- Email: [email protected]
Teaming Up to Take Down Community Acquired Bloodstream Infections
and clinician satisfaction 4.4 at insertion and removal. During the evaluation one patient experienced a 33 day dwell time until device was removed without complication due to clinical judgment. Implications: With the results experienced above, use of the trial device will continue. Conclusions: The 2.25” device with coiled tip guidewire offers a new alternative in PIV placement for difficult stick patients that is easy to use and performs better than the current conventional PIV options used by this VAT.
extracted included: age, gender, number of attempts, difficulty, success and modality used to aid IV placement. Descriptive statistics and chi-square tests were used to analyze data. Results: Between February 4th, 2014 and March 17th, 2014 there were 1083 patient-nurse encounters reported for peripheral IV placement, totaling 1470 attempts. Forty-nine percent were female; mean age was 6 years (SD: 6.67, Range: 0 days-23 years). Ultimately, 939 (86.7%) had successful IV placement. Of those, 709 (75.5%) were placed on the first attempt, 184 (19.6%) on second attempt, 46 (4.9%) on third attempt. Visualization and/or palpation 49.3% of the time; infrared (AccuveinTM) device 40.5%; US 8.0%; trans-illumination 1.0%. For difficult access patients who ultimately had an IV placed, visualization and/or palpation was used 50.6% of the time; infrared device 38.8%; US 9.3%; trans-illumination 1.3%. US was used 117 times overall, and ultimately resulted in 71 (60.7%) successful IV placements. There was a significant difference in age versus overall successful IV placement (p < .001). Implications/Conclusions: Vascular team nurses use ultrasound infrequently for peripheral IV placement, including in children with difficult access. Methods to increase its skillful use in difficult access patients and improve successful IV placements should be explored.
Standardizing the Reporting of Central Line Tip Location Patti Dickinson Background: Interpretation of central line tip location varied greatly between radiologists and Vascular Access (VA) nurses, and among individual radiologists. Purpose: To standardize the reporting of tip location from radiologist to VA nurse, among VA nurses, and from VA nurse to Hospitalists and to community RNs. Project Description: We researched expert opinions on ideal tip location and methods of measuring using anatomical landmarks. We presented an extensive report at a meeting of VA nurses and radiologists. Results: It was agreed that radiologists would report tip location in centimeters below the carina, and the PICC would be adjusted to the ideal depth. VA nurses decided to set our target at 3cm below carina with patient upright to accomodate fluctuations in PICC depth due to patient position. Implications: Tip location reporting has become objective and measurable, consistent among radiologists and RNs. This applies to initial insertion CXR, and subsequent radiological procedures that include tip view. Conclusions: This has improved and simplified communication between departments and among ourselves, the VA nurses, for the benefit of the patients receiving our services.
Teaming Up to Take Down Community Acquired Bloodstream Infections Karie Falder
The Use of Ultrasound for Peripheral IV Placement By Vascular Team Nurses at a Tertiary Children’s Hospital Marsha Elkhunovich Background: Children receiving treatment in the hospital frequently require intravenous (IV) access, which can be painful and challenging. Many children’s hospitals have specialized vascular access nurses who use vein visualization devices, including ultrasound(US), to assist in peripheral IV placement. While there have been several studies that described the use and benefits of US guided IV placement, none have examined nurse US guided IV placement in children. Purpose: Our objectives were to describe the prevalence and success rate of US guided peripheral IV placement by vascular access team nurses at our institution in children of different ages. Project Description: We retrospectively reviewed quality assurance data kept by our institution’s vascular access team between February 4th, 2014 and March 17th, 2014. Data
258
j
JAVA
j
Vol 20 No 4
j
Background: Advances in medical technology have allowed pediatric patients to be discharged home with complex devices including central venous catheters (CVC). In order for these patients to be safely discharged, families are required to be trained to care for these catheters. At a large children’s hospital, extensive family education and training for CVCs was already established. However, the other caregivers in the home (home health nurses) were not receiving the same training. In an effort to target these caregivers, an educational program was designed and implemented in 2011. Purpose: The purpose of the project was to develop a successful and sustainable CVC educational program for home health nurses in the community in order to standardize care and decrease community acquired bloodstream infections. Project: The program was originally designed and implemented by nurses on a gastroenterology unit and now it has expanded to include instructors from the vascular access team, hematology oncology and clinical nurse specialists from each discipline. All home health nurses providing care to pediatric patients in the region are welcome to attend the free class with educational hours offered. The class is structured with lecture time and skills practice through simulation. Results: Since the project began in 2011, 27 classes have been offered and 232 nurses have attended (72% RN/28% LVN) from 25 different home health companies in the region. Community acquired infection rates for the pediatric gastroenterology patient population has decreased by 36.3% since the class began. Hematology and oncology rates will be monitored in 2015 to coincide with the date they joined the program.
