Abstract
Preventing central line associated bloodstream infections (CLABSIs) are a significant part of everyday care in a hospital. Liebrecht and Lieb (2016) state that a CLABSI infection has a mortality rate of 12-25%. If a patient were to get a CLABSI, that not only is a significant adverse event for a patient, but also costs the organization a substantial amount of money.
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One significant piece of preventing infections and medication errors is labeling all intravenous medication lines. According to Wolf (2016), IV medication errors are preventable, and these errors can cause an even higher adverse event for a patient more so than other medications. Both labeling central line dressings and intravenous medication lines with change date, time and medication running are important to keep patients as healthy and safe as healthcare providers can. Doing these simple steps for prevention of these issues can prevent adverse patient events and will save lives.
Policy and Procedure
The policy and procedure that I chose to cover is the IV policy at my clinical agency. This policy covers two major factors in preventing CLABSIs and medication errors. These factors are labeling all central line dressings with date and time of change along with initials. The other portion is labeling all IV medication lines with change date, time, initials and medication running. This is not only apart of this policy but it is best practice.
A vital factor to note for this project is the IV policy at my clinical agency was currently changing so it was new for all staff. Finding the new policy for myself and other staff members was a little challenging because the wording must be correct with the policy website called policy tech. The best way to find the correct policy is with the policy number, which most staff did not know.
Since the policy was revised, the new policy was being emailed out to all staff members. Each year, there are learning modules to be completed online based on pertinent policies per unit. The new changes were communicated to staff via this route to ensure staff knew of the major changes.
The other great piece about my clinical agency’s IV policy is that it is entirely evidence-based. All the references used to create the policy are noted at the end of the policy itself. Some of the major references noted are from the CDC, Infusion Nurses Society, The Joint Commission, and Intravenous Nurses Society but there are many more than these.
More current practice standards that my agency follows is from the Infusion Therapy Standards of Practice. Gorski et al. (2016) also suggests that labeling all IV medication lines with date and time, name of medication and the initials of who prepared the medication is essential in preventing medication errors and adverse patient events.
Observations
There was an opportunity for me to observe an IV infusion nurse changing a central line dressing. This opportunity showed me the correct steps that needed to be taken to appropriately change central line dressings and recognize when I see deviations from this process. While observing this RN, I had a checklist and policy my agency used to follow correct steps. This RN followed policy step by step. The only thing that I saw that I questioned because I work with sterile technique everyday in the operating room, was the RN while cleansing the site scrubbed site, around the site, then back to the site. The Association of Surgical Technologist (2008) state, “Once the boundaries/periphery of the skin prep have been reached, the sponge should be discarded and not brought back over the clean area. The most important principle of skin prep is prepping always progresses from the clean to the dirty area.” Other than this one thing I saw, the RN followed each step of the checklist and policy without deviation.
After following registered nurses on all different units throughout my clinical agency, I found many deviations from the IV policy and procedures. Roughly 41% of all patients I observed had the change date and time on the IV medication running and 30% had the medication labeled. The central line dressings were labeled 56% of the time. The data got better once the IV access nurse started working with the educators on the units. The Joint Commission (2014) states, “tubing should be labeled to mitigate against the chance of misconnection, especially in circumstances where multiple IV lines are in use (p.4). Audits started to be performed on the units because of the data that I and the IV access nurse were providing. Because of the new policy rolling out, this was a big change for staff, so I do feel as time went on, I saw more of the policy being followed and more nurses recognizing the errors.
One factor that I found for nurses not doing the labeling of lines or dressings is time. I did find nurses were not always comfortable with changing central lines so that task did get pushed off past the 7 days a few times, but also due to time. I heard a lot about acuity of patients and the number of patients nurses would have leading them to skip past these steps.
There could be some serious consequences for skipping some of these easy steps. One major long-term risk factor in not labeling central line dressings is infection. CLABSIs can be prevented. According to Barnes et al. (2015), CLABSIs are not only extremely costly for a patient’s health but also economically for a healthcare institution. “It was estimated that 5,520 to 20,239 lives would be saved annually with best practice implementation” (Barnes et al.,2015, p.6). Following best practice for insertion and maintenance for central lines, including labeling dressings and documentation, is crucial for better patient health outcomes.
Not labeling IV medication lines proposes short term possible long-term risks including medication errors and infection. Labeling medications, especially high alert medications or patients with multiple lines, helps staff to recognize which medication is running where and to decrease chances of running the wrong medications together. It is essential to label all IV tubing to indicate the correct line and device, and to place the label near the connection to the device (Gorski et al, 2016, p.84). One question is: does labeling central line dressings and all IV tubing with change date and time, and medications running reduce the risk of CLABSIs and medication errors compared to not labeling within 6 months? I truly believe prevention is key for any adverse patient reaction and following these standard practice guidelines will prevent infection and medication errors at a higher rate than not.
