Quality and Safety
Nurses playing critical role in reducing hospital-acquired infections
Even with 35 years in the profession, Joan Walsh, a Rhode Island Hospital nurse manager, was still impressed when a nurse on her staff speculated that a patient's diarrhea might have been caused by acetaminophen and not a feared infectious disease typically acquired in hospitals. Diarrhea is a red flag for Clostridium difficile, which has clinicians on high alert because it's easily spread, difficult to treat and potentially life-threatening.
Even though acetaminophen doesn't typically cause diarrhea, Walsh followed up on the hunch that Danielle Robin, RN, had about her patient. Sure enough, Walsh learned that the drug had been administered in a liquid form that actually can cause bowel difficulties.
Such expert and conscientious care by nurses is essential to efforts to fight C. difficile, as it's called, as well as other infections spread in health care settings. Hospitals are under increasing regulatory and financial pressures to prevent hospital-acquired conditions (HACs) and nurses play a critical role in these efforts. These infections can complicate, lengthen and otherwise make a patient’s stay unpleasant while also taxing the resources of already stressed hospitals.
"Nurses are observant and they have excellent critical-thinking skills and judgment," says Walsh, MSN, RN, APRN, a nursing quality and safety manager. "They are an integral part of the team and they are the ones with the patients all day long. They get to know them so well."
Lifespan takes an interdisciplinary approach, involving multiple departments in efforts to reduce hospital-acquired infections. But nurses across the Lifespan system serve critical roles in the consistent implementation of evidence-based strategies to help avoid them.
Nurses respond to spike in respiratory illnesses
When a nasty respiratory virus season led to a spate of hospital-acquired infections at Hasbro Children’s Hospital two years ago, nurses jumped into action.
Following that 2015-16 winter, nurse leaders and infection control nurses joined staff from the PICU to hopefully prevent a reoccurrence, according to Julie Jefferson, MPH, RN, then director of infection control at Rhode Island Hospital.
What they came up with was a plan to screen all visitors and family members for infection. The next year, those who screened positive were asked to postpone their visits to see patients or to don masks, gowns and gloves. In the first year, there was a 50 percent drop in cases.
Continued . . .
The initiative proved so successful it was expanded to all of Hasbro, adult oncology, transplant units and the Lifespan Cancer Institute.
By March 2018, during an unusually active flu season, units that were not screening saw a 3.5-fold increase in cases while units that were screening saw just a 1.4-fold increase.
“Our patients were safer this year due to the combined efforts of nurses, secretaries, infection control practitioners, and all those who participated in the planning and execution of our plan,” says Jefferson.
But their efforts won’t stop there.
“Opportunities to improve the program for next year are already being discussed,” Jefferson says.
The difficulty with C. difficile
The elderly and people with health issues are most at risk for C. difficile, as well as people who have been taking antibiotics. A 2015 study by the US Centers for Disease Control estimated that C. difficile caused half a million infections and 15,000 deaths in a single year and that $3.8 billion in medical costs could be saved over five years. The CDC designated it as an "urgent threat," its most serious classification for a group of 18 drug-resistant infections.
At The Miriam Hospital, nurses are now following a variety of practices to battle C. difficile, which can cause severe diarrhea, fever, appetite loss and abdominal pain. It is spread through feces and its spores can live on surfaces for a relatively long period of time.
The Miriam’s epidemiology and infection control director Nancy Vallande, MS, MT, and infection preventionist Susan Steeves, MSN, RN helped spearhead an initiative that developed into the C. difficile Collaborative.
"In keeping with our goal of ‘zero harm,’ we wanted to improve our rates,” says Vallande.
Today, the hospital is reaping the rewards of a multipronged approach. It begins with the vigilance of floor nurses such as Lauryn Breen, RN. Since being hired at The Miriam nearly four years ago with degrees in nursing and biology, she has been actively involved in C. difficile prevention and ultimately served on the collaborative to help bring change to her unit, 4W.
Early on, Breen marked high-touch areas in patient rooms with a substance that illuminates when hit with a black light. It helped identify places that could somehow be overlooked for cleaning after patients were discharged. That led to improved sanitary practices, including using disposable blood-pressure cuffs.
Frontline nurses are now being supported in their efforts through an electronic panel, which helps to identify appropriate patients for testing. It focuses on establishing whether a patient has had three or more episodes of diarrhea in 24 hours but has not been taking a laxative. A stool specimen is then collected for testing.
The quicker C. difficile patients are identified the more rapidly they can be moved into isolation rooms. There, nurses are expected to don gloves and gowns and to practice appropriate hand hygiene. In addition, they now use absorbent liners in commodes and bedpans to decrease exposure to stool, which in turn decreases transmission. Nurses are also ensuring that stethoscopes and thermometers are dedicated just for these patients.
Nurses, in addition to certified nursing assistants, were all given competency training regarding the importance of hand hygiene and personal protective equipment.
Another intervention is the establishment of the "scrub club,” which is made up of nurses and other hospital staff. Dedicated to cleaning rooms and shared equipment, a scrub club is initiated every time a hospital-acquired case of C. difficile is identified. In addition, monthly proactive scrub clubs strive to maintain a safe and clean environment.
"Change is always hard, but I try to be a cheerleader,” says Breen. “The nursing staff have been very receptive to piloting our new initiatives. Without their support to pilot new methods, we wouldn't have been able to implement so many changes throughout the hospital.”
Along with additional measures undertaken at The Miriam by environmental services and other departments – such as disinfection of rooms with sporicidal bleach and newly purchased ultraviolet devices – the efforts by nurses have contributed to an encouraging decline in C. difficile cases. From 2015 to 2017, the number of cases of C. difficile fell from 92 to 53, a 42 percent drop.
Success preventing urinary infections
Lifespan nurses are also waging a battle against catheter-associated urinary tract infections (CAUTIs). While not life-threatening, these infections can slow the recovery of patients and increase medical costs.
Over the years, "bundles" of safe practices have been established and continue to evolve.
When Walsh decided to research the problem, she reviewed hospital data and found that CAUTIs typically affected women and were related not to insertion of flexible Foley catheters but to their continued use.
While an external catheter for men has long been in use, there was not one in use for women. That, she says, is when "I did a little digging." Her research led her to the PureWick, a device for women that wicks urine away from the body and captures it in a storage container. This allows the amount of urine to be measured so that medical staff can monitor a patient's urinary function and hydration.
The device was initially tested at Rhode Island Hospital in Walsh's critical care unit and The Miriam’s Medical Surgical Unit. It went so well that it was then implemented at all Lifespan hospitals.
The adoption of the device is expected to help decrease CAUTI events, but what is also important is changing culture and long-standing practices, says Gail Jackson, RN, infection prevention coordinator at Newport Hospital, where she's been in nursing since 1987. Every day she gets a report of which patients have a urinary catheter and then she visits the nursing unit to talk to staff.
"I ask why that patient requires an in-dwelling catheter and what our plan is for removing it as soon as possible," Jackson says. "Our utilization over the last two years has reduced significantly."
Elizabeth Bryand, RN, who works in the nursing education department at Newport Hospital, says the decision to remove the catheter requires a comprehensive care plan.
"This involves critical thinking on the nurse's part to assess and evaluate the patient's bladder function and coordination of care with ancillary staff to be sure the patient's toileting needs are met,” she says. “However, the nurse will gladly take on this responsibility knowing that removing the catheter as soon as possible is in the best interest of the patient and will reduce the risk of complications.”