Reduce infection caused by poor habits
Agency spends years honing process
(Editor’s note: This story is part of an occasional series on what home care agencies are doing to control and prevent infections. See Homecare Quality Management, November 1999, p. 133, for a related story about preventing the spread of drug-resistant bacteria.)
No home care quality manager wants to hear that the agency has a problem with infection control, or even that the agency has one patient with an easily avoidable infection. But now that patients and their caregivers are taking over more responsibilities in handling intravenous care, infection control is a greater challenge than ever before. So it’s a good idea to have an ongoing quality improvement process that measures infection rates and assesses the cause of all patient infections.
The Visiting Nurse Association of Southeast Missouri has had an extensive infection control program since 1996, lately focusing on patients with central venous catheters and bladder catheters.
The program has worked. The agency’s infection rate for central venous catheters has been 0.5 infections per 1,000 device days, which is practically nothing, says Pat Huttegger, RNC, BSN, quality improvement director in the Cape Girardeau, MO, office. The agency has five offices in southeast Missouri.
The bladder catheter rate has ranged up to 4.4 infections per 1,000 device days. While this rate is higher than managers would like to be, it has improved since the agency implemented some quality improvement changes.
The path to improvement
Here’s how the agency has improved its infection control program:
• Track down the cause of each infection. The Visiting Nurse Association of Southeast Missouri has a standing policy that requires a culture whenever a patient has a suspected infection related to a central line catheter, Huttegger says.
"Late in 1998, we had a patient who developed an infection and I suspected what the problem was before the culture was ordered," she says. "It was an organism caused by a failure to wash your hands and it’s very common when hand washing isn’t done."
In this case the patient had been doing the infusions, apparently had not been using the good hand washing techniques the home care staff had taught the patient.
Coincidentally, another patient had a central line catheter infection within the same quarter, and again the cause was the patient’s poor hand washing technique.
By methodically finding the cause of each of those infections, Huttegger could see the beginning of a trend that needed to be stopped. So the agency began to use clinical teaching pathways that nurses use to document all of the different techniques they have taught patients. (See sample infusion therapy and urinary incontinence pathways, inserted in this issue.)
During each visit, nurses review the teaching material. The one-page pathways have columns for five visits in which nurses record the dates of the patient teaching. More pages can be used if the visits continue.
• Assess safety of equipment. Huttegger wasn’t pleased with the agency’s bladder catheter infection rate, which ranged from 2.2 infections per 1,000 device days to 4.4 infections per 1,000 device days.
"We studied these rates within the agency and found that the offices that were using silicone catheters were having fewer infections and less frequent infections than the offices using other types of catheters," she says.
So Huttegger showed the manager of an office where the silicone devices were not being used the infection data, comparing that office to the ones where the silicone devices were used. "I said that I had another office that used to have a fairly high rate and they have switched over to the silicone catheters and their rate dropped," she adds.
The office manager decided to switch, and the following week Huttegger spoke with a field nurse who said she could already see a difference among the patients whose catheters were switched to silicone devices. Those patients, who had previously complained a great deal, were calling the office far less.
• Monitor how caregivers/patients handle the catheters. Some patients have a family member who takes care of the catheter care and cleaning. In those cases, the nurse will visit the patient only once a month to change the catheter and review whether the caregiver is following the procedures correctly.
"We check to see if they’re using a good technique to prevent infection," Huttegger says. "For example, if they empty the Foley bag and leave the drainage spot dangling while they’re emptying the urine, then there’s an avenue for potential infection, for bacteria to travel up through the bag and into the bladder."
Nurses prevent problems by monitoring
To prevent those problems, nurses monitor the caregivers and patients as they perform the procedures, and they reinforce hand washing and other sterile techniques.
This patient education has increased in recent years as the agency has cut visits to handle Medicare and interim payment system pressures.
"There are fewer visits, so we teach families how to do IV therapy," Huttegger says. "In 1996, we didn’t teach them to do it to the extent that we do now."
In the beginning, nurses spend more time walking patients through the process of caring for their catheters. "It usually takes longer when it’s someone with IV therapy; we have to teach them to do their own infusions and flush their lines," she explains.
For example, patients who do their own infusion care must flush out their catheter line with saline and give themselves the proper dose of medication. Then they have to clean the injection caps and be careful not to touch and contaminate anything where the tubing attaches to the needle.
Nurses mostly continue to do the dressing changes, which is a very sterile procedure, although there are occasions when a patient’s caregiver is comfortable enough with the procedure to be taught how to do it.
• Pat Huttegger, RNC, BSN, Quality Improvement Director, Visiting Nurse Association of Southeast Missouri, 1143 N. Kings Highway, Cape Girardeau, MO 63701. Telephone: (573) 335-5256.
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