2015
Implications: This program can be designed and tailored for multiple patient populations with varying complexities and medical devices. Conclusions: An educational program targeting home health nurses in the community that care for complex patients with central venous catheters can decrease community acquired infection rates and complications.
Utilization of a New and Improved Dressing for Implanted Ports Jami DeNigris Background: Between 2012 and 2014, there have been 12 needlesticks related to implanted ports on a 47 bed Oncology Unit. Eleven out of the twelve needlesticks were related to de-accessing the Huber needles with ten related to the safety not retracting due to the dressing sticking to the top of the needle. The nurses were unable to safely utilize the safety mechanism put in place for the needle. Needlesticks can place healthcare workers at risk for diseases such as, hepatitis and HIV. Needlesticks also cost the hospital money with follow-up care for the employee. Purpose: To decrease needlesticks related to de-accessing Huber needles. Project or Case Description: Trial a new improved CHG dressing for implanted port needles with a non-adherent center that does not adhere to the Huber needles. The center of the dressing provides better skin protection and during the trial was also found to cause less skin irritation for the patient. The dressing is large enough to accommodate Huber needles and is removed effortlessly from the patient. Results: Over a 2 month trial of the product, no needlesticks were reported related to Huber needles. Implications: Needlestick injuries are a real patient and nurse safety concern. OSHA recommends the use of needle safety devices. Oncology patient skin is also at higher risk of adhesive-related skin trauma and skin irritation, and may benefit from a more gentle dressing. Any patient with an accessed Huber needles would have this dressing placed. The CHGgel antimicrobial component of this dressing may provide an added benefit to an immune suppressed patient population. Conclusions: Utilizing this improved CHG dressing for ports can affectedly decrease needle sticks related to Huber needles. Needlestick safety is crucial for the safety of nurses and the healthcare team. This trial also has shown to provide better skin protection and less irritation for the patient. The trial of this new dressing has proved its effectiveness.
Health Economic Impact of BIOPATCHÒ; Protective Disk in Peripheral Intravenous (IV) Catheters: A U.S. Hospital Perspective. Nicole Ferko Purpose/Design: Recent guidelines, such as the Center for Disease Control and Prevention, recommend replacing peripheral IV catheters when clinically indicated, instead of routine replacement. These guidelines may be met with resistance
due to perceived infection risk. This study assessed clinical and economic outcomes of using a chlorhexidine gluconate impregnated sponge dressing, BIOPATCHÒ Protective Disk, according to new peripheral IV replacement recommendations. Methods: A model was developed to predict 1-year outcomes with/without use of BIOPATCHÒ. With standard of care (i.e., no antimicrobial dressing), it was assumed catheters were replaced every 72 hours based on past guideline recommendations. With BIOPATCHÒ, catheters were replaced every 7 days according to its instructions for use. Inputs included patients admitted annually (400-bed hospital), proportion receiving peripheral IV, length of stay, nursing time/wages, catheter costs, BIOPATCHÒ cost, and number of attempts per successful IV start. Inputs were derived from literature and national averages where available. Sensitivity analyses (varying base-case inputs +20%) were conducted. Results: For an estimated 15,026 patients receiving a peripheral IV catheter in a 400-bed hospital, adoption of BIOPATCHÒ was predicted to avert 24,042 peripheral IV starts and 52,411 needle-sticks annually versus standard care. The analysis predicted that BIOPATCHÒ was associated with annual cost savings of $122,870 (sensitivity range: $75,427$170,314) when considering averted catheter supply costs. Further potential cost avoidance of $440,337 (sensitivity range: $352,269-$528,404) was predicted with BIOPATCHÒ for averted nursing time associated with less catheter replacements. Results were robust to sensitivity analyses. Limitations: These analyses were not based upon head-tohead clinical comparisons. Conclusion: This study suggests that integrating use of BIOPATCHÒ as part of a hospital’s adoption of clinically indicated replacement for peripheral IV can result in fewer invasive procedures, material cost savings and less nursing time. Findings are aligned with Affordable Care Act goals of improving patient experience and hospital efficiency.
