts, and medical gas system verifiers and action checklists to help emergency planners assess and fulfill staffing needs, additional expertise required, and management needs. It also contains a tool kit with a list of supplies and equipment needed for operation of a reopened facility.

The information is available online at http://www.ahrq.gov/path/katrina.htm.

Advanced Practice Nurses Act and Expanded Medicaid Coverage
AACN joins the American Nurses Association in commending Sen. Daniel Inouye (D-Hawaii) for his efforts to expand Medicaid coverage of advanced practice nursing services through the introduction of the Medicaid Advanced Practice Nurses and Physician Assistants Access Act (S. 1515).

The proposed legislation would increase patients’ access to essential heathcare services, especially needed in rural and underserved areas. A companion bill, H.R. 2716, was introduced in the U.S. House of Representatives in May by Reps. John Olver (D-MA), Sherwood Boehlert (R-N.Y.), Lois Capps, RN, (D-Calif.) and Steven LaTourette (R-Ohio). To support this legislation, contact your congressional representatives. Additional information is available online at http://capwiz.com/criticalcare/issues/bills/?billtype=S.&billnumb=1515&congress=109.

Standards for Patient Safety Taxonomy
The National Quality Forum has endorsed a National Voluntary Consensus Standard for a patient safety taxonomy.

The standard—representing the consensus of more than 260 healthcare providers, consumer groups, professional associations, purchasers, federal agencies, and research and quality improvement organizations—establishes the nation’s first standardized integrative classification system for healthcare errors and other patient safety problems.

Voluntary Medical Error Reporting
JCAHO has hailed the enactment of federal patient safety legislation that will encourage the voluntary reporting of medical errors, serious adverse events and their underlying causes.
The Patient Safety and Quality Improvement Act of 2005, signed by President Bush, will promote cultures of safety across healthcare settings by establishing federal protections that encourage thorough, candid examinations of the causes of healthcare errors and the development of effective solutions to prevent their recurrence. Previously, evaluative information about the underlying causes of adverse events was not always considered confidential or protected from lawsuits, a fact that the Institute of Medicine blamed for driving errors underground and slowing progress in improving patient safety.

Since first encouraging similar legislation in 1997, JCAHO and other healthcare and patient safety advocates have testified on numerous occasions before congressional committees to urge passage of a comprehensive patient safety bill. They say that major opportunities to improve patient safety can be created by providing caregivers the same types of legal protections long available to airline pilots and air traffic controllers.

The Patient Safety and Quality Improvement Act of 2005 provides full federal privilege to patient safety information that is transmitted to a Patient Safety Organization. JCAHO expects to create or become part of a Patient Safety Organization under the auspices of its new International Center for Patient Safety and seek federal approval under a new process to be created by the Department of Health and Human Services.

Patient Safety Worldwide
Recognizing that healthcare errors seriously harm one in every 10 patients around the world, the World Health Organization has designated the Joint Commission on Accreditation of Healthcare Organizations and the Joint Commission International as the world’s first WHO Collaborating Centre dedicated solely to patient safety. The action is aimed at reducing the unacceptably high numbers of serious medical injuries around the world each day.

The collaboration among the Joint Commission, JCI and WHO will focus worldwide attention on patient safety and best practices that can reduce safety risks to patients, and coordinate international efforts to spread these solutions as broadly as possible. This will be accomplished by collaborating internationally with ministries of health, patient safety experts, national agencies on patient safety, healthcare professional associations and consumer organizations.

The Joint Commission International Center for Patient Safety, which was launched earlier this year by the Joint Commission and JCI, will operationalize this effort by forging partnerships with leaders in both developing and developed countries to identify healthcare safety needs and match these with proven solutions and best practices.

Apply for Nurse in Washington Internship Scholarships

Scholarship applications are now being accepted for the Nurse in Washington Internship program, which provides nurses the opportunity to learn how to influence healthcare through the legislative and regulatory processes. The program is scheduled for March 12 through 16 in Washington, D.C. AACN endorses this program. Additional information is available online at http://www.nursing-alliance.org/niwi.htm.


Sponsored by Philips Medical Systems
New Grants Support Studies Relevant to Bedside Practice
Beginning in January 2006, three AACN grants of up to $10,000 each sponsored by Philips Medical Systems will be awarded to qualified proposals relevant to bedside clinical practice. Each grant supports a nurse who is experienced in research in conducting a clearly articulated study relevant to clinical nursing practice in acute or critical care. Funds may be used for original research or replication of existing research.

Proposals for the first round of funding must be received no later than Jan. 1, 2006. Studies selected should be completed in time for oral and poster presentations at the National Teaching Institute and Critical Care Exposition in May 2007 in Atlanta, Ga. The principal investigator will receive funding for travel, two nights’ lodging and complimentary registration for the NTI.

Areas of inquiry, selection criteria and submission instructions are available online at www.aacn.org > Research > Grants.

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