Special Report – Infection Prevention

Preventing central line–associated bloodstream infections

Central line–associated bloodstream infections (CLABSIs) are among the most common hospital-acquired infections. Patients diagnosed and treated for CLABSIs require additional therapies and interventions, have longer stays, and face an increased risk of serious harm or death.

CLABSIs also raise healthcare costs. Over the past several years, most insurers have stopped reimbursing healthcare organizations for the increased costs of treating CLABSIs and certain other preventable conditions. Because nurses access and maintain these central lines, we’re in a key position to understand the risks of these infections—and we’re in a key position to prevent them.

Defining CLABSI

In 2001, the Centers for Disease Control and Prevention (CDC) defined CLABSI as a primary bloodstream infection in a patient with a central line in place during the 48 hours before infection, when no other infection source exists. The agency points out that some infection sources can be occult; therefore, CLABSI surveillance sometimes may overestimate the incidence of catheter-related bloodstream infections.

Understanding the types of vascular-access catheters available can increase your knowledge of CLABSI prevention strategies. (See Types of vascular-access catheters.)

Types of vascular-access catheters

Evidence-based guidelines for CLABSI reduction

Several national organizations regularly release evidence-based guidelines on CLABSI prevention, including the CDC, Infusion Nurses Society, and Society for Healthcare Epidemiology of America. This article summarizes the main recommendations in the CDC’s 2011 “Guidelines for the prevention of intravascular catheter-related infections.” These recommendations stress that healthcare organizations can achieve the greatest improvement when using multiple evidence-based strategies in a bundled approach. They also highlight the importance of collecting and reporting performance data on bundle elements to benchmark against other organizations and drive improvement.

  1. Train clinicians who insert and maintain catheters about the indications for catheters, proper insertion and maintenance procedures, and infection-control measures.
  2. Use the catheter with the fewest lumens necessary; infection risk increases with more access points.
  3. Perform hand hygiene and maintain aseptic technique before and after insertion and care of intravascular catheters.
  4. Use maximal sterile barrier precautions during catheter insertion, including a cap, mask, sterile gown, sterile gloves, and full-body sterile drape.
  5. Use a cap, mask, gloves, and a small sterile, fenestrated drape for peripheral arterial catheter insertion. Use maximal barrier precautions when inserting a cathe­ter at the femoral or axillary site; these sites have higher infection risks.
  6. Disinfect the insertion site with greater than 0.5% chlorhexidine with alcohol prep before inserting a central venous catheter (CVC) or arterial catheter and during dressing changes. Allow the prep to dry completely before inserting the catheter or applying a new dressing.
  7. Use ultrasound-guided placement to reduce the number of insertion attempts and complications.
  8. Avoid routine catheter replacement to help prevent infection.
  9. Use a sterile transparent, semipermeable dressing for short-term CVCs, or a sterile gauze dressing if the site is bleeding or the patient is diaphoretic. Change gauze dressings every 2 days and transparent dressings every 7 days. With a tunneled catheter, change the transparent dressing once a week until the site heals. Change dressings as needed—for instance, when they’re loose, soiled, or damp.
  10. Report changes to the catheter-insertion site, including pain on palpation, redness, warmth, or purulent drainage.
  11. Use 2% chlorhexidine wash for daily skin cleaning.
  12. Use sutureless devices to secure catheters.
  13. Use antiseptic ointment at hemodialysis-catheter sites after insertion and after each dialysis session. Don’t use antiseptic ointment on other types of CVCs because it may promote fungal infections and antibiotic resistance.
  14. Replace continuous infusion tubing no more often than every 96 hours but at least every 7 days. Change blood-product or fat-emulsion tubing every 24 hours; change propofol tubing every 6 to 12 hours.
  15. Change needleless connectors at least as often as tubing.
  16. Keep all components of the I.V. system or transducer system sterile, and minimize the number of entries.
  17. When accessing the catheter, use an appropriate antiseptic and access only with sterile devices.
  18. If CLABSI rates don’t decline despite use of core strategies, use a chlorhexidine-impregnated sponge dressing for patients older than 2 months and antiseptic/antibiotic-coated catheters for all patients.

