Ask The Expert Archive
Welcome to the Ask the Expert Blog. In this area of the site, we provide answers to questions submitted by those in the clinical community who,
like you, are making efforts to reduce BSIs. Please feel free to ask us any questions, and in a future Blog update, we will do our very best to
answer those questions that are of the greatest concern to visitors. Please check back regularly, and be sure to sign up for our Getting to Zero BSI "alerts on demand" so that you will be alerted immediately of when we have posted new content to this and other areas of our site.
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Biography
Q1: I have heard of the Keystone Project. Can you tell me more about the project?
A1:
The Michigan Keystone ICU Project was a joint partnership between the Michigan Health & Hospital Association and the Johns Hopkins University.
View More...The analysis was focused on an intervention to reduce the rate of catheter-associated bloodstream infections that was implemented in 103 ICUs in Michigan in 2004. The project worked to ensure that clinicians used a simple checklist when inserting catheters into ICU patients. Following the checklist was associated with a 66% reduction in these infections throughout the state of Michigan, saving over 1500 lives and $200 million in the first 18 months alone.
Q2: What were the outcomes of the Keystone Project?
A2:
The success of safety initiatives such as the Keystone ICU Project, which resulted in a decreased mean rate of CA-BSIs from 7.7/1,000 catheter days to 1.4/1,000 catheter days at 16-18 months, is evidence that sustained diligence achieves positive results.
View More...A 66% decrease in CA-BSIs was maintained over the course of the 18-month study, which covered a total of 375,757 catheter days in the ICU at 103 hospitals.
Q3: What was critical to the success of the Keystone Project?
A3:
The Keystone Project's success was based on a comprehensive, sustained approach that included CA-BSI intervention practices such as hand washing and full-barrier precautions during line insertion, chlorhexidine cleaning of the skin, avoidance of the femoral site, and removal of unnecessary catheters.
View More...A unit-based safety culture and daily goals sheets were developed as well as continued education on infection control practices. Other success factors were the use of central-line carts, checklists and nurses' ability/empowerment to stop procedures if practitioners did not adhere to best practices.
Q4: Can you provide a brief overview of the problem specific to catheter-associated bloodstream infections?
A4: Although intravascular catheters are indispensable for managing the care of critically ill patients, they can be associated with serious infections.
View More... It certainly is something that is near and dear to the hearts of infection control practitioners in light of the significant morbidity and mortality that these infections cause.
According to data from the Center for Disease Control, the risk of exposure to these devices per ICU day is about 48%, which actually accounts for 15 million central catheter days annually. The average rate of catheter-associated BSIs in ICUs that has been historically reported has been 5.3 per 1000 central line days. Those of you who are participating in the National Healthcare Safety Network and benchmarking with the CDC's data are probably aware that this particular rate is much lower based on a number of factors. The obvious goal for everyone is to get that rate as low as possible. The attributable mortality has been estimated at about 18%, which means that as many as approximately 28,000 ICU patients will die in the United States each year as a result of catheter-associated BSIs.
Q5: Why are patients at risk for catheter-associated bloodstream infections?
A5: Today's patient populations are increasingly more sick than in the past and those entering the emergency room and admitted to the hospital tend to be more susceptible due to underlying illnesses.
View More... Patients admitted to the hospital can have invasive devices such as a central line and/or a urinary drainage catheter. Patients admitted to the hospital's ICU can also have these devices and may require another device such as a ventilator for breathing support. Many of these patients have compromised immune systems making them more susceptible to infection. Patients with central lines are more susceptible to getting a Central Line-Associated Bacteremia (CLAB).
Q6: What are the components of a catheter bundle?
A6: Hand hygiene
Hand hygiene leads the list. The operators that put in these lines and the folks that maintain these lines are going to have transient hand flora that they have picked up through the care of other patients or by touching environmental surfaces.
View More... Therefore, the removal of such transient flora through hand hygiene practice is critical for anyone who is dealing with an intravascular line. Use of an alcohol-based waterless product or antiseptic soap and water are recommended.
Maximal Barrier Precautions
The second component is maximal barrier precautions and the literature is very clear about this. This is a critical and necessary part of the placement of a central line. It means covering the patient with a sterile drape from head to toe with a small opening at the site of the insertion. It means that the operator needs to be wearing a cap, mask, sterile gown and sterile gloves.