A Collaborative Journey Towards Zero Catheter-Associated Bloodstream Infections Deborah Foss Background: Central Line Associated Bloodstream Infection (CLABSI) rates within our large emergency centered hospital were above the National Healthcare Safety Network (NHSN) benchmark reported despite using standard practice guidelines to prevent CLABSIs. Purpose: Review current practices and implement evidencebased process improvements to achieve a goal of zero CLABSIs. Project: The Infection Prevention Team worked collaboratively across disciplines and nursing units to decrease CLABSI. Comprehensive bundle was introduced in 2010 to reduce CLABSI rates from 3.3/1000 catheter days. Additional evidence-based practices were incrementally initiated to target zero infections throughout the next four years. Best practices included the use of a catheter securement device, nursing education with return demonstrations, and competency development to support standard protocols for central line dressing
2015
j
Vol 20 No 4
j
JAVA
j
259
extracted included: age, gender, number of attempts, difficulty, success and modality used to aid IV placement. Descriptive statistics and chi-square tests were used to analyze data. Results: Between February 4th, 2014 and March 17th, 2014 there were 1083 patient-nurse encounters reported for peripheral IV placement, totaling 1470 attempts. Forty-nine percent were female; mean age was 6 years (SD: 6.67, Range: 0 days-23 years). Ultimately, 939 (86.7%) had successful IV placement. Of those, 709 (75.5%) were placed on the first attempt, 184 (19.6%) on second attempt, 46 (4.9%) on third attempt. Visualization and/or palpation 49.3% of the time; infrared (AccuveinTM) device 40.5%; US 8.0%; trans-illumination 1.0%. For difficult access patients who ultimately had an IV placed, visualization and/or palpation was used 50.6% of the time; infrared device 38.8%; US 9.3%; trans-illumination 1.3%. US was used 117 times overall, and ultimately resulted in 71 (60.7%) successful IV placements. There was a significant difference in age versus overall successful IV placement (p < .001). Implications/Conclusions: Vascular team nurses use ultrasound infrequently for peripheral IV placement, including in children with difficult access. Methods to increase its skillful use in difficult access patients and improve successful IV placements should be explored.
Standardizing the Reporting of Central Line Tip Location Patti Dickinson Background: Interpretation of central line tip location varied greatly between radiologists and Vascular Access (VA) nurses, and among individual radiologists. Purpose: To standardize the reporting of tip location from radiologist to VA nurse, among VA nurses, and from VA nurse to Hospitalists and to community RNs. Project Description: We researched expert opinions on ideal tip location and methods of measuring using anatomical landmarks. We presented an extensive report at a meeting of VA nurses and radiologists. Results: It was agreed that radiologists would report tip location in centimeters below the carina, and the PICC would be adjusted to the ideal depth. VA nurses decided to set our target at 3cm below carina with patient upright to accomodate fluctuations in PICC depth due to patient position. Implications: Tip location reporting has become objective and measurable, consistent among radiologists and RNs. This applies to initial insertion CXR, and subsequent radiological procedures that include tip view. Conclusions: This has improved and simplified communication between departments and among ourselves, the VA nurses, for the benefit of the patients receiving our services.
Teaming Up to Take Down Community Acquired Bloodstream Infections Karie Falder
The Use of Ultrasound for Peripheral IV Placement By Vascular Team Nurses at a Tertiary Children’s Hospital Marsha Elkhunovich Background: Children receiving treatment in the hospital frequently require intravenous (IV) access, which can be painful and challenging. Many children’s hospitals have specialized vascular access nurses who use vein visualization devices, including ultrasound(US), to assist in peripheral IV placement. While there have been several studies that described the use and benefits of US guided IV placement, none have examined nurse US guided IV placement in children. Purpose: Our objectives were to describe the prevalence and success rate of US guided peripheral IV placement by vascular access team nurses at our institution in children of different ages. Project Description: We retrospectively reviewed quality assurance data kept by our institution’s vascular access team between February 4th, 2014 and March 17th, 2014. Data
258
j
JAVA
j
Vol 20 No 4
j
Background: Advances in medical technology have allowed pediatric patients to be discharged home with complex devices including central venous catheters (CVC). In order for these patients to be safely discharged, families are required to be trained to care for these catheters. At a large children’s hospital, extensive family education and training for CVCs was already established. However, the other caregivers in the home (home health nurses) were not receiving the same training. In an effort to target these caregivers, an educational program was designed and implemented in 2011. Purpose: The purpose of the project was to develop a successful and sustainable CVC educational program for home health nurses in the community in order to standardize care and decrease community acquired bloodstream infections. Project: The program was originally designed and implemented by nurses on a gastroenterology unit and now it has expanded to include instructors from the vascular access team, hematology oncology and clinical nurse specialists from each discipline. All home health nurses providing care to pediatric patients in the region are welcome to attend the free class with educational hours offered. The class is structured with lecture time and skills practice through simulation. Results: Since the project began in 2011, 27 classes have been offered and 232 nurses have attended (72% RN/28% LVN) from 25 different home health companies in the region. Community acquired infection rates for the pediatric gastroenterology patient population has decreased by 36.3% since the class began. Hematology and oncology rates will be monitored in 2015 to coincide with the date they joined the program.
2015
Implications: This program can be designed and tailored for multiple patient populations with varying complexities and medical devices. Conclusions: An educational program targeting home health nurses in the community that care for complex patients with central venous catheters can decrease community acquired infection rates and complications.
