Reduce ED infections by making nurses accountable

As an ED nurse was inserting a urinary catheter in a young man who had been critically injured in a motor vehicle collision, the trauma surgeon was watching closely.

"He noticed that, unknown to her, she had contaminated the catheter with part of her sleeve," recalls Ann White, APRN, MSN, CCNS, CEN, CPEN, a clinical nurse specialist for emergency services at Duke University Hospital in Durham, NC.

The surgeon immediately stopped the procedure, says White, and ordered that a new insertion tray and catheter be set up. "This raised the awareness of all the nurses in the room," says White. "What we do might seem inconsequential, but to that trauma surgeon it was very significant. He did not want his patient to get a urinary tract infection from a contaminated catheter."

Because the hospital's trauma surgeons are continually evaluated for infection rates, White explains, they take great pains to make ED nurses aware they are part of the infection surveillance for each patient.

"When they are pegged with a hospital-acquired infection on their patient, they look to where that patient came in and what occurred," says White.

In this type of scenario, which happened more than once in White's ED, "there was a degree of embarrassment involved." White first reviewed the nurses' technique, then reminded them that they also have the right to stop a procedure if anyone is interfering with maintaining strict asepsis.

"Nobody else should be a barrier to that," says White. "If the orthopedic resident is moving a patient's leg while you are trying to insert a catheter, call a 'time out.'"

Tracer pinpoints source

ED infection rates have gone down significantly at Trinity Regional Medical Center in Fort Dodge, IA, says Amy Mundisev, RN, BSN, CEN, ED clinical educator, because of changes in standard of care and Medicare reimbursement.

If a patient is diagnosed with a catheter-associated urinary tract infection (CAUTI), a tracer is done to show where and when a contaminated catheter was placed, and by whom. "These numbers are shrinking significantly," says Mundisev.

The number of CAUTIs in various areas, including the emergency department, is posted throughout the hospital, says Mundisev, which motivates ED nurses to be extra careful. "This has increased accountability to slow down, because of the negativity that may be associated with a patient that develops a CAUTI from the emergency department," she says.

Urine culture results might reveal, for example, that a patient's infection was caused by a skin contaminant microbe that got inserted with a catheter in the ED. "It's essentially a given that a young man who comes in from a motor vehicle collision didn't come here with any bacteria in his bladder," says White.

A patient who acquires an infection in the ED requires antibiotics and has a longer length of stay, says White, and the hospital has increased costs and decreased reimbursement. "What ED nurses do is absolutely huge in preventing infections," she says.

Publically reported data on infection rates has shifted the focus from inpatient areas to the entire continuum of care, says White — including the ED. "The whole sequence of care is included," she says. "The ED doesn't get a 'by' anymore, for all of those metrics." (See related stories on clinical practices to reduce infections and getting catheters discontinued, below.)


For more information on preventing ED-acquired infections, contact:

  • Jenny Bosley, RN, MS, CEN, Emergency Department, Thomas Jefferson University Hospital, Philadelphia, PA. Phone: (215) 955-2656. Fax: (215) 955-8559. E-mail:
  • Amy Mundisev, RN, BSN, CEN, Clinical Educator, Emergency Department, Trinity Regional Medical Center, Fort Dodge, IA. Phone: (309) 779-3293. E-mail:
  • Ann White, APRN, MSN, CCNS, CEN, CPEN, Clinical Nurse Specialist, Emergency Services, Duke University Hospital, Durham, NC. Phone: (919) 681-0352. Fax: (919) 681-8521. E-mail:

Stop needless infections with these simple steps

During various in-services on preventing hospital-acquired infections, emergency nurses at Duke University Hospital in Durham, NC, hear one message repeated over and over: Asepsis can't be rushed.

"Even though this is an ED, that doesn't give you permission to cut corners on basic aseptic procedures," says Ann White, APRN, MSN, CCNS, CEN, CPEN, clinical nurse specialist for emergency services. "When you are drawing blood, doing venipuncture, or inserting a urinary catheter, you don't speed through those things."

You need to allow the cleansing agent to dry the appropriate amount of time in order to foster the most antimicrobial environment, for example, says White. Use these practices to prevent infections:

• Have a designated nurse monitor hand washing for anyone entering a patient's room.

Consulting physicians coming from inpatient areas bring hospital microbes down into the ED, says White, while patients bring in community microbes. "We are approaching this from both of those areas," she says. "We have been very successful in increasing compliance."

• Each month, have ED nurses review a case of a real patient.

During in-services, says White, "it isn't unusual for us to select cases involving a patient with a hospital-acquired infection who was seen in the ED. It points out that we play a big part in this."

• Bring an extra catheter with you as a "back-up."

"Like a baseball player with his lucky socks, I can't start a urinary catheter without an 'extra' at the bedside," says Amy Mundisev, RN, BSN, CEN, ED clinical educator at Trinity Regional Medical Center in Fort Dodge, IA.

This saves you from taking off your gloves and leaving the room if the catheter should become contaminated, Mundisev explains.

If a catheter is placed in a female's vagina instead of the urethra, Mundisev typically has the nurse leave it in place while the "back-up" catheter is getting ready to place, avoiding the area where the contaminated catheter is. "Usually I tell nurses to 'go above' the misplaced catheter," she says. "Once the new and sterile catheter is placed, the old contaminated one can be removed and thrown away."

Clinical Tip

Allow nurses to get catheters discontinued

ED nurses at Thomas Jefferson University Hospital in Philadelphia can now get a patient's urinary catheter discontinued, based on a set of parameters in a newly implemented urinary catheter protocol.

"Nurses are empowered to question the need for a catheter," says Jenny Bosley, RN, MS, CEN, an ED clinical nurse specialist. A urinary catheter may be necessary only for a short-term need, she explains. For instance, a patient with acute shortness of breath may require treatment for acute pulmonary edema or heart failure with diuretics.

The patient may be too unstable to get out of bed to void, or may have a pre-existing condition that may prevent him or her from getting out of bed frequently to void, says Bosley. "Once the catheter is no longer needed, get it discontinued," she says.