Quality Improvement Paper
Up to 25% of catheter related bloodstream infections (CRBSI) result in death (Fletcher, 2005). In addition to increased treatment cost and overall hospitalization stay this type of hospital acquired infection can be detrimental to patient outcomes. CRBSIs are classified as nosocomial infections, which are defined as infections that patients acquire while receiving medical treatment within healthcare facilities. National Patient Safety Goals are established yearly by the Joint Commission, this includes the prevention of infections specifically preventing bloodstream infections (Hospital National Patient Safety Goals, 2018). The purpose of this paper is to discuss CRBSIs regarding the etiology, healthcare workers involved and potential solutions to decrease these occurrences.
Patient Safety Issue:
Never events are defined as an “error in medical care that is clearly preventable, and serious in its consequences for the patient” (Yoder-Wise, 2015, p. 584). Bloodstream related infections fall under this category, meaning this even should have never happened. Typically, between 3%-16% of catheterizations result in CRBSIs (Fletcher, 2005). In any healthcare setting that is too high of a rate for never events. Central venous catheterization (CVC), have the highest incidence rate of CRBSI, in addition it is the most lethal and costly complication (Fletcher, 2005). Each year in the United States CVC account for over 80,000 CRBSIs cases (Pronovost et. al., 2006).
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CRBSIs are caused when bacteria travel from the catheter hub and enter the bloodstream (Fletcher, 2005). There are certain risk factors that can contribute to a patient’s susceptibility for acquiring CRBSIs. These include prolonged duration of catheterization, bacterial colonization at the insertion site or catheter hub, and substandard care of the catheter (Marschall et. al., 2008). The longer the catheter is in place the patients risk for CRBSIs increases because of exposure time of bacteria to the open area of tissue (Marschall et. al., 2008). Bacterial colonization is an obvious explanation for CRBSIs. It would seem like a preventable risk, however, even with proper hand hygiene, surgical aseptic insertion technique and proper skin disinfection for preparation of insertion, infections still occur (Marschall et. al., 2008). Substandard care of catheters can lead to infection from excessive manipulation of a catheter or improper assessment and management (Marschall et. al., 2008). All of these reasons have the potential to increase bacteria at the insertion site thus leading to a CRBSI.
All healthcare workers involved in patient care who have CVCs are responsible for prevention of infection. For the purposes of this paper, nurses, physicians and the patient will be discussed in their contribution to CRBSIs. CRBSIs are extremely costly to the patients, on average CRBSIs can costs over $33,000 (Leistner, Hirsemann, Gastmeier, & Geffers, 2014). In addition, CRBSIs can increase hospital length of stay of patients by 7-10 days (Leistner et. al., 2014). This increase in cost and length of stay can put increased stress on patients thus hindering their ability to heal (Christian et al, 2007).
Nurses are responsible for providing a high standard of patient-centered care, this includes proper assessment and management of CVCs. Daily assessments are needed to maintain proper care of CVCs (Marschall et. al., 2008). Studies have shown that increasing the number of patients a nurse cares for increases the incidences of CVC related CRBSIs (Fridkin, Pear, Williamson, Galgiani, & Jarvis, 1996). By increasing the patient to nurse ratio this decrease the nurse’s ability to safely care for their patients (Fridkin et. al., 1996). If a nurse is not able to implement the nursing process properly, patient outcomes will suffer.
Doctors have similar roles to nurses in regards to stopping CRBSIs. They as well need to maintain proper and safe care towards the patients. The physician should be able to recognize a CRBSI and implement to correct treatment course (Shah, Bosch, Thompson, & Hellinger, 2013). In the past physicians were responsible for the insertion of CVCs however, properly trained nurses can also insert them (Alexandrou et. al., 2012). It is important for both members of the healthcare team, nurses and physicians, to work together and provide high quality care to patients with catheters. This includes proper education for all healthcare members on CRBSIs in order to prevent them (Warren et. al., 2004).
