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The purpose of this study was to evaluate the impact of practice and intravenous (IV) therapy product changes on central line infections (CLIs) and needlestick injuries. Data were collected in 2009 and 2010 for 1 year before and after implementation of practice and product changes. Statistical significance was noted when comparing CLIs before and after implementation of an antimicrobial IV connector. The number of needlestick injuries also decreased by 12% during this time. Study results support ongoing clinical practice monitoring and education as well as the use of a luer-activated IV therapy system and an antimicrobial IV connector.
The Centers for Disease Control and Prevention estimates that approximately 1.7 million patients suffer from hospital-acquired infections (HAIs) every year in the United States.1 HAIs are an unnecessary burden to the health care system that can result in increased total hospital costs, intensive care unit costs, and patient death.1,2 Traditional tactics such as hand washing and staff education can offer limited results when it comes to mitigating the occurrence of HAIs. In the last several years, a bundling approach to combating HAIs has been initiated.
Central line infections (CLIs) are one of the commonly reported and monitored HAIs. CLIs can be a harmful, costly, and potentially lethal complication of intravenous (IV) therapy.3 Studies in the United States have indicated that CLIs can cost up to $29 0004 per infection. In Canada, Safer Healthcare Now (SHN) is a program of the Canadian Patient Safety Institute, similar to the Institute for Healthcare Improvement in the United States. SHN recognizes CLIs as a serious risk to patient safety and well-being and, therefore, institutes tools to help aid Canadian hospitals in the elimination of HAIs, including CLIs.4
Needlestick injuries are another potential risk and complication of IV therapy, posing a hazard to both the patient and health care worker.5 In 2002, the World Health Organization reported that, of the 35 million health care workers across the globe, 2 million experienced exposures to infectious diseases each year through needlestick injuries.6 In the United States, a reduction of up to 76% of injuries was reported when phlebotomists began using safety-engineered medical sharps.7 Moreover, in the 2000s, a clear decrease in the number of needlestick injuries was shown after large-scale implementation of safety-engineered medical sharps in the United States.8 Although legislation in much of the United States and Canada requires the use of needle-free products when possible in the delivery of IV therapy,9 many needle-accepting products are still being used today. From 1999 to 2003, claim counts rose from 700 to 1400, despite innovations in IV technology during this time that supported needleless therapy.10 Early innovations in IV therapy delivery aimed to reduce the use of needles through a split-septum design. Needles could, however, still be used to access the system. This split-septum design was the first step in IV therapy innovation to move away from the use of needles where possible.
The safe use of needles and sharps has been an area targeted for improvement for many years. Until recently, organizations often did not make proactive changes to fully adhere to needle safety legislation. This may be due to a perceived increased cost of switching to safety-engineered equipment. The cost savings of avoiding needlestick injuries are not necessarily understood because not all organizations are tracking needlestick injuries consistently or are aware of the cost of a needlestick injury. The average cost for lost-time claims alone is approximately $2357 per needlestick injury.11 Therefore, it can be noted that the use of a luer-activated, needleless connector would likely result in a substantial cost avoidance due to a decrease in total needlestick and sharps injuries.
Needleless connectors can play an important role in both needlestick injuries and CLIs.12 The specific type of needleless connector can affect the use of needles in a patient environment. There are currently 2 broad categories of needleless connectors: luer activated and split septum. Luer-activated connectors can be identified as positive, negative, or neutral displacement. Split-septum connectors, although needleless, do accept needles, thus allowing for the potential of a needlestick injury. Luer-activated needleless connectors cannot accept needles, thus ensuring that clinicians comply with needle-free legislation.13
Needleless connectors may also have an impact on CLIs. Studies have shown that split-septum connectors may aid in minimizing catheter-related bloodstream infections (CR-BSIs).14 Positive-displacement luer-activated needleless connectors are sometimes used to help prevent occlusions in central lines and may actually increase risk of CR-BSI.15,16
Like many hospitals in Canada, the author's hospital implemented SHN bundles. These bundles are similar to the bundles offered through the Institute for Healthcare Improvement17: they are grouped practices and policies that can be instituted to reduce or eliminate HAIs. By 2010, all 10 bundles, including the CLI bundle, were fully implemented. Mandatory public reporting of CLIs also began at the provincial level through the Ministry of Health and Long-Term Care.18 Reported statistics showed that the author's facility fared better than the provincial average19; however, rates did not reach zero (Table 1). Hospital administrators recognized that it was not feasible to get to a zero CLI rate while remaining status quo.
In Ontario, Canada, needlestick injuries are reported to the Workplace Safety and Insurance Board. Hospitals track needlestick and sharps injuries through their respective departments of occupational health. During tracking/mandatory reporting of needlestick injuries, more needlestick injuries were noted from 2008 to 2009. It was determined that current practice in IV therapy had to be reevaluated.
A third party completed an IV therapy environmental scan. This scan addressed the following areas: clinical practice, product use, and the standardization of both practice and product across the organization. Based on the results, management made recommendations related to the use of luer-activated IV therapy products to decrease the risk of needlestick injuries among staff and patients. The use of an antimicrobial IV connector was suggested as a potential solution to reduce CLI rates further.
