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New Practices Dramatically Affect Care

Long accepted as a risk related to a valuable intervention, catheter-associated bloodstream infections are becoming a thing of the past at Children’s Hospital of New Jersey at Newark Beth Israel Medical Center.

“We’ve seen dramatic results in decreasing the number of line infections in our unit,” says Coleen Murphy, RN, assistant nurse manager of the Pediatrics Critical Care
Center at Children’s. “People see this as a real process with human results, and they
feel empowered.”

The hospital joined a multiyear, multicenter initiative by the National Association of Children’s Hospitals and Related Institutions (NACHRI) to prevent catheter-associated bloodstream infections and to evaluate the results.
“Eventually, this will set the national standard of care, and to be in on it from the ground-breaking entry level is exciting,” says Diane B. Stewart, RN, MSN, CCNS, CPNP, CDE, diabetes educator at Children’s.

A dramatic difference

Before the study began, between one and a handful of Children’s patients developed a central line bloodstream infection monthly; the 19-bed Pediatric ICU did not track the rate.

The new protocols were implemented on October 1, 2006; since then, the unit had 1,285 line days without infection and only one catheter-associated bloodstream infection during the entire year. “We never realized how dramatically our practice could change and affect care,” Murphy says.

According to protocol, Lynn Lawlor, RN, dons sterile gloves and a mask before touching the central line at the insertion site.

RNs advocate

Nurses play a critical role in preventing central line infections. They are responsible for their own actions as well as those of others; they must stop a procedure if all of the protocol steps are not taken.

“Participation in the study has enabled our nurses to become true advocates for their patients,” says Kristin Goldmacher, RN, research coordinator at Children’s. “It also, by default, has strengthened the bonds we have as an interdisciplinary team. We’re always working together for one common goal — the benefit of the patients.”


Children’s physicians received an invitation from NACHRI to participate in the study, and the hospital jumped at the opportunity.

“It was a chance to decrease central line infections and decrease morbidity and mortality of children,” Murphy says. “It was an honor to try to establish best practices to that end.”

Pediatric facilities often lack sufficient patient volume to generate enough data in order to obtain statistically significant results. “By participating in this study, we get the numbers to have meaningful data,” says Nan Mayland, RN, BSN, CCRN, clinical educator for the Children’s Hospital PICU.

Children’s nurses and physicians met in person with teams from the other 28 hospitals before implementing evidence-based practice changes. Weekly conference calls and spontaneous e-mails followed as the hospitals encountered problems or questions arose.

For example, in switching to chlorhexidine gluconate to clean central line ports of entry, facilities discovered the products came in two different concentrations, raising concerns that the higher concentration could lead to line degradation. However, if facilities used different strengths, it could affect the data. The hospitals quickly came up with a plan to use the same lower-strength swabs.

“It helped getting feedback from many institutions,” Stewart says.
Goldmacher taught the PICU’s 70 nurses one-on-one about the study, the new protocols, and policy changes, while the physician liaison trained the physicians. Posters and open forums helped to reinforce the education.

Changes in practice

The study team developed bundles of interventions to be completed during catheter insertions, dressing changes, and weekly maintenance checks on every line.
Before a line is inserted, a sterile drape is placed over the patient’s entire body, instead of draping just the specific area. Everyone in the room must wear a mask. Chlorhexidine gluconate replaces betadine and alcohol for cleaning the site.

“We had another major culture change, which was ‘don’t touch a line if you don’t have to,’” Goldmacher says. “We were changing our central line dressings Monday, Wednesday, Friday, and PRN. We felt we were doing the best thing by being proactive, even if it didn’t necessarily need changing. As a result of the collaborative, we change our dressings once a week or PRN.”

Nurses wear sterile gloves and a mask when touching the line at the insertion site, for example, when changing dressings, medication tubings, stopcocks, t-connectors, or TPN or lipid solutions. All lines must be primed over a sterile field.

When opening the lines for any reason, nurses now scrub the connections with chlorhexidine for 30 seconds and allow them to dry for 30 seconds before changing a bag or syringe. No waving or blowing to speed drying is permitted. Nurses wear clean gloves when the activity takes place at the pump.

During daily rounds, the team discusses whether a central line is still needed. Children’s also put together a central line cart, which contains everything needed to start or maintain a line, including checklists and forms developed for each bundle, which are designed for real-time completion.

At Children’s Hospital of New Jersey at Newark Beth Israel Medical Center, nurses use chlorhexidine
gluconate swabs to clean central line ports of entry.

Final guardians

“It’s been an empowering tool for the nurses,” Murphy says. “We are the final guardians. If we see something not being done exactly according to the protocol, we stop the process and, depending on the breach, either stop and continue the proper way or restart the process.”

Consequently, participating in the study required more documentation than in the past. “There was an increase in the amount of paperwork we had to do, but it wasn’t tremendous,” says Sue Krauss, RN, BSN, CCRN, a staff nurse in the PICU. “The checklists are helpful, because they remind everyone of what is supposed to be done. Since it’s a new procedure, it’s helpful to have a reminder.”

Word spreads

The one infection in 1,285 line days strongly affected the entire staff. The team had had up to 268 infection-free days before a prominently displayed chart reflected the infection — dropping back to zero. “The morale went down dramatically,” Stewart says. “It took a while to get it back up.”

The hospital held thank-you breakfasts and gave gift cards for any new ideas. They searched for reasons why an extremely ill child developed an infection — to learn from and to prevent it from happening again. The root cause analysis found that when the Cardiac Surgery Service cared for the patient’s right atrial line, they did not follow the same dressing change protocol as the rest of the units.

“As soon as they realized that was part of the reason for the infection, they came to us and we taught them what we were doing. They totally bought into it,” Stewart says.
As time passed and as the number of infection-free days on the chart began to rise, nurses began to feel accomplished again, Murphy says. Clinicians throughout the hospital soon learned of the team’s success in reducing infections. Physicians from other units have asked to learn the protocol.

Goldmacher has found the unit’s culture has changed dramatically, not just in how nurses care for the lines but also in how they work as a team with one another and with the physicians.

“What we do every day affects morbidity and mortality,” Murphy says. “Having best practices and using evidence-based medicine is the future of nursing. We all have a duty to be educated about these practices.”


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By | 2020-04-15T15:23:18-04:00 January 14th, 2008|Categories: New York/New Jersey Metro, Regional|0 Comments

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