Possible Solution #1:
One solution that can be utilized is proper patient to nurse ratios. This topic was briefly mentioned earlier in the paper. By implementing safer patient to nurse ratios, this allows nurses to complete comprehensive patient care. When there is an increase of patients per one nurse, it becomes harder for that nurse to complete every tasks assigned. These important tasks include proper assessment and management of CVCs. Understaffing and increased patient to nurse ratios can be from hospitals wanting to decrease operating costs, however, this actually hurts hospitals in the long run due to increased patient stays (Fridkin et. al., 1996). The solution would be to increase nursing staff to have safe ratios. This would allow for the correct patient care of CVC thus decreasing the incidences of CRBSIs
A study completed by Fridkin et. al., delved deeper into this topic (1996). Granted this study is older but the same principles still apply. The purpose of this study was to determine risk factors of CRBSIs, specifically CVC related risk factors (Fridkin et. al., 1996). The design of this study was a cohort and case control study of surgical intensive care unit (SICU) patients with CVCs (Fridkin et. al., 1996). CVC related CRBSI rates were measured as well as monthly SICU patient to nurse ratios (Fridkin et. al., 1996). The results of this study showed that CRBSI rates increased when there was s creased presence of nurses (Fridkin et. al., 1996). This study showed that an increase work load on nurses hindered their ability from properly taking care of CVCs (Fridkin et. al., 1996).
Possible Solution #2:
Another solution to decrease the rate of CRBSIs is implementing education programs hospital wide on CRBSI. By properly educating healthcare personnel on all aspects of care, (insertion, maintenance and assessment) the rate of CRBSI decreases (Marschall et. al., 2008). Education allows the healthcare team to have the correct knowledge and skills required and in return they are then more likely to adhere to preventive measures thus improving patient outcomes (Marschall et. al., 2008).
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Warren et. al., created a research study with the objective to determine if education programs could decrease the incidences of CRBSIs (2004). The study design was pre-intervention and post-intervention observational study (Warren et. al., 2004). A mandatory education program was implemented focusing on proper practices for preventing CRBSI (Warren et. al., 2004). The education program was a self-study module in addition to staff meeting at the hospital (Warren et. al., 2004). Reinforcing the information was another component of this program, this was accomplished by posting fact sheets and posters throughout the hospital (Warren et. al., 2004). There were 74 cases of CRBSI before the implementation of the education program, and after the education program the hospital reported 41 cases of CRBSIs (Warren et. al., 2004). More importantly it was estimated that over the three years this study took place the hospital saved between $103,600 and $1,573,000 (Warren et. al., 2004).
Both of the proposed solutions are beneficial to decreasing the rate of CRBSIs. However, implementing mandatory education programs on CRBSIs is the preferred solution. From Warren et. al. research study, the implementation of an education program is more cost beneficial to the hospital (2004). The fact that over three years one hospital had an estimated saving of $103,600-$1,573,000 without hiring additional staff (Warren et. al., 2004). Ideally hiring more nurses to decrease the patient to nurse ratio would be the preferred solution, however, this plan is not feasible for every hospital. Not every hospital has the money to hire more full time nurses, which is why a self-study education program is more realistic.
To present the action plan to a nurse manger, nurses first need to assess the problem on their unit and establish a need for change. Gathering research studies such as Warren et. al. (2004), and Marschall et. al. (2008), will help strength a nurse’s action plan because of their result that education programs show a decrease in CRBSIs. The implementation of SMART goals will help to achieve desired results by creating obtainable objectives (Yoder-Wise, 2015). After talking with a nurse manager and showing her the current issue of CRBSIs, research supporting education programs on CRBSIs, and creating attainable goals, the implementation phase of the action plan should begin. Ideally hospitals should follow the Warren et. al. education program because of the successful results (2004). The entire healthcare team should be involved therefore time needs to be factored into the action plan. These goals will not change overnight, the Warren et. al. model spanned three years (2004). After all these steps have been implemented then proper evaluation should take plan to determine if the rates of CRBSI deceased.
CVC related CRBSI have this highest mortality rate of all CRBSI (Fletcher, 2005). This type of infection is costly to both the patient and the hospital because of the increased length of hospitalization. Implementing safe patient to nurse staffing ratios helps to decrease the rates of CRBSIs because nurse can focus more attention on their patients and give high quality care. In addition, it has been proven by implementing mandatory education programs on CRBSI this ultimately will decrease the infection rate. Both the physicians and the nurses, as well as the entire healthcare team, need to work together to find an effective solution to decrease the mortality rate of CRBSIs.
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