Change in Practice: Preventing Hospital Associated Infections

April Shannon

Walden University

NURS 4000 Section 04, Research and Scholarship for Evidence-Based Practice

November 18, 2012

Change in Practice: Preventing Hospital Associated Infections
Benjamin Franklin was quoted as saying “an ounce of prevention is worth a pound of cure.” With the increasing costs of healthcare and the emergence of multi-drug resistant organisms this truth still resonates today. Hospital associated infections (HAIs), have been a complication in hospitals for many years. The purpose of this assignment is to address this problem in nursing practice, and discuss evidence on practices that will address this issue.
The problem
Hospital associated infections (HAIs) can be defined as an infection acquired in hospital by a patient who was admitted for a reason other than that infection. An infection occurring in a patient in a hospital or other healthcare facility in whom the infection was not present or incubating at the time of admission. This includes infections acquired in the hospital but appearing after discharge, and also occupational infections among staff of the facility (central line associated bloodstream infections, catheter associated urinary tract infections, surgical site infections, ventilator associated pneumonia, etc.) (World Health Organization, 2002). HAI’s have become one of the leading caused of hospital related deaths in the United States. However, these infections have been proven to be highly preventable.
Many initiatives have been launched in order to reduce the incidence of HAIs. At the facility in which I work, several projects and protocols have implemented in a attempt to reduce the patients’ as well as the staffs’ risk of acquiring an infection. Foam hand sanitizer dispensers have been installed inside and outside of each patient’s room. Electric paper towel dispensers have been at all sinks. Upon admission to the ICU each patient is swabbed for colonized methicillin-resistant Staphylococcus aureas (MRSA) in the nares, any open or draining wound is also cultured to identify any infectious organisms. Once a patient is identified as being positive for a multi-drug resistant or other infectious organism they are placed in isolation. The doors of patients who have been placed on any type of isolation precautions are clearly marked with colored signage, which instructs the type of personal protective equipment needed before entry, as well as what type of hand hygiene will be necessary upon departure. Volunteer surveyors walk around monitoring and recording data on hand hygiene habits upon entry and exiting patients’ rooms. During the nursing assessment each shift the nurse is required to document an appropriate cause for maintaining an indwelling urinary catheter or central venous catheter, as doctors are often unaware of the length of time these devices have been in place or if they continue to be necessary.
Although these are all great initiatives to aid in the reduction of HAIs, however, there is still work to be done. While we have seen a decrease in the number of HAIs we have been unable to reach our goals. Our current practices should be changed to empower nurses to discontinue urinary catheters without a doctor’s order to eliminate the incidence of prolonged or inappropriate use of the invasive device.
Recent statistics show that MRSA deaths surpass the mortalities related to AIDS (Kenneley, 2011). Another important change that should take place is my unit is that all patients should be immediately placed on contact isolation upon admission to the unit. To often patients have been cared for on our unit for a number of days before they we are aware of their infection with a multi-drug resistant organism. Most recently, the 2011 update to the Center for Medicare & Medicaid Services Hospital Inpatient Prospective Payment System rule included new reporting provisions for central line-associated bloodstream infections (CLABSI) in intensive care units and high-risk nurseries, as well as surgical site infections, which will affect future payment determinations (Christian, Classen, & Griffin, 2012).
Practice Change
Ensuring competence involves educational programs that highlight how transmission occurs. This empowers the workforce to apply this knowledge in preventing transmission (Kenneley, 2011). Education should not only include proper techniques and protocol but also in-depth information about the transmission of infectious organism. Nurses should be kept up to date on evidence-based practice regarding prevention as well as information regarding biofilms and proper equipment sanitizing techniques. Although education of proper insertion techniques for invasive devices, proper care and maintenance essential, education alone has not been proven to reduce HAIs over time.
Nurses stand at the forefront of this much needed change. It is imperative that they are included in the framework for prevention. Infection control departments and committees should be comprised largely of nurses who have not only been educated on the subject but who have also worked at the bedside and understands the plight of the bedside nurse. Infection prevention requires an interdisciplinary approach each healthcare entity must work together for the safety of the patient. Respiratory care should assist in the provision of optimal and frequent oral care of ventilated patients, and oral care should only be provided as often as clinically proven to bring about optimal patient outcomes. The use of procedural checklist to ensure adherence to infection prevention practices has proven to be effective. Initiatives such as “scrub the hub” referring to the requirement to sanitize the injection site of all central lines for at least 30 seconds before accessing the catheter have also proven to be effective. Another evidence-based change includes performing an infection risk assessment prior to performing an invasive procedure. Several research studies have been conducted in order to bring about these evidence-based changes.

