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A practical approach to designing and performing a focused study
A practical approach to designing and performing a focused study Marguerite McMillan Jackson, RN, PhD, CIC, FAAN San Diego, California
Designing and performing focused studies is part of the regular work of infection surveillance, prevention, and control, and the methodologyof a prevalence surveyused in this practice forum will be familiar to many infection control professionals. A practical example of a focused study to evaluate cost savings from extendingintravenous catheter site and administration set change frequencyfrom 72 hours to 96 hours illustrates the steps required. Suggestedreferences for additional information are included at the end of the article. (AJICAm J Infect Control 1997;25:520-8) Design and performance of focused studies is part of the regular work of infection control professionals (ICPs). "Focused study" is a term from the jargon used in research on quality improvement. The term implies that an answer to a question or a solution to a problem can be obtained within a reasonable time and that there is some practical value to the information obtained. This article uses a practical example of an issue facing m a n y ICPs to review the steps in planning, implementing, and evaluating a focused study. The process and tools described in this example should help ICPs to design and implement a variety of focused studies. BACKGROUND Memorial Hospital* is a 250-bed c o m m u n i t y hospital in the western United States. The hospital has a 15-bed critical care unit, a busy emergency department, and the usual hospital services. The ICP shares an administrative assistant with the quality improvement nurse and the two utilization m a n a g e m e n t coordinators. The physician chair of the Infection Control Committee spends 1 h o u r each week meeting with the ICP and is available by telephone for emergency consultation. There has been a steady decrease in the average daily census for Memorial Hospital as managed care has penetrated the region. For the past 3
*All data are fictitious and the scenario is hypothetical. From the Epidemiology Unit, University of California San Diego Medical Center. Reprint requests: Marguerite Jackson, RN, PhD, CIC, FAAN, Epidemiology Unit, UCSD Medical Center, 200 W. Arbor Dr., San Diego, CA 92103-8951. Copyright © 1997 by the Association for Professionals in Infection Control and Epidemiology, Inc. 0196-6553/97 $5.00 + 0
520
17/49/84565
months the census averaged approximately 140 patients per day. The average census in the critical care unit was 12 patients per day during that time. On the basis of the findings in the Study on the Efficacy of Nosocomial Infection Control study in the 1970s, the Centers for Disease Control and Prevention estimated that a ratio of 1 ICP to 250 occupied beds was adequate for prevention and control of infection in acute care hospitals. 1 Although needs and programs have changed substantially in the last 20 years, this ratio is still c o m m o n l y used by hospital administrators. In planning for the next budget year, the administrator of Memorial Hospital slated the ICP position for reduction to a half-time position largely because of the falling census. At about the same time, the employee health nurse retired, and the administrator decided not to fill the position but, instead, to offer the ICP the option of taking a fulltime position that combined the functions of the employee health nurse and the ICR Because Memorial Hospital is the only hospital in this small town, and the ICP needed a full-time job, the ICP accepted the combined position. Memorial Hospital has an active employee health program for postexposure m a n a g e m e n t of sharps injuries and exposure to blood. This program is consistent with the requirements of the Bloodborne Pathogens Standard of the Occupational Safety and Health Administration. The program, which was set up by the employee health nurse years ago, is now the ICP's responsibility. The average n u m b e r of reported injuries and blood exposures is five or six each month, and a variety of sharp devices and splash situations cause these exposures. Three or four times a year, an injury caused by an intravenous (IV) catheter stylet is reported. Memorial Hospital does not use safety IV catheters, primarily because of the unit cost ($1.70 for a safety IV catheter versus 70 cents for the stan-
AJIC Volume25, Number6
Jack$olq. 5 2 1
T a b l e 1. Information needed for focused study to determine whether decreasing the frequency of IV catheter
reinsertion and change of administration sets from 72 to 96 hours for inpatients at Memorial Hospital will save enough money to purchase safety IV catheters Information needed
No. of peripheral IV catheters purchased each year and unit cost Unit costs for supplies needed to start an IV infusion, including administration sets No. of peripheral ly catheters Length of stay
Nursing time to insert peripheral IV catheter Cost of safety IV catheter
Cost of nursing time, including benefits Data for past year for average daily census, total patient-days, and frequency distribution of number of patients by length of stay and total patient-days Results of analyses of data from prevalence survey
Report of results for administrator and Infection Control Committee
Where is it available?
How is it obtained?
How long will it take to obtain it?
Purchasing Department Purchasing Department
Ask purchasing agent
1-2 wk
Ask purchasing agent
1-2 wk (ask at same time as information about IV catheters)
Observation of patients Calculation from prevalence study data Literature search or interview of several nurses Vendors
Access prevalence survey data
1 day with three or four surveyors (5 min per patient) 1 day at computer (3-4 min to look up data on each patient)
Human Resources Department Information Systems Department
Access computer database for discharge dates of patients, up to 6-7 days after prevalence survey Ask several nurses; then observe and time two or three nurses inserting IV catheter Ask vendors for price quote for volume obtained from purchasing department Ask representative of Human Resources Department Ask representative of Information Systems Department
Computer database created by using Epilnfo software
Enter data into computer database and perform data analyses
Computer database created by using Epilnfo software
Compile all data and write report
dard IV catheter). However, 4 years ago a needleless IV access system was established throughout the facility to reduce puncture injury risks once an IV catheter was in place. Problems P u n c t u r e i n j u r i e s o f h o s p i t a l s t a f f . A few weeks ago, a critical care nurse sustained a puncture injury while inserting an IV catheter. The nurse had received the hepatitis B vaccine series, and a blood test showed that the postvaccine serology was positive for immunity. The patient was a known injection drug user, but it was unknown whether he was positive for h u m a n immunodeficiency virus (HIV) at the time of the injury. He consented to testing, and the results were available 6 days later. He was HIV negative. The nurse was distressed because she had to wait 6 days for the test results. In addition, she had chosen not to take antiviral medications, because of a possible pregnancy and this created additional anxiety during the 6-day waiting period. When the nurse asked why Memorial
2-3 hr for observations; less time for interviews 1 day to 2 wk, depending on vendor's responsiveness 1-2 days, depending on representative's responsiveness 1 day to 2 wk, depending on responsiveness of personnel in Information Systems Department 1-2 wk (3-4 min for entry of data on each patient); several hours for data analyses, depending on person's skills 2-3 days, depending on efficiency in compiling data and writing report
Hospital did not use safety IV catheters, the ICP told her it was because very few IV catheter-related injuries were reported each year and the unit cost of the safety catheter was much more than the unit cost of the standard catheter. She was not satisfied with this answer and asked what could be done to change the policy. C h a n g e in f r e q u e n c y of I V c a t h e t e r
reinsertion.
At the last Infection Control Committee meeting, the committee agreed to decrease the frequency for 1V catheter insertion at a new site and administration set changes from 72 to 96 hours. The Committee thought that this measure would reduce costs considerably but had no estimate of how much money could be saved. The Committee asked the ICP to conduct a focused study to answer this question. The ICP decided to include in this focused study an estimate of the increased cost of using safety IV catheters, to determine whether the cost savings from reducing the frequency of IV catheter reinsertion and administration set changes would neutralize the increased cost of safety IV catheters.
AJIC December 1997
5 2 2 Jackson
DATA COLLECTION FORM: PREVALENCE SURVEY DATE Nursing Unit Census for this date Number of patients with peripheral IV catheters ..... NOTE: Use extra blocks of forra if patient has more than one Bed No. Med Rec Admit Date Admit .Name* Number Time D/C Date
D/C Time
LOS Hours
SURVEYOR
3e of vaseular access, or more than one LOS Cath Days Type Label Date i Time Y N YN Y N Y N YN Y N Y N YN Y N Y N YN Y N Y N YN Y N Y N YN Y N Y N YN Y N Y N YN Y N YN YN YN YN YN Y N
. Appear 1239 1239 1239 1239 1239 1239 1239 1239 1239 1239
N~dleless? Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N
Pump Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N
Infusion C I C I C I C I C I C I C I C I C I C I
Fig. 1. Data collection form for prevalence survey. Y,Yes; N, no; 1, OK; 2, red and swollen; 3, infiltrated; 9, unable to observe; C, continuous; I, intermittent. *Use name only if it is necessary to access computerized data later. Otherwise, use only medical record number.
