Preventing PIV Infections

Preventing PIV Infections

Peripheral Intravenous Line (PIV) complications can be aggravating at best and deadly at worst. To get more information about this topic and to learn about a new invention from 3M, we interviewed Joseph Hommes, VSN, RN, VA-BC, Technical Service Specialist, 3M Medical Solutions Division to find out more.

Please explain PIVs, their complications, and the use of CHG skin preps and regrowth of bacteria.

Peripheral intravenous (PIV) lines are commonly placed in the arm to administer medications and fluids for therapeutic purposes. In fact, they are the most common vascular access procedure performed on hospitalized patients with 60 to 90 percent of patients requiring an IV catheter during their hospital stay.1

PIVs are often considered lower risk for infection than central lines because of their shorter dwell time and placement,2 but PIVs can be associated with preventable complications such as inflammation, dislodgement, phlebitis, and peripheral line-associated bloodstream infections (PLABSI). And like central line-associated bloodstream infections (CLABSI), PLABSI can lead to a rise in patient morbidity, length of stay, and health care costs for the patient and facility.3

The reason why regrowth may occur so quickly even after the use of CHG skin preps is related to the location of the bacteria,4 the presence of microbial biofilms on skin,5 and the significant variability of bacteria density and species from one person’s skin to another.6 Research studies show that up to 20 percent or more of the total skin flora is beyond the reach of routine disinfection. These bacteria are located in skin crevices where lipids and the superficial cornified epithelium protect them; and deep in the roots of hair follicles and sebaceous glands where they cannot be removed without injuring the skin.7 According to Gonzalez et al, biofilms with or without underlying dermal disease, will help reduce the efficacy of CHG, which, in turn can contribute to bacterial regrowth.8 In the case of peripheral vascular catheter or needleless connector use, the sustained presence of an antimicrobial agent serves to keep the bacterial counts low to absent.9

How can health care systems protect patients against these PIVs?

All IVs have the potential to be contaminated through two sources: extraluminal, where bacteria originate on the skin surface and intraluminal, where bacteria enter via the catheter hub or IV access point.

Although PIVs aren’t monitored or researched as frequently as central lines, it’s extremely important that health care facilities and clinicians pay close attention to these lines because approximately 1.6 million PIV infections occur each year globally.10

A growing interest in comprehensive PIV maintenance bundles is emerging based on different recommendations or practice standards from the Centers for Disease Control and Prevention (CDC) guidelines,11 Infusion Nurses Society (INS),12 and the Society for Healthcare Epidemiology of America (SHEA) compendium guidelines.13 One recently published study from Mercy Hospital in St. Louis, MO found that implementing a comprehensive PIV maintenance bundle was associated with a decrease in the rate of PLABSIs, from 0.57 to 0.11 per 1000 patient days (p < 0.001).14

Why should health care systems work harder to protect patients against these PIV infections? How dangerous are they?

PLABSI can be incredibly detrimental to both patients and health care facilities. In addition to PLABSI being potentially fatal for some patients, it can significantly impact a facility financially, with some cases costing $10,000 to $20,000 per patient,15 and up to $40,000 in intensive care unit (ICU) settings,16 giving hospitals a large incentive to prevent PLABSIs to improve patient outcomes and reduce costs.

What do the 3M antimicrobial PIV dressings do? How is this better than what is otherwise offered? Have you done any research on their effectiveness? If so, can you give me some information about the research and its conclusions?

Short-term PIVs account for a mean of 23 percent of all hospital-acquired CRBSIs.17 Additionally, one hospital determined that the leading source of health care-acquired S. aureus bloodstream infections over an 8-year period was associated with PIVs due to normal skin flora migrating down the catheter tract through the IV line.18

Protecting patients from risks associated with PIVs needs to start with the surface of the skin, disinfecting the catheter IV access points and continuing through monitoring the catheter insertion site until it is removed. The latest addition to 3M’s portfolio in the fight against extraluminal contamination of PIVs is the 3M Tegaderm™ Antimicrobial I.V. Advanced Securement Dressing. This dressing provides site visibility, catheter securement, and enables consistent application. Chlorhexidine Gluconate (CHG) is integrated throughout the adhesive to better suppress regrowth of skin flora on prepped skin for up to 7 days as compared to non-antimicrobial dressings.19 The transparent dressing allows continuous site visibility to enable early identification of complications at the insertion site. It is also designed to minimize catheter movement and dislodgement.