CDC recommendations also stress the critical importance of removing catheters when they’re no longer needed. As nurses, we should speak up to other healthcare team members when a patient’s catheter is no longer necessary. In collaboration with the multidisciplinary team, we can have a dramatic impact in reducing preventable infections by implementing CDC recommendations rigorously.

Selected reference
O’Grady NP, Alexander M, Burns, LA, et al.; Healthcare Infection Control Practices Advisory Committee. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control. 2011;39(4 Suppl 1):S1-34.

Cass Piper Sandoval is a clinical nurse specialist in adult critical care at the University of California San Francisco Medical Center.


Click to read the next article: Preventing surgical-site infections

 

Operationalizing the ANA CAUTI prevention tool in acute-care settings

NOTE FROM THE EDITOR: The American Nurses Association (ANA) led an initiative in collaboration with the Centers for Medicare & Medicaid Services’ Partnership for Patients to develop a unique tool to prevent catheter-associated urinary tract infections (CAUTIs). Developed through a technical expert panel of nurses, the tool is available in this Special Report.

If you work in a medical-surgical unit, an intensive care unit, or an operating room, you need to understand your vital role in preventing CAUTIs. ANA has developed an evidence-based CAUTI prevention tool to aid bedside clinicians in preventing UTIs during everyday clinical practice. Expected outcomes from using this tool are preventing harm, saving lives, and lowering costs.

Implementing the tool into practice helps bedside nurses make sound clinical decisions related to indwelling urinary catheter (IUC) use. Consistent use of the tool highlights appropriate clinical questions and prevents inappropriate short-term IUC use. The tool prompts nurse-driven timely catheter removal and promotes best practices for catheter insertion, maintenance, and removal. It also guides nurses through key components of complete bladder assessment. Differentiating and prioritizing interventions based on individualized assessment findings related to complete bladder emptying, urinary retention, and incontinence are important in preventing CAUTIs.

How one hospital operationalized the tool

This article shares strategies used to operationalize the CAUTI prevention tool into nursing practice through the nursing education’s skin champion program at St. Francis Hospital, The Heart Center®, in Ro­slyn, New York—part

of Catholic Health Services Long Island (CHSLI). In 2012, this award- winning, 300+-bed, acute-care hospital was recognized as a top-performing National Database of Nursing Quality Indicators® hospital.

St. Francis had tried many strategies to decrease IUC use before serving as a pilot hospital to review the ANA CAUTI prevention tool. Its infection prevention team invited the wound, ostomy, and continence nurse (WOCN) to join the CAUTI prevention team and offer suggestions and alternatives to current strategies. Leading the initiative, this team included an infection prevention nurse from each of CHSLI’s acute- and long-term care hospitals. The team also invited WOCNs and nurse educators from all CHSLI hospitals. Over a 6-week period, two face-to-face meetings and three conference calls were held. The result was an updated IUC policy and protocol to promote early IUC removal, subsequently approved by chief nursing officers and then medical executive committees (MECs) at the individual CHSLI hospitals.
In addition, CHSLI made several catheter-related product changes. All catheter insertion kits were converted to include urometers instead of drainage bags, to decrease incidence of broken systems. Also, the male external catheter was converted to a new product with silicone adhesive (available in multiple sizes) as an alternative to inappropriate IUC insertion.

As these changes were implemented, the skin champion program was updated to include didactics related to CAUTI prevention. Data-collection metrics related to IUC use during the skin champion’s monthly pressure-ulcer point-prevalence study were added. Education focused on stabilizing the catheter, maintaining a closed system, following manufacturer guidelines for insertion techniques, ensuring the tubing was kink-free, and maintaining the urometer below bladder level and off the floor. When these efforts successfully reduced IUC insertion rates, the hospital’s catheter-use rates began to
decrease.