QSEN Competencies
Each category of QSEN represents a goal to make nursing even better.There are six QSEN competencies that I can apply to my clinical experience. Each of these competencies represents why this concern needs to be addressed and why it is significant in everyday practice.
QSEN Quality Improvement Competency
After following the IV access nurse, it was apparent how dedicated she is to her patients. She may be the person they call on for PICC line insertions and hard IV sticks, but she is always learning herself and making sure she along with others deliver quality nursing care. The quality of care is always an important factor in patient health outcomes especially for infection prevention and decreasing medication errors. As a nurse, understanding that quality care is not just being timely with medications or doing well on yearly reviews, but it is about data and evidence-based practice standards. “The ethical responsibility of quality improvement includes commitment to provide the best-known care as well as the ethical conduct of the process itself” (Sherwood and Barnsteiner, 2012, p.15).
QSEN Patient Centered Care (PCC) Competency
The infusion access nurse made each patient apart of their care and made sure they understood all parts of their care especially when it came to their central lines and medications. Sherwood and Barnsteiner (2012) suggests that keeping patients apart of their plan of care can help prevent errors because patients are familiar with what should be happening in their plan of care. Patients feel more comfortable when they understand what is going on with their health and their plan of care. Involving patients allows them to keep some control over their health and more engaged in their care plans.
My agency, Aurora Medical Center-Oshkosh, takes pride on providing patient centered care and working as a team by allowing patients a right to be a part of their healthcare plan whether it be religious values or preferences. “Care decisions are based on knowledge of patient values, beliefs, and preferences so that patients and their families are treated with respect and honor, included as partners in care and treated safety allies” (Sherwood and Barnsteiner,2012, p.15). What we do as nurses should always be about our patients and being an advocator for them is one of the best attributes we have as a nurse.
QSEN PCC & Teamwork & Collaboration Competencies
The IV access nurse works very closely with the staff RN, physicians and infectious disease. Her job is to coordinate care with these healthcare members to make sure the patients plan of care is appropriate especially if they need more than a peripheral line.
Aurora makes each patient feel appreciated and valued while staff provides them excellent care. This is especially important in my practice as well because I feel each patient should be treated as an individual not just another patient. Working in a team provides patients with more minds working together and creates a better outcome in providing superior care.
QSEN Evidence Based Practice (EBP)
The IV access nurse has taught me so much in the few hours that I had spent with her. She has created many if not all the policies based on the APIC and INS guidelines and other evidence she has researched. Showing staff members that a new policy is coming from actual evidence supported data will increase the likely hood of compliance and understanding of the change. Sherwood and Barnsteiner (2012) sugget that best practice comes really from research and is evidence-based. Many of the RNs, including the IV access RN, rely heavily on and form policies based on evidence. I also rely on research and evidence because it all ties together with how a nurse should practice. Experience such as judgement and expertise of what we think works and tying that into what is proven to work is essential in being a quality nurse.
QSEN Safety Competency
Labeling central line dressings and IV tubing are very important regarding patient safety. I came across many dressings and IV tubing not labeled. The definition of safety in nursing is to minimize the risk of harm to patients not only through evidence-based practice and polices but also through the individual performance of each nurse (Sherwood and Barnsteiner,2012, p.242). Some of the medications were high risk and could cause an adverse reaction if another medication would be run with it. What I did find interesting is the ICU was more consistent with having everything labeled. Some of these patients had eight or more medications running, so labeling is extremely vital in knowing which line is running where particularly with limited IV access.
QSEN Informatics Competency
Nurses use informatics every day to retrieve information. Basic charting allows us to go back and look at information. “Informatics is a thread through all the competencies to help manage care through documentation in electronic health records, decision support tools, and safety alerts” (Sherwood and Barnsteiner,2012, p.16). The central lines that were not labeled needed to be addressed, so the IV access nurse would show me where to look to find the date of placement and last dressing change.
Literature Review and Interventions
Preventing medication errors and infections such as CLABSIs are an important factor in everyday nursing care. Matocha (2013) states that on every shift, central line dressings should be checked for correct labeling, catheter necessity, and integrity of the dressing. Also, not having the dressing labeled with date and time is against the INS standards of practice, which my clinical agency also follows. Not following these standards, or not checking the dressings integrity and documenting it could lead to a CLABSI infection. With every shift change, nurses should be assessing the entire patient including the central line dressing and need for the central line itself.