It’s important to note that peripheral line bundles should also include disinfection and protection at all intraluminal access points too. Using a peripheral line bundle that includes 3M Curos™ Disinfecting Caps for Needleless Connectors and 3M Curos Tips™ Disinfecting Cap for Male Luers provides effective disinfection of catheter IV access points. Effective disinfection of needleless connectors and male luers on PIV lines has been associated with a significant decrease in primary PLABSI.20

What else do you think is important for people to know about PIV bloodstream infections?

It’s critical for clinicians to better understand that PIVs are responsible for a significant number of total infections. According to a recent survey of 650 U.S. infection preventionists and clinicians, only 60 percent of infection preventionists are familiar with their facility’s PLABSI prevention protocols and procedures, yet 56 percent of all respondents believe that PLABSI poses a real threat to patient safety.21

With up to 90 percent of patients requiring a PIV during their hospital stay,22 clinicians should be paying closer attention to PIV care, making it a central part of their infection risk reduction programs. To get started, free educational courses about how to address clinical challenges associated with PIVs are available at 3M’s online learning platform, 3M Health Care Academy.

 


  1. Helm RE, Klausner JD, Klemperer JD, Flint LM, Huang E. Accepted but unacceptable: Peripheral IV catheter failure. J Infus Nurs. 2015; 38(3): 189-203.
  2. Hadaway L. Short Peripheral intravenous catheters and infections. J Infus Nurs. 2012; 35(4): 230-240.
  3. Kilgore, M. and Brossette, S. Cost of bloodstream infections. Am J Infect Control. 2008; 36: S172 (e171-e173).
  4. Selwyn, S and Ellis, H. Skin Bacteria and Skin Disinfection Reconsidered, British medical journal, 1972, 1, 136-140.
  5. Gonzalez T, Biagini, Myers JM, Herr AB and Hershey K. Staphylococcal biofilms in atopic dermatitis. Curr Allergy Asthma Rep (2017) 17: 81.
  6. Gao Z, Tseng, C-h, Pei Z and Blaser MJ Molecular analysis of human forearm superficial skin bacterial biota. Proc Natl Acad Sci USA (2007) 104: 2927-2932.
  7. Selwyn, S and Ellis, H. Skin Bacteria and Skin Disinfection Reconsidered, British medical journal, 1972, 1, 136-140.
  8. Gonzalez T, Biagini, Myers JM, Herr AB and Hershey K. Staphylococcal biofilms in atopic dermatitis. Curr Allergy Asthma Rep (2017) 17: 81.
  9. Casey AL, Karpanen TH, Nightingale P, and Elliott TSJ. An invitro comparison of standard cleaning to a continuous passive disinfection cap for the decontamination of needle free connectors. Antimicrobial Resist Infect Ctrl (2018) 7:50.
  10. Assumes median PVC infection incidence 0.2% (Helm RE, Klausner JD, Klemperer JD, Flint LM, Huang E. Accepted but unacceptable: Peripheral IV catheter failure. J Infus Nurs. 2015; 38(3): 189-203.); and average PVC dwell time of 3 days.
  11. Centers for Disease Control and Prevention. Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf
  12. Gorski L. A., Hadaway L., Hagle M., McGoldrick M., Orr M., Doellman D. Infusion therapy standards of practice. J Infus Nurs. 2016;39(suppl 1):S1-S159. https://www.ins1.org/Default.aspx?TabID=251&productId=113266
  13. Society for Healthcare Epidemiology of America (SHEA). Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals, 2014. http://www.shea-online.org/index.php/practice-resources/priority-topics/compendium-of-strategies-to-prevent-hais
  14. Duncan, M, Bernatchez, S.F. et al. A Bundled Approach to Decrease the Rate of Primary Bloodstream Infections Related to Peripheral Intravenous Catheters The Journal of the Association for Vascular Access, Volume 23, Issue 1, 15 – 22.
  15. Kilgore, M. and Brossette, S. Cost of bloodstream infections. Am J Infect Control. 2008; 36: S172 (e171-e173).
  16. Elward, A.M., Hollenbeak, C.S., Warren, D.K., and Fraser, V.J. Attributable cost of nosocomial primary bloodstream infection in pediatric intensive care unit patients. Pediatrics. 2005; 115: 868–872.
  17. Mermel L. Short-term peripheral venous catheter-related bloodstream infections: A systematic review. Clin Infect Dis. 2017; 65(10):1757-62
  18. Mestre G, Berbel C, Tortajada P, et al. Successful multifaceted intervention aimed to reduce short peripheral venous catheter-related adverse events: A quasiexperimental study. Am J Infect Control. 2013;41: 520-526.
  19. 3M data on file.
  20. 3M data on file.
  21. Survey of 650 infection preventionists and clinicians, commissioned by 3M and conducted by a third-party research firm in April 2018, Human Factors and the Future of Infection Prevention, 2018. 3M data on file.
  22. Znigg, Walter et al, peripheral venous catheters: an under-evaluated problem. International Journal of Antimicrobial Age sj. Volume l34 S38-S42.
Working in the ER: It’s Not Like on TV