Developing the ANA CAUTI prevention tool

In the first quarter of 2014, St. Francis’ WOCN specialist (the author of this article) was recruited to be part of ANA’s technical expert panel (TEP) for developing an evidence-based CAUTI prevention tool. (See Technical expert panel members.) The TEP was charged with gathering evidence for tool development, which included guidelines from the Centers for Disease Control and Prevention (CDC), a literature review, and expert consensus. The expert consensus was carried out by independent TEP online input, teleconferences, face-to-face interactions, and meetings. The process involved a split-panel expert analysis, a clinical pilot, and revisions. The clinical pilot included evaluation from three hospitals in the Hospital Engagement Network, 14 other hospitals, and three clinical liai­sons; the liaisons served in the roles of WOCN, infection prevention RN, and quality-improvement manager. St. Francis’s WOCN was one of the clinical liaisons, helping to bring tool evaluation in the clinical setting to her hospital.

Technical expert panel members

The evaluation strategy for the tool’s pilot program was to have a nursing education group use the tool when IUC insertion was ordered. If the patient’s clinical criteria met CDC insertion recommendations, the clinical nurse specialist or nurse educator buddied with another clinical RN to insert the catheter using the ANA insertion checklist. For each insertion, they completed a questionnaire to evaluate the tool’s effectiveness and document feedback for the TEP.

At that point, the CAUTI prevention tool was fully integrated into the skin champion program at St. Francis. The skin champions expanded their personal knowledge base on how to assess for complete bladder emptying when an IUC is removed. They also gained a better understanding of the rationale for straight catheterization—specifically how this procedure can be used short-term to retrain the flaccid bladder and help improve urinary function. Nurses found the male external cathe­ters useful for patients who had urinary incontinence without underlying retention issues. They also requested new products, such as female urinals and more bladder scanners.

Clearly, St. Francis’ skin champion program was evolving and the hospital culture was changing. Nurses began to understand that IUCs are needed only in specific clinical situations, as outlined by the CDC.

Developing a policy for system-wide use

After the CAUTI prevention tool was released publicly at the 2015 ANA Quality Conference in Orlando, it was used to develop a policy for use across the CHSLI system. Infection prevention RNs and WOCNs from all CHSLI hospitals collaborated to develop a system policy and procedure for IUC insertion, maintenance, and removal. The policy is complete and currently is being presented to the MEC for approval. Order sets are being built into the electronic health record (EHR) and an education strategy is in development. The policy will be integrated into the EHR, establishing an order set for IUC insertion, maintenance, and removal.

At St. Francis, outcomes for hospital-acquired CAUTI rates, IUC use rates, and compliance with evidence-based IUC insertion and maintenance are
monitored through several mechanisms.

  • The infection prevention nurse team monitors all
    CAUTI incidence rates.
  • The WOCN asks the skin champion team to collect data on IUC use and tracks and trends rates during monthly point-prevalence studies.
  • The nursing education and infection prevention departments collaborate with the IUC vendor to conduct annual point-prevalence and insertion assessments. This deeper examination of all indwelling catheters, types of maintenance performed, and which units are inserting IUCs yields greater insight into the effectiveness of CAUTI prevention education.

Changing the culture

The ANA CAUTI prevention tool has helped change the culture around IUC insertion at St. Francis. Our nurses now have a better understanding of why CAUTI prevention is so important—and how they can help improve patient outcomes by always asking “Why is this IUC being inserted?”

Selected reference
American Nurses Association. ANA CAUTI Prevention Tool. 2015. http://nursing
world.org/ANA-CAUTI-Prevention-Tool

Chenel Trevellini is a Certified Wound Ostomy Continence Nurse (CWOCN) at St. Francis Hospital, The Heart Center®, in Roslyn, New York. She served on the technical expert panel to develop the CAUTI tool.


