Clinical Nurse Specialist Practice: Impact on Emergency Department Blood Culture Contamination.

PURPOSE/OBJECTIVES: Blood culture collection is a common procedure performed in emergency departments. Rate of blood culture contamination is a metric that is tracked by organizations to ensure appropriate treatment for patients suspected of having bacteremia and ensure appropriate use of hospital resources. A team of nurses and technicians undertook a quality improvement project to decrease blood culture contamination rates in a suburban emergency department. DESCRIPTION OF THE PROJECT: The project included use of standardized blood culture collection kits, creation of a dedicated collection team, and implementation of a new blood culture collection device. OUTCOME: Through this work, blood culture contamination rates decreased from greater than 3.0% to less than 1.5% consistently for nearly 24 months. CONCLUSIONS: Providing feedback and continued monitoring has made this quality improvement initiative a success for the department and the organization and has resulted in cost savings of nearly 2 million dollars.

Enhanced infection control interventions reduced catheter-related bloodstream infections in the neonatal department of Hung Vuong Hospital, Vietnam, 2011-2012: a pre- and post-intervention study.

Background: Catheter-related bloodstream infections (CR-BSI) cause high neonatal mortality and are related to inadequate aseptic technique during the care and maintenance of a catheter. The incidence of CR-BSI among neonates in Hung Vuong Hospital was higher than that of other neonatal care centres in Vietnam. Methods: An 18-month pre- and post-intervention study was conducted over three 6-month periods to evaluate the effectiveness of the intervention for CR-BSI and to identify risk factors associated with CR-BSI. During the intervention period, we trained all nurses in the Department of Neonatology on BSI preventive practices, provided auditing and feedback about aseptic technique during catheter care and maintenance, and reorganised preparation of total parenteral nutrition. All neonates with intravenous catheter insertion ≥48 h in the pre- and post-intervention period were enrolled. A standardised questionnaire was used to collect data. Blood samples were collected for cultures. We used Poisson regression to calculate rate ratio (RR) and 95% confidence interval (CI) for CR-BSI incidence rates and logistic regression to identify risk factors associated with CR-BSI. Results: Of 2225 neonates enrolled, 1027 were enrolled in the pre-intervention period, of which 53 CR-BSI cases occurred in 8399 catheter-days, and 1198 were enrolled in the post-intervention period, of which 32 CR-BSI cases occurred in 8324 catheter-days. Incidence rates of CR-BSI significantly decreased after the intervention (RR = 0.61, 95% CI 0.39-0.94). Days of hospitalisation, episodes of non-catheter-related hospital-acquired infections, and the proportion of deaths significantly decreased after the intervention (p < 0.01). The CR-BSI was associated with days of intravenous catheter (odds ratio [OR] = 1.05, 95% CI 1.03-1.08), use of endotracheal intubation (OR = 2.27, 95% CI 1.27-4.06), and intravenous injection (OR = 8.50, 95% CI 1.14-63.4). Conclusions: The interventions significantly decreased the incidence rate of CR-BSI. Regular refresher training and auditing and feedback about aseptic technique during care and maintenance of catheters are critical to reducing CR-BSI.

The value of the infection prevention and control nurse led MRSA ward round.

Meticillin-resistant S. aureus (MRSA) is prevalent in most parts of the world. The study took place at Queen Elizabeth Hospital Birmingham (QEHB) a UK tertiary referral hospital. At QEHB innovative nurse led daily ward rounds for patients that acquire hospital acquired MRSA during their hospital stay are undertaken. The aim is to optimise care delivered for these patients whilst at QEHB, thereby reducing the risk of infection in patients with healthcare-acquired MRSA. A segmented Poisson regression model suggests that the MRSA bacteraemia rate was affected where an 88.94% reduction (p = 0.0561) in bacteraemias was seen by the introduction of these ward rounds. We describe a nurse led MRSA ward round which was associated with a lower rate of MRSA bacteraemias.

[Nursing sensitive outcomes and staffing: a review on healthcare associated infection]. / Esiti sensibili alle cure infermieristiche e staffing:le infezioni correlate all'assistenza.Revisione della letteratura.

