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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22 ICT August 2018 what is the best type of catheter to use in a patient. We have so many different types now within peripherals and centrals, with multiple insertion methods and designs. The standard of practice is to choose the type of catheter that has the greatest likelihood of reaching the end of therapy with the minimal number of devices used, and preserving peripheral vessels so that you don't have to go to a central venous catheter during the course of care. The more you can decrease central venous catheter usage, the better the patient will be. But some hospitals still aren't taking that preventive, proactive approach; they are still reactionary and trying to get by the best they can. They are not conducting an upfront analysis because they do not have a team of people with those analytical skills. Staff nurses are not thinking about it because all they can see is an overload of work. Hospitals that are strapped for revenue usually have staff that are so overworked and so burdened, they are stretched to their breaking point and all they are trying to do is make it through to the end of their shift — they are not really thinking about the outcomes that they are producing. Now, there's the other end of the spectrum where that problem does not exist; these hospitals have taken this proactive approach and are looking at the outcomes and then working backward to figure out how to replicate success." G a m i n g t h e s y s t e m i s t e m p t i n g when hospitals lack specialized teams or individuals, and seek to avoid identifying and repor ting central line -associated bloodstream infections (CLABSIs). "One thing that we do see is hospitals trying to reduce the number of central lines, with the thought being, if there are no central lines, there is no chance of a bloodstream infection that can be counted against them," Hadaway says. "We see hospitals that are now refusing to allow as many central lines as they had before, so they have reduced the number of PICCs that they are putting in, which is probably a good thing because there has been a lot of overuse and erroneous decisions to put in those central lines for no good clinical reason. There is also a movement toward using peripherals and midlines because hospitals want to get patients through to the end of their therapy with as few complications and infections as possible. So, these institutions are carefully applying the catheter decision- making process, with good criteria. Sadly, other facilities are still just reacting to the notion, 'Well, we can't tolerate CLABSIs so we are just not going to put in any central lines, regardless of whether patients need them or not.' If a central line is not inserted, it cannot get infected and counted as a CLABSI. So many hospitals are relying almost exclusively on peripheral and midine catheters. Then there are the people who really want to know what their infection rates are with those types of catheters. We still see too many poor line placements and suboptimal maintenance, and a failure to recognize complications early enough. There is also the additional issue of peripheral catheters used before the central line was placed; they may actually be the cause of the CLABSI but it gets blamed on the central line because no one is paying attention to the peripherals." H a d a w a y c o n t i n u e s , "There are so many things for the nurse to consider, that it often is beyond the scope of a med/surg or bedside staff nurse who is already overloaded and burdened. I think it's asking far too much of that staff nurse to make these critical decisions about what catheter the patient needs; these staff nurses just don't have time to think about the questions, much less look for the answers. Performing evidence-based practice is so important these days. We go to great lengths when we write the standards of practice for INS to ensure that we have the evidence to back up the recommendations that we put forth and the statements that we make. But when nurses are faced with the fact that not everything has an evidence-based answer and when you are faced with the questions in hurried clinical practice settings, you don't have time to go to the internet to conduct a literature search and read 15 papers and fgure out the best approach. Some nurse administrators are not allowing time to do evidence-based practice, so the value of infusion teams and specialists is underscored." The institution's infection preventionist(s) can be the champion for good vascular access and infusion practices and the behavior change that is often needed to foster positive change. "The IP is seeing the clinical outcomes as well as the fscal picture," says Hadaway, "so, this individual is well suited to championing proper vascular access practices and programs at healthcare facilities. They realize that their institution is losing revenue when a patient develops a CLABSI. They know the hospital gets penalized if it is in the lower 25th percentile of all hospitals in the country and how it impacts annual Medicare payments." Making this business case for infusion teams and specialists is essential to revenue preservation, but as Hadaway and Dalton, et al. (2014) obser ve, "While infusion therapy is pervasive throughout the entire facility, the business of infusion services has received very little attention, including using appropriate models for infusion cost analysis; cost-effective distribution of infusion therapy responsibilities among professionals and departments; calculating cost avoidance for positive patient outcomes; cost savings on time, supplies, and equipment used; and return on investment from use of infusion teams." Hadaway emphasizes, "I think the most successful hospitals are the ones that examine their outcomes and identify the approaches that produce better outcomes. They also know to study what went wrong as well as what went right. If they have an outcome that is not so good, they ask themselves, 'What did we miss? What could we have done differently or better?' Some facilities, instead of looking at outcomes, they look at productivity, such as the number of venipunctures or lines placed, but that won't tell them if they had CLABSIs that decreased their revenue. Many nurses don't understand the ways money comes into hospitals and how the business side of the operation works. They don't understand DRGs and cost-containment issues versus revenue-producing issues. We know that complications such as vein thrombosis can be high with PICC use in some patient populations. The goal is to choose the least invasive device, so that means use of short and long peripheral catheters. Long peripheral catheters are relatively new type of peripheral catheter that can function well for the entire course of therapy and avoid use of PICCs that add risks of complications and therefore costs and added length of hospitalization." In the INS whitepaper, Making the Business Case for Infusion Teams: The Purpose, People, and Process, Hadaway and Wise, et al. (2013) note, "Currently, the United States is in the early stages of restructuring many aspects of fnancing its healthcare system with the introduction of value-based payments and pay-for-performance programs. The impact of these changes on infusion teams is yet to be determined; however, the renewed emphasis on improving patient outcomes and I think the most successful hospitals are the ones that examine their outcomes and identify the approaches that produce better outcomes. Tey also know to study what went wrong as well as what went right. Ò

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