P u r p o s e s of f o c u s e d s t u d y
After discussion with several people, including the quality improvement nurse, the utilization management coordinators, and the chair of the Infection Control Committee, the following purposes of the study were listed: 1. To determine the proportion of patients at Memorial Hospital who have one or more peripheral IV catheters and other types of vascular access devices in place on a given day 2. To evaluate peripheral site management for compliance with current protocols for labeling sites, use of the needleless IV access system, and management and use of infusion pumps 3. To estimate the proportion of patients with peripheral IV catheters who would require fewer catheter insertions with a change from the 72-hour to the 96-hour frequency of site change 4. To estimate the savings in nursing time and supply costs achieved by a decrease in the frequency of changes in IV catheter sites and administration sets 5. To estimate the incremental cost of using safety IV catheters instead of standard IV catheters 6. To determine whether the savings from decreasing the frequency of changes in the IV catheter site and administration sets would offset the increase in costs of using safety IV catheters The quality improvement nurse offered to help with the study in exchange for collecting information about management and use of the IV catheter and the infusion pump. Also, one of the utilization management coordinators agreed to help because
she was interested in knowing m o r e a b o u t patients with temporary and permanent (e.g., Hickman and Broviac) central lines. METHODS
Table 1 outlines the information needed and where and h o w to obtain it and shows estimates of the time required to obtain the information. Many of these tasks can be accomplished concurrently. Information is required from several persons w h o m a y not be able to deliver it immediately. In addition, data collection forms need to be developed, and a computerized data entry screen needs to be created, so that data can be entered and analyzed accurately. It was agreed that a 1-day prevalence survey was the most time-efficient m e t h o d for collecting m u c h of the required data. Fig. 1 is a sample data collection form for a prevalence survey. (For ease of use the lines should be spaced more widely in such a survey form than they are in this sample.) A substantial quantity of information can be collected at one time with use of this form. The persons conducting the survey (surveyors) should p e r f o r m a pilot test with a few patients to ensure that use of the survey is workable. Copies of the form placed on a clipboard can be carried from bedside to bedside by each surveyor. Three surveyors can p e r f o r m a 1-day prevalence survey of all inpatients at Memorial Hospital. In a general nursing unit, one surveyor can obtain the information from one patient in a b o u t 5 minutes at the patient's bedside, b u t in the critical care unit it m a y be necessary to spend m o r e time with each patient.
AJIC
Jackson
Volume 25, Number 6
DATA COLLECTION FORM: PREVALENCE SURVEY DATE Nursing Unit 2WMED Census for this date 14 Number of patients with peripheral IV catheters 10 NOTE: Use extrablocksof form if ivied Rec Admit Bed No. Number Date 203 1265798 5/1/97
has morethan one Admit D/C
LOS
Time
D/C Date
Time
Hrs
0230
5/3/97
1430
60
still here
5/7
SURVEYOR MMJ
5/1/97
or morethan one
£()S Days 2
Cath
type Perip
Label
Date
O N ~N
Time
Appear
Y(~ ~239
Needle less?
1476943 4128/97
0830
pump-
same
site
208
1345990 4/30/97
0945
5/3/97
0840
95
3
Perip
Y ~) !Yt~
! 209
1834966 4/29/97
1235
5/1/97
1630
52
2
Centr
Y N
Y N
t 239
Y N
210
1794390 5/1/97
Perip O N
1567993 4/29/97 1865098 4/20/97
2000 1450 5/7
0
214
5/1/97 5/5/97 stillhere
20
211
0030 1200 0330
Y~D Y ~ Y{~ Y ( ~ Y~ Y@
Q)239 1209 ~239 (~239
216
1769450 511197
37
3 N ~
~2 3 9
2'7
1964320
1640 1400
2ndlV
4/26/97
0400 2200
1(~39
~ N
~) N
Y N
12 3 9
Y N
(~ N
Y I ~ 1~2 3 9
Y(~
Y(~
6 17td
514/97
Perip
Y N ~N
Y(~
Perip Yt~) Perip
Y N
Y~
Y N
~N
1
Perip ~
8
Perip (4Y_~N ~_~N Y ~
N
218
1543276 511197
0830
512197
1230
28
1
Centr
220
1684947 4•30•97
1300
5/2197
1630
51
2
Perip ( ~ N
51
Y N
N
Infusion
CO
9 td* Perip ~ N O N ~ ) N
site
5/2/97
yPU~
(.~N
205
2nd
523
C (~)
~
I
N
C (~
(~N (~N !Y(~ 'YO
Y(~) ON (~N Y~)
C(~ C~ (.~I C~
~
~
N
[1)239 ~ N
~
~) I
N
Y~
Y N
Y N
12 3 9
]Y N
~N
Y(~
~)239
(~.)N
0
C (~
~I
N
C@
Y(~)
~(~I
1221
1543780 4•29•97
1000
511197
1300
2
None
Y N
Y N ly N
1 23 9
Y N
Y N
C I
] 222
1954697 4128/97
0300
stillher¢
5/7
9 td
Centr
Y N
Y N !y N
1239
Y N
ON
cO)
223
1496807 4/18/97
0800
still here
5/7
19 td
Peril)
Y 0
Y~
Y ~
1~ 3 9
~
N
~) N
C0
Central
line also
Centr
Y N
Y N
Y N
12 3 9
Y N
~ N
C Q)
Fig, 2. Completed data collection form for prevalence survey. The form is filled out in two stages. Information in italics is completed at time of survey. Information in bold is completed 6 days after survey by accessing computer database for admission and discharge dates and times and by calculating length of stay in hours (if fewer than 96 hours) and in days (0 days = <24 hours; 1 day = 24-47 hours, 2 days = 48-71 hours; 3 days = 72-95 hours; 4 days = 96-119 hours, etc. Values for hours are rounded to nearest hour). *td, To date (for patients still in the facility at the time computer is checked for admission and discharge dates. In this example, this was done on 5/7/97).
Performance of survey
At a designated time on the day of the prevalence survey, the surveyors divide the work of conducting the survey in the general nursing units and critical care unit, so that each surveyor has approximately the same n u m b e r of patients to evaluate. The surveyors introduce themselves to the patients, evaluate the appearance of the peripheral IV site, and note whether a central line is in place, whether an infusion p u m p is being used, and whether the use is continuous or intermittent. This information is recorded on a data collection form (e.g., Fig. 1). It is helpful to have a computer listing of the names of all patients, bed numbers, and medical record numbers. However, because some patients may be discharged from the hospital and new patients m a y be admitted before the surveyor visits a unit, it is best to complete the form at the time of the visit for the survey. Fig. 2 is a completed data collection form for one nursing unit with a census of 14 patients on the day of the survey. Note that some of the infor-
mation (in italics and circled) is completed during the survey; the remainder of the information (in bold) is filled in later. Because length of stay is a critical piece of information, it is important to wait several days to complete the form, so that m a n y of the patients identified during the prevalence survey will have completed the hospital stay. In this example, the forms were completed 6 days after the survey date. Data Analysis
The data entry screen for creating a computer database from the collected data is shown in Table 2. This example uses a software program called Epiinfo.2. 3 Once the data are collected, they are entered into this database so they can be analyzed easily. The ICP can enter the data or delegate data entry to an administrative assistant. Once the process becomes familiar, data entry for each patient requires 3 to 4 minutes. The software program permits data to be analyzed by a variety of methods. For example, data for each nursing unit
AJIC
524 Jackson
December 1997
Table 2, Data entry screen for use with Epilnfo* computer database for prevalence surveyt Epllnfo DATA ENTRY: PREVALENCE SURVEY {UNIT} {BED} {MEDREC} {SURVEYOR}__ I=MJ 2=DM 3=SP {ADDATE} {ADTIME} #### use 24 hour clock {STILHRE} <_> Y = yes; N = no STILHRE = still here as of 6 days after survey {DCDATE} {DCTIME} #### {LOSHRS}## {LOSDAYS}### Calculate length of stay in hours (if fewer than 96 hours) and in days for all stays. Calculate days as follows: 0 days = < 24 hours; 1 day = 24-47 hours; 2 days = 48-71 hours; 3 days = 72-95 hours; and 4 days = 96-119 hours, etc. Round hours to nearest whole hour. Do not calculate hours after 95 hours. For all yes/no responses, use Y = yes and N = no. CODE {APPEAR} 1 = OK; 2 = red/swollen; 3 = infiltrated; 9 = unable to observe CODE {SITE} 1 = peripheral; 2 = central; 3 = arterial; 4 = other; 9 = none CODE {NEEDLES} Y = yes and N = no (needleless iV access device) {SITE1}_ {LABEL1} <_> {DATE1} < > {TIME1} <_> {APPEAR2} {NEEDLSl} < > {PUMP1} < > {INFUS1}_ C = continuous; I = intermittent {SITE2}_ {LABEL2} <_> {DATE2} <_> {TIME2}_> {APPEAR2} {NEEDLS2} < > {PUMP2} < > {INFUS2}_ C = continuous; I = intermittent *Epilnfo is word-processing, database, and statistics system computer software in the public domain. It was developed by the CDC and World Health Organization.2,3 1-### = numeric fields; _ _ = character fields; = date fields; <_> = yes/no fields. Fields are areas where data are entered from data collection sheets.