. Nursing sensitive outcomes and staffing: a review on healthcare associated infection. INTRODUCTION: Healthcare associated infections (HAI) continue to be an unresolved problem in hospital settings. AIM: To assess the relationship between nurse staffing and healthcare associated infections in different settings. METHODS: From April to May 2015 a review of literature was conducted consulting PubMed, CINAHL and Cochrane Library. RESULTS: An increased amount of Registered Nurse Hours Per Patient Day (RNHPPD) and nurse-to-patient ratio was associated to a decreased occurrence of HAI. In particular an increase of RNHPPD was associated to a reduction of postoperative (OR 0.83, IC95% 0.0.70-0.99), and ventilator-associated pneumonia (OR 0.21, IC95% 0.08-0.53). Even the number of urinary tract infections (-34%) and sepsis (OR 0.54, IC95%: 0.31-0.92) decreased significantly. The most significant results associated to an increase of HPPD were obtained in intensive care units. CONCLUSIONS: The review showed the correlations between nurse staffing and the most frequent HAIs. Nursing managers should be aware of the adequate nurse-to-patient ratios and skill-mix in order to inform decision making and improve the quality and safety of patients care.

Meningitis: Know the Symptoms.

This app is intended to be a reference resource for the symptoms of meningitis and septicaemia.

CLABSI Reduction Strategy: A Systematic Central Line Quality Improvement Initiative Integrating Line-Rounding Principles and a Team Approach.

BACKGROUND: Central line-associated bloodstream infections (CLABSIs) are the most common hospital-acquired infections costing hospitals millions of dollars annually. An evidence-based practice literature review revealed that utilizing a systematic team approach for proper line maintenance is effective in reducing CLABSI rates. PURPOSE: The purpose of this quality improvement initiative was to reduce the CLABSI rate in the neonatal intensive care unit from 3.9 per 1000 line days in 2011 by at least 50% in 2014. Policies, protocols, team members utilized, competencies, and techniques were created and a formal line-rounding and dressing change competency was established. The competency included specific criteria for performing daily line rounds and a 2-person sterile technique for dressing changes. FINDINGS/RESULTS: Central line-associated bloodstream infection rate was effectively reduced from 3.9 in 2011 to 0.3 per 1000 line days in 2014, with an overall 92% improvement. IMPLICATIONS FOR PRACTICE: Introduction of a dedicated CLABSI team has been shown to be effective in the reduction of CLABSI rates in the neonatal intensive care unit. IMPLICATIONS FOR RESEARCH: Further research is needed to evaluate how a team approach could be used to reduce other hospital-acquired conditions; catheter-associated urinary tract infection, and hospital-acquired pressure ulcers.

Magnet® Hospital Recognition Linked to Lower Central Line-Associated Bloodstream Infection Rates.

Central-line-associated bloodstream infections (CLABSI) are among the deadliest heathcare-associated infections, with an estimated 12-25% mortality rate. In 2014, the Centers for Medicare and Medicaid Services (CMS) began to penalize hospitals for poor performance with respect to selected hospital-acquired conditions, including CLABSI. A structural factor associated with high-quality nursing care and better patient outcomes is The Magnet Recognition Program®. The purpose of this study was to explore the relationship between Magnet status and hospital CLABSI rates. We used propensity score matching to match Magnet and non-Magnet hospitals with similar hospital characteristics. In a matched sample of 291 Magnet hospitals and 291 non-Magnet hospitals, logistic regression models were used to examine whether there was a link between Magnet status and CLABSI rates. Both before and after matching, Magnet hospital status was associated with better (lower than the national average) CLABSI rates (OR = 1.60, 95%CI: 1.10, 2.33 after matching). While established programs such as Magnet recognition are consistently correlated with high-quality nursing work environments and positive patient outcomes, additional research is needed to determine whether Magnet designation produces positive patient outcomes or rewards existing excellence.

[The impact of closed system and 7 days intravascular administration set replacement on catheter related infections in a general intensive care unit: a before-after study]. / Efficacia della linea chiusa e sostituzione delle linee infusionali ogni 7 giorni sulle infezioni da catetere vascolare in una terapia intensiva polivalente: studio pre-post.