Working in the ER: It’s Not Like on TV

If you’ve ever watched a series like Grey’s Anatomy or ER, you know that hospital scenes are always dramatic on screen. And if they’re in the emergency department—well, they pretty much always are. In real life, though, that’s not quite the case. Sure, there are times where the ER can get hectic. So to get the real truth in honor of Emergency Nurses Week, we decided to go straight to the source.

Sarah Emami, RN, BSN, CEN, CCRN, a staff RN in the ED at Sibley Memorial Hospital admits that she was surprised when she began working as an emergency nurse. “I thought working in the ER would involve a lot more Code Blue situations and ACLS [advanced cardiac life support] protocols. There are a lot of these situations, but mostly you’re preventing people from reaching a critical situation,” says Emami.

Emami, who has worked in the ER for six years, decided to work there because she loves a fast-paced environment as well as having a lot of autonomy as a nurse. Before working in the ER, she worked in the ICU and doing that gave her a lot of critical care experience, albeit at a much slower rate.

Even though she’s worked in the ER for a while now, Emami admits that there are still surprises. “Most people don’t think about the food that they eat: they eat junk food, processed food, and fast food a majority of the time, and they are surprised when they are tired, lethargic, and have GI issues,” she explains. Another surprise is that “people want a fast fix for chronic medical conditions.”

The biggest challenges for Emami about working in the ER are what she calls “boarders.” These are patients who are admitted to the hospital, but have to stay in the ER because there are no available rooms or there’s not enough staffing at the time. Emami also says that managing patient expectations can be tough—like the aforementioned desire for a “quick fix,” and teaching them that the best way to stay healthy is a combination of a good diet, exercise, and stress management.

When she can get through to patients about how to stay healthy, that’s the best. “The biggest rewards are when I can teach a patient something new about their diet, medication, or how to navigate the health care system,” says Emami.

Changing Up the On-Demand Nursing Market

Changing Up the On-Demand Nursing Market

Nurses know what happens when a colleague has to call out due to sickness or an emergency or is due for vacation—others often end up working double shifts. If you want to, that’s one thing. But when it’s required because of lack of staff, it can cause the nurses to feel overworked and contribute to their stress and anxiety. There’s now a nursing staffing agency that operates via an App, and it’s changing the way nurse staffing occurs.

“There have always been nursing staffing agencies that have served our clientele for more than 100 years, but they have historically been using traditional, inefficient methods of scheduling via spreadsheets, fax machines, and telephone. We believe that we are the first truly on-demand, app-based nursing agency for the per-diem market,” explains Chris Caulfield, RN, FNP-C, one of the founders of IntelyCare. “There wasn’t a good solution for nursing coverage for last-minute call outs or to fill in holes in the schedulers’ calendar on a shift-by-shift basis.”

IntelyCare on-demand nursing appCaulfield co-founded the business with health care IT expert Ike Nnah in 2015. They currently serve post-acute nursing organizations using RNs, LPNs, and CNAs. To date, they serve more than 200 skilled nursing facilities, rehabs, and assisted living facilities in Massachusetts, Rhode Island, Ohio, and Pennsylvania.

