Learning Objective #1: Identify the association between nursing IV practice and the rates of catheter related bloodstream infections (CRBSI)

Learning Objective #2: Discuss four evidence-based IV practices that can impact the quality of patient care through the reduction of catheter related bloodstream infections (CRBSI)

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BACKGROUND/OBJECTIVES Intravenous catheters are a fundamental adjunct to patient care. They provide vascular access for hemodynamic monitoring and the delivery of fluids and medications and although necessary and widely used, their use puts patients at risk for local and systemic infectious complications (O'Grady, Alexander, Patchen Dellinger, Gerberding, Heard, & Maki, 2002). The rates of IV bloodstream infections (BSI) at our acute care facility greatly exceeded the National Nosocomial Infections Surveillance System (NNIS) and Center for Disease Control (CDC) pooled means for CR-BSI. A program was therefore designed to determine the best evidence based practices for the prevention of catheter-related bloodstream infections and to implement the best practices beyond the basic principles of asepsis and sterile technique that nurses can endorse, which strongly impact the quality and economic aspects of health care (Penne, 2002). The objective was to improve the quality and standard of care for patients receiving intravenous (IV) Therapy in the hospital setting through a reduction in the rates of IV associated infections. Incorporated into the program was a study designed to assess our current IV practices, improve those practices, and to measure the effects of the practices on infection rates. METHODS An extensive literature review was conducted to determine the best IV practices for the prevention of catheter-related bloodstream infections and an assessment for their applicability in our hospital setting. The CDCynergy model was the theoretical framework selected for the program and study. This is a model developed by the Centers for Disease Control and relies on the utilization of epidemiologic data to identify and analyze a health problem and to design a successful intervention and management process (McKenzie & Smeltzer, 2001). The study design is a quality improvement approach (Penne, 2002) using a time series design with a non-randomized, non-control, quantitative, comparison study of before and after interventional IV infection rates. The planned strategy was an educational program designed and incorporated to improve infection control and IV practice and management and targeted to all clinicians and practitioners who insert or manage IVs. Utilization of the model for transforming research findings into clinical practice emphasized evidence-based IV therapy policy and procedure revisions, an organizational commitment, and change agents and processes (education). The education curriculum included a one hour review of the revised policy and practice changes which were revised to reflect evidence-based practices, and a review of the prior year's catheter related infection rates presented in a graph format. The second hour included a one hour practicum of IV insertion and maintenance with return demonstration. Outcome measures were a reduction in catheter-related infections rates and staff compliance with practice standards. The evaluation methodology employed before and after interventional auditing to measure current practice and the simultaneous surveillance and comparison of infection rates. The same methods and tools for data collection and analysis were used pre and post-intervention. RESULTS/ CONCLUSIONS Descriptive statistics with frequencies and percentages were utilized to express the aggregate and unit-specific rates of overall compliance with the policy and with practice standards. The CDC and NNIS surveillance definitions of catheter-related bloodstream infection and IV site infection were selected as inclusion criteria for this study. The results revealed improved compliance for all indicators post-interventionally. The baseline rate of CR-BSI exceeded the 90th percentile for the CDC mean of 3.9 infections/1000 central catheter days for all intensive care units. The rates of CR-BSI decreased to at or below the NNIS and CDC pooled means after the study was initiated but prior to implementation of the interventions which was initially attributed to the Hawthorne effect but the sustained rate of infection below the 25th percentile was attributed to program implementation and success. The rates for local IV site infection decreased from 0.9 infections/1000 patient days pre-intervention to 0.3 infections/1000 patient days post-intervention and have been sustained at that level for consecutive quarters. Benchmarks for this parameter do not exist but internal trending of the data helps the organization measure performance over time. An incidental finding from the study was the associated relationship manifested between nurse technician practice while performing venipuncture and the rates of IV infections and the rates of needlestick injuries in that group. The program was therefore made more comprehensive by examining the impact of education and improved practice on reduced rates of needlestick injuries. Staff compliance with the IV policy and practice standards improved for all indicators post-interventionally. The effect of increased staff compliance and proficiency with IV insertion and management was associated with the sustained improvement in the rates of IV associated infections. Applying the CDCynergy model to identify a problem of epidemiological significance and plan a communication-based implementation program was strongly associated with a decreased risk of infection to our patients. Improved staff compliance with policy and technique were attributed to the interventional program since the impact of the program on the rates of IV infection was ultimately evaluated and four of five requirements of causal inference were satisfied: (a) a theoretical basis for the expected relationship existed as defined by the program's theory, (b) the program preceded the outcome in time, (c) a statistically significant association existed between the program and the outcome, and (d) the outcome measures were reliable and valid. The 5th requirement (other explanations were ruled out) could not be assumed as many patient variables could not be calculated (Grembowski, 2001). LESSONS LEARNED Employing established, epidemiologically-based standards for IV rate calculation allowed the organization to evaluate performance against national benchmarks involve staff in setting goals and measuring progress to improve performance. Our organization-wide approach, involvement of staff and information dissemination concerning rates of infection and practice compliance improved performance and standardized practice by eliminating variation and ensuring engagement of the stakeholders. The results of the study, implementation of the program and the presumed impact on infection rates may succeed in other settings and could serve as an epidemiologically-based template for research utililzation and implementation of evidence-based practice to improve the quality of practice and patient care in the hospital setting.