Evidence supporting this change
As shown in a qualitative study, conducted at a hospital in southwest Florida, in which phenomenology was used, it is important to address the experiences and challenges faced by the nurses in order to optimize infection prevention practices. In this study fifteen full time medical surgical nurses participated in a 45-minute probing telephone interview, in which they discussed challenges such as time, native training, changing protocol and products, product related issues, patient compliance and interruptions, and care from other units or home. (Morrison, 2012) The information gathered was presented to the CLABSI committee at the institution and a plan was formed. Six months after implementation of the plan, based on the nurses’ lived experiences, the rate of infections dropped 64% (Morrison, 2012).
Ventilator associated pneumonia is another costly and difficult to prevent HAI. The use of chlorhexidine rinses and an oral care protocol have been implemented in many facilities. One quantitative, quasi-experimental pre-intervention -post-intervention study regarding its efficacy was conducted in a 247-bed acute care teaching hospital in Providence, Rhode Island. The sample consisted all patients admitted to any of its three critical care units and on mechanical ventilation at any time over the 18-month study period (Cuccio, et al., 2012). The hospital implemented an oral care protocol that called for a chlorhexidine 0.12% mount rinse, mechanical tooth brushing, and optimal oral care. Data was collected on the incidence of VAP for 6 months prior to implementing the intervention, and then 1 year post intervention. Oral care was provided every 6 hours, all staff was thoroughly trained on the new protocol, and products were tailored to meet the needs of the providers. Over the 1 year period following the intervention VAP rates decreased from 4.3 to 1.86 per 1000 ventilator days during the study period (Cuccio, et al., 2012).
Evaluating the Change
In order to evaluate the results of these changes, a committee of nurses will be formed in order to collect data regarding the incidence of HAIs. A quasi-experimental conducted before and after all interventions would be optimal. Nurses can record any signs or symptoms of infection daily, and thoroughly and accurately document interventions. Procedural checklists should be implemented in order to ensure that each procedure or intervention is carried per protocol. All healthcare associated infections should be recorded and graphed so that trends are clearly identified. Results should be posted where they are visible for all staff, and trends will be discussed in shift huddles and staff meetings.
Summary
In conclusion, healthcare associated infections continue to be a major issue and one of leading causes of death among hospitalized patients. These infections have been proven to be highly preventable and many initiatives and protocols have been implemented in order to decrease or eliminate their incidence. With proper education, an interdisciplinary approach, and the implementation of care bundles there has been great improvement, but there is still work to be done. Nurses must continue to advocate for and protect their patients, removed unnecessary invasive devices, and collaborate with interdisciplinary teams in order to achieve optimal patient outcomes.

Reference

Christian, G., Classen, D., & Griffin, F. (2012). Leadership best practices to prevent hospital-associated infections. Journal of Patient Safety , 8 (3), 144-148.

Cuccio, L., Cerullo, E., Paradis, H., Padula, C., Rivet, C., Steeves, S., et al. (2012). An evidence-based oral care protocol to decrease ventilator-associated pneumonia. Dimensions of Critical Care Nursing , 31 (5), 301-308.

Kenneley, I. (2011). Stopping HAIs at their source. The Nurse Practioner , 36 (9), 47-51.
Morrison, T. (2012). Qualitative analysis of central and midline care in the medical/surgical setting. Clinical Nurse Specialist , 26 (6), 323-328.

World Health Organization. (2002, December). Prevention of hospital-acquired infections: A practical guide.