Skin antisepsis
The third element of a bundle relates to the use of chlorhexidine as the skin antiseptic for the removal of skin flora at the insertion site. There is a lot of data around this, but the study that is most commonly referenced is Dr. Maki's study that was published in The Lancet back in the early 1990s. Here he did a comparison of povidone iodine, alcohol and chlorhexidine and found that chlorhexidine was superior in reducing the skin flora around the insertion site and actually has a residual effect that does not exist with alcohol and povidone iodine.
Site selection
Optimal catheter site selection is critical. Data would suggest that lines that are placed utilizing the subclavian vein have the lowest risk of infection. This is certainly something that has been controversial amongst intensivists putting in these lines. The internal jugular is a site that appears to be easier for intensivists to insert a line into. Anesthesiologists obviously prefer this site as well.
The other issue with subclavian placement has to do with the expertise of the operator because of the risk of pneumothorax with the insertion in that site. However, the data in published literature strongly suggests that the subclavian is preferred and has a lower infection risk.
Daily review
Daily review of line necessity is a critical part of a bundle for prevention of catheter-associated BSIs. This is obviously one that is near and dear to our hearts in infection control, because we all know that any invasive device carries a risk of infection. The integrity of the skin, which is the primary defense against infection, is jeopardized with the insertion and we need to get the line out as soon as possible, because each day that it is inserted represents a risk for the introduction of organisms, either via the skin or through the manipulation of the line.
Jeanne E. Zack, PhD, RN, CIC
Biography
Q7: How have you mapped out processes related to changing the central line dressing? Would you share that experience?
A7:The process we outlined was part of the program and tools we used to further drive down bloodstream infection rates in the surgical burn trauma unit. We used two tools to assist with defining the current state processes: fishbone diagramming and flow charting.
View More...
To get a visual baseline of our existing processes, we conducted a brainstorming meeting. In this meeting, we identified and memorialized the causes of the bloodstream infections we had experienced on a fishbone diagram. Our fishbone diagram was complex and we noted that that the most critical items related to poor and improper technique. More specifically, they clustered around inadequate hand washing and dressings not being changed on time based on best practices recommendations.
The fishbone diagram helped the team sort ideas into useful categories before beginning the flowcharting process for central line maintenance. The flowcharting step involved creating a mapping framework using sticky notes or other placeholders until we refined the steps which succinctly reflected the process. In doing so, we could visually see and understand the existing process. This enabled us to more readily note unneeded steps and additionally, identify more efficient ways to accomplish tasks. Analyzing all aspects relating to central line maintenance care lent itself well to flowcharting these processes, and from this, we developed educational pictorials for the staff to reference.
Q8: You stated that one of the critical factors to continued success in zero tolerance was feedback of the infection rates to the staff. How long did it take you to collect those rates and how often were they fed back to the staff?
A8: We have a "home-grown" system through the hospital so we get our data every single day and typically feed it back to the nursing staff on a monthly basis, unless there is a compelling event that necessitates that we feed back this information sooner.
Q9: In your work at Missouri Baptist, you implemented a scrub-the-hub maintenance bundle in your ICUs. What was included in this bundle? Did it have an impact on your catheter-associated bloodstream infection rate?
A9: After celebrating being at zero, we were surprised when an infection was detected in the one ICU, particularly since in addition to ongoing multi-disciplinary rounds, we had instituted an ongoing feedback loop which involved improvement measures to prevent infections from occurring in similar circumstances.
View More...
We use the IHI Bundle for insertion practices, maximal barrier precautions and other practice bundle recommendations, including the use of a checklist to monitor compliance.
When I did some observations and looked at the practice, I found that the nurses were not scrubbing the hub of the access port prior to injecting medications or antibiotics into the line. In response, we borrowed best practices from a colleague at another hospital and created a poster that reminded nurses that they needed to "scrub the hub". These posters were placed on our televisions throughout our hospital and screensavers on the computers on wheels used for charting.
In addition to the poster it was agreed that we also needed some sort of maintenance bundle. One of my colleagues, Chris Abe at Rady Children's Hospital in San Diego, allowed me to use this bundle. It has to do with performing hand hygiene, putting on clean gloves prior to accessing a line, performing a 30-second scrub-the-hub using alcohol and friction in a twisting motion, just a twisting motion on the hub, as if you were juicing an orange.
