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Innovative Nursing-Led Initiative Effective in Decreasing Central-Line Infections: Presented at ONS

By Bonnie Darves

PHOENIX, AZ -- November 17, 2005 -- Central-line infections are not only a difficult problem to manage and treat, they are also associated with considerable morbidity and mortality in cancer patients and others who must be catheterized.

In the United States, central-line infections are contracted by an estimated 150,000 US inpatients annually.

By combining an innovative approach to safe-practice improvements with effective communication and change-management strategies, 2 Ohio nurses were able to effectively eradicate catheter-related bloodstream infections (CR-BSI) in the ICUs of their respective institutions.

In their presentation here on November 11^th at the Oncology Nursing Society 6^th Annual Institutes of Learning (ONS), Suzanne Brungs, RN, MSN, OCN, CCRN, and Mary Nicholson, RN, BSN, CIC, shared with attendees the results of a project that involved making relatively minor practice changes to achieve major reductions in CR-BSI in 10 area hospitals.

Two key elements of the project -- dubbed "Operation Cover Up" -- were not easy changes to implement, but they paid off, noted Ms. Brungs, critical care and oncology nurse, Cincinnati Veterans Administration, Cincinnati, Ohio, who served as project coordinator.

The main changes, she said, were to substitute a full-body drape for the typical 2-ft by 2-ft drape when placing the line, and replacing povidone-iodine with tinctured chlorhexidrine in the patient-preparation cleaning process.

"The most challenging part of the project was making the best practice 'stick,'" Ms. Brungs said. "We basically had to take away the unwanted products and make it easier to do things right."

The hospitals marketed the project with clever printed materials and slogans, such as "Dress for Success and Prevent Infection" and a chart that detailed the actual time required to perform the safe practices: 10 seconds to use the hand gel, 50 seconds to place the maximum-sterile barriers, and an additional minute to use the chlorhexidrine and let it dry before putting in the line.

The ICU poster tagline "2 Minutes to Save a Life -- Priceless," a take-off on a popular MasterCard ad campaign, helped to convince ICU nurses that the process changes "weren't that much more time-consuming [than standard practice]," Ms. Brungs said.

The nursing challenges were myriad, but most were eventually overcome, Ms. Brungs and Ms. Nicholson explained.

First, the full-body drapes are cumbersome to place (it takes 2 individuals approximately 45 seconds to place the drape), and some alert patients were not comfortable with having their faces covered with it, noted Ms. Nicholson, infection control nurse, Christ Hospital, Cincinnati, 1 of the project sites.

In addition, use of the clear chlorhexidrine wash made it difficult initially to see which areas had been cleaned. That was remedied by asking the manufacturer to add the tincture to make it more visible.

Ultimately, project leaders were able to convince preparation-kit suppliers to reconfigure the central-line kits so that they included only the desired items, which saved nurses from having to effectively reassemble the kits. The new kits became available about 1 year into the project.

A third safe practice required that nurses wear sterile gowns and caps when installing the lines, which was nothing short of a "culture shock," Ms. Brungs noted.

The other barrier the project leaders encountered was getting beyond "the myth of perfection," Ms. Brungs said. Initially, some opponents of the project in the 10 hospitals that eventually participated claimed that they "didn't have an infection problem" or cited the fact that their infection rates were already below the 25% benchmark set by the National Nosocomial Infections Surveillance System (NNIS).

"But after the infection rates began to drop, it was harder for people to ignore the project or resist participating," Ms. Brungs said. "We still have some naysayers, but the success became an impetus for those people to get on board."

Adherence rates in the 2 hospitals where it was launched increased from approximately 40% at the start of the project, to between 80% and 100% 13 months later.

Project leaders responded to naysayers' comments by providing hard data: Studies have shown that using maximum-sterile barriers during central-line insertion can reduce catheter-related septicemia rates 6-fold; and replacing povidone-iodine washes with chlorhexidrine reduces infections by as much as 50%.

Initiated in November 2003 following receipt of a grant from the US Agency for Health Care Research & Quality, the project involved enlisting the visible support of both nurses and physicians, as well as administrators, within each participating institution.

Ms. Brungs said it is critical to identify a physician champion for the safety-improvement initiative and to request active support from the hospital administration leaders.


[Presentation title: Operation Cover Up: Decreasing Central Line Infections.]

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