can be analyzed separately to alert the quality improvement nurse to specific problem areas (e.g., a small proportion of sites labeled or few needleless IV access devices used) and to areas where there is little room for improvement (e.g., greater than 90% compliance with policies and procedures). RESULTS
The data collected for one nursing unit during the prevalence survey are summarized in Tables 3 and 4. Entry of data for the entire hospital into one table (e.g., 137 inpatients on all units) would show the prevalence of use of peripheral catheters and other vascular access devices, the management of IV sites, and the use of infusion pumps, for Memorial Hospital on the day of the survey. Validating data as representative
Prevalence survey data are more likely to be representative of long-term data for the hospital if the survey is performed in the middle of the week rather than on a weekend. In Table 3, one half (7) of the 14 patients were discharged before 72 hours. Patients who had a short stay (less than 24 hours) would require only a single IV catheter, regardless of whether the frequency of IV site change was 72 or 96 hours. For one patient, who stayed between 72 and 95 hours, reinsertion of the IV catheter would not have been required if the frequency of site change were 96 hours. Three of the four patients who had a long stay (> 9 days), had peripheral IV catheters that would require
site and administration set changes at 4-day rather than 3-day intervals with the change in site rotation from 72 to 96 hours. Central lines were also used for these patients, however, and peripheral 1V catheters might not have been required continuously throughout their stay, depending on the diagnoses and reasons for use of vascular access. To assess whether the data obtained are representative, it is important to compare the distribution of length of stay for patients at Memorial Hospital on the day of the prevalence survey with that for all Memorial Hospital patients during the past year. In addition, the information obtained during the prevalence survey is used to calculate cost data for 1 year. The data on length of stay for the past year are obtained from the hospital's Information Systems Department. In this hypothetical example, the data from Information Systems Department for the past year show that Memorial Hospital had 12,000 admissions, an average length of stay of 4.2 days, and 50,400 patient-days. Sixty-five percent (7800) of the 12,000 discharges were for lengths of stay shorter than 72 hours (20,000 patient-days). The remaining 4200 admissions were for stays of 72 hours or longer (30,400 patient-days). The results of the prevalence survey of 137 patients showed that about half of patients who stayed 72 hours or longer had a peripheral catheter in place that day for about 2100 patients per year. It is also assumed that these 2100 patients also represent
AJIC Volume 25, Number 6
Jackso~z 525
"fable 3, Summary created after entry of data from prevalence survey in Epilnfo computer database: data for evaluation of IV catheter site management for labeling of sites, use of needleless IV access system, and infusion pump use and management Site
Label
Date
Needeless catheter
Time
Infusion No. of
Type
No,
No.
(%)
No.
(%)
No.
(%)
Appearance No.
(%)
No.
(%)
pumps
Type
No.
10
6
(60)
6
(60)
3
(30)
OK Red, swollen Infiltrated
(80) (10) (10)
8
(80)
6 for 5 sites
Continuous Intermittent
3
Intermittent
5 6 for 5 iV sites 3
0 1
Intermittent Intermittent
1 1
Site 1
Peripheral
Central None
8 1 1
3 1
Site 2
Peripheral Central
1 1
0
0
0
OK
one half of the patient-days (15,200 patient-days) for this group of admissions. Calculating potential savings
The ICP must calculate the potential savings from reduction in the frequency of peripheral IV catheter reinsertion and changes of administration sets. To do this, calculate the potential savings from avoided restarts that apply only to patients whose lengths of stay are longer than 72 hours (2100 patients x their first 3 days = 6300 patient days). Subtract these patient days from the total cumulative lengths of stay for these patients (15,200 patient days). This subtraction is done because the initial (first) IV catheter insertion would occur regardless of the reinsertion frequency or length of stay. This leaves a potential of 8900 patient days during which the change from 72-hour reinsertions to 96-hour reinsertions would result in fewer reinsertions cumulatively. If these 2100 patients who were hospitalized longer than 72 hours had peripheral catheters continuously during their stay, the calculations would be as follows: 8900 patient-days/3 days = 2967 IV catheter reinsertions at 72 hours; 8900 patientdays/4 days = 2225 IV catheter reinsertions at 96 hours; 2967 - 2225 = 742 IV catheter reinsertions avoided. Obviously, individual patients have varying lengths of stay longer than 72 hours and may be discharged I, 2, or 3 days after a new catheter is inserted. Thus patient days are only a crude estimate of the effect of a change in insertion cycle intervals. Because all peripheral IV catheters in these patients who were hospitalized longer than 72 hours would not last for 96 hours, and some sites would not be changed at 96 hours because of difficult access issues (for example,
1
0
fragile veins) or the likelihood of discharge within a few hours, a "fudge factor" was added to come up with a round number of 800 IV restarts potentially avoided by reinsertion of IV catheters at 96 hours. Added to this would be the cost savings from changing the administration sets less frequently for peripheral and other types of intravascular catheters. Estimating costs and cost savings
The purchasing agent tells the ICP that last year the hospital purchased 23,000 IV catheters (all gauges) at an average cost of 70 cents per unit, for a total cost of $16,100. For the same number of safety catheters at an average cost of $1.70 each, the total cost would be $39,100. The difference in cost would be $23,000. By interviewing nurses and observing insertion of IV catheters, the ICP determines that insertion of an IV catheter requires an average of approximately 30 minutes of nursing time. This time includes performance of tasks such as collecting supplies, preparing the patient, inserting the 1V catheter, changing the administration set, cleaning up and discarding wastes, and recording the procedure on the patient's chart. The representative from the Human Resources Department tells the ICP that the average nursing salary with benefits is $25 per hour ($12.50 for 30 minutes). According to the purchasing agent, the supplies cost an average of $7 for each peripheral IV insertion. Therefore the estimated cost savings of avoiding 800 peripheral catheter reinsertions is almost $16,000 (Table 5). The ICP shares this information with the hospital administrator, who asks whether part of a nursing position can be eliminated by ma~king this change. The administrator points out that such an
AJIC 526
December 1997
Jackson
T a b l e 4. Summary created after entry of data from
T a b l e 5 . Estimated costs of supplies and nursing time
prevalence survey in Epilnfo computer database: length of stay in relation to use of peripheral catheter
for reinsertion of peripheral IV catheters, Memorial Hospital, 1997
Length of stay
0-23 hours (0 days) 24-47 hours (1 day) 48-71 hours (2 days) 72-95 hours (3 days) 96-119 hours (4 days) 120-143 hours (5 days) 144-167 hours (6 days) 168-181 hours (7 days) 182-205 hours (8 days) >9 days* Total
Total No. of patients
1 2 4 1 0 0 1 0 1 4 14
%
7.1 14.3 28.6 7.1
No. with Cumulative peripheral % catheter
7.1 21.4 50.0 57.1
1 1 2 1
7.1
64.3
1
7.1 28.7 100.0
71.4 100.0
1 3 10
*Patientsstill hospitalized.