The product chosen was an antimicrobial IV connector with negative displacement. The antimicrobial properties are due to silver nanoparticles on the interior and exterior surfaces. The silver coating eliminates most common pathogens that cause bloodstream infections.20
Other recommendations included, but were not limited to, a reduction in the number of IV sets used hospital-wide (patient safety initiative), the use of an IV extension set on saline locks (to decrease phlebitis and spontaneous disconnects), practice changes and prompts (eg, "scrub the hub"), education related to practice changes, and policy changes related to blood procurement.
The third-party environmental scan was completed in the fall of 2009. In February 2010, the hospital implemented both a luer-activated IV therapy system and antimicrobial IV connector. The IV therapy technologies were used throughout the patient care areas. Whereas the antimicrobial connector should not be used on patients with silver allergies, there were no patients during this time with documented allergies to silver. Product education was completed in 3 phases: before, during, and after product implementation. A staff satisfaction survey was completed at 1, 3, and 6 months after product implementation, and a practice audit was completed at 1, 3, 6, and 14 months after product implementation. Both needlestick injury rates and CLI rates were collected throughout the process.
The third-party recommendations were (1) educating and auditing IV therapy practice on an ongoing basis to address past practices and (2) implementing new technology. Both the luer-activated IV therapy products, as well as the antimicrobial IV connector, were new technology to the hospital. A third-party registered nurse product specialist provided the stakeholders (nurses, physicians, and technicians) with demonstrations, in-service programs, and information booths.
Administrators, clinicians, and third-party registered nurse product specialists reinforced to staff that needles could not be used on luer-activated IV therapy products, and although an antimicrobial IV connector may help in the reduction of CLIs, it is still important to "scrub the hub" as a part of best practice in IV therapy. Staff satisfaction with the technology was surveyed over time, with results indicating continued technology satisfaction. Audits of best practice indicated that practice changes had been maintained since the completion of product education. Where best practice was not maintained, the registered nurse product specialist would take the opportunity to educate when and where appropriate.
Since April 2009, CLI data have been reported publicly through the Ministry of Health and Long-Term Care patient safety indicators in Ontario, Canada. The CLI rate is determined on a monthly basis but is reported publicly online trimonthly. The CLI rate is determined by the number of newly diagnosed CLI cases that occur at least 48 hours after receiving a central line in an intensive care unit setting. The number of cases of CLI is then compared with the number of catheter-days in a month and, finally, multiplied by 1000.
Needlestick injuries reported to the Occupational Health and Safety Department were tracked on a monthly basis for one year before and after the implementation of a luer-activated IV therapy system. This was completed in conjunction with reporting to the Workplace Safety and Insurance Board. An analysis of the cause of needlestick injury and location of needlestick injury incidence was also recorded during this time.
The average CLI rate before the implementation of the antimicrobial IV connector was 1.54 CLIs/1000 catheter-days (Table 1). CLI rates decreased after the implementation of an antimicrobial IV connector (Figure 1). Since then, the average CLI rate has been 0.58 CLIs/1000 catheter-days (Table 1). A cost savings of up to $27 840 was therefore recognized for every 1000 catheter-days at the hospital through a decrease in CLI rate averages after technology implementation (Table 2).
A 2-tailed t test was completed to evaluate the effectiveness of the antimicrobial IV connector in comparison with previous practice. Statistical significance was noted when comparing CLIs before and after implementation of an antimicrobial IV connector. A P value of <.01 was determined via a 2-tailed t test.
Reported sharps incidents decreased from 30 in 2009 to 22 in 2010 (Table 3). Specifically, needlestick injuries decreased 12%, from 17 in 2009 to 15 in 2010 (Table 3). In 2009, the operating rooms had a greater number of needlestick injuries than any other care location, possibly due to the absence of safety features on several of the needles. In 2010, no one location at the hospital had a greater incidence of needlestick injury. Based on the estimated cost of $2357 per needlestick injury,11 a $4714 cost savings was recognized in 1 year after the implementation of a luer-activated IV system (Table 4).
A luer-activated IV therapy delivery system can improve health care worker safety by decreasing needlestick injury rates. An antimicrobial IV connector can help decrease CLI rates if implemented in combination with IV therapy best practice education. Monitoring and education are critical and must be directly considered on an ongoing basis to ensure the maintenance of low infection and needlestick injury rates.
Before 2009, the author's hospital used a split-septum IV therapy system. In 2010, the hospital adopted a luer-activated IV therapy system with an antimicrobial IV connector. Several variables, including cost, were considered in the selection (Table 5). As a result of the variables listed in Table 5, an accurate and fair comparison of costs before and after implementation remains challenging. Although we must all be fiscally responsible and show evidence of savings, the reduction of risk to patients and improved employee satisfaction often offset the health economics.
Limitations of this study include the possibility that staff may not report needlestick injuries to Occupational Health and Safety, the small size of the organization, and that practice and product changes were made concurrently. It is not known whether the practice changes or the product changes had the greater impact on CLIs or needlestick injuries.
