By Anne Federwisch
Ever since her article on achieving zero catheter-related blood stream infections (CRBSIs) appeared in the Journal of the Association for Vascular Access (JAVA) in December 2007, Sophie Harnage, RN, BSN, has become very popular.
“I get calls and e-mails daily from everywhere throughout the country,” says the clinical manager of infusion therapy services at Sutter Roseville Medical Center (SRMC) in Roseville, Calif. “People asking me specific questions about the team, how many members, how long you’re there, what catheter do you use — many different types of questions.”
Her popularity is not surprising, due to the magnitude of the problem in terms of patient outcomes and financial costs, as well as the nationwide focus on hospital-acquired infections. The Centers for Disease Control and Prevention (CDC) estimates there are at least 250,000 cases of CRBSI annually, with an associated attributable mortality rate of 12% to 25%, and a cost of $25,000 to $56,000 per infection. Reducing CRBSIs was a target of the Institute for Healthcare Improvement’s (IHI) 100,000 Lives Campaign, which was underway when Harnage started building her bundle, and has been folded into the IHI’s updated 5 Million Lives Campaign.
Harnage’s bundle builds on best practice models from around the country, CDC and IHI recommendations, an extensive literature review, and new product technology. In her JAVA article, she cites the specific rationale for each particular practice in her bundle, which varies for each of the seven steps.
Other practitioners’ intense interest also stems from the facility’s impressive results. Before SRMC developed the bundled practices, the hospital recorded 11 CRBSIs in 2005. However, in the two years since implementation, there have been no infections on any of the more than 4,000 PICC lines that have been inserted using the sequence of seven practices (see sidebar).
Notably, during the 15-month period of time chronicled by Harnage’s article, PICC insertions increased by 103%, while interventional radiology referrals decreased to less than 2%. Patients are sent to interventional radiology if an anatomical blockage prevents the nurse from threading the catheter completely through, because a radiologist can bypass the blockage. “I don’t know what the industry standard is, but I wouldn’t be surprised if it’s 30% in other areas,” says Deborah Dix, RN, MS, director of cancer services at SRMC.
What’s the secret?
And their success can be replicated, Harnage notes. “It’s not rocket science,” she says frequently.
The key to success is the use of a specially trained team of nurses to insert PICCs, instead of other non-tunneled central venous catheters, using the bundle and following up on the patients throughout their stay. Team members must complete a course on ultrasound-guided PICC insertion; demonstrate competencies in understanding the anatomy of the veins and chest; commit to using ultrasound-guided technique in all insertions, rather than falling back on a previously learned technique; and religiously follow the bundle. “It’s self-fulfilling,” Harnage says. “The team [members have] generated a tremendous level of confidence in their [own] abilities. Thereby, they insert a tremendous number of PICCs, which results in consistent, repeated, reliable results, which increases the confidence in their skills.”
The first step is locating the basilic vein in the upper arm using ultrasound. Evidence has shown that the bacteria counts are much less on the upper arm versus subclavian, jugular, or femoral insertion points, she notes.
Nurses use full-barrier precautions during the procedure. “The insertion process is something like you would see in an OR,” Dix says. “The patient is covered. The nurse is covered. The skin is prepped just like it would be before an incision. They don’t let people wander in and out while they’re doing it. When we use the term ‘maximum barrier precautions,’ that’s the level of scrutiny that’s being applied.”
Next in the sequence is the central line dressing kit, which was revised to include a two-step cleansing and disinfecting process, a chlorhexidine gluconate impregnated foam disk, and a stabilization device.
The facility decided to change its connector system for the subsequent step in the process. “We chose a neutral system needle-less connector because you don’t have to worry about clamping,” Harnage says. While it’s not magic, its ease of use helps prevent problems “if you correctly flush your line and take care of your line,” she says.
The smooth septum of this new connector also facilitates the next practice — IV connector septum disinfection. “You’re not dealing with crevices in the grooves,” she says. The protocol calls for a vigorous, back-and-forth scrubbing of the connector with an alcohol pad for 5 to 10 seconds.
The flushing protocol comes next. The nurses flush implanted ports and dialysis catheters with heparin, but all other central lines are flushed with normal saline. The team members conduct an inservice for the rest of the nursing staff on proper technique. “We are really on top of the educational piece to maintain these lines,” Harnage says.
The final — and essential — practice involves diligent monitoring of the lines by the team.
“I think the big message is, you can’t just be a PICC-stick-and-run team,” Harnage emphasizes. “You can’t just insert the line and never see it again. I think that’s where you lose the consistency and the reliability.”