Click to read the next article: Operationalizing the ANA CAUTI prevention tool in acute-care settings

 

hospital-acquired infections

Moving toward zero hospital-acquired infections

As a nurse, you’re likely familiar with the added workload of caring for patients with healthcare-associated infections (HAIs)—catheter-associated urinary tract infections (CAUTIs), central line–associated bloodstream infections (CLABSIs), surgical-site infections (SSIs), and ventilator-associated pneumonia (VAP).

HAIs impose a staggering burden: More than 700,000 occur in American hospitals each year; on any given day, about one in 25 inpatients have one or more HAIs. How many patients would that translate to in your facility? Typically, these patients require more intensive monitoring, more frequent interventions, and more direct care than other patients and have longer stays.

What’s more, at least 75,000 of patients with HAIs die in the hospital. Those who survive to discharge may experience short-term or lifelong disabilities that significantly affect quality of life and earnings potential and strain family relationships. Direct annual costs of HAIs come to nearly $10 billion.

Almost half of HAIs are linked to invasive devices, such as urinary catheters, central lines, and ventilators, or surgery. Think about how many patients in your facility have these devices or undergo surgery. As you can imagine, opportunities to acquire HAIs are numerous—but so are opportunities to prevent them.

By leading and participating in prevention efforts, nurses can play a major role in reducing these infections. Recently, nurses have been collaborating with infection preventionists, physicians, quality-improvement specialists, pharmacists, and others to significantly decrease HAIs and reduce their impact on patients, families, nurses and other caregivers, and hospital bottom lines. Together, we’ve crafted and implemented both innovative and basic solutions.

Nationally, we’ve seen positive outcomes of these efforts, including a 46% decrease in CLABSIs and a 19% decrease in SSIs between 2008 and 2013. Yet much work remains to reduce these numbers toward the goal of zero. (In fact, CAUTIs increased 6% between 2009 and 2013.) Nurses are uniquely qualified to lead change and transform healthcare processes and outcomes to reduce the burden of HAIs.

This special report updates you on best practices, innovative monitoring and tools, prevention processes, and intervention strategies to assist you in leading the journey toward reducing HAIs. Each article offers succinct over­views of important HAI topics. We hope you’ll find them useful as you collaborate with other healthcare professionals to achieve the goal of zero HAIs. n

Selected references
Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2010. http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/workforce/IOM-Future-of-Nursing-Report-1

Magill SS, Edwards JR, Bamberg W, et al.; Emerging Infections Program Healthcare-
Associated Infections and Antimicrobial Use Prevalence Survey Team. Multistate point-prevalence survey of health care–associated infections. N Engl J Med. 2014;370(13):
1198-208.

Zimlichman E, Henderson D, Tamir O, et al. Health care–associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med. 2013;173(22):2039-46.

Amanda Hessels is a postdoctoral research fellow at Columbia University School of Nursing, Center for Interdisciplinary Research to Prevent Infections, and a nurse scientist at Meridian Health in Neptune, New Jersey.


Click to read the next article: Catheter-Associated Urinary Tract Infection Prevention Tool

 

ventilator-associated pneumonia

Evidence-based strategies to prevent ventilator-associated pneumonia

Defined as pneumonia that develops within 48 of endotracheal intubation, ventilator-associated pneumonia (VAP) is the most common hospital-acquired infection in critical care units. It leads to longer intensive-care stays, increased mechanical ventilation time, greater mortality, and higher costs.

Although VAP incidence in the United States has declined to 0.0 to 4.4 cases per 1,000 patient days, it remains a concern. Prevention strategies focus on three causative mechanisms—bacterial colonization of the respiratory and upper GI tracts, aspiration of contaminated secretions, and contamined respiratory equipment. Understanding evidence-based strategies can help you reduce your patients’ VAP risk.