Some of the things I noticed on the units were nursing talking about not enough time to do things like these central line dressing changes and would pass it off to the next shift or nurses didn’t do this task enough and felt uncomfortable changing the dressing in a sterile manner. According to the Association for Professionals in Infection Control and Epidemiology, Barnes et al. (2015) states, “The risks of central line use are significant. Central lines are a major risk factor for bloodstream infection, are associated with a 2.27-fold increased risk for mortality and drive up health costs. It is apparent that CLABSI represents not only a serious and ongoing patient safety threat but also a major economic burden for healthcare providers”. What could be done to combat this issue is to provide staff with more education, hands on and ongoing training for central line dressing changes and discuss the importance of why it needs to be done the way it needs to be done. Also, having quick, easy access cheat sheets on how to change a central line and pictures of what a good dressing looks like would help nurses who do this task infrequently (Matocha,2013).
The other concern is not having IV tubing labeled with date and time change and medication running. Not having medications labeled with the medication running, date, time and initials, especially with multiple IV lines or high-risk medications, could result in patient harm. Aust (2011) suggests some interventions for this issue would be to label all IV tubing and catheters, tracing all lines before giving any medications and making this also apart of shift report when handing off patients. Doing this process should be a standard part of everyday nursing care especially when giving report to the oncoming nurse.
IV medications are known to have a higher medication error rate over any other medication. Strbova, Mackova, Miksova and Urbanek (2015) suggest, “all drugs prepared for parenteral administration should be correctly labelled. Drugs with the highest risk are those not administered immediately after preparation and the risk increases significantly if their labelling is not sufficiently clear” (p.2). Labeling IV medications only decreases the risk of a medication error resulting in patient harm. The more IV lines there are, the more chances there are to give the wrong medication or give it with a medication that is not compatible; here is where labeling IV medication lines near the pump and near the port closest to the patient plays a significant role (The Joint Commission,2014, p.4). This intervention was being implemented at my clinical agency and was one of the barriers as staff felt placing one label should be adequate but research shows having both sites labels further decreases chances of medication error.
An alarming statistic from a study done in the UK about preventing medication errors and infection as stated by Lavery (2011), 43% of medications were not labeled or incorrectly labeled, 49% selected the wrong IV infusion rate and 100% of staff deviated from aseptic technique (p. S30). Aseptic technique involves scrubbing the port or hub with 2% chlorhexidine or 70% isopropyl alcohol for 15 seconds and allow to air dry for 30 seconds (Lavery,2011, p.S32). I did observe nurses scrubbing the port but most of the time it was for far less than the 15 seconds that is recommended.
Recommendations and Improvements
One major recommendation to combat part of the training and education issue is to incorporate a learning center for all staff. A learning center would be an area in the education department where educators, super users, clinical nurse specialists or qualified staff could educate staff on various nursing practices and skills. Nurses could come here to brush up on skills, utilize different equipment and supplies, and have some hands-on training at their convenience. This learning center would also be something required for new nurses to go through to make sure their skill level is adequate and they are comfortable before and during their practice. Chaghari, Saffari, Ebadi, and Ameryoun (2017) state, “The empowering education refers to self-direction and practicality. Self-directed learning represents self-centeredness and initiative in learning. Also, practicality is application of training in job functions”. Allowing staff to come during work or non-working hours to brush up on skills or ask questions will create a safe environment for staff to feel comfortable about asking for help with their skills.
An improvement for central line dressing changes would be to have a bundle for central lines to prevent a CLABSI. O’Neil et al. (2016) suggest having a bundle to show nurses how to care for central lines. This bundle would include visual aids and literature on how to do a proper dressing change, accessing the catheters and supplies, and other education materials on how to properly care for a central line. This would especially be a great resource for staff members who infrequently perform this task.
Another enhancement for practice and the agency is to adapt a better acuity tool but also educate staff on higher acuity patients; which goes back to the learning center idea. Incorporating a MEWS system or modified early warning system to help nurses score patients based on their vital signs. Mathukia, Fan, Vadyak, Biege and Krishnamurthy (2015) state, “The Modified Early Warning System (MEWS) is one of such systems that use temperature, blood pressure, pulse, respiratory rate, and level of consciousness with each progressive higher score triggering an action.” This tool not only provides nurses with information for deteriorating patients but also shows the acuity level of this patient. Patients are becoming sicker leading them to be on a higher acuity level. Nursing school does not always teach nurses how to prepare for the level of acuity that will be seen, it’s more on the job training.
