Lead Nurse Infection Prevention Solihull Care Trust UK
Vascular access is one of the most common healthcare interventions carried out today. One study has highlighted that in the region of 63% of patients were noted to have a peripheral line.(1) These devices carry with them a recognised risk of infection. Approximately three in every 100 patients admitted to hospital in the UK acquire a bloodstream infection, and nearly one-third of these infections are related to central venous access devices.(2) In the UK, the National Audit Office reported that 30% of all healthcare-associated infections could be prevented through the better application of policy in practice.(3) So how can practitioners begin to make a difference in terms of vascular-associated infections?
There is no shortage of guidance pertaining to the management of intravascular devices to reduce the risk of infection. In 2001, the Infection Control Nurses Association (ICNA) in the UK began collaboration with 3M Healthcare to produce a set of guidelines for professionals on best practice to reduce infections associated with vascular devices.(4) Whilst these guidelines were the first of their kind in the UK, they were not subjected to the rigorous review of evidence with which we are now familiar. Nonetheless, they were a useful tool for practitioners, providing references for local policy in addition to a helpful proforma to audit service and practice provision at a local level.
In 2001, the Department of Health published the first set of evidence-based infection control guidelines which included care of central venous access devices (CVADs).(5) Unlike the ICNA document, these guidelines had been subject to a systematic review of evidence around the subject, and provided specialist practitioners with the evidence on which to base local policy.
In addition, in response to national concern about increasing infection rates, the Department of Health produced its toolkit aimed at improving practices to prevent infection associated with vascular devices. Saving Lives used a care bundle approach, initially to CVAD and later to peripheral devices, to provide practitioners with a system to ensure best practice at every intervention.(6)
It was important therefore that ICNA reviewed its guidance to the profession to ensure best practice and reduce confusion in the midst of differing tools and guidance.
The review process
ICNA and 3M Healthcare were committed to ensuring that practitioners were provided with good-quality information in their armoury to fight infection. An initial meeting with both parties identified that the publication of additional guidelines would have likely resulted in increased confusion amongst staff rather than be helpful. It was agreed that the most practical approach would be to identify gaps in information provision which professionals would find useful and which could be widely used across all areas of healthcare service, without there being reinvention of the wheel in each and every organisation.
The group identified a series of underlying principles which they felt should be applied to all individual tools produced. First, it was essential that any publications should be aimed at addressing the key recommendations within the epic (evidence-based practice in infection control) guidelines, where there were no pre-existing supporting documents. It was essential that whatever was produced did not reinvent the wheel or replace any existing tools but was there as additional support material.
Secondly, in developing the tools it was essential where necessary that documents were designed to enable professionals to tailor to meet local need whilst holding fast to the central guidelines from epic. Another driving principle was the need to have these documents readily available for all target groups and easily updatable to ensure that, as far as possible in this ever-changing arena, documents could be kept current. Therefore, web-based documents were considered essential in the success of the toolkit. In addition, having guidelines on the internet provides patient and carers with a reputable source of information regarding the care of their lines.
What do we need?
In taking forward the toolkit, the group identified key areas where providing ready-made documentation would be adding quality to care whilst avoiding duplication of effort across the country. There was no doubt that devising a policy framework and training package was an essential starting point to enable a competent trained workforce in delivering care. We also know that documentation of interventions is poorly carried out, which in turn contributes in part to lines remaining in situ for longer than the evidenced optimum to reduce infection risks. Therefore devising record sheets that staff could use both for the documentation of insertion and ongoing care, that were easy to use with minimal effort, would be an essential component. Monitoring compliance with practice is also an essential element of care. Therefore two audit tools were included, the first an audit of organisational systems around device management, and secondly an observational audit toll for insertion and ongoing maintenance.
A third area where gaps were identified pertained to the provision of information to patients. It was clear from the guidelines that involving the patients in the care of their lines with regard to preventing infection was essential. Not only was there a need to describe infection prevention for line care, but fundamentally there also needed to be a good information sheet aimed at teaching patients and carers good hand hygiene techniques. Thus the information elements of the tool were conceived.
One of the key areas identified from the work was the lack of specific guidance relating to infection prevention associated with these devices in paediatric care. Therefore, despite the lack of specific guidance, the general principles from adult care were followed and all patient documentation records and information sheets were also produced in child-friendly formats, identified by the Preventing Infection Associated with Vascular Access (PIVA) bear logo.
Is it a success?
It is essential to note that the PIVA toolkit was never designed to be a complete programme for staff to implement in its entirety, as undoubtedly many teams already had good-quality information and tools in place. However, it was recognised that tools such as these were a great addition to the infection prevention arsenal. As with many infection prevention interventions, it has not been possible to single out the success of this kit in reducing infection rates, and indeed that was never really the sole aim of the project. If at any point staff or patients have benefited from the information contained in the programme and in some small way have changed their practice, then “yes”, the kit has definitely been a success. We know from monitoring hits that both practitioners and memebers of the public are accessing the material. We also know from feedback received from colleagues that they do find the tool helpful, but they have also provided us with constructive comments about how the existing tools can be improved and, perhaps more importantly, where additional tools are required.
What of the future?
Thanks to the ongoing commitment of both organisations, work is continuing on refining the tools and making new additions. ICNA has now become the Infection Prevention Society, but the driving principles behind the organisation remain unchanged. This new organisation will continue to collaborate with other key stakeholders to provide educational and practice-based tools. There is no doubt that this outwardly seeming simple solution is applicable across all corners of healthcare and indeed the globe, and we would encourage practitioners to consider the approach.
In conclusion, we would like to offer thanks to all of those who contributed to the process, in particular the working group, Pauline Hobbs, Heather Loveday, Laura Kempton-Smith, Jean Law and staff from 3M Healthcare.
- Nystrom B. J Hosp Infect 1983;13:26-9.
- Coello R, et al. J Hosp Infect 2003;53:46-57.
- National Audit Office. The management and control of hospital associated infection in Acute NHS Trusts in England. London: The Stationery Office; 2000. Available at:www.nao.org.uk
- Infection Control Nurses Association. Guidelines for preventing intravascular catheter-related infection. Bathgate: ICNA/Fitwise; 2001.
- Pratt R, et al. J Hosp Infect 2001;47 Suppl:S1-82. Available at:www.epic.tvu.ac.uk
- Department of Health. Saving Lives: a delivery programme to reduce health care associated infection including MRSA: skills for implementation. Available at: www.dh.gov.uk
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