Recognized evidence-based strategies

Several professional organizations have developed or endorsed evidence-based guidelines for VAP prevention. Here are four of the most commonly recommended strategies.

Use an endotracheal tube with a lumen for 
continuous suction of subglottic secretions.

 

Contaminated secretions pool above the endotracheal tube cuff and migrate into the lungs even with a properly inflated cuff. Continuous removal of these secretions by suctioning reduces aspiration risk. Endotracheal tubes with a continuous subglottic suction lumen are linked to re-duced VAP rates and decreased duration of mechanical ventilation in patients who need more than 48 hours of ventilation.

Keep the head of the bed elevated 30 to 45 degrees.

 

Unless medically contraindicated, keep the head of the bed elevated for patients with a high aspiration risk, including those who are on mechanical ventilation or have an enteral feeding tube. Supine positioning is linked to higher bacterial counts in aspirated secretions than semirecumbent positioning. Use the bed’s angle-indication device to ensure an accurate elevation angle; nurses’ estimates of the angle have been shown to be inaccurate.

Commit to an oral care protocol using chlorhexidine.

 

Within 48 hours of hospitalization, the oral flora of critically ill patients changes to include potential respiratory pathogens rarely found in healthy persons. The endotracheal tube provides a migration route for organisms to travel to the lungs. Oral hygiene protocols with chlorhexidine help combat colonization of the respiratory tract and reduce dental plaque (which acts as a bacterial reservoir). Although chlorhexidine 0.12% solution is the most commonly used concentration, no firm consensus exists for the most effective concentration. The strongest evidence for chlorhexidine has been reported in the cardiac surgery population, although many hospitals regularly use it for noncardiac surgical patients.

Change the ventilator circuit only when visibly soiled.

 

Studies evaluating contaminated ventilator circuits show that changing circuits more often doesn’t reduce pneumonia incidence. In fact, changing circuits less often may reduce exposure to infectious aerosols. Before patient repositioning, drain the condensation in circuits away from the patient. For details on disinfecting and sterilizing respiratory equipment, visit www.cdc
.gov/mmwr/preview/mmwrhtml/rr5303a1.htm.

Other best practices

The practices described below are recommended for VAP by at least one professional organization, although they’re not cited as often as the above interventions.

Use NIPPV to avoid intubation or reintubation.

 

Noninvasive positive pressure ventilation (NIPPV) can be a useful alternative to mechanical ventilation. It has been particularly effective in avoiding the need for intubation in patients who are in the acute phase of chronic obstructive pulmonary disease or heart-failure exacerbation. NIPPV also can be used during weaning to shorten duration of intubation (unless contraindicated).

Use effective weaning strategies to reduce
 mechanical ventilation days.

 

Because VAP risk rises 1% to 3% every day the patient remains on mechanical ventilation, effective strategies to promote weaning can indirectly lower the risk. Nurse- or therapist-driven weaning protocols that include daily assessment for readiness to wean lead to shorter mechanical ventilation periods.

Additional emerging strategies coordinate sedation cessation with spontaneous breathing trials and include early mobility and delirium assessment to promote freedom from the ventilator. The American Association of Critical-Care Nurses (AACN) introduced the evidence-based ABCDE bundle as an organizational approach to coordinating these complex multidisciplinary weaning efforts. ABCDE stands for Awakening and Breathing Coordination, Delirium Monitoring and Management, and Early Mobility.

Avoid nasotracheal intubation.

 

Nasal obstruction with an endotracheal tube (or feeding tube) can prevent clearing of sinus drainage, leading to hospital-acquired sinusitis and aspiration of contaminated secretions. When possible, avoid nasotracheal intubation.

Potentially effective strategies

Silver-coated endotracheal tubes and kinetic beds aren’t recommended by any organization, but some supporting evidence suggests these strategies may be effective.

Use silver-coated endotracheal tubes.

