Nursing Practice Excellence: A Key to Infection Prevention


Carrie Sona, RN, MSN, CCRN, CCNS*
Barnes-Jewish Hospital
St. Louis, Missouri, USA

Lynn Schallom, RN, MSN, CCRN, CCNS**
Barnes-Jewish Hospital
St. Louis, Missouri, USA


The importance of sanitary conditions dates to Florence Nightingale (1820-1910), who helped link sanitation with healing, actions that led to sharply reduced death rates. (1) Nurses have been at the forefront of infection prevention ever since. Hospitals now face pressure from the public, media and regulatory agencies to eliminate hospital- acquired infections. Reimbursement changes from the Centers for Medicare and Medicaid Services (CMS) recently were instituted for many of these preventable complications. The Institute for Healthcare Improvement (IHI), the Agency for Healthcare Research and Quality (AHRQ) and others have assembled best practice care bundles for the prevention of central line-associated bloodstream infection (CLA-BSI), urinary tract infection (UTI), ventilator-associated pneumonia (VAP) and surgical site infection (SSI). Clostridium difficile-associated diarrhea, resistant organisms such as methicillin-resistant Staphylococcus aureus, multidrugresistant Acinetobacter, and vancomycin-resistant Enterococcus, all occurring with increasing frequency, provide additional challenges to critical care clinicians.

Preventing these infections has become the daily work of nurses in hospitals across the country, a role that is multifaceted. Nurses serve as gatekeepers for compliance related to hand hygiene protocols and contact precautions, including full-barrier precautions during the insertion of central venous catheters (CVC) and other sterile procedures. They must ensure proper skin preparation for CVC placement and stop insertions when sterility is breached. Nurses operate within the multiprofessional team to provide solutions that work on the unit level, to ensure a culture of excellence and to advocate for safe staffing levels. Nurses perform routine and outbreak surveillance for resistant organisms; they provide education on measures to decrease infections and implement best practice interventions crucial to improving patient outcomes. This article will focus on a few of the specific nursing contributions that have led to decreased CLA-BSI and VAP rates.

The Joint Commission 2009 Hospital Patient Safety Goals address the reduction of healthcare-associated infections and speak to CLA-BSI specifically. Most teams already have brought appropriate interventions to their hospitals. Research has shown that one of the best-known ways to prevent infection is to provide staff education. Education of all staff involved in the care of patients with CVCs has led to the reduction of CLA-BSI. (2-4) Staff must be familiar with best practices related to hand hygiene, site selection, skin preparation with chlorhexidine-based cleanser, the use of standardized kits, full sterile barrier precautions, catheter hub and injection port cleansing, and removal of the catheter after it is no longer medically necessary. These practices should be included in the orientation process and as an annual competency for nurses and physicians. In addition, nurses often assume administrative duties to ensure that all of the components included in the best practices are implemented. Nurses ensure that supplies are available, insertion carts are assembled to encourage proper technique, processes for the “scrub the hub” campaigns are in place and hand hygiene compliance is monitored. They engage in solutions that work on the unit level.

Monitoring compliance with these practices in many hospitals is accomplished through the use of a central line checklist. The use of a checklist has decreased the incidence of CLA-BSI, and The Joint Commission has included the use of a checklist in its safety goals. (3) These checklists are developed in collaborative teams. Nurses are responsible for securing them to carts or individual CVC kits, for monitoring sterile technique, for ensuring the checklist completion and for collating and disseminating data.

VAP is another hospital-acquired infection that institutions are working to eliminate. As with CLA-BSI, the educational and administrative duties are delegated to nurses, who must ensure compliance. Education also has been proven an effective intervention to decrease the incidence of VAP. (5) Staff should be familiar with the head of bed elevation protocols, ventilator circuit and secretion management, hand hygiene, daily wakeup breathing trials, early mobilization and sedation management. Nurses must be able to identify and manage patient risk factors.