option is the only way to save real salary dollars. The ICP is discouraged by the realization that the savings in nursing time is not reflected in savings of real dollars. Because there is no nursing team for insertion and management of IV catheters (IV team), part of a salaried position could not be eliminated. In addition, avoiding 800 reinsertions of IV catheters is equivalent to avoiding fewer than 3 reinsertions each day. Consequently the nursing time saved daily is negligible and the time would be shifted to other nursing activities. DISCUSSION
In this example, the only real savings is in the cost of supplies. Using data for peripheral catheters and administration sets only to generate a savings of the $23,000 required to purchase safety IV catheters without affecting the budget, it would be necessary to avoid reinsertion of 3286 peripheral IV catheters ($23,000/$7 per insertion = 3286 insertions). This scenario is not realistic for Memorial Hospital, because of the patient population, the declining census, and the declining length of stay in the hospital. Most of the resources for purchasing safety IV catheters will need to come from another source. The administrator might decide, however, that the cost of this safety measure is warranted, because the measure (1) would spare personnel from the anxiety and stress of a puncture injury exposing them to the blood of a patient and (2) would save the costs for care of such puncture injuries, with their potential for HIV seroconversion. The administrator might agree to the cost increase, even though it would result in a budget increase,
Supplies and nursing time
IV catheter IV start kit Nonsterile gloves (one pair) Administration set ($3.00-$7.00) Total cost for supplies for one reinsertion Total cost of supplies for 800 IV catheter reinsertions avoided Total cost for nursing time for 800 IV catheter reinsertions avoided Total costs saved
Cost
$0.70 1.20 0.10 5.00 $7.O0 $5,600.00 10,000.00 $15,600.00
if a compelling case were presented to the budget committee. As pointed out in this example, patients who have a long stay in the hospital (that is, stay longer than 8 to 10 days) provide the greatest potential for avoiding reinsertion of IV catheters, but their needs for vascular access vary considerably during the hospital stay. The potential for cost savings will depend on the proportion of patients who stay in the hospital longer than 72 hours, the proportion who have insertion of peripheral IV catheters, and the length of stay in the hospital. In an average community hospital, the proportion of patients who stay longer than 72 hours is likely to be relatively small. Also, the estimate of 800 IV reinsertions avoided in this example may be an overestimate. The savings from decreasing the frequency of administration set changes for other intravascular devices (for example, central and arterial lines) could be estimated from another prevalence study or from further analysis of data collected in this survey. Focused studies are used to obtain information about use of devices, patient care practices, and costs. In the current example, a hypothetical problem was presented from two sources: the injured nurse's questioning of hospital policy on use of safety IV catheters and the Infection Control Committee's request for evaluation of the cost savings from a proposed practice change. Additional data were collected for use by the quality improvement nurse to improve consistency in practices for labeling IV catheter sites, use of the needleless IV access system, and site evaluation for redness, swelling, and infiltration. Evaluating unit-specific information about these practices will assist the quality improvement nurse in targeting interventions to improve quality of care. The prevalence
AJIC Volume25, Number6
s u r v e y c a n b e r e p e a t e d in 6 m o n t h s to a n s w e r the q u e s t i o n "Did p r a c t i c e s i m p r o v e ? " Overall, this a s p e c t of the s u r v e y a n d the a p p l i c a t i o n of its results constitutes a useful quality improvement project with multidisciplinary components. The utilization management coordinator can also d e t e r m i n e h o w m a n y p a t i e n t s h a v e c e n t r a l lines a n d w h i c h p a t i e n t s are c a n d i d a t e s f o r infusion services at h o m e . T h e c o o r d i n a t o r c a n u s e t h e s e d a t a to verify t h a t c u r r e n t m e t h o d s f o r identifying s u c h p a t i e n t s i n c l u d e e v e r y o n e identified in the p r e v a l e n c e survey. P r e v a l e n c e s u r v e y s a r e a relatively efficient w a y to collect a large a m o u n t of d a t a in a relatively s h o r t time. A p r e v a l e n c e s u r v e y c a n also b e u s e d to e n u m e r a t e r i s k f a c t o r s for n o s o c o m i a l (hospit a l - a s s o c i a t e d ) i n f e c t i o n s a n d to e s t a b l i s h s o m e types of d e n o m i n a t o r data. H o w e v e r , the u s e of a p r e v a l e n c e s u r v e y as a s u r v e i l l a n c e m e t h o d for i n f e c t i o n o u t c o m e s ( n u m e r a t o r ) h a s several s h o r t c o m i n g s . Firs t, the n u m b e r of n o s o c o m i a l infect i o n s d e t e c t e d o n a n y given d a y is relatively small, a n d d e t e c t i o n of e a c h i n f e c t i o n r e q u i r e s f r o m several m i n u t e s (o h a l f a n h o u r or m o r e . T h e p r i m a ry r e a s o n for this s h o r t c o m i n g is t h a t m a n y o f the d a t a e l e m e n t s n e e d e d to e n s u r e t h a t n o s o c o m i a l i n f e c t i o n c r i t e r i a are m e t a r e n o t a v a i l a b l e o n the d a y of the s u r v e y (e.g., l a b o r a t o r y results a n d radiologic results). S e c o n d , i n f 0 r m a t i o n n e e d e d f o r the d i a g n o s i s of a n o s o c o m i a l i n f e c t i o n is r e c o r d e d in different p l a c e s in the n u r s i n g unit. R e l e v a n t i n f o r m a t i o n m a y b e o n f o r m s at the b e d s i d e (e.g., t e m p e r a tures); in t h e inurse's h e a d b u t n o t yet r e c o r d e d (e.g., frequency, urgency, a n d b u r n i n g o n u r i n a tion, for a p a t i e n t w i t h a n o s o c o m i a l u r i n a r y t r a c t infection); in ~he m e d i c a l r e c o r d (e.g., p h y s i c i a n ' s p r o g r e s s notes[ t h a t specify clinical signs of l o w e r r e s p i r a t o r y infection); o r online in a c o m p u t e r (e.g., l a b o r a t o r y d a t a s h o w i n g a n elevated w h i t e b l o o d cell c o u n t w i t h a "shift to the left"). T h e r e m a y b e o n l y o n e o r t w o c o m p u t e r s at t h e n u r s e s ' s t a t i o n a n d u s e r s m u s t c o m p e t e for space. Third, if d e v i c e - d a y s ' a r e u s e d as the d e n o m i n a t o r , a prevalence survey does not provide information a b o u t d u r a t i o n of device use. B e f o r e startiflg a f o c u s e d study, it is i m p o r t a n t to develop the list]of questions t h a t m u s t be a n s w e r e d (e.g., Table 1). !This strategy will help the ICP to decide w h i c h m e t h o d s will be m o s t useful for o b t a i n i n g spec!fic i n f o r m a t i o n . T h e r e are m a n y possible approfiches to a f o c u s e d s t u d y a n d o t h e r types of research. Selection of the m o s t a p p r o p r i a t e i,
Jackson 5 2 7 m e t h o d s d e p e n d s o n the p u r p o s e s of the study, the r e s o u r c e s available, a n d the deadline for results. I thank my colleagues at the Universityof California San Diego Medical Center--DianaC. McPherson, RN, BSN, CIC,and Leland S. Rickman, MD--formany fruitful discussions about focused studies and other research. References
1. Haley RW, Culver DH, White JW, et al. The efficacy of infection surveillance and control programs in preventing nosocomial infections in U.S. hospitals. Am J Epidemiol 1985;121:182-205. 2. Stafford Consulting. Epi Easy 2000: interactive training manual. A beginners guide to EpiInfo, 1996. (Available from Stafford Consulting, 2295 Needham Road, Suite 98A, E1 Cajon, CA 92020-2051, [800] 988-3363. Introductory nqanual and disks $25 in early 1997:) 3. Dean AG, Dean JA, Coulombier D, et al. Epilnfo version 6.03 manual and disks for a word processing, database, and statistics system for epidemiology on microcomputers, 1994. (Available from USD Inc., 2075-A West Park Place, Stone Mountain, GA 30087, [770] 469-4098; manual and disks $50 in early 1997.) Suggested
reading
Abramson JH. Making sense of data: a self-instructional manual on the interpretation of epidemiologic data. 2nd ed. New York: Oxford University Press; 1994. Association for Professionals in Infection Control and Epidemiology, Inc. APIC infection control and applied epidemiology: principles and practice. St. Louis: Mosby; 1996. [See Pt II, section A: Methods of data analysis.] Creswell JW. Research design: qualitative and quantitative approaches. Thousand Oaks (CA): Sage Publications; 1994. Davidson F. Principles of statistical data handling. Thousand Oaks (CA): Sage Publications; 1996. DeVellis RE Scale development: theory and applications. Thousand Oaks (CA): Sage Publications; 1991. Friedman GA. Primer of epidemiology. 4th ed. New York: McGraw-Hill; 1994. Girden ER. Evaluating research articles from start to finish. Thousand Oaks (CA): Sage Publications; 1996. Grady KE, Wallston BS. Research in health care settings. Thousand Oaks (CA): Sage Publications; 1988. Harrison MI. Diagnosing organizations: methods, models, and processes. 2nd ed. Thousand Oaks (CA]:Sage Publications; 1994. Hem-y GT. Practical sampling. Thousand Oaks (CA): Sage Publications; 1990. Hennekens CH, Buring JE. Epidemiology in medicine. Boston: Little, Brown and Co.; 1987. Kraemer HC, Thiemann S. How many subjects? Statistical power analysis in research. Thousand Oaks (CA): Sage Publications; 1987. Lilienfeld DE, Stolley PD. Foundations of epidemiology. 3rd ed. New York: Oxford University Press; 1994. Lorig K, Stewart A, et al. Outcome measures for health education and other health care interventions. Thousand Oaks (CA): Sage Publications; 1996. Miller DC. Handbook of research design and social measurement. 5th ed. Thousand Oaks (CA): Sage Publications; 1991. Morse JM. Qualitative health research. Thousand Oaks (CA): Sage Publications; 1992.
528
AJIC December 1997
Jackson
Nas TK Cost-benefit analysis: theory and application. Thousand Oaks (CA): Sage Publications; 1996. Norell SE. Workbook of epidemiology. New York: Oxford University Press; 1995. Norman GR, Streiner DL. PDQ statistics. 2nd ed. St. Louis: Mosby; 1996. Norman GR, Streiner DL. Biostatistics: the bare essentials. St. Louis: Mosby; 1994. Patton MQ. Utilization-focused evaluation: the new century text. 3rd ed. Thousand Oaks (CA): Sage Publications; 1997. Polit DF. Data analysis and statistics for nursing research. Stamford (CT): Appleton & Lange; 1996. Sacket DL, Haynes RB, Guyatt GH, Tugwell R Clinical epidemiology: A basic science for clinical medicine. 2nd ed. Boston: Little, Brown and Co.; 1991. Sapsford R, Jupp V. Data collection and analysis. Thousand Oaks (CA): Sage Publications; 1996.