 

Soon after intubation, endotracheal-tube surfaces become coated with a bacterial biofilm. Silver-coated tubes provide antibacterial properties and discourage bacterial adherence, leading to delayed colonization and delayed VAP. Expert opinions on silver-coated endotracheal tubes vary, ranging from “suitable for use” to “additional studies are needed” to “generally not recommended.”

Use kinetic beds.

 

One meta-analysis found that continuous lateral rotation via the kinetic bed led to reduced VAP rates. However, VAP prevention guidelines rarely include this intervention. The kinetic bed remains “generally not recommended” by The Society for Healthcare Epidemiology of America, while the Institute for Clinical Systems Improvement states the bed is “not recommended for routine use.” Rationales for not using the bed include lack of positive impact on death rates and ventilation duration; also, this bed isn’t available in some healthcare organizations.

Multifaceted problem, multidirectional solution

VAP is a multifaceted problem that calls for a multidirectional solution. Successful VAP prevention strategies require interdisciplinary cooperation, education, and monitoring of guideline adherence. The complexity of prevention interventions can make protocol compliance challenging; healthcare facilities may want to group small sets of evidence-based interventions together for easier implementation. Bundling interventions has been shown to promote changes in healthcare professionals’ practices while providing a useful framework for measuring and reporting compliance. (See Nursing practices that help prevent VAP.)
For resources on implementing VAP prevention and ventilator weaning strategies, visit the AACN website (www.aacn.org).

Nursing practices that help prevent VAP

References

Aboelela SW, Stone PW, Larson EL. Effectiveness of bundled behavioural interventions to control healthcare-associated infections: a systematic review of the literature. J Hosp Infect. 2007;66(2):101-8.

American Association of Critical-Care Nurses. Implementing the ABCDE bundle at the bedside. 2010. www.aacn.org/wd/practice/content/actionpak/withlinks-ABCDE-ToolKit.content?menu=practice

American Association of Critical-Care Nurses. Oral care for patients at risk for ventilator-associated pneumonia. 2010. www.aacn.org/wd/practice/content/oral-care-practice-alert.pcms?menu=practice

American Association of Critical-Care Nurses. Ventilator-associated pneumonia. 2008. www.aacn.org/wd/practice/content/vap-practice-alert.pcms?menu=practice

Balas MC, Vasilevskis EE, Olsen KM, et al. Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Crit Care Med. 2014;42(5):1024-36.

Burns SM. AACN Essentials of Critical Care Nursing. 3rd edition. New York: McGraw-Hill; 2014.

Delaney A, Gray H, Laupland KB, Zuege DJ. Kinetic bed therapy to prevent nosocomial pneumonia in mechanically ventilated patients: a systematic review and meta-analysis. Crit Care. 2006;10(3):R70.

Dickenson S, Zalewski CA. Oral care during mechanical ventilation: critical for VAP prevention. Society of Critical Care Medicine; 2008. www.sccm.org/Communications/Critical-Connections/Archives/Pages/Oral-Care-During-Mechanical-Ventilation—Critical-for-VAP-Prevention.aspx

Dudek MA, Weiner LM, Allen-Bridson K, et al. National Healthcare Safety Network (NHSN) report, data summary for 2012, device-associated module. Am J Infect Control. 2013;41(12):1148-66.

Haas CF, Eakin RM, Konkle MA, Blank R. Endotracheal tubes: old and new. Respir Care. 2014;59(6):933-52.

How-to guide: Prevent ventilator-associated pneumonia. Cambridge, MA: Institute for Healthcare Improvement; 2012. www.ihi.org/resources/Pages/Tools/HowtoGuidePreventVAP.aspx

Institute for Clinical Systems Improvement. Healthcare protocol: Prevention of ventilator-associated pneumonia. 5th ed. November 2011. www.icsi.org/_asset/y24ruh/VAP.pdf

Jones DJ, Munro CL, Grap MJ. Natural history of dental plaque accumulation in mechanically ventilated adults: a descriptive correlational study. Intensive Crit Care Nurs. 2011;27(6):299-304.

