Infection Control Today

AUG 2018

ICT delivers to infection preventionists & their colleagues in the operating room, sterile processing/central sterile, environmental services & materials management, timely & relevant news, trends & information impacting the profession & the industry

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21 August 2018 ICT related litigation, along with an increase in complaints and questions about infusion care at a four-hospital system. Numerous discussions with colleagues indicated infusion teams were being disbanded, leaving no personnel for data collection on complication rates or medication errors. Additionally, challenges associated with patient and clinician safety or patient satisfaction may not have been addressed. These changes are often made in the name of cost savings; however, those data are also not found in the published literature." Lynn Hadaway, M.Ed., RN-BC, CRNI, president of Lynn Hadaway Associates, Inc. in Georgia, reports that she sees hospitals at both ends of the fnancial spectrum and that while infusion teams are being eliminated at some hospitals, other, larger healthcare systems with the resources, are moving the needle toward better outcomes thanks to these specialized teams. "It's a mixed bag," Hadaway says. "Some hospitals are going broke and they can't see their way out of their fnancial mess to fgure out ways to do things better; by disbanding infusion teams, or not having them at all, they are digging their hole deeper. I recently saw an article that said the number of hospitals reporting zero CLABSIs had been reduced by half, so there are not as many hospitals that are doing as well at decreasing their infection rates to zero. That suggests we are going in the wrong direction. But then in certain regions of the country, we do see an increase in the number of infusion teams. Some institutions have developed teams that are expanding their catheter-insertion services; for instance, instead of just putting in PICCs, nurses are now learning to put in other types of central venous catheters, so they are expanding their scope of practice." The lack of standardization in hospitals, despite well-publicized and accessible guidelines and recommendations governing vascular access and infusion therapy, is a signifcant challenge that infusion teams can help address. Hadaway sees the confusion daily in the online forums she monitors. "When I look at the questions that clinicians are posting, and the answers to those questions, I realize the great variance in practice that exists and we have a signifcant opportunity to educate them," Hadaway says. "Some clinicians are saying, 'We do XYZ," while others are saying "No, we are doing ABC," and there is a world of difference between them — we can't have the same good outcomes from both processes that are so different, or can we? That's the problem, as sometimes we don't know whether one process is better than the other and sometimes it's a variety of practices within the same hospital. The other day I was discussing an order for fushing and locking a catheter; the question was, is a pre-flled manufacturer's saline syringe a device or a drug. Well, according to the FDA, it is regulated as a device, and so the question was, 'Well, can nurses use this without an order?' Well, that depends upon the policy and the procedure of your hospital. The person said, 'We don't have those.' Well, why not? The bottom line was at that facility, anyone who writes orders had to prescribe how they fushed and locked the catheter, and I think that could lead to nothing but chaos in the facility. With so many differences, and so many preferences among the doctors, physician assistants and nurse practitioners, how is the staff nurse to know what is to be done? That seems like a nightmare scenario." Many staff nurses are at a disadvantage because they are not taught to any degree about infusion therapy and lack the critical-thinking skills necessary to make important clinical decisions. As Hadaway and Dalton, et al. (2014) observe, "Currently, there is a growing emphasis on patient safety and measurement of patient satisfaction, the urgent need to rein in costs by driving waste and ineffciencies from our delivery systems, and radically changing reimbursement structures for healthcare. At the same time, there is minimal prelicensure education on infusion therapy and vascular access for nurses, pharmacists, and physicians. Additionally, the technology of infusion therapy continues to expand without support from well-designed clinical trials to guide appropriate implementation of these devices." "The knowledge level of the nurse depends on the nursing school, of course," says Hadaway. "Most nursing students don't learn about IV therapy in most nursing schools. The core essentials curriculum for a BSN program that is determined by the American Association of Colleges of Nursing is divided into nine topics and IV therapy is not included. Now, it depends upon the arrangement between the college and the hospital; when I went to school, the school of nursing and the hospital was the same legal entity — we were a school within the hospital. But now, a college is separate from the hospital, so it depends upon the contract between the hospital and the school as to whether those nursing students can do invasive procedures. Without infusion teams to take these students under their wings and supervise them, they don't receive any proper instruction. The nursing school or hospital might have a simulation lab where nurses can perform a couple of venipunctures on an anatomical model, and they might get a chance to administer a dose of medication during some of their clinicals, but as far as receiving instruction in dressings, trouble- shooting lines and equipment, working with diffcult patients who have difficult venour access, they don't have the knowledge about how to prevent infections and ensure good outcomes." Hadaway continues, "The Joint Commission says that hospitals must document competencies before the clinician is allowed to do the job; but it's a conundrum — how are they documenting these competencies? A nurse may have started a line on an anatomical model in a classroom, but that's about the extent of it. The use of ultrasound to start peripheral catheters is quite common, but many hospitals turn the equipment over to clinicians without teaching them how to use it. In the hands of someone with appropriate knowledge and skill, that ultrasound device will allow you to stick one time and only one time, and allow that patient go through his or her entire hospitalization with just one stick. But in the hands of someone without that knowledge and skillset, ultrasound is wasted. It requires a specifc level of expertise." Knowledge and implementation gaps in infusion therapy persist, and Hadaway says hospitals are opening themselves up to clinical and legal liability even as they shortsightedly slash budgets. "I think it would be relatively easy to prove the fnancial beneft of these highly skilled, specialized teams," she says. "But when hospitals are in survival mode, they are not focusing on that. Many hospitals that eliminate infusion teams are trying to cut cost centers and trim expenses. They are thinking very short term and justify their actions to eliminate infusion specialists by assuming that a nurse is a nurse is a nurse, and everybody can do this, when they don't realize the level of skill that proper infusion takes. Another thing adding to the challenge is patient acuity and the complexity of decisions about Some hospitals are going broke and they can't see their way out of their fnancial mess to fgure out ways to do things better; by disbanding infusion teams, or not having them at all , they are digging their hole deeper. Ò

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