INTRODUCTION: The incidence of catheter related Bloodstream infections (BSI) is high in intensive care units (ICU). AIM: To evaluate the BSI rate in a population of patients admitted to a General ICU before and after the implementation of the 2011 CDC guidelines. METHODS: Retrospective observational study on patients admitted from January 2009 to December 2013. The infusion and monitoring lines were changed every 96 hours for the first 30 months, and every 7 days for the next 30. In all patients a closed infusion line with needle-free connectors pressure was used (Microclave). The following catheters were considered in the study: central venous catheter (CVC), arterial cannula (ART) and Swan Ganz catheter (SG). RESULTS: During the period with change every 96 hours 15 BSI were observed over 13395 catheters/days (C/D), 1.12 per 1000 C/D, while when lines where changed every 7 days 11 BSI were observed over 13120 C/D, 0.83 per 1000 C/D. A statistically significant reduction of BSI was observed in SG catheters (4.17 vs. no BSI p = 0.02), while the CVCS (1.12 vs 1.45 - p = 0.37) and ART (0.35 vs 0.36 - p = 0.61) infection rates remained unchanged. CONCLUSIONS: The replacement of infusion lines every 7 days in our sample did not increase the BSI, helping to reduce the costs.

Epidemiology and outcomes of bloodstream infections in patients discharged from the emergency department.

OBJECTIVE: To determine the outcomes of patients discharged from the emergency department (ED) with a bloodstream infection (BSI) and how these outcomes are influenced by antibiotic treatment. METHOD: We identified every BSI in adult patients discharged from our ED to the community between July 1, 2002, and March 31, 2011. The medical records of all cases were reviewed to determine antibiotic treatment in the ED and at discharge. Microorganism sensitivities were used to determine whether antibiotics were appropriate. These data were linked to population-based administrative data to determine specific patient outcomes within the subsequent 2-week period: death, urgent hospitalization, or an unplanned return to the ED. RESULTS: A total of 480 adults with BSI were identified (1.49 cases per 1,000 adults discharged from the department). Compared to controls (321,048 patients), BSI patients had a significantly higher risk of urgent hospitalization (adjusted OR 2.1 [95% CI 1.6-2.8]) and unplanned return to the ED (adjusted OR 4.1 [95% CI 3.3-4.9]). Outcome risk was significantly lowered in BSI patients who received appropriate antibiotics in the ED and at discharge. In elderly patients, the risk of urgent hospitalization increased significantly as the time to appropriate antibiotics was delayed. CONCLUSIONS: BSI patients discharged from the ED have a significantly increased risk of urgent hospitalization and unplanned return to the ED in the subsequent 2 weeks. These risks decrease significantly with the timely provision of appropriate antibiotics. Our results support the aggressive use of measures ensuring that such patients receive appropriate antibiotics as soon as possible.

[The effect of bundle care on central line associated bloodstream infection in a medical intensive care unit].

BACKGROUND & PROBLEMS: While the central line catheter is a common device used in intensive medical care, it is a frequent source of nosocomial infection. The central line associated bloodstream infection (CLABSI) rate at our medical ICU had increased steadily, with an average rate between January and May 2011 of .47%. We used a cross-team approach to implement bundle care as a strategy to reduce the CLABSI rate. PURPOSE: We designed a project to reduce the CLABSI rate below .3% in our ICU. RESOLUTION: This project was conducted between June 2011 and May 2012. Our strategy included providing a sterile towel, implementing maximal barrier precautions (head to toe), designing an illustration explaining how to use 2% CHG, establishing a procedures and care checklist, implementing quality assurance for procedures and care, and providing education on bundle care. RESULTS: The CLABSI rate reduced to .24% after project implementation. This result was below the target of .30%. CONCLUSIONS: We want to share this experience to help other hospitals and units improve critical care quality and to continue working to achieve a zero-tolerance infection rate.

Improving outcomes for patients receiving transarterial chemoembolization for hepatocellular carcinoma.

Hepatocellular carcinoma is a cancer with increasing incidence in the veteran population. This type of cancer can be treated with transarterial chemoembolization, an invasive procedure performed by specially trained interventional radiologists. The most common serious complications are liver failure, sepsis secondary to ischemic cholecystitis or liver abscess, gastrointestinal bleeding, and death. However, nursing staff and physicians often have little or no experience in caring for patients in the hospital who have had this procedure. Patient safety can be threatened by this lack of knowledge. Sources of threat to patient safety are described by the Institute of Medicine as falling into 4 categories: management, workforce, work processes, and organizational culture. To promote patient safety, defenses need to be deployed to address each category. In this article, the author provides a case example, describes threats to the patient's safety, and describes a plan to improve the care of all patients undergoing this procedure.

Developing blood borne virus services across prisons in Wales, UK.