Streiner DL, Norman GR. Health measurement scales: a practical guide to their development and use. 2nd ed. New York: Oxford University Press; 1995. Streiner DL, Norman GR. PDQ epidemiology. 2nd ed. St. Louis: Mosby; 1996. The survey kit. Thousand Oaks (CA): Sage Publications; 1995. (This 9-volume kit is designed to enable readers to prepare and conduct surveys and become better users of survey results. The booklets in the ldt are practical, easy to use, and written for novice researcl~ers. The entire kit costs about $100; each volume can also be purchased separately.) Valanis B. Epidemiology in nursing and health care. 2nd ed. Norwalk (CT): Appleton & Lange; 1992. Vogt WR Dictionary of statistics and methodology: a nontechnical guide for the social sciences. Thousand Oaks (CA): Sage Publications; 1993. Wenzel RR Assessing quality health care: perspectives for clinicians. Baltimore: Williams & Wilkins; 1992.
Practice Forum articles should address infection prevention and control practices and related applications of epidemiology. Items should be limited to two to five typed double-spaced pages. Please send items to the Editor, Elaine L. Larson, RN, PhD, FAAN, CIC, Georgetown University, School of Nursing, 3700 Reservoir Rd., N. W., Washington, DC 20007.
Designing and performing focused studies is part of the regular work of infection surveillance, prevention, and control, and the methodologyof a prevalence surveyused in this practice forum will be familiar to many infection control professionals. A practical example of a focused study to evaluate cost savings from extendingintravenous catheter site and administration set change frequencyfrom 72 hours to 96 hours illustrates the steps required. Suggestedreferences for additional information are included at the end of the article. (AJICAm J Infect Control 1997;25:520-8) Design and performance of focused studies is part of the regular work of infection control professionals (ICPs). "Focused study" is a term from the jargon used in research on quality improvement. The term implies that an answer to a question or a solution to a problem can be obtained within a reasonable time and that there is some practical value to the information obtained. This article uses a practical example of an issue facing m a n y ICPs to review the steps in planning, implementing, and evaluating a focused study. The process and tools described in this example should help ICPs to design and implement a variety of focused studies. BACKGROUND Memorial Hospital* is a 250-bed c o m m u n i t y hospital in the western United States. The hospital has a 15-bed critical care unit, a busy emergency department, and the usual hospital services. The ICP shares an administrative assistant with the quality improvement nurse and the two utilization m a n a g e m e n t coordinators. The physician chair of the Infection Control Committee spends 1 h o u r each week meeting with the ICP and is available by telephone for emergency consultation. There has been a steady decrease in the average daily census for Memorial Hospital as managed care has penetrated the region. For the past 3
*All data are fictitious and the scenario is hypothetical. From the Epidemiology Unit, University of California San Diego Medical Center. Reprint requests: Marguerite Jackson, RN, PhD, CIC, FAAN, Epidemiology Unit, UCSD Medical Center, 200 W. Arbor Dr., San Diego, CA 92103-8951. Copyright © 1997 by the Association for Professionals in Infection Control and Epidemiology, Inc. 0196-6553/97 $5.00 + 0
520
17/49/84565
months the census averaged approximately 140 patients per day. The average census in the critical care unit was 12 patients per day during that time. On the basis of the findings in the Study on the Efficacy of Nosocomial Infection Control study in the 1970s, the Centers for Disease Control and Prevention estimated that a ratio of 1 ICP to 250 occupied beds was adequate for prevention and control of infection in acute care hospitals. 1 Although needs and programs have changed substantially in the last 20 years, this ratio is still c o m m o n l y used by hospital administrators. In planning for the next budget year, the administrator of Memorial Hospital slated the ICP position for reduction to a half-time position largely because of the falling census. At about the same time, the employee health nurse retired, and the administrator decided not to fill the position but, instead, to offer the ICP the option of taking a fulltime position that combined the functions of the employee health nurse and the ICR Because Memorial Hospital is the only hospital in this small town, and the ICP needed a full-time job, the ICP accepted the combined position. Memorial Hospital has an active employee health program for postexposure m a n a g e m e n t of sharps injuries and exposure to blood. This program is consistent with the requirements of the Bloodborne Pathogens Standard of the Occupational Safety and Health Administration. The program, which was set up by the employee health nurse years ago, is now the ICP's responsibility. The average n u m b e r of reported injuries and blood exposures is five or six each month, and a variety of sharp devices and splash situations cause these exposures. Three or four times a year, an injury caused by an intravenous (IV) catheter stylet is reported. Memorial Hospital does not use safety IV catheters, primarily because of the unit cost ($1.70 for a safety IV catheter versus 70 cents for the stan-
AJIC Volume25, Number6
Jack$olq. 5 2 1
T a b l e 1. Information needed for focused study to determine whether decreasing the frequency of IV catheter
reinsertion and change of administration sets from 72 to 96 hours for inpatients at Memorial Hospital will save enough money to purchase safety IV catheters Information needed
No. of peripheral IV catheters purchased each year and unit cost Unit costs for supplies needed to start an IV infusion, including administration sets No. of peripheral ly catheters Length of stay
Nursing time to insert peripheral IV catheter Cost of safety IV catheter
Cost of nursing time, including benefits Data for past year for average daily census, total patient-days, and frequency distribution of number of patients by length of stay and total patient-days Results of analyses of data from prevalence survey
Report of results for administrator and Infection Control Committee
Where is it available?
How is it obtained?
How long will it take to obtain it?
Purchasing Department Purchasing Department
Ask purchasing agent
1-2 wk
Ask purchasing agent
1-2 wk (ask at same time as information about IV catheters)
Observation of patients Calculation from prevalence study data Literature search or interview of several nurses Vendors
Access prevalence survey data
1 day with three or four surveyors (5 min per patient) 1 day at computer (3-4 min to look up data on each patient)
Human Resources Department Information Systems Department
Access computer database for discharge dates of patients, up to 6-7 days after prevalence survey Ask several nurses; then observe and time two or three nurses inserting IV catheter Ask vendors for price quote for volume obtained from purchasing department Ask representative of Human Resources Department Ask representative of Information Systems Department
Computer database created by using Epilnfo software
Enter data into computer database and perform data analyses
Computer database created by using Epilnfo software
Compile all data and write report
dard IV catheter). However, 4 years ago a needleless IV access system was established throughout the facility to reduce puncture injury risks once an IV catheter was in place. Problems P u n c t u r e i n j u r i e s o f h o s p i t a l s t a f f . A few weeks ago, a critical care nurse sustained a puncture injury while inserting an IV catheter. The nurse had received the hepatitis B vaccine series, and a blood test showed that the postvaccine serology was positive for immunity. The patient was a known injection drug user, but it was unknown whether he was positive for h u m a n immunodeficiency virus (HIV) at the time of the injury. He consented to testing, and the results were available 6 days later. He was HIV negative. The nurse was distressed because she had to wait 6 days for the test results. In addition, she had chosen not to take antiviral medications, because of a possible pregnancy and this created additional anxiety during the 6-day waiting period. When the nurse asked why Memorial
2-3 hr for observations; less time for interviews 1 day to 2 wk, depending on vendor's responsiveness 1-2 days, depending on representative's responsiveness 1 day to 2 wk, depending on responsiveness of personnel in Information Systems Department 1-2 wk (3-4 min for entry of data on each patient); several hours for data analyses, depending on person's skills 2-3 days, depending on efficiency in compiling data and writing report
Hospital did not use safety IV catheters, the ICP told her it was because very few IV catheter-related injuries were reported each year and the unit cost of the safety catheter was much more than the unit cost of the standard catheter. She was not satisfied with this answer and asked what could be done to change the policy. C h a n g e in f r e q u e n c y of I V c a t h e t e r
reinsertion.
At the last Infection Control Committee meeting, the committee agreed to decrease the frequency for 1V catheter insertion at a new site and administration set changes from 72 to 96 hours. The Committee thought that this measure would reduce costs considerably but had no estimate of how much money could be saved. The Committee asked the ICP to conduct a focused study to answer this question. The ICP decided to include in this focused study an estimate of the increased cost of using safety IV catheters, to determine whether the cost savings from reducing the frequency of IV catheter reinsertion and administration set changes would neutralize the increased cost of safety IV catheters.
AJIC December 1997
5 2 2 Jackson
DATA COLLECTION FORM: PREVALENCE SURVEY DATE Nursing Unit Census for this date Number of patients with peripheral IV catheters ..... NOTE: Use extra blocks of forra if patient has more than one Bed No. Med Rec Admit Date Admit .Name* Number Time D/C Date
D/C Time
LOS Hours
SURVEYOR
3e of vaseular access, or more than one LOS Cath Days Type Label Date i Time Y N YN Y N Y N YN Y N Y N YN Y N Y N YN Y N Y N YN Y N Y N YN Y N Y N YN Y N Y N YN Y N YN YN YN YN YN Y N
. Appear 1239 1239 1239 1239 1239 1239 1239 1239 1239 1239
N~dleless? Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N
Pump Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N
Infusion C I C I C I C I C I C I C I C I C I C I
Fig. 1. Data collection form for prevalence survey. Y,Yes; N, no; 1, OK; 2, red and swollen; 3, infiltrated; 9, unable to observe; C, continuous; I, intermittent. *Use name only if it is necessary to access computerized data later. Otherwise, use only medical record number.