Nurses today are having to absorb much more information in a short amount of time to keep up with the patient populations. Nguyen (2015) states, “After we have a proper and updated assessment of acuity, we can match the work required to the skills, experience, capacity, and availability of the nurse. The nurse isn’t overloaded, the work is equitably distributed, and we create a safer environment for both nurses and patients” (p.38). Whether a veteran or newer nurse, education needs to be provided for higher acuity patients especially if those patients are outside the normal patient population of the unit. Providing the units with a better acuity system to level load assignments will help alleviate part of the not having enough time due to acuity to perform essential tasks.
Labeling central line dressings and all IV medications not only prevents CLABSIs and medication errors but it also makes everyday practice in caring for patients easier. Patients’ acuity levels are increasing which is requiring more medications and more lines resulting in nurses needing to pay much closer attention to their care. These changes in practice will result in safer, quality patient care.
References
AST Standards of Practice for Skin Prep of the Surgical Patient. (2008, October 20). In Association of Surgical Technologists. Retrieved from http://www.ast.org/uploadedFiles/Main_Site/Content/About_Us/Standard_Skin_Prep.pdf
Aust, M. (2011, July). Tubing Misconnections. American Journal of Critical Care, 20(4), 346. https://doi:10.4037/ajcc2011966
Barnes, S., Olmsted, R. N., Monsees, E., Harris, J., Khoury, R., Hadaway, L., & Downham, G. (2015, December). Guide to Preventing Central Line-Associated Bloodstream Infections. In Association for Professionals in Infection Control and Epidemiology. Retrieved from https://apic.org/Resource_/TinyMceFileManager/2015/APIC_CLABSI_WEB.pdf
Chaghari, M., Saffari, M., Ebadi, A., & Ameryoun, A. (2017, January). Empowering Education: A New Model for In-service Training of Nursing Staff. Journal of Advances in Medical Education & Professionalism, 5(1), 26-32. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5238493/
Gorski, L., Hadaway, L., Hagle, M. E., McGoldrick, M., Orr, M., & Doellman, D. (2016, January). INFUSION THERAPY STANDARDS OF PRACTICE. Journal of Infusion Nursing, 39(1S), 1-155.
Lavery, Irene. “Intraevnous therapy: preparation and administration of IV medicines.” British Journal of Nursing, vol. 20, no. 4, 7 Mar. 2011. CIHNAL Plus with Full Text.
Liebrecht, C. M., & Lieb, M. C. (2016, July 15). Incorporating Quality and Safety Values into a CLABSI Simulation Experience. Nursing Forum, 52(2). https://doi.org/10.1111/nuf.12175
Managing risk during transition to new ISO tubing connector standards. (2014, August 20). In The Joint Commision. Retrieved from https://www.jointcommission.org/assets/1/6/SEA_53_Connectors_8_19_14_final.pdf
Mathukia, C., Fan, W., Vadyak, K., Biege, C., & Krishnamurthy, M. (2015, April 1). Modified Early Warning System improves patient safety and clinical outcomes in an academic community hospital. Journal of Community Hospital Internal Medicine Perspectives, 5(2). http://doi:[10.3402/jchimp.v5.26716]
Matocha, D. (2013, September). Achieving Near-Zero and Zero: Who Said Interventions and Controls Don’t Matter? The Journal of the Association for Vascular Access, 18(3), 157-163.
Nguyen, A. (2015, January). Acuity-based staffing: Reducing costs, increasing quality. Nursing Management, 46(1), 35-39. https://doi:10.1097/01.NUMA.0000459555.94452.e2
O’Neil, C., Ball, K., Wood, H., McMullen, K., Kremer, P., & Jafarzadeh, R.,…Warren, D. (2016, March 21). A Central Line Care Maintenance Bundle for the Prevention of Catheter-Associated Bloodstream Infection in Non-ICU Settings. Infection Control and Hospital Epidemology, 37(6), 692-698. https://doi.org/10.1017/ice.2016.32P
Sherwood, G., & Barnsteiner, J. H. (2012). Quality and safety in nursing: A competency approach to improving outcomes. Hoboken, NJ: Wiley-Blackwell
Strbova, P., Mackova, S., Miksova, Z., & Urbanek, K. (2015, July 31). Medication Errors in Intravenous Drug Preparation and Administration: A Brief Review. Journal of Nursing and Care, 4(5), 1-5. https://doi:10.4172/2167-1168.1000285
Wolf, Z.R. (2016, July). Medication Errors Involving the Intravenous Administration Route: Characteristics of Voluntarily Reported Medication Errors. Journal of Infusion Nursing, 39(4), 235-248. https://doi:10.1097/NAN.0000000000000178
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