Preventing medical adhesive-related skin injury (MARSI).

Medical adhesive-related skin injury (MARSI) is an overlooked and underestimated problem. While awareness of this issue is growing, it is not fully understood by health professionals in a variety of clinical settings. Medical adhesive products are often applied and removed incorrectly, which, albeit unintentionally, causes skin damage. In many cases, MARSI should be considered a preventable injury. Organisations should have processes in place to educate health professionals in acute and community facilities in preventing MARSI; these processes should include the use of products that help to prevent these injuries, including medical adhesive removers. This article will explore this topic and relate it to the most recent consensus document.

Medical adhesive-related skin injuries associated with vascular access.

Establishing vascular access and preventing infection, both at insertion and during ongoing care is generally the top priority; the maintenance of optimal skin integrity is often a distant secondary consideration. Skin can react to different types of dressings or adhesives, or problems can arise relating to the securement of lines or the development of sensitivities to cleaning solutions. Clearly, these scenarios are not limited to the securement of vascular access devices; however, a patient with a long-term vascular access device may not have other options for vascular access, which makes this a very important and yet largely unrecognised area. A review of the limited literature that existed up to March 2015 showed it was typically concerned with skin tears connected with dressings and removal, and contact irritant dermatitis. The tissue viability team and vascular access team reviewed the current products associated with a typical vascular access dressing to ensure it was fit for purpose and where at all possible had good scientific literature for validation. The team worked proactively to recognise those patients at risk with the early identification of potential medical adhesive-related skin injuries (MARSI). To facilitate this an algorithm was developed that offers a step-by-step approach, clearly outlining what to do to prevent MARSI and its treatment should it develop. These reactions can result from other factors than the dressing alone, and an increase in these kinds of skin reaction in patients who are on chemotherapy regimens is being explored further. Through the implementation of an algorithm, education for both staff and patients and collaborative working between vascular access and tissue viability teams, a reduction in these phenomena has been seen despite an increasing number of at-risk patients.

Preventing intraluminal occlusion in peripherally inserted central catheters.

Peripherally inserted central catheters (PICCs) are used in a variety of specialties. Infective and thrombotic complications are widely reported but little has been written about the complications of persistent withdrawal occlusion (PWO) or complete luminal occlusion in PICCs. An audit was conducted of all patients who had a PICC in situ for a 6-week period, using a combination of reviewing clinical documentation and local departmental databases, physical review of inpatients and discussion with the relevant clinical nurse specialists in haematology, oncology, outpatient antibiotic therapy and the vascular access team, to determine the degree of PWO or occlusion but also to review possible financial implications in the introduction of a more expensive product. It was difficult to determine a rate for either PWO or complete occlusion owing to the diversity of the patient cohort and the tertiary nature of the organisation; the occlusion rate was estimated at 5%, but there was general agreement this was underestimating the problem. A needle-free connector was subsequently introduced for all PICCs in haematology, oncology and hepatobiliary services. Following the change in needle-free connector, 180 PICCs were inserted by the vascular access team on one of the organisation's sites over a 12-month period, with a total dwell time of 9702 catheter days (mean: 53.9 days, median: 35 days), a PWO rate of 1/1000 catheter days and total occlusion rate of 0.4/1000 catheter days. The time for insertion to complication of PWO or occlusion ranged from 9 to 144 days. Despite poor baseline data the results suggested the introduction of the bi-directional needle-less connector had a positive impact on the PWO and occlusion rates in PICCs.

Effective strategies for reducing the incidence of catheter-related bloodstream infections.

Various prevalence surveys have revealed high rates of catheter-related bloodstream infection, which can cause patients so much harm and are expensive to treat. Yet most of these infections can be prevented with good practice. To this end, national guidelines and initiatives have been introduced outlining the procedures that will reduce infection rates. However, it is easy to be overwhelmed by the sheer number of recommendations. Care bundles were therefore created to identify the core group of procedures that must be adhered to in order to reduce infection rates. As a result, they have made it easier for health professionals to implement evidence-based practice. This article describes the care-bundle approach and how it has reduced infection rates. It also describes the latest recommendations on best practice, recently published in epic3, and outlines the issues staff and NHS organisations are likely to face when implementing them.

Implementation of nursing grand rounds at a large acute hospital trust.

This article outlines the implementation of nursing grand rounds (NGRs) in one of the largest NHS teaching hospitals in the UK, to share clinical and professional expertise in providing quality and evidence-based care to registered nurses and allied health professionals. A pilot was successfully trialled on one hospital site for 3 months, which was then rolled out across the organization. The objectives of the programme encouraged participation from clinical nurse specialist colleagues to promote their role and present their work, including evidenced-based care, service improvement and research. A variety of multidisciplinary team members attended and highly evaluated the 3-month pilot NGRs. The criticism of having an inappropriately sized venue was addressed, and this coupled with offering food before lectures has encouraged greater participation and networking.

Establishment of an outpatient and home parenteral antimicrobial therapy service at a London teaching hospital: a case series.

BACKGROUND: Outpatient and home parenteral antimicrobial therapy (OHPAT) is becoming increasingly commonplace in the UK, enabling those patients who would previously have been obliged to remain in hospital for intravenous treatment to be managed as outpatients or in their own homes. The OHPAT service at St Mary's Hospital, London, was established in 2004. This paper describes the types of infection, antimicrobial management and outcomes of patients referred to the service in the 3.5 years since its inception. PATIENTS AND METHODS: All inpatients were eligible for OHPAT, provided that they had a serious infection requiring parenteral therapy, were well enough to leave hospital and fulfilled other criteria. We initially used an outpatient clinic model, but as the service developed, treatment was often delivered in patients' homes, with the OHPAT team providing training and assessment of primary care staff. RESULTS: Four hundred and sixty-seven patients were referred to the service between September 2004 and April 2008. Of these, 273 received 303 courses of OHPAT, 48 were discharged on oral therapy and 3 patients declined outpatient therapy; the remaining 143 patients were deemed unsuitable for inclusion, most commonly because the patient was too unwell for discharge (28.7%) or their social situation was inappropriate (14.7%). Causative organisms were identified in two-thirds of cases, with methicillin-resistant Staphylococcus aureus implicated in one-third of these. Mean treatment length was 24 days (range 1-165 days), with 7394 inpatient bed-days saved. Less than 5% of patients were readmitted within 28 days with infection- or drug-related problems. There were no cases of Clostridium difficile-associated diarrhoea during or after outpatient treatment, despite extensive use of cephalosporins and other broad-spectrum agents. Patients found the service highly satisfactory and felt that it had improved their quality of life during the treatment period. CONCLUSIONS: The introduction of the OHPAT service at St Mary's Hospital has proved to be of benefit to patients and hospital efficiency alike.