Stay on top of catheter quality, nurses urged
September 1, 1999 6 minutes read
Stay on top of catheter quality, nurses urged
Devices could affect infection, mortality rates
A controversial 1996 report that created a scare in critical care medicine concerning the quality of central venous catheters has faded over time. But it’s left lingering questions for nursing administrators about what to do if the catheters used by nurses in their departments are raising potentially harmful red flags. The alarming rise of nosocomial infection rates in ICUs, for example, has focused on catheters as possible culprits.
Critical care departments are among the highest users of central venous catheters. And while hospital product evaluation committees are said to be doing a good job on quality oversight, experts are advising nurse managers to rely more on their own judgment on what constitutes quality, but get help and second opinions from expert resources. Don’t take someone else’s word, they say.
The controversial report, published in the Journal of the American Medical Association (JAMA), stated that use of pulmonary artery catheters was responsible for high mortality rates and longer ICU stays.1
The report immediately triggered loud debates over catheter quality, sending even major manufacturers in to quell clinicians’ concerns.
Clinicians concerned about safety
But after reviewing the findings, most clinicians concluded that catheters were in fact safe to use; however, they should be used carefully, especially when utilized in conjunction with other complicated therapies.
The catheters themselves weren’t often at fault, but played a minor role when employed with other invasive interventions and monitoring equipment in the ICU, most observers concluded. There was also the possibility of human error or poor handling, they added.
The controversy may have died down, but it hasn’t disappeared. Some hospital-level clinicians are still bothered by the questions raised by the JAMA report.
"If there are questions, look for outside resources," advises Sandra Reiner, RN, CIC, an infection control coordinator at Northwestern Memorial Hospital in Chicago. "Not all catheters are the same; but they’re not always responsible for the problems with patients," she cautions.
Don’t take the blind road; Reiner further advises nurse managers to seek outside help. There’s plenty of help available, she adds. Hospital infection control departments are the likely first stop for advice. And speak up, even if doing so contradicts the hospital endorsement of a product.
Unfortunately, as yet there are no uniform or standard quality tests when evaluating catheters in-house. But guidelines for the use of a range of ICU technology, including central venous catheters, have been published.
The American Association of Critical Care Nurses (ACCN) in Aliso Viejo, CA, for one, has established research-based practice protocols as a guide for clinicians on the optimal use of a range of ICU technologies.
The Society for Critical Care Medicine in Anaheim, CA, offers published guidelines on catheter and other technology usage.
Push for uniform catheter usage
But these resources don’t necessarily focus on steps in conducting formal product evaluations in the ICU. And catheter makers, while they are actively sponsoring research, are usually guided by self-interest and aren’t objective information sources, Reiner cautions.
AACN, however, is leading a nationwide program to create greater consistency in catheter usage in hemodynamic monitoring that may offer more direction.
Awareness of quality is growing, says Thomas S. Ahrens, RN, DNS, CCRN, a research scientist and clinical nurse specialist at Barnes Jewish Hospital in St. Louis. He has studied and written extensively about the JAMA catheter controversy.
In light of the absence of uniform testing protocols for nurse managers the quality assurance process, according to Reiner and Ahrens, begins with these preliminary considerations:
• Consider a catheter study
Consider whether you should launch a unitwide catheter study. In many cases, the problem is likely to involve bloodborne pathogens. If so, the hospital’s infection control department (ICD) will need specific data about the incidence of the infection rate. The ICD staff will recommend whether a study is in order, based on information provided by your personnel.
If the problem involves rising mortality or acuity rates, the risk management and resource utilization department should be contacted for similar direction. Do not attempt to ignore or keep the growing trend a secret. The information will inevitably be revealed, Reiner says. Also, catheter studies can be time- and labor-intensive activities that could tie up a clinical nurse specialist who has other responsibilities. Make certain you are prepared to undertake such an enterprise, she adds.
Three years of data may be necessary
• Get sufficient evidence
In weighing whether to undertake a catheter study, do not base your conclusions on reported incidents within a few months. Especially in a large critical care unit of 20 or more beds, the available incidence data should go back farther than six months or a year, according to Reiner. In some instances, the ICD will require one to three years’ data before determining whether to recommend a study.
In many cases, a type or brand of catheter may provide superficial evidence that patients are taking longer to wean or transfer to a step-down. Infections may be originating not from the catheter, but from unclean tubing or pump surfacing in a catheter, says Ahrens. Remember, patients’ acuity in the ICU is higher today, and that trend could alter your data to appear that a problem may be worse than it is, he adds. Therefore, make certain your data is relatively clean.
• Analyze the problem
In preparing to approach the ICD or evaluation committee, make certain you’ve covered your bases. Track down systems’ breakdown areas that may be linked to a possible catheter problem by specific elements such as suspected problem site, individual nurse or physician, and patient-related factors such as age, gender, acuity, comorbidities, diagnoses, and underlying disease factors.
Also, present the data in various forms such as infection rates per 1,000 patient days or the number of catheter days per number of patient days. These presentations will offer unit outsiders an easier means of reaching a decision about the gravity of the problem, says Reiner.
• Weigh switching catheters
In doing so, consult with key members of your product evaluation committee. Usually, the committee has a nursing representative. But also seek guidance from colleagues, including physicians, from outside hospitals, says Ahrens. Determine whether they are experiencing similar problems with their catheters.
If not, obtain as much product information in the form of objective controlled studies to recommend that the hospital switch to another type of catheter. Most catheters are roughly equal in quality and safety. But no catheter, regardless of make, is problem-free, Ahren notes.
A hospital is likely to consider changing its product type or brand in light of compelling evidence, especially if the catheter demonstrates greater value — i.e., a longer life span, fewer problems, at the same price per unit, Reiner says. Several studies have looked at the efficacy of heparin-coated and anti-microbial impregnated catheters for their infection-resistance value. So check the literature, Reiner advises.
• Limit vendor information
Although the information may be helpful, manufacturers’ priorities usually differ from clinicians’ when assessing technology, says Ahrens. "Manufacturers have a vested interest in selling new technology rapidly and in large volumes," Ahren says.
At least a half dozen companies manufacture central venous catheters. Each one has merits, but only one may be right for your unit, Reiner cautions.
• Get the team’s buy-in
Include nurses and other personnel in discussions. A major debate involving catheters relates to the levels of types of antibiotic lumen materials used for treating many of today’s catheters.
Ask one of your clinical nurse specialists to research the literature and provide recommendations regarding the merits of using treated triple-lumen vs. untreated catheters and when.
Conduct a product re-evaluation regularly that involves the clinical staff, advises Reiner. Once every two or three years is a good interval.
Reference
1. Connors AF, Speroff T, Dawson NV, et al. The effectiveness of right heart catheterization in the initial care of critically ill patients. JAMA 1996; 276:889-896.
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