P u r p o s e s of f o c u s e d s t u d y
After discussion with several people, including the quality improvement nurse, the utilization management coordinators, and the chair of the Infection Control Committee, the following purposes of the study were listed: 1. To determine the proportion of patients at Memorial Hospital who have one or more peripheral IV catheters and other types of vascular access devices in place on a given day 2. To evaluate peripheral site management for compliance with current protocols for labeling sites, use of the needleless IV access system, and management and use of infusion pumps 3. To estimate the proportion of patients with peripheral IV catheters who would require fewer catheter insertions with a change from the 72-hour to the 96-hour frequency of site change 4. To estimate the savings in nursing time and supply costs achieved by a decrease in the frequency of changes in IV catheter sites and administration sets 5. To estimate the incremental cost of using safety IV catheters instead of standard IV catheters 6. To determine whether the savings from decreasing the frequency of changes in the IV catheter site and administration sets would offset the increase in costs of using safety IV catheters The quality improvement nurse offered to help with the study in exchange for collecting information about management and use of the IV catheter and the infusion pump. Also, one of the utilization management coordinators agreed to help because
she was interested in knowing m o r e a b o u t patients with temporary and permanent (e.g., Hickman and Broviac) central lines. METHODS
Table 1 outlines the information needed and where and h o w to obtain it and shows estimates of the time required to obtain the information. Many of these tasks can be accomplished concurrently. Information is required from several persons w h o m a y not be able to deliver it immediately. In addition, data collection forms need to be developed, and a computerized data entry screen needs to be created, so that data can be entered and analyzed accurately. It was agreed that a 1-day prevalence survey was the most time-efficient m e t h o d for collecting m u c h of the required data. Fig. 1 is a sample data collection form for a prevalence survey. (For ease of use the lines should be spaced more widely in such a survey form than they are in this sample.) A substantial quantity of information can be collected at one time with use of this form. The persons conducting the survey (surveyors) should p e r f o r m a pilot test with a few patients to ensure that use of the survey is workable. Copies of the form placed on a clipboard can be carried from bedside to bedside by each surveyor. Three surveyors can p e r f o r m a 1-day prevalence survey of all inpatients at Memorial Hospital. In a general nursing unit, one surveyor can obtain the information from one patient in a b o u t 5 minutes at the patient's bedside, b u t in the critical care unit it m a y be necessary to spend m o r e time with each patient.
AJIC
Jackson
Volume 25, Number 6
DATA COLLECTION FORM: PREVALENCE SURVEY DATE Nursing Unit 2WMED Census for this date 14 Number of patients with peripheral IV catheters 10 NOTE: Use extrablocksof form if ivied Rec Admit Bed No. Number Date 203 1265798 5/1/97
has morethan one Admit D/C
LOS
Time
D/C Date
Time
Hrs
0230
5/3/97
1430
60
still here
5/7
SURVEYOR MMJ
5/1/97
or morethan one
£()S Days 2
Cath
type Perip
Label
Date
O N ~N
Time
Appear
Y(~ ~239
Needle less?
1476943 4128/97
0830
pump-
same
site
208
1345990 4/30/97
0945
5/3/97
0840
95
3
Perip
Y ~) !Yt~
! 209
1834966 4/29/97
1235
5/1/97
1630
52
2
Centr
Y N
Y N
t 239
Y N
210
1794390 5/1/97
Perip O N
1567993 4/29/97 1865098 4/20/97
2000 1450 5/7
0
214
5/1/97 5/5/97 stillhere
20
211
0030 1200 0330
Y~D Y ~ Y{~ Y ( ~ Y~ Y@
Q)239 1209 ~239 (~239
216
1769450 511197
37
3 N ~
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2'7
1964320
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4/26/97
0400 2200
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~ N
~) N
Y N
12 3 9
Y N
(~ N
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Y(~
Y(~
6 17td
514/97
Perip
Y N ~N
Y(~
Perip Yt~) Perip
Y N
Y~
Y N
~N
1
Perip ~
8
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N
218
1543276 511197
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512197
1230
28
1
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220
1684947 4•30•97
1300
5/2197
1630
51
2
Perip ( ~ N
51
Y N
N
Infusion
CO
9 td* Perip ~ N O N ~ ) N
site
5/2/97
yPU~
(.~N
205
2nd
523
C (~)
~
I
N
C (~
(~N (~N !Y(~ 'YO
Y(~) ON (~N Y~)
C(~ C~ (.~I C~
~
~
N
[1)239 ~ N
~
~) I
N
Y~
Y N
Y N
12 3 9
]Y N
~N
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~)239
(~.)N
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C (~
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~(~I
1221
1543780 4•29•97
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Y N
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1 23 9
Y N
Y N
C I
] 222
1954697 4128/97
0300
stillher¢
5/7
9 td
Centr
Y N
Y N !y N
1239
Y N
ON
cO)
223
1496807 4/18/97
0800
still here
5/7
19 td
Peril)
Y 0
Y~
Y ~
1~ 3 9
~
N
~) N
C0
Central
line also
Centr
Y N
Y N
Y N
12 3 9
Y N
~ N
C Q)
Fig, 2. Completed data collection form for prevalence survey. The form is filled out in two stages. Information in italics is completed at time of survey. Information in bold is completed 6 days after survey by accessing computer database for admission and discharge dates and times and by calculating length of stay in hours (if fewer than 96 hours) and in days (0 days = <24 hours; 1 day = 24-47 hours, 2 days = 48-71 hours; 3 days = 72-95 hours; 4 days = 96-119 hours, etc. Values for hours are rounded to nearest hour). *td, To date (for patients still in the facility at the time computer is checked for admission and discharge dates. In this example, this was done on 5/7/97).
Performance of survey
At a designated time on the day of the prevalence survey, the surveyors divide the work of conducting the survey in the general nursing units and critical care unit, so that each surveyor has approximately the same n u m b e r of patients to evaluate. The surveyors introduce themselves to the patients, evaluate the appearance of the peripheral IV site, and note whether a central line is in place, whether an infusion p u m p is being used, and whether the use is continuous or intermittent. This information is recorded on a data collection form (e.g., Fig. 1). It is helpful to have a computer listing of the names of all patients, bed numbers, and medical record numbers. However, because some patients may be discharged from the hospital and new patients m a y be admitted before the surveyor visits a unit, it is best to complete the form at the time of the visit for the survey. Fig. 2 is a completed data collection form for one nursing unit with a census of 14 patients on the day of the survey. Note that some of the infor-
mation (in italics and circled) is completed during the survey; the remainder of the information (in bold) is filled in later. Because length of stay is a critical piece of information, it is important to wait several days to complete the form, so that m a n y of the patients identified during the prevalence survey will have completed the hospital stay. In this example, the forms were completed 6 days after the survey date. Data Analysis
The data entry screen for creating a computer database from the collected data is shown in Table 2. This example uses a software program called Epiinfo.2. 3 Once the data are collected, they are entered into this database so they can be analyzed easily. The ICP can enter the data or delegate data entry to an administrative assistant. Once the process becomes familiar, data entry for each patient requires 3 to 4 minutes. The software program permits data to be analyzed by a variety of methods. For example, data for each nursing unit
AJIC
524 Jackson
December 1997
Table 2, Data entry screen for use with Epilnfo* computer database for prevalence surveyt Epllnfo DATA ENTRY: PREVALENCE SURVEY {UNIT} {BED} {MEDREC} {SURVEYOR}__ I=MJ 2=DM 3=SP {ADDATE}
can be analyzed separately to alert the quality improvement nurse to specific problem areas (e.g., a small proportion of sites labeled or few needleless IV access devices used) and to areas where there is little room for improvement (e.g., greater than 90% compliance with policies and procedures). RESULTS
The data collected for one nursing unit during the prevalence survey are summarized in Tables 3 and 4. Entry of data for the entire hospital into one table (e.g., 137 inpatients on all units) would show the prevalence of use of peripheral catheters and other vascular access devices, the management of IV sites, and the use of infusion pumps, for Memorial Hospital on the day of the survey. Validating data as representative
Prevalence survey data are more likely to be representative of long-term data for the hospital if the survey is performed in the middle of the week rather than on a weekend. In Table 3, one half (7) of the 14 patients were discharged before 72 hours. Patients who had a short stay (less than 24 hours) would require only a single IV catheter, regardless of whether the frequency of IV site change was 72 or 96 hours. For one patient, who stayed between 72 and 95 hours, reinsertion of the IV catheter would not have been required if the frequency of site change were 96 hours. Three of the four patients who had a long stay (> 9 days), had peripheral IV catheters that would require
site and administration set changes at 4-day rather than 3-day intervals with the change in site rotation from 72 to 96 hours. Central lines were also used for these patients, however, and peripheral 1V catheters might not have been required continuously throughout their stay, depending on the diagnoses and reasons for use of vascular access. To assess whether the data obtained are representative, it is important to compare the distribution of length of stay for patients at Memorial Hospital on the day of the prevalence survey with that for all Memorial Hospital patients during the past year. In addition, the information obtained during the prevalence survey is used to calculate cost data for 1 year. The data on length of stay for the past year are obtained from the hospital's Information Systems Department. In this hypothetical example, the data from Information Systems Department for the past year show that Memorial Hospital had 12,000 admissions, an average length of stay of 4.2 days, and 50,400 patient-days. Sixty-five percent (7800) of the 12,000 discharges were for lengths of stay shorter than 72 hours (20,000 patient-days). The remaining 4200 admissions were for stays of 72 hours or longer (30,400 patient-days). The results of the prevalence survey of 137 patients showed that about half of patients who stayed 72 hours or longer had a peripheral catheter in place that day for about 2100 patients per year. It is also assumed that these 2100 patients also represent
AJIC Volume 25, Number 6
Jackso~z 525
"fable 3, Summary created after entry of data from prevalence survey in Epilnfo computer database: data for evaluation of IV catheter site management for labeling of sites, use of needleless IV access system, and infusion pump use and management Site
Label
Date
Needeless catheter
Time
Infusion No. of
Type
No,
No.