Utilization of a New and Improved Dressing for Implanted Ports Jami DeNigris Background: Between 2012 and 2014, there have been 12 needlesticks related to implanted ports on a 47 bed Oncology Unit. Eleven out of the twelve needlesticks were related to de-accessing the Huber needles with ten related to the safety not retracting due to the dressing sticking to the top of the needle. The nurses were unable to safely utilize the safety mechanism put in place for the needle. Needlesticks can place healthcare workers at risk for diseases such as, hepatitis and HIV. Needlesticks also cost the hospital money with follow-up care for the employee. Purpose: To decrease needlesticks related to de-accessing Huber needles. Project or Case Description: Trial a new improved CHG dressing for implanted port needles with a non-adherent center that does not adhere to the Huber needles. The center of the dressing provides better skin protection and during the trial was also found to cause less skin irritation for the patient. The dressing is large enough to accommodate Huber needles and is removed effortlessly from the patient. Results: Over a 2 month trial of the product, no needlesticks were reported related to Huber needles. Implications: Needlestick injuries are a real patient and nurse safety concern. OSHA recommends the use of needle safety devices. Oncology patient skin is also at higher risk of adhesive-related skin trauma and skin irritation, and may benefit from a more gentle dressing. Any patient with an accessed Huber needles would have this dressing placed. The CHGgel antimicrobial component of this dressing may provide an added benefit to an immune suppressed patient population. Conclusions: Utilizing this improved CHG dressing for ports can affectedly decrease needle sticks related to Huber needles. Needlestick safety is crucial for the safety of nurses and the healthcare team. This trial also has shown to provide better skin protection and less irritation for the patient. The trial of this new dressing has proved its effectiveness.
Health Economic Impact of BIOPATCHÒ; Protective Disk in Peripheral Intravenous (IV) Catheters: A U.S. Hospital Perspective. Nicole Ferko Purpose/Design: Recent guidelines, such as the Center for Disease Control and Prevention, recommend replacing peripheral IV catheters when clinically indicated, instead of routine replacement. These guidelines may be met with resistance
due to perceived infection risk. This study assessed clinical and economic outcomes of using a chlorhexidine gluconate impregnated sponge dressing, BIOPATCHÒ Protective Disk, according to new peripheral IV replacement recommendations. Methods: A model was developed to predict 1-year outcomes with/without use of BIOPATCHÒ. With standard of care (i.e., no antimicrobial dressing), it was assumed catheters were replaced every 72 hours based on past guideline recommendations. With BIOPATCHÒ, catheters were replaced every 7 days according to its instructions for use. Inputs included patients admitted annually (400-bed hospital), proportion receiving peripheral IV, length of stay, nursing time/wages, catheter costs, BIOPATCHÒ cost, and number of attempts per successful IV start. Inputs were derived from literature and national averages where available. Sensitivity analyses (varying base-case inputs +20%) were conducted. Results: For an estimated 15,026 patients receiving a peripheral IV catheter in a 400-bed hospital, adoption of BIOPATCHÒ was predicted to avert 24,042 peripheral IV starts and 52,411 needle-sticks annually versus standard care. The analysis predicted that BIOPATCHÒ was associated with annual cost savings of $122,870 (sensitivity range: $75,427$170,314) when considering averted catheter supply costs. Further potential cost avoidance of $440,337 (sensitivity range: $352,269-$528,404) was predicted with BIOPATCHÒ for averted nursing time associated with less catheter replacements. Results were robust to sensitivity analyses. Limitations: These analyses were not based upon head-tohead clinical comparisons. Conclusion: This study suggests that integrating use of BIOPATCHÒ as part of a hospital’s adoption of clinically indicated replacement for peripheral IV can result in fewer invasive procedures, material cost savings and less nursing time. Findings are aligned with Affordable Care Act goals of improving patient experience and hospital efficiency.
A Collaborative Journey Towards Zero Catheter-Associated Bloodstream Infections Deborah Foss Background: Central Line Associated Bloodstream Infection (CLABSI) rates within our large emergency centered hospital were above the National Healthcare Safety Network (NHSN) benchmark reported despite using standard practice guidelines to prevent CLABSIs. Purpose: Review current practices and implement evidencebased process improvements to achieve a goal of zero CLABSIs. Project: The Infection Prevention Team worked collaboratively across disciplines and nursing units to decrease CLABSI. Comprehensive bundle was introduced in 2010 to reduce CLABSI rates from 3.3/1000 catheter days. Additional evidence-based practices were incrementally initiated to target zero infections throughout the next four years. Best practices included the use of a catheter securement device, nursing education with return demonstrations, and competency development to support standard protocols for central line dressing
2015
j
Vol 20 No 4
j
JAVA
j
259