In a time of pandemic, staffing shortages, and a myriad of related woes, having an “epidemiology nurse” make rounds, checking on patients with central venous lines and other devices that may seed infections, may seem like a luxury. It actually is a wise investment.
A recent study estimated the average central line-associated bloodstream infection (CLABSI) costs $48,108, while increasing patient mortality by 12% to 25%.1 These costs and patient consequences may ensue if the central line is not routinely observed and maintained, which includes prompt removal when warranted.
Thus, one hospital system justified hiring two epidemiology nurses in 2018 after years of trying — with some success — to claw back CLABSI rates by various interventions.
Lisa Gentile, RN, an epidemiology nurse at UConn Health in Fairfield, CT, does daily device rounds to check on central lines and Foley catheters. She described the process recently in a webinar held by the Association for Professionals in Infection Control and Epidemiology.
“Before we hit the bedside, we start with a chart review,” Gentile said. “We get a list of the patients that have been admitted and have a central line or a Foley. We look in their chart to see what the indication is, get some background, and then we hit the floor and we go into the rooms.”
At that point, Gentile converses and collaborates with staff, getting any updates on the patient’s condition.
“We are boots on the ground,” she says. “We are staff education and support in real time. And we do see that this has made a tremendous difference. We discover potential infection risks using connection and conversation with staff and act as a resource.”
For example, Gentile recalls a patient admitted overnight that had an incorrect dressing over the central line and other factors that increased infection risks.
After redoing the line insertion site with a chlorhexidine (CHG) dressing per hospital policy, she reviewed the case and found that the anesthesiologist who placed the line did not have CHG dressing.
“When we learned that, we worked with them to get the CHG dressing to be part of their anesthesia cart, so that going forward any central line that got put in would have the correct dressing at the time of the line placement,” she says. “CHG is impregnated into the dressing, and its use is endorsed by the CDC (Centers for Disease Control and Prevention) as a best practice.”
Foley catheters also are checked by the nurse epidemiologist since they can seed patient infections if poorly maintained. The resulting catheter-associated urinary tract infections can cause patient discomfort, prolonged hospital stay, and increased cost and mortality, the CDC reports.
“It has been estimated that each year, more than 13,000 deaths are associated with UTIs,” the CDC notes.2
Through beside visits and conversation with staff, Gentile discovered that Foley catheters were being improperly drained through the sample port.
“I was asked by asked by nursing staff if it was OK to flush a Foley through the sample port, because a particular patient had a lot of sediment and the Foley was not draining well,” she said. “Many of their colleagues were doing this because there was apprehension about breaking that red [irrigation] seal. We all know that you don’t want to break that red seal unless there’s an absolute need for an irrigation.”
Moreover, Gentile was told by the manufacturer that draining the catheter through the sample port was an off-label use of the product.
“It was an ‘aha’ moment for us,” she says. ‘This led to re-education and [renewed] focus during our annual nursing competencies.”
‘Completely Unacceptable’
The epidemiology nurses provide critical oversight and prevent infections, and their presence can be traced back to a grim CLABSI report in 2006, says Nancy DuPont, RN, MPH, CIC, nursing director of epidemiology at UConn.
“In the first half of the year, we were experiencing seven central line infections per 1,000 catheter days in our adult ICU (intensive care unit), which then, and by today’s standards, is completely unacceptable,” she said. “And as horrifying as I’m sure everybody recognizes this is, at least we had a starting point to create our plan moving forward.”
In beginning to focus on reducing CLABSIs, DuPont soon noticed a Hawthorne effect, as workers, knowing the process was now being studied, subtly and perhaps unconsciously, changed their behavior enough to make the rates begin to fall.
The effort continued over several years, including ongoing re-education on proper protocol and new interventions.
“We started looking into ultrasound guidance for the purpose of placing peripheral IVs,” she said. “And we also developed central line carts for the units that had central lines placed most of the time.”
By 2010, they had cut the CLABSI baseline rate in half.
“We also provided unit achievement reports, which were distributed throughout the hospital and delivered to the key stakeholders of each unit,” DuPont says. “They displayed days since last infection, as well as device-related infections, influenza immunization, and hand hygiene compliance, and were to be reviewed during staff meetings.”
In a prototype for the eventual use of nurse epidemiologists, providers and nurses began to note whether a patient had a line or a device in place. “Then we conducted daily central line dressing rounds and those, at this time, were mainly conducted by the unit managers,” she said.
In daily safety huddles, infection prevention reported the number of days since the last infection, and whether any lines could be removed. CLABSIs fell to zero, only to spike up in 2016.
“That is when we went into full intervention mode yet again,” DuPont said. “We had unit-based staff meetings with the ICU staff. Infection prevention and quality was also involved with these meetings. We would discuss interventions to be done with the central lines and, also, the rates of infection, as well as other patient safety activities that we were concerned about. We also created enhanced central line and Foley catheter rounding tools.”
In addition, the UConn team implemented an easy-to-use antiseptic swab with a shorter scrub and dry time for catheter insertion.
“In 2018, we implemented a special central line insertion site dressing, which was impregnated with CHG,” DuPont says. “At this point in time, we took the device rounds from the responsibility of the manager, and they were conducted by the infection prevention team. We decided to take the responsibility into our own hands.”
Although considerable progress had been made, DuPont said it was time to reach out to leadership and let them know infection control was struggling to maintain low rates of CLABSIs. “This has a major impact on patients, patient families, length of stay, [and] financial burden,” they reminded.
They made their case, and the nurse epidemiologist positions were greenlighted in 2018.
“They were in put place to conduct device rounds on each patient every day, assisting in insertion site skin care, assessment of alternatives to the use of central lines, providing real-time education to bedside nurses, assisting them, providing education to the providers as well, and really interacting and collaborating with the staff,” she said.
In the second half of 2018, CLABSIs fell from four infections to two in the first half.
“We had a blip in 2019, but since then we have sustained a rate of maybe one central line infection per year, including the first half of 2022,” DuPont said. “We were also able to decrease central line utilization days and, of course, that is a direct result of the epidemiology nurse role.”
- Lowery J, Hays MJ, Burch A, et al. Reducing central line-associated bloodstream infection (CLABSI) rates with cognitive science-based training. Am J Infect Control 2022; Mar 17. doi: 10.1016/j.ajic.2022.03.011. [Online ahead of print].
- Centers for Disease Control and Prevention. Urinary tract infection (catheter-associated urinary tract infection [CAUTI] and non-catheter-associated urinary tract infection [UTI]) events. National Healthcare Safety Network. Published January 2023. https://www.cdc.gov/nhsn/pdfs/pscmanual/7psccauticurrent.pdf