The business is changing how on-demand nurses are used because they are able to cover a number of shifts that are requested by the facilities with only two- to twelve-hours’ notice. As a result, staff nurses don’t have to pull a mandatory double, and other nurses who can fill the spot get to choose when, where, and how much they would like to work.

Caulfield stresses, though, that this type of work is not for new graduates, as they believe nursing professionals should have at least a year of experience before they begin floating to various facilities. But being able to browse an App and determine extra shifts they can take on is already changing the workplace for nurses.

“On-demand nursing is a great option for nurses who want more flexibility, higher pay, and who like a change of scenery,” says Caulfield. “I strongly believe that over the next two-five years, there will be some flavor of on-demand nursing—either from an outside staffing agency or an Internal per-diem pool—at every licensed health care facility in the U.S.”

Johnson & Johnson “Nurses Innovate Quickfire Challenge” Now Open for Submissions

Johnson & Johnson “Nurses Innovate Quickfire Challenge” Now Open for Submissions

Earlier this week, Johnson & Johnson started a challenge for all U.S. nurses to participate in and contribute. The “Nurses Innovate QuickFire Challenge” is designed for nurses to submit ideas for new devices, health technologies, protocols and/or treatment approaches. Participants can receive up to $100,000 in grants from this challenge, and also receive mentoring and coaching access through Johnson & Johnson Innovation, JLABS.

(PRNewsfoto/Johnson &amp; Johnson)

Innovation in patient care has a long and linear history with nursing, from figures like Florence Nightingale, Nurse Jean Ward, and Nurse Rebecca Koszalinkski. The combination of nurses’ patient experience and insight and resourcefulness provides them with a unique perspective in the healthcare field, allowing them to have significant and crucial input in addressing health challenges.

Yet a nationwide survey showed Johnson & Johnson that nearly half of Americans (41%) are unaware of the role that nurses play in developing new medical tools and solutions. However, the majority (66%) believe that all medical professionals are capable of coming up with lifesaving ideas, and 75% of those surveyed believe nurses should have platform to submit ideas and inventions for improving patient care.

Investing in nurses is part of Johnson & Johnson’s storied history, as the company has provided funding for scholarships, employment opportunities, and more since their start in 1897. Previous efforts to help nurses include the “Campaign for Nursing’s Future,” which took care of a nursing shortage and increased the nursing workforce by more than one million.

The challenge is open now through February 1, 2019. Applicants should meet the following criteria:

  • Uniqueness of the idea
  • Potential impact on human health
  • Feasibility of the idea
  • Thoroughness of approach
  • Identification of key resources and plan to further idea

For more information about the Johnson & Johnson Nurses Innovate QuickFire Challenge, visit nursing.jnj.com/home.

Honoring Our Veterans With Innovative Nursing Care

Honoring Our Veterans With Innovative Nursing Care

As nurses, we know every patient is special, but I can think of no greater contribution I can make right now than being a nurse to those who’ve served our country. I work every day with veterans dealing with dementia in my role as the clinical nurse leader for the geriatric extended care line at the Chillicothe Veterans Affairs Medical Center in Ohio.

As a clinical nurse leader with a background in evidence-based practice, I’m always looking for ways to improve the long-term care environment for our veterans with dementia. One idea we arrived at is focused on therapeutic design, which encompasses many things all addressing the senses, thus improving the external environment in a way that can lead to internal healing and peace. Agitation, anxiety, and depression are common in individuals with dementia; we’ve seen how therapeutic design can help alleviate these symptoms.

One tactic we’ve introduced is the use of interactive cats. You may have seen these for sale in stores or online. They have touch sensors in their head, ears, and cheeks and will nuzzle in when petted; these toys purr just like real cats. The point is that through therapeutic design we now have patients with dementia who love to play with these toys; many haven’t been around pets for many years.

We’ve also installed a jukebox in a common area; this music has transformed a sterile setting into one with lively sounds throughout the day. Songs can evoke feelings, bring back fond memories, and bring smiles to faces. As you walk down our main hallway murals brighten the walls and bring color and life. We also have implemented aromatherapy, which is calming and helps patients sleep better as well as reduces their pain.