One of these risk factors is colonization of the mouth, making oral care a priority. Nurse researchers have investigated the role of oral care in the prevention of VAP, (6-11) which has led to better understanding about why inconsistencies in practice occur and what technique, frequency and products are required for optimal oral hygiene.

Multiprofessional teams working in concert with physician leaders achieve the best results. (12-15) Successful process improvement teams boast open communication, offer clear goals, and establish systems to measure and share results with staff. Unit champions encourage ownership for change and engage bedside staff in the process. Teamwork and positive unit culture are crucial for successful interventions to eliminate hospital-acquired infections.

Lastly, inadequate nurse-to-patient ratios have been linked to increases in nosocomial infections. (16-17) Workload issues may affect compliance with sterile technique or hand hygiene; nurses may be less focused on practices to prevent complications, such as turning and gastric residual volume checks. (18)

Staff leaders, in roles such as nurse manager, clinical nurse specialist, infection control specialist or nurse practitioner, play an integral role in ensuring safe practices. They develop checklists, perform data collection and function as change agents. Without the contributions of these individuals and the work of the bedside nurse, many of the reductions in infection rates would not be possible. Nurses are vigilant advocates for patients and are the key to infection prevention in the intensive care unit.

References

1. Nightingale F. 1980.  Notes on Nursing: What It Is, and What It Is Not (1859). New York: Churchill Livingstone.

2. Coopersmith CM, et al. Effect of an education program on decreasing catheter-related bloodstream infections in the surgical intensive care unit. Crit Care Med. 2002;30:59-64.

3. Pronovost P, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J  Med. 2007;355:2725-2732.  

4.  The Joint Commission. 2009 National Patient Safety Goals Web site. http://www.jointcommission.org/patientsafety/nationalpatientsafetygoals. Accessed December 15, 2008.

5. Zack JE, et al. Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia. Crit Care Med. 2002;30:2407-2412.

6. Binkley CJ, et al. Survey of oral care practices in US intensive care units. Am J Infect Control. 2004;32:161-169.

7. Grap MJ, et al. Oral care interventions in critical care: frequency and documentation. Am J Crit Care. 2003;12:113-118.

8. Munro CL, et al. Oral health and care in the intensive care unit: state of the science. Am J Crit Care. 2004;13:25-33.

9.  Cutler CJ, et al. Improving oral care in patients receiving mechanical ventilation. Am J Crit Care. 2005;14:389-394.

10. Treloar DM, et al. Use of a clinical assessment tool for orally intubated patients. Am J Crit Care.1995;4:355-360.

11. Pearson LS. A comparison of the ability of foam swabs and toothbrushes to remove dental plaque: implications for nursing practice. J Adv Nurs. 1996;23:62-69.

12. Fox M. Toward a zero VAP rate:  personal and team approaches in the ICU.  Crit Care Nurs Q.  2006;2:108-116.  

13. Goeschel Ca, et al. Nursing lessons from the MHA keystone ICU project:  developing and implementing an innovative approach to patient safety. Crit Care Nurs Clin North Am. 2006;18:481-492.  

14. Harrigan S, et al.  Developing and implementing quality initiatives in the ICU:  strategies and outcomes. Crit Care Nurs Clin North Am. 2006;18:469-479. 

15. Jain M, et al.  Decline in ICU adverse events, nosocomial infections and cost through a quality improvement initiative focusing on teamwork and culture change. Qual Saf Health Care. 2006;15:235-239.

16. Archibald, et al.  Patient density, nurse-to-patient ratio and nosocomial infection risk in a pediatric cardiac intensive care unit. Pediatr Infect Dis J. 1997;16:1045-1048.

17. Needleman J, et al.  Nurse-staffing levels and the quality of care in hospitals. N Engl J Med. 2002;346:1715-1722.  

18. Metheny N, et al.  Gastric residual volume and aspiration in critically ill patients receiving gastric feedings. Am J Crit Care. 2008;17:512-519. 

Disclosures

*Author has no disclosures to report.

**Author has no disclosures to report.