We have had one infection in this unit since we implemented these interventions, and I continue to go back there to do rounds and work with the nurses because I truly believe that you cannot perform infection prevention and control from your office. We have to be interactive and working with the nurses constantly.
Carol Hatler, PhD, RN
Biography
Q10: What does it mean when referring to evidence-based practice and why do key opinion leaders or institutions feel it is so important to use evidence to support the decisions that are made in clinical practice?
A10: Evidence-based practice is the conscientious, explicit and judicious use of theory-derived, research-based information in making decisions about care delivery to individuals or groups of patients and in consideration of individuals' needs and preferences.
View More...This definition is found in Ingersoll's article: Evidence-based nursing: What it is and what it isn't found in Nursing Outlook 2000.
(Ingersoll, G. I. (2000) Evidence-based nursing: What it is and what it isn't. Nursing Outlook, 48, 151-152.)
Evidence is not necessarily proof, because the variances in human behavior are so wide, we can't talk about proof, but we can talk about what the evidence supports, what the evidence indicates or those types of ideas. One of the reasons why it is important to consider evidence from research as a part of your practice is that it can identify activities that need to be included in care, and also identify activities that may NOT add anything to the care we provide.
Q11: Can you provide examples of various sources of evidence?
A11: There is no single-best source of evidence, but rather, a variety of places where we go to for evidence.
View More...When I talk to staff nurses about where they go if they have a question or a concern about patient care, almost invariably they will talk about going to colleagues or rely on their own experience or even intuition as the basis for care. The advantage to this particular strategy is that it is a relatively quick source of evidence. The disadvantage is that the experience may be limited. We all know nurses who have 20 years of experience, but we also know nurses who have one year of experience 20 times. Consequently, these nurses have not been able to integrate experiences into reasoning that has the depth and breadth seen with seasoned veteran nurses. So you have to be very careful about those colleagues that you go to as sources of evidence.
Policy and procedure is a less ambiguous source of evidence, but as we all know, policies and procedures that we have in our institutions may not necessarily be based on the latest evidence.
Expert opinion is another source of evidence, but experts can be wrong as well. It is therefore prudent to consult a few sources prior to implementing a practice change.
Evidence from research studies has a greater likelihood of being effective as it has been tried and has demonstrated its effectiveness. One of the things that I talk with nurses about when we are talking about changing practices based on evidence is to ask them, "What nurse would you rather have care for your family member? Would you rather have a nurse who says I do this because that's the way I was taught or that's the way we’ve always done it," or a nurse who says, "I'm doing this the way I do because the evidence demonstrates that this is the most effective way to provide care for a particular problem?"
Joan Hebden, RN, MS, CIC
Biography
Q12: What's the extent of non-compliance with evidence-based practices for central line maintenance?
A12: In terms of compliance with evidence-based practice guidelines, we are encountering a lot of difficulty with translation.
View More...I think the data is clearly there. There is a tremendous wealth of literature. The Centers for Disease Control and Prevention endorse these recommendations and the Joint Commission has explicitly stated that we need to employ evidence-based practices. However, when we look at a number of studies that have assessed attitudes toward practice guidelines we see otherwise. The quotes from at least four published papers range from attributing non-compliance to lack of awareness of the importance of line maintenance, lack of application of evidence to practice, staff attitudes and lack of strong institutional commitment. We are not translating evidence-based practice to the bedside to the degree that it needs to be done.
Q13: What is known about lack of compliance with guidelines and human factors studies?
A13: Joan Hebden was part of a team with AP Gurses at the University of Maryland who studied human factors.
View More...This was a qualitative study done to explore the underlying causes for non-compliance with evidence-based guidelines aimed at preventing four types of healthcare-associated infections (including BSI) in the surgical intensive care (SICU) setting.
Systems ambiguity explains non-compliance with guidelines aimed at preventing catheter-related bloodstream infections. Ambiguities may be related to tasks, responsibilities and methods, expectations and exceptions.
Strategies reported to reduce ambiguity included clarification of expectations from healthcare providers with respect to guideline compliance through education, development of tools that provide an overview of information critical for guideline compliance, use of standardized orders, clarification of roles of care providers and use of decision-support tools.
On August 31,2009, CareFusion Corporation completed its spinoff form CardinalHealth, Inc. References to Cardinal Health in the materials posted on this website prior to August 31, 2009, may relate to CareFusion and the business operated by CareFusion following the spinoff.
