Guidelines Reduce Bloodstream Infections in the Oncology Unit

In 2008, the Centers for Medicare & Medicaid Services ruled that bloodstream infections (BSIs) from indwelling catheters in inpatients would be classified as "never events" and hospitals would no longer be reimbursed for treating these infections. As most nurses know, BSIs in patients with central venous catheters (CVCs) can be difficult to prevent. Consumer Reports recently reported that central-line infections account for 15% of all hospital infections and at least 30% of the 99,000 infection-related deaths that occur in hospitals each year. After observing a higher-than-expected number of BSIs in patients on the oncology unit at Seton Medical Center in Austin, Texas, Karla Smiley, RN, OCN, and Andrea Walker decided guidelines were needed to reduce this rate. BSIs are life-threatening; by some estimates, 20% to 35% of patients with severe sepsis and 40% to 60% with septic shock die within 30 days. Patients who survive sometimes have serious morbidity.

In Smiley and Walker’s oncology unit, patients routinely receive chemotherapy, biotherapy, blood products, antibiotics, and other treatments delivered via port-a-caths (PACs) and PICC lines. For patients with cancer—particularly those with neutropenia—BSIs present a serious risk to their well being. In the investigators' oncology unit, patients routinely receive chemotherapy, biotherapy, blood products, antibiotics, and other treatments through port-a-caths (PACs) and PICC lines. To ensure that the guildelines would be effective, Smiley and Walker knew they would need to involve the entire multidisciplinary team in the effort to prevent BSIs. This included nurses, clinical assistants, the PICC line insertion team, housekeeping, the transport team, and the imaging department.

One of the first steps was to educate each department on necessary precautions to take with neutropenic patients. The guidelines emphasize the importance of good communication within the multidisciplinary team “to provide safe care for patients.” This includes requiring use of a biopatch for all PACs and PICC lines. The guidelines also detail methods for changing catheter tubing and for using PACs accessed at another facility. Because patients with neutropenia are at much greater risk of complications from BSIs, Smiley and Walker created special rules for establishing a “Protected Environment” for these patients. Each day, these patients must receive a bath and change of linens. The rules discuss detailed room cleaning and outline steps for educating the patient and family on the need for scrupulous attention to cleanliness. As part of the new program, the nursing staff was re-educated on managing CVCs and instructed on the new guidelines and then tested for competency.

In the 2 years prior to establishing the CVC guidelines, the oncology unit at Seton Medical Center recorded 21 BSIs. This number dropped to 0 within 6 months of implementing the guidelines. In 2009, only 3 patients experienced a BSI, and these were traced to "translocation of bacteria into the bloodstream," rather than failure to follow the guidelines. In addition to improving safety and quality of life for patients, this dramatic decline in the rate of BSIs reduces costs associated with extended stays and additional treatment. The authors said the guidelines have also raised the standard of nursing practice at their facility, and their goal is to implement them throughout the network.