(%)
No.
(%)
No.
(%)
Appearance No.
(%)
No.
(%)
pumps
Type
No.
10
6
(60)
6
(60)
3
(30)
OK Red, swollen Infiltrated
(80) (10) (10)
8
(80)
6 for 5 sites
Continuous Intermittent
3
Intermittent
5 6 for 5 iV sites 3
0 1
Intermittent Intermittent
1 1
Site 1
Peripheral
Central None
8 1 1
3 1
Site 2
Peripheral Central
1 1
0
0
0
OK
one half of the patient-days (15,200 patient-days) for this group of admissions. Calculating potential savings
The ICP must calculate the potential savings from reduction in the frequency of peripheral IV catheter reinsertion and changes of administration sets. To do this, calculate the potential savings from avoided restarts that apply only to patients whose lengths of stay are longer than 72 hours (2100 patients x their first 3 days = 6300 patient days). Subtract these patient days from the total cumulative lengths of stay for these patients (15,200 patient days). This subtraction is done because the initial (first) IV catheter insertion would occur regardless of the reinsertion frequency or length of stay. This leaves a potential of 8900 patient days during which the change from 72-hour reinsertions to 96-hour reinsertions would result in fewer reinsertions cumulatively. If these 2100 patients who were hospitalized longer than 72 hours had peripheral catheters continuously during their stay, the calculations would be as follows: 8900 patient-days/3 days = 2967 IV catheter reinsertions at 72 hours; 8900 patientdays/4 days = 2225 IV catheter reinsertions at 96 hours; 2967 - 2225 = 742 IV catheter reinsertions avoided. Obviously, individual patients have varying lengths of stay longer than 72 hours and may be discharged I, 2, or 3 days after a new catheter is inserted. Thus patient days are only a crude estimate of the effect of a change in insertion cycle intervals. Because all peripheral IV catheters in these patients who were hospitalized longer than 72 hours would not last for 96 hours, and some sites would not be changed at 96 hours because of difficult access issues (for example,
1
0
fragile veins) or the likelihood of discharge within a few hours, a "fudge factor" was added to come up with a round number of 800 IV restarts potentially avoided by reinsertion of IV catheters at 96 hours. Added to this would be the cost savings from changing the administration sets less frequently for peripheral and other types of intravascular catheters. Estimating costs and cost savings
The purchasing agent tells the ICP that last year the hospital purchased 23,000 IV catheters (all gauges) at an average cost of 70 cents per unit, for a total cost of $16,100. For the same number of safety catheters at an average cost of $1.70 each, the total cost would be $39,100. The difference in cost would be $23,000. By interviewing nurses and observing insertion of IV catheters, the ICP determines that insertion of an IV catheter requires an average of approximately 30 minutes of nursing time. This time includes performance of tasks such as collecting supplies, preparing the patient, inserting the 1V catheter, changing the administration set, cleaning up and discarding wastes, and recording the procedure on the patient's chart. The representative from the Human Resources Department tells the ICP that the average nursing salary with benefits is $25 per hour ($12.50 for 30 minutes). According to the purchasing agent, the supplies cost an average of $7 for each peripheral IV insertion. Therefore the estimated cost savings of avoiding 800 peripheral catheter reinsertions is almost $16,000 (Table 5). The ICP shares this information with the hospital administrator, who asks whether part of a nursing position can be eliminated by ma~king this change. The administrator points out that such an
AJIC 526
December 1997
Jackson
T a b l e 4. Summary created after entry of data from
T a b l e 5 . Estimated costs of supplies and nursing time
prevalence survey in Epilnfo computer database: length of stay in relation to use of peripheral catheter
for reinsertion of peripheral IV catheters, Memorial Hospital, 1997
Length of stay
0-23 hours (0 days) 24-47 hours (1 day) 48-71 hours (2 days) 72-95 hours (3 days) 96-119 hours (4 days) 120-143 hours (5 days) 144-167 hours (6 days) 168-181 hours (7 days) 182-205 hours (8 days) >9 days* Total
Total No. of patients
1 2 4 1 0 0 1 0 1 4 14
%
7.1 14.3 28.6 7.1
No. with Cumulative peripheral % catheter
7.1 21.4 50.0 57.1
1 1 2 1
7.1
64.3
1
7.1 28.7 100.0
71.4 100.0
1 3 10
*Patientsstill hospitalized.
option is the only way to save real salary dollars. The ICP is discouraged by the realization that the savings in nursing time is not reflected in savings of real dollars. Because there is no nursing team for insertion and management of IV catheters (IV team), part of a salaried position could not be eliminated. In addition, avoiding 800 reinsertions of IV catheters is equivalent to avoiding fewer than 3 reinsertions each day. Consequently the nursing time saved daily is negligible and the time would be shifted to other nursing activities. DISCUSSION
In this example, the only real savings is in the cost of supplies. Using data for peripheral catheters and administration sets only to generate a savings of the $23,000 required to purchase safety IV catheters without affecting the budget, it would be necessary to avoid reinsertion of 3286 peripheral IV catheters ($23,000/$7 per insertion = 3286 insertions). This scenario is not realistic for Memorial Hospital, because of the patient population, the declining census, and the declining length of stay in the hospital. Most of the resources for purchasing safety IV catheters will need to come from another source. The administrator might decide, however, that the cost of this safety measure is warranted, because the measure (1) would spare personnel from the anxiety and stress of a puncture injury exposing them to the blood of a patient and (2) would save the costs for care of such puncture injuries, with their potential for HIV seroconversion. The administrator might agree to the cost increase, even though it would result in a budget increase,
Supplies and nursing time
IV catheter IV start kit Nonsterile gloves (one pair) Administration set ($3.00-$7.00) Total cost for supplies for one reinsertion Total cost of supplies for 800 IV catheter reinsertions avoided Total cost for nursing time for 800 IV catheter reinsertions avoided Total costs saved
Cost
$0.70 1.20 0.10 5.00 $7.O0 $5,600.00 10,000.00 $15,600.00
if a compelling case were presented to the budget committee. As pointed out in this example, patients who have a long stay in the hospital (that is, stay longer than 8 to 10 days) provide the greatest potential for avoiding reinsertion of IV catheters, but their needs for vascular access vary considerably during the hospital stay. The potential for cost savings will depend on the proportion of patients who stay in the hospital longer than 72 hours, the proportion who have insertion of peripheral IV catheters, and the length of stay in the hospital. In an average community hospital, the proportion of patients who stay longer than 72 hours is likely to be relatively small. Also, the estimate of 800 IV reinsertions avoided in this example may be an overestimate. The savings from decreasing the frequency of administration set changes for other intravascular devices (for example, central and arterial lines) could be estimated from another prevalence study or from further analysis of data collected in this survey. Focused studies are used to obtain information about use of devices, patient care practices, and costs. In the current example, a hypothetical problem was presented from two sources: the injured nurse's questioning of hospital policy on use of safety IV catheters and the Infection Control Committee's request for evaluation of the cost savings from a proposed practice change. Additional data were collected for use by the quality improvement nurse to improve consistency in practices for labeling IV catheter sites, use of the needleless IV access system, and site evaluation for redness, swelling, and infiltration. Evaluating unit-specific information about these practices will assist the quality improvement nurse in targeting interventions to improve quality of care. The prevalence
AJIC Volume25, Number6