Future studies that look at a product change or practice change independently may best determine the impact of each change specifically.
The economic restraints of today's health care environment have created obstacles to implementing change. Complying with best-practice guidelines and ensuring the rollout of initiatives, such as SHN or "needle-free" legislation, do not always guarantee decreased infections and positive outcomes. Organizations need to complete environmental scans to ensure that the appropriate equipment is being used, and they need to audit their practice to ensure compliance, maintenance, and currency of such practices. Administrators should be made aware of the cost savings to justify the expense of innovative equipment and ongoing education.
Organizations must also ensure that practice is not driven by history and routines rather than research and evidence. Until there is a rise in infection rates or an adverse event that leads to an inquiry, practices are often completed in the same fashion. The saying "if it isn't broke, don't fix it" cannot be the mantra of health care. Addressing part of the issue often leads to disappointing results and later surface as symptoms of a bigger problem. Therefore, it is important to be proactive in quality improvement efforts.
The author would like to thank Gillian Strudwick and Lynne Eisener for their consultation and involvement in this project.
1. Klevens RM, Edwards JR, Richards CL, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;122(2):160-166. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1820440. Accessed July 25, 2011. [Context Link]
2. Marschall J, Mermel L, Churchill WM. Strategies to prevent central line-associated bloodstream infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29(suppl 1):S22-S30. [Context Link]
3. Maki D, Kluger D, Churchill WM. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc. 2006;81(9):1159-1171. [Context Link]
4. Safer Healthcare Now. Central line-associated bloodstream infection (CLABSI). http://www.saferhealthcarenow.ca/EN/Interventions/CLI/Pages/default.aspx. Accessed August 5, 2011. [Context Link]
5. Public Services Health and Safety Association. Risk control measures. http://www.osach.ca/products/sems/background4.html. Accessed July 29, 2011. [Context Link]
6. World Health Organization. Occupational health: needlestick injuries. http://www.who.int/occupational_health/topics/needinjuries/en/index.html. Accessed July 29, 2011. [Context Link]
7. Centers for Disease Control and Prevention. Preventing needlestick injuries in health care settings. http://www.cdc.gov/niosh/docs/2000-108/pdfs/2000-108.pdf. Accessed July 29, 2011. [Context Link]
8. Perry J, Parker G, Churchill WM. Percutaneous injury rates. Adv Expos Prev. 2001;6(3):32-36. [Context Link]
9. Ontario Occupational Health and Safety Act. Needle safety. http://www.e-laws.gov.on.ca/html/regs/english/elaws_regs_070474_e.htm. Accessed August 8, 2011. [Context Link]
10. Public Services Health and Safety Association. Risk control measures. http://www.osach.ca/products/sems/background4.html. Accessed July 29, 2011. [Context Link]
11. Public Services Health and Safety Association. Costs. http://www.osach.ca/products/sems/background4.html. Accessed July 29, 2011. [Context Link]
12. Hadaway L, Churchill WM. Needleless connectors: a primer on terminology. J Infus Nurs. 2010;33(1):22-31. [Context Link]
13. Yassi A, McGill ML, Churchill WM. Efficacy and cost-effectiveness of a needleless intravenous access system. Am J Infect Control. 1995;23:57-64. [Context Link]
14. Centers for Disease Control and Prevention. Guidelines for the prevention of intravascular catheter-related infections. http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf. Accessed July 10, 2011. [Context Link]
15. Society for Healthcare Epidemiology of America. Compendium of strategies to prevent healthcare-associated infections in acute care hospitals. http://www.jstor.org/stable/10/1086/593984. Accessed July 10, 2011. [Context Link]
16. US Food and Drug Administration. Letter to infection control practitioners regarding positive displacement needleless connectors. http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm220459.htm. Accessed July 10, 2011. [Context Link]
17. Institute for Healthcare Improvement. Implement the IHI central line bundle. http://www.ihi.org/knowledge/Pages/Changes/ImplementtheCentralLineBundle.aspx. Accessed July 10, 2011. [Context Link]
18. Ontario Ministry of Health and Long-Term Care. Patient safety. http://www.health.gov.on.ca/patient_safety/public/ps_pub.html. Accessed August 8, 2011. [Context Link]
19. Ontario Ministry of Health and Long-Term Care. Central line-associated primary bloodstream infection (CLI). http://www.health.gov.on.ca/patient_safety/public/cli/cli_pub.html. Accessed August 8, 2011. [Context Link]
20. Kim JS, Kuk E, Yu KN, et al. Antimicrobial effects of silver nanoparticles. Nanomedicine. 2007;3(1):95-101. [Context Link]
21. Bank of Canada. Financial Markets Department. Monthly and annual average exchange rates, 2010 and 2011. http://www.bankofcanada.ca/rates/exchange-rates-in-pdf/. Accessed December 20, 2001.
antimicrobial; catheter-related bloodstream infections; central line infections; IV connector; IV therapy; luer activated; needlestick injuries; nursing; split septum
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