Klompas M, Branson R, Eichenwald EC, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Inf Control Hosp Epidemiol. 2014;35 Suppl 2:S133-54.

Klompas M, Speck K, Howell MD, Greene LR, Berenholtz SM. Reappraisal of routine oral care with chlorhexidine gluconate for patients receiving mechanical ventilation: systematic review and meta-analysis. JAMA Intern Med. 2014;174(5):751-61.

Kollef M. Preventive strategies in VAP: focus on silver-coated endotracheal tubes. In: Moriarty TF, Zaat SAJ, Busscher HJ. Biomaterials Associated Infection. New York, NY: Springer; 2013: 531-5.

MacIntyre NR, Cook DJ, Ely EW, et al; American Collecge of Chest Physicians; American Association for Respiratory Care; American College of Critical Care Medicine. Evidence-based guidelines for weaning and discontinuing ventilatory support; a collective task force facilitated by the American Collecge of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest. 2001;120(6 Suppl), 375S-95S.

Perrie H, Windsor S, Scribante J. Nurses’ accuracy in estimating backrest elevation. S Afr J Crit Care. 2007;23(1):10-4.

Rebmann T, Greene LR. Preventing ventilator-associated pneumonia: an executive summary of the Association for Professionals in Infection Control and Epidemiology, Inc, Elimination Guide. Am J Infect Control. 2010;38(8):647-9.

Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R; CDC; Healthcare Infection Control Practices Advisory Committee. Guidelines for preventing health-care–associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. 2004;53(RR-3):1-36.

Torres A, Serra-Batlles J, Ros E, et al. Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: the effect of body position. Ann Intern Med. 1992;116(7):540-3.

Amy Shay is an assistant professor of clinical at the University of Cincinnati College of Nursing in Cincinnati, Ohio, and is on the nursing staff at Miami Valley Hospital in Dayton, Ohio.

Preventing surgical-site infections

Surgical-site infections (SSIs) can lead to increased postoperative stays, higher readmission rates and healthcare costs, and poorer health outcomes. In a 2014 study, SSIs tied with pneumonia as the most common infection in hospitals, accounting for 21.8% of total infections. These facts and figures underscore the need for robust SSI prevention strategies. Implementing evidence-based interventions can greatly reduce SSI risk. (See Risk factors for SSIs.)

Risk factors for SSIs

Prevention guidelines

The Healthcare Infections Advisory Committee published guidelines for SSI prevention in 1999. The guidelines have been updated and are currently undergoing final review.

In 2014, “A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals: 2014 Update” was published as a collaborative endeavor by the Society for Healthcare Epidemiology, Infectious Diseases Society of America, Association of Professionals in Infection Control, American Hospital Association, and The Joint Commission. This document outlines the following prevention practices:

  • Give antibiotic prophylaxis according to guidelines. Limit postoperative duration of antibiotic therapy.
  • Don’t use razors to remove hair at the operative site, and limit hair removal to areas where hair may interfere with the surgical incision.
  • Control blood glucose in patients scheduled for cardiac surgery, those with diabetes, and those known to have elevated preoperative blood glucose.
  • During the perioperative period, maintain body temperature at 95.9° F (35.5° C) or higher.
  • Use an alcohol-based skin prep unless contraindicated.
  • Use impervious wound protectors for gastric and biliary surgery.
  • Perform SSI surveillance and provide feedback on SSI rates to surgeons and other stakeholders.
  • Educate patients and families about their role in SSI prevention.
  • Develop policies, procedures, and protocols based on evidence-based standards, such as those of the Centers for Disease Control and Prevention, Association of periOperative Registered Nurses (AORN), and other professional societies.

Special approaches

Besides these core strategies, a recommended special approach to SSI prevention involves screening for Staphylococcus aureus and decolonizing high-risk patients with an anti-staphylococcal agent, particularly in the orthopedic or cardiac setting.