s u r v e y c a n b e r e p e a t e d in 6 m o n t h s to a n s w e r the q u e s t i o n "Did p r a c t i c e s i m p r o v e ? " Overall, this a s p e c t of the s u r v e y a n d the a p p l i c a t i o n of its results constitutes a useful quality improvement project with multidisciplinary components. The utilization management coordinator can also d e t e r m i n e h o w m a n y p a t i e n t s h a v e c e n t r a l lines a n d w h i c h p a t i e n t s are c a n d i d a t e s f o r infusion services at h o m e . T h e c o o r d i n a t o r c a n u s e t h e s e d a t a to verify t h a t c u r r e n t m e t h o d s f o r identifying s u c h p a t i e n t s i n c l u d e e v e r y o n e identified in the p r e v a l e n c e survey. P r e v a l e n c e s u r v e y s a r e a relatively efficient w a y to collect a large a m o u n t of d a t a in a relatively s h o r t time. A p r e v a l e n c e s u r v e y c a n also b e u s e d to e n u m e r a t e r i s k f a c t o r s for n o s o c o m i a l (hospit a l - a s s o c i a t e d ) i n f e c t i o n s a n d to e s t a b l i s h s o m e types of d e n o m i n a t o r data. H o w e v e r , the u s e of a p r e v a l e n c e s u r v e y as a s u r v e i l l a n c e m e t h o d for i n f e c t i o n o u t c o m e s ( n u m e r a t o r ) h a s several s h o r t c o m i n g s . Firs t, the n u m b e r of n o s o c o m i a l infect i o n s d e t e c t e d o n a n y given d a y is relatively small, a n d d e t e c t i o n of e a c h i n f e c t i o n r e q u i r e s f r o m several m i n u t e s (o h a l f a n h o u r or m o r e . T h e p r i m a ry r e a s o n for this s h o r t c o m i n g is t h a t m a n y o f the d a t a e l e m e n t s n e e d e d to e n s u r e t h a t n o s o c o m i a l i n f e c t i o n c r i t e r i a are m e t a r e n o t a v a i l a b l e o n the d a y of the s u r v e y (e.g., l a b o r a t o r y results a n d radiologic results). S e c o n d , i n f 0 r m a t i o n n e e d e d f o r the d i a g n o s i s of a n o s o c o m i a l i n f e c t i o n is r e c o r d e d in different p l a c e s in the n u r s i n g unit. R e l e v a n t i n f o r m a t i o n m a y b e o n f o r m s at the b e d s i d e (e.g., t e m p e r a tures); in t h e inurse's h e a d b u t n o t yet r e c o r d e d (e.g., frequency, urgency, a n d b u r n i n g o n u r i n a tion, for a p a t i e n t w i t h a n o s o c o m i a l u r i n a r y t r a c t infection); in ~he m e d i c a l r e c o r d (e.g., p h y s i c i a n ' s p r o g r e s s notes[ t h a t specify clinical signs of l o w e r r e s p i r a t o r y infection); o r online in a c o m p u t e r (e.g., l a b o r a t o r y d a t a s h o w i n g a n elevated w h i t e b l o o d cell c o u n t w i t h a "shift to the left"). T h e r e m a y b e o n l y o n e o r t w o c o m p u t e r s at t h e n u r s e s ' s t a t i o n a n d u s e r s m u s t c o m p e t e for space. Third, if d e v i c e - d a y s ' a r e u s e d as the d e n o m i n a t o r , a prevalence survey does not provide information a b o u t d u r a t i o n of device use. B e f o r e startiflg a f o c u s e d study, it is i m p o r t a n t to develop the list]of questions t h a t m u s t be a n s w e r e d (e.g., Table 1). !This strategy will help the ICP to decide w h i c h m e t h o d s will be m o s t useful for o b t a i n i n g spec!fic i n f o r m a t i o n . T h e r e are m a n y possible approfiches to a f o c u s e d s t u d y a n d o t h e r types of research. Selection of the m o s t a p p r o p r i a t e i,
Jackson 5 2 7 m e t h o d s d e p e n d s o n the p u r p o s e s of the study, the r e s o u r c e s available, a n d the deadline for results. I thank my colleagues at the Universityof California San Diego Medical Center--DianaC. McPherson, RN, BSN, CIC,and Leland S. Rickman, MD--formany fruitful discussions about focused studies and other research. References
1. Haley RW, Culver DH, White JW, et al. The efficacy of infection surveillance and control programs in preventing nosocomial infections in U.S. hospitals. Am J Epidemiol 1985;121:182-205. 2. Stafford Consulting. Epi Easy 2000: interactive training manual. A beginners guide to EpiInfo, 1996. (Available from Stafford Consulting, 2295 Needham Road, Suite 98A, E1 Cajon, CA 92020-2051, [800] 988-3363. Introductory nqanual and disks $25 in early 1997:) 3. Dean AG, Dean JA, Coulombier D, et al. Epilnfo version 6.03 manual and disks for a word processing, database, and statistics system for epidemiology on microcomputers, 1994. (Available from USD Inc., 2075-A West Park Place, Stone Mountain, GA 30087, [770] 469-4098; manual and disks $50 in early 1997.) Suggested
reading
Abramson JH. Making sense of data: a self-instructional manual on the interpretation of epidemiologic data. 2nd ed. New York: Oxford University Press; 1994. Association for Professionals in Infection Control and Epidemiology, Inc. APIC infection control and applied epidemiology: principles and practice. St. Louis: Mosby; 1996. [See Pt II, section A: Methods of data analysis.] Creswell JW. Research design: qualitative and quantitative approaches. Thousand Oaks (CA): Sage Publications; 1994. Davidson F. Principles of statistical data handling. Thousand Oaks (CA): Sage Publications; 1996. DeVellis RE Scale development: theory and applications. Thousand Oaks (CA): Sage Publications; 1991. Friedman GA. Primer of epidemiology. 4th ed. New York: McGraw-Hill; 1994. Girden ER. Evaluating research articles from start to finish. Thousand Oaks (CA): Sage Publications; 1996. Grady KE, Wallston BS. Research in health care settings. Thousand Oaks (CA): Sage Publications; 1988. Harrison MI. Diagnosing organizations: methods, models, and processes. 2nd ed. Thousand Oaks (CA]:Sage Publications; 1994. Hem-y GT. Practical sampling. Thousand Oaks (CA): Sage Publications; 1990. Hennekens CH, Buring JE. Epidemiology in medicine. Boston: Little, Brown and Co.; 1987. Kraemer HC, Thiemann S. How many subjects? Statistical power analysis in research. Thousand Oaks (CA): Sage Publications; 1987. Lilienfeld DE, Stolley PD. Foundations of epidemiology. 3rd ed. New York: Oxford University Press; 1994. Lorig K, Stewart A, et al. Outcome measures for health education and other health care interventions. Thousand Oaks (CA): Sage Publications; 1996. Miller DC. Handbook of research design and social measurement. 5th ed. Thousand Oaks (CA): Sage Publications; 1991. Morse JM. Qualitative health research. Thousand Oaks (CA): Sage Publications; 1992.
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AJIC December 1997
Jackson
Nas TK Cost-benefit analysis: theory and application. Thousand Oaks (CA): Sage Publications; 1996. Norell SE. Workbook of epidemiology. New York: Oxford University Press; 1995. Norman GR, Streiner DL. PDQ statistics. 2nd ed. St. Louis: Mosby; 1996. Norman GR, Streiner DL. Biostatistics: the bare essentials. St. Louis: Mosby; 1994. Patton MQ. Utilization-focused evaluation: the new century text. 3rd ed. Thousand Oaks (CA): Sage Publications; 1997. Polit DF. Data analysis and statistics for nursing research. Stamford (CT): Appleton & Lange; 1996. Sacket DL, Haynes RB, Guyatt GH, Tugwell R Clinical epidemiology: A basic science for clinical medicine. 2nd ed. Boston: Little, Brown and Co.; 1991. Sapsford R, Jupp V. Data collection and analysis. Thousand Oaks (CA): Sage Publications; 1996.
Streiner DL, Norman GR. Health measurement scales: a practical guide to their development and use. 2nd ed. New York: Oxford University Press; 1995. Streiner DL, Norman GR. PDQ epidemiology. 2nd ed. St. Louis: Mosby; 1996. The survey kit. Thousand Oaks (CA): Sage Publications; 1995. (This 9-volume kit is designed to enable readers to prepare and conduct surveys and become better users of survey results. The booklets in the ldt are practical, easy to use, and written for novice researcl~ers. The entire kit costs about $100; each volume can also be purchased separately.) Valanis B. Epidemiology in nursing and health care. 2nd ed. Norwalk (CT): Appleton & Lange; 1992. Vogt WR Dictionary of statistics and methodology: a nontechnical guide for the social sciences. Thousand Oaks (CA): Sage Publications; 1993. Wenzel RR Assessing quality health care: perspectives for clinicians. Baltimore: Williams & Wilkins; 1992.
Practice Forum articles should address infection prevention and control practices and related applications of epidemiology. Items should be limited to two to five typed double-spaced pages. Please send items to the Editor, Elaine L. Larson, RN, PhD, FAAN, CIC, Georgetown University, School of Nursing, 3700 Reservoir Rd., N. W., Washington, DC 20007.