Importantly, caregivers report that they appreciate the value of sensory-stimulation interventions, which have proven helpful in improving caregiver confidence and reducing distress. Happier patients have also led to a decrease in caregiver burnout rates. This is a stark contrast from how things were before, when veterans who were cognitively impaired would be in a unit with bland colors on the walls, no pictures to look at, and little to remind them of home.

Recently, I had the opportunity to share the lessons I have learned while implementing this innovation with others in the Veterans Affairs system, the largest integrated health care system in the country. The VA is in a unique position to advance, change, and disrupt the way America delivers health care. At the Veterans Health Administration’s Innovation Experience, held in Washington, D.C., I was able to share my experiences and help the entire system understand how we’ve provided better care and support for veterans.

In addition to presenting, I also learned from others, such as Shannon Munro, PhD, who is chair of the national VA nursing research field advisory committee. She serves veterans as a nurse researcher, nurse practitioner, and many other roles. Munro and her team in Salem, Virginia, have significantly reduced the risk of developing hospital-acquired pneumonia by providing consistent oral hygiene during hospital admissions. They named their initiative Hospital-Acquired Pneumonia Prevention by Engaging Nurses (Project HAPPEN); it encourages clinical staff to assist veterans to complete oral care two-to-three times each day. This practice ensures non-ventilated patients receive oral care by providing consistent staff training, educating patients about oral care, and its association with pneumonia, and standardizing oral care supply and distribution. At the Salem VA Medical Center, the incidence of pneumonia decreased by 92% from the baseline in the first year. The intervention has expanded across eight VA hospitals, yielding an estimated cost avoidance of $4.7 million and 21 veteran lives saved to date.

We know our veterans gave their all when they were in active duty. Now, we are glad to work together to ensure we are providing the best in care, as well as the innovations in care, that are needed now and into the future.

Using Video Games to Train Nurses

Using Video Games to Train Nurses

Whether you like retro games such as Pac Man, Centipede, or Asteroids or more modern ones like World of Warcraft, Call of Duty, or Madden NFL, you’ve got to admit that there’s something fun about making your way to the next level or finally getting a really high-scoring game. Mercy Medical Center in Baltimore, Maryland has taken the concept of video games one step further—and is using them to teach skills and information to its nurses.

Susan Finlayson, DNP, RN-NE-BC, Sr. Vice President, Operations and Stacey Brull, DNP, RN, NE-BC, Sr. Director Research, Education and Nursing Informatics, at Mercy Medical Center, took time to answer our questions.

How are video games used to help in training nurses?

We use video games as a teaching tool to help explain complex information, onboard new nurses, and provide an alternative to classroom training. Using both plug-and-play games as well as customized games provides our nurses with information they need when they need it, and in a fun, interactive format.

The World of Salus™ is an excellent example of a video game that we use in orientation to cover key topics pertinent to nurses starting at Mercy. Instead of sitting through 3 days of classroom lectures, our new employees venture into a World where they create an avatar, earn badges, explore knowledge objects, compete on a leaderboard, and complete challenges to make it to Finales and receive their certificate of completion.

The World of Salus is a complex adventure game; however, we also simpler games that we can quickly customize for more specific types of training. Doesn’t playing a slot machine game to learn about infection control practices sound like fun?

Video games also help identify areas needing further training and education. As with most technologies, we are able to develop specific reports telling us areas where a nurse(s) may have struggled with a specific topic as well as areas needing less time and attention. Video games, with reporting functions, create individualized learning plans for the learner versus a one-size-fits-all.

Are these regular nurses or nursing students?

The current games we use are primarily for current and new nurses entering Mercy Medical Center.

Please explain in detail how you use them.

We started small using free online games in staff meetings and other learning environments where we could plug and play our material. For example, one of our educators was teaching specific regulatory information and used a quizzing game during her presentation as an interactive tool to supplement her lecture. Another educator used a QR code to have employees perform a scavenger hunt through an online app during their unit orientation.