PURPOSE: This paper aims to describe the strategies being put in place to develop blood borne virus (BBV) services across prisons in Wales, UK, in response to the recommendations for prisons within the Welsh Government's Blood Borne Viral Hepatitis Action Plan for Wales. DESIGN/METHODOLOGY/APPROACH: A task and finish group was established to ensure multidisciplinary engagement between healthcare and custody staff. A service improvement package was developed focusing on awareness raising and/or development of clinical services for prisoners, prison officers and prison healthcare staff. FINDINGS: Prison healthcare staff have undergone training in BBVs and are being supported to deliver clinical services to prisoners. Training has been delivered in pre/post test discussion and dried blood spot testing; care pathways have been established between prison and community specialists for treatment referrals. An e-learning module is being rolled out to raise awareness amongst custody staff and encourage occupational hepatitis B vaccination. Literature on "liver health" has been produced to be given to every prisoner across Wales. SOCIAL IMPLICATIONS: It is envisaged that BBV services will become a routine part of prison care in Wales. Data on activity are being collected for evaluation and it is hoped that tackling BBVs in prisons will help reduce rates of infection both within prisons and in the wider community. ORIGINALITY/VALUE: This paper describes new initiatives that have been established to tackle BBVs across Welsh prisons and will be relevant to any prison healthcare staff looking to develop similar services.

Use of a 1-piece chlorhexidine gluconate transparent dressing on critically ill patients.

BACKGROUND: New transparent dressings with chlorhexidine gluconate in the dressing are available. OBJECTIVES: To compare the effectiveness of a new 1-piece occlusive dressing that incorporates chlorhexidine gluconate with that of a dressing plus a chlorhexidine gluconate patch in maintaining the low rate of catheter-related bloodstream infections in the intensive care unit and to evaluate nurses' satisfaction with and cost of the new dressing. METHODS: A quality improvement observational study was done in an adult medical-surgical intensive care unit. All patients with a central venous catheter had initial and/or subsequent dressing changes done with the new dressing. The central catheter bundle elements of the Institute for Healthcare Improvement were followed. Patients were monitored for catheter-related bloodstream infections, and the rate of infection was calculated. RESULTS: During the study period of 1881 device days, the infection rate was 0.051 per 1000 device days, compared with a rate of 0.052 in 2008. Nurses preferred the new dressing. Cost savings were $3807. CONCLUSION: A low rate of catheter-related bloodstream infections can be maintained, nurses' satisfaction achieved, and cost savings realized with the new dressing.

Utilizing a line maintenance team to reduce central-line-associated bloodstream infections in a neonatal intensive care unit.

OBJECTIVE: To determine the association of a central-line maintenance team on the incidence of central-line-associated bloodstream infections (CLABSIs) in the neonatal intensive care unit (NICU). STUDY DESIGN: Central line maintenance in the NICU was limited to a line team starting in March 2008. CLABSI rates were determined before (December 2006 to February 2008) and after implementation of the line team ( March 2008 to August 2010) utilizing consistent National Healthcare Safety Network definitions. Rates were calculated by birth weight categories and overall. Data analysis was performed by two-proportion t test using Minitab. RESULT: Overall CLABSI decreased by 65% after implementation of the line team. Pre intervention, mean overall CLABSI rate was 11.6 /1000, as compared with 4.0/1000 after intervention (P<0.001). Birth-weight-specific CLABSI rates also decreased significantly. Decreased infection rates were sustained over time. CONCLUSION: A line team provided for standardized, consistent central-line maintenance care leading to a significant, sustained decrease in CLABSI in a NICU.

Prevention of central venous catheter-related infection: update.

Central venous catheters (CVCs) are an essential part of modern-day healthcare, but infections associated with these devices continue to cause significant morbidity and mortality. There are many approaches for the prevention of CVC-related infection and these are outlined in national guidelines. The Department of Health Saving Lives campaign has developed a care-bundle for the prevention of CVC-related infections that focuses on the fundamental actions to be undertaken during the catheter insertion process and ongoing care. If the rate of catheter-related infection remains high despite the implementation of these infection prevention strategies, the use of novel antimicrobial technologies and practices may be considered. These include CVCs that contain antimicrobial agents, such as antiseptics or antibiotics, needleless intravenous (IV) access devices coated with silver and/or chlorhexidine, IV dressings incorporating chlorhexidine, and the use of antimicrobial catheter lock solutions, such as antibiotics, chelators or ethanol. This article outlines the different types of CVCs available, the risk of infection associated with their use and established and novel measures for prevention of these infections.