Nurse’s role in SSI prevention

As a nurse, your role in preventing SSIs is comprehensive and spans the continuum of care. You play a crucial part in executing or promoting implementation of evidence-based practices. For example, provide counseling and education during the initial preoperative visit, especially related to smoking cessation and glucose control in patients with diabetes. Encourage patients to report new rashes, breaks in skin integrity, and new-onset respiratory infections before surgery. Although data suggest the effectiveness of antiseptic showers or cloths is unresolved, AORN recommends instructing patients to bathe or shower with soap or an antiseptic before surgery, noting that reducing skin microorganisms may lower the risk of developing an SSI. If the patient will use a chlorhexidine antiseptic for preoperative skin cleaning, instruct him or her to lather with the soap and leave it on the skin for 2 minutes before rinsing it off.

Interventions before, during, and after surgery

SSI prevention requires action and vigilance during the preoperative, intraoperative, and postoperative periods, as described below.

Preoperative interventions

Validate and ensure that the patient has followed all preoperative instructions. Maintain the patient’s body temperature; a low temperature may increase the infection risk by causing vasoconstriction. Active warming can reduce this risk. AORN recommends warming patients at risk for hypothermia at least 15 minutes before anesthesia induction.

Risk factors for hypothermia include certain types and extents of surgery or anesthesia, low body weight, cool irrigations in body cavities, and blood administration. Cardiac surgery patients and patients with diabetes may be at risk for elevated blood glucose during and after surgery. Current guidelines recommend keeping the patient’s blood glucose level at 180 mg/dL or lower; insulin via injection or I.V solution may be required preoperatively.

Intraoperative interventions

To ensure razors aren’t used to remove hair before surgery, many hospitals have eliminated them from the operating room (OR). Also, surgical prep must be applied correctly and allowed to dry before the initial incision.

The OR nurse is integral to ensuring all skin antisepsis parameters are met. Unless contraindicated, an alcohol-based prep is recommended. Generally, surgical antibiotic prophylaxis is administered by anesthesia before incision; some healthcare organizations have added surgical prophylaxis to their preoperative checklist. The OR nurse should ensure prophylaxis guidelines are followed and the antibiotic is given before incision. OR doors must remain closed during surgery and traffic flow must be minimized.

Postoperative interventions

Postoperative wound care should be managed closely. In the postanesthesia care unit, check all dressings for drainage and closure. Hand hygiene and strict asepsis during dressing changes are critical. Monitor the patient’s temperature; as needed and ordered, implement warming techniques. At discharge, carefully review postoperative instructions with the patient.

Using the best available evidence

Implementing evidence-based guidelines requires a coordinated multidisciplinary approach. As we transition from silos of care to a collaborative approach, nurses continue to play a pivotal role in promoting and implementing SSI prevention strategies while bringing the best available evidence to the bedside.

Selected references

Anderson DJ, Podgorny K, Berrios-Torres SI, et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;
35(6):605-27.

Association of periOperative Registered Nurses (AORN). Recommended practices for environmental cleaning. In: Perioperative Standards and Recommended Practices; 2014 Edition. Denver, CO: AORN, Inc.; 2014.

Magill SS, Edwards JR, Bamberg W, et al.; Emerging Infections Program Healthcare-
Associated Infections and Antimicrobial Use Prevalence Survey Team. Multistate point-prevalence survey of health care-associated infections. N Engl J Med. 2014;370(13):
1198-208.

Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999;20(4):250-78.

Yokoe DS, Anderson, DJ, Berenholtz, SM, et al. A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals: 2014 Update. May 1, 2014. http://shea-online.org/index.php/practiceresources/priority-topics/compendium-of-strategies-to-prevent-hais

Linda R. Greene is manager of infection prevention at Highland Hospital, University of Rochester Medical Center, in Rochester, New York.


Click to read the next article: Evidence-based strategies to prevent ventilator-associated pneumonia

 

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