The three keys to reduced PICC infections
Education, education, and education
How do you keep PICC infections to a minimum? It may sound like the $100,000 question, but at least one agency seems to have the answer down pat.
Guthrie Advantage Home Infusion Services in Sayre, PA, had a 0% infection rate in its most recent quarterly report, covering 38 placements. That was no fluke either, as Renee Marshall, RN, clinical director for Guthrie, will attest. An infection rate of well under 2% is the norm.
How do they do it? Marshall says it boils down to educating patients, staff, and nurses from other agencies regarding proper aseptic technique, and leaving nothing to chance.
Marshall emphasizes that patients are never allowed to do their own dressing changes, a fact she says is paramount to low infection rates.
"We do not allow and don’t encourage and empower patients to change their own dressings," she says. "We tell patients that if there is any loosening of the dressing, the only thing they are encouraged to do is reinforce it if it is coming loose at the ends."
Marshall notes that there is a very good reason for being so strict with patients.
"We find that, even when they are changing their dressing in our ambulatory infusion site, patients don’t understand the importance of aseptic technique," she says. "They touch things they are not supposed to touch, and it’s simply because they don’t realize the importance."
And then there’s the fact that many patients have just one good hand to work with due to the placement of the IV. So rather than allowing patients to change their own dressings, Guthrie teaches patients when a dressing should be reinforced and when they should call.
"They can describe it too us over the phone, and at that time we can determine if it necessitates a nurse going out there or if it can wait until the next visit," says Marshall, adding that "we provide thorough education for the patient so they’re not calling us unnecessarily."
Reduced costs don’t equal reduced visits
You might think that reduced expenses and lower reimbursement rates would prohibit an agency from doing more visits than are absolutely necessary. But Guthrie takes care of the possibility for such "extra" visits upfront.
"Our dressing changes are scheduled weekly, but we also stipulate in our plan of treatment that we will do a dressing change as needed," notes Marshall. "That is established with the insurance companies upfront."
It is also important to note that patients are provided with educational materials specific to their therapy. Guthrie has put together extensive teaching materials that cover a wide range of topics. More importantly, the materials cater to Guthrie’s patient population.
"We are in a rural setting, and sometimes the literacy may not be the best, so our material is geared toward that patient population," says Marshall. "We use a lot of pictures and actually developed the teaching materials on our own."
To avoid overwhelming patients with pages of information they won’t need, Guthrie gives patients only materials that are specific to their therapy.
"We have specific instructions that deal with gravity drip, how to aseptically draw up syringes, even materials specific to each different pump we use," says Marshall. "The patient is not getting a packet of information they have to sift through. We only provide them with the information they need and put that in a folder."
Nurse education
Marshall says a common mistake many home infusion providers make is assuming nurses know all there is to know about dressing changes.
"A lot of times the assumption is that any nurse would know how to perform a dressing change, but we don’t leave anything to chance," notes Marshall. "We have developed an IV course for our nurses, and we encourage nurses who work for the agencies we subcontract with to take our course, or at least take our materials."
The dressing change procedure is discussed in the IV course. (See PICC line dressing change procedure, p. 28.) But more importantly, it’s included in every dressing kit that goes out Guthrie’s door.
Customized dressing kits
Guthrie uses a company that makes "customized" dressing kits for the agency, which Marshall says has also helped keep the infection rates down.
[Editor’s note: Guthrie’s kits are ordered from The Clinipad Corporation, in Norwich, CT. Telephone: (860) 571-0100.]
"It may not be what’s different about it; it’s just what we felt were essential supplies," says Marshall.
Each kit includes:
• one 13 x 18 drape;
• one pair of sterile gloves;
• one isopropyl alcohol swabstick, triples;
• one iodophor PVP swabstick, triples;
• one Cliniguard protective dressing swabstick;
• one 1¼2 x 3 tape strips.
"We put one strip of the foam tape under the hub of the PICC line so we never have a hub irritating the patient’s skin," explains Marshall. "We don’t want to compromise the skin integrity, and sometimes those hubs can irritate the patient’s skin or even break the skin. We also use another strip to actually secure the PICC line in place."
Other supplies in the kit include:
• one 1 x 18 Transpore tape roll;
• two 2 x 2 cotton gauze sponges;
• one 4 x 43¼4 Tegaderm dressing;
• dressing change policy.
Most important, according to Marshall, is the dressing change policy. "When the nurse opens that kit, the policy is right there, and it’s cut and dried and to the point," she says. "Our agency name and the contents of the kit are on the label, and on the flip side is our dressing change policy."
This is important because covering a 23-county area in rural Pennsylvania, Guthrie often subcontracts the nursing services to home health agencies. By keeping the dressing change procedure in each kit, all nurses follow the same procedure for keeping the site sterile.
"The combination of education and the meticulous attention to maintaining aseptic technique while performing catheter site care and dressing changes have been the critical success factors in maintaining the reduction in infection-related complications for us," says Marshall.
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