We now create a lot of our games. For example, we have a game called The Quest for Magnet Status where nurses had to go to different pyramids and learn about the components of the Magnet Model. Each pyramid has a hieroglyphic that the nurse needs to decode to find the secret of the ancient legend. Other types of games we have created include puzzles, trivia, and races. We have even begun to venture into virtual reality games.

Regardless of the type of game we use, our goal is to utilize the best game mechanics in developing a positive avenue for engagement. Since we know people are playing online games all over, why not use games in training?

What video games are used?

We create a lot of our own video games, but we also use Kahoot, Classcraft, C3Softworks, and other online games in our gaming toolbox.

How did you come up with the idea to use them?

We were seeing a lot of our employees texting under the table or continuously checking their phones during classroom presentations. We had the ability to pull reports indicating that staff members were just clicking the “next” button all the way through our online modules on our learning management system in order to answer the obligatory questions at the end. More importantly, we found that despite teaching—and many times reteaching—behaviors and outcomes weren’t changing. Therefore, we knew we had to find a more effective and efficient way to reach our staff and came across a new term at the time called “gamification.”

We looked extensively into what gamification was and how it was being used in other sectors to see if we could adapt it in health care. We even took a course on gamification. Through this discovery phase, we knew we had to give gaming and gamification a try, and now that we have, we would never go back.

What benefits have you seen as a result of using video games? 

Our staff is more excited to learn because learning doesn’t seem like a chore anymore. The games are clearly more pleasing to the senses, using a wide variety of aesthetics and music which connects the player’s emotions with the content. We have even conducted research demonstrating gaming as better in terms of user satisfaction and retention of information when compared to didactic classroom learning and e-learning modules in a learning management system.

In addition, games are a wonderful tool for teaching material that isn’t used a lot or reinforcing aspects of a course to the students. Since the end-user can quickly go in and learn what they need to know, they are more intrinsically motivated to play. There is so much diversity in games, too. Games can easily be changed using different colors, different interactions, or different game mechanics. And, games are adaptable so they can be used for quick need-to-knows as well as competency management. Having an employee play a timed code cart video game to find the necessary equipment in a code situation is much more powerful than having a cart open in a classroom for the employee to “explore.” Video games have improved the way our staff critically thinks and approaches problems.

How do the nurses respond to it?

The nurses love using games in learning. They enjoy the fact that it is self-paced, providing them with as little or as much time as they need to learn the content. The environment provides them with opportunities to make mistakes and learn from them without feeling incompetent. In fact, our orientees have enjoyed The World of Salus so much that our current staff is asking if they can go back through orientation and play the game. That statement is a true testament to the impact video games have had on our organization.

How long do they use them? What do they do? 

Video games provide the end user the ability to play when they want and where they want. The World of Salus game takes about 4 hours to complete in its entirety. Other games, such as Code Card Blitz, take about 15 minutes.

Do you use video games all the time for training nurses?   

We use games as much as we can in training. If we aren’t using games, we are committed to using some type of interactive teaching tool in our training including a variety of multimedia and online media platforms.

How do video games help nurses learn with real patients? 

The world of possibilities using video games is mind-blowing. Whether the game is single player, multiplayer, 2D, 3D, or virtual, a video game could be made for just about any situation and any type of patient. The good news is that having these situations in a video game provides nurses with the ability to make mistakes without harming a patient. To us, providing a safe, fun environment where nurses can essentially create their own learning pathway will help them make better choices when working with real patients in any health care setting.

What are the challenges to using video games in this way?

One of the biggest challenges to using video games in training is having the time and resources to develop them. Making video games isn’t easy and needs a variety of skilled professionals. The World of Salus took a little over two years to develop.

What are the rewards? 

Engaged staff! When you have nurses asking for additional training or wondering when the next contest or game is coming, you have their attention. When you have their attention, you have better outcomes and more satisfied staff.

Is there anything else that you think is important for people to know?

Since gaming is relatively new and innovative in health care, we wanted to be at the forefront. But there is still a lot of research that needs to be conducted to better understand the uses of gaming in nursing education. Having said that, using games to help train nurses has been one of the most exciting and energizing journeys we have been on at Mercy.

However, don’t reinvent the wheel.  Reach out to other fellow gaming educators, like us, and learn from each other. The sky is the limit, and it’s a great time to take training to a new level in health care.

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