Will your next emergency patient obtain a hospital-acquired infection?

(Editor's note: This is a two-part series on prevention of hospital-acquired infections in the ED. This month's issue provides information on avoiding infections when invasive procedures are performed, reducing the risk of infection with peripheral IV insertion, using alternatives to invasive procedures, giving central line education to ED nurses, and decreasing the use of central lines and urinary catheters. Next month, we'll cover how to determine if your patient has arrived at the ED with an infection, tips for cleaning the equipment you use, and strategies to improve compliance with hand hygiene.)

You are the first person to place an intravenous (IV) line or insert a Foley catheter in a critically ill patient. Could your carelessness cause a dangerous complication for your patient later in the hospital stay?

"The last thing we want to have happen is for a patient to develop a hospital-acquired infection as a result of our hasty process," says Mary M. Pelton, RN, CEN, an ED nurse at Carteret General Hospital in Morehead City, NC. "It is of the utmost importance to have in mind how we, as emergency nurses, can prevent infection in patients that we provide interventions on."

The first step for ED nurses is to "acknowledge that you have the ability to make or break the chain of infection for the patient," says Hillary Mitchell, RN, clinical coordinator for the ED at Methodist Hospital of Sacramento (CA). "You are the first poke, the first tube placement, or the first contamination that can lead to a hospital-acquired infection."

The ED is the "starting gate," says Amy Tyler, RN, BSN, CEN, staff development specialist for the ED and clinical decision unit at Christiana Care Health System in Wilmington, DE. "Infection acquired in the ED will affect the course of the patient's illness. It may permanently affect their general health."

Every emergency nurse must "take responsibility for the care and outcomes" of all patients, "regardless of whether they are a septic patient or a simple laceration," Mitchell says. "Don't discount the impact the ED practice standards can have on outcomes for the patient who is admitted to the hospital." Here are clinical practices to reduce risks of hospital-acquired infections in your ED:

Insist on sterile technique.

At Tufts Medical Center in Boston, ED nurses use a checklist for preventing Central Line-Associated Bacteremia (CLAB) during central line insertion. This documents that appropriate precautions are taken during the line insertion to maintain sterile technique. [The checklist used by ED nurses is included.]

"At any point in time during the insertion of a central line, if a nurse witnesses that sterile technique is broken, they notify the practitioner inserting the line," says Alexandra Penzias, RN, MEd, MSN, CEN, clinical nurse educator for the Department of Emergency Medicine. "The procedure is halted until sterile technique can be ensured."

When inserting a urinary catheter, cleanse the perineum with 10% aqueous solution of povidone-iodine using the device supplied, says Mitchell. "Do a single attempt insertion of the catheter," she says. "If it is accidentally inserted into the vagina on female patients, a new catheter should be obtained and utilized."

Use chlorhexidine gluconate-impregnated dressings.

These dressings are known to reduce the risk of CLAB. Penzias says. "They are placed over the insertion site," she says. "They allow visibility of the site and only need to be changed every seven days."

Prepare skin appropriately before venipuncture or starting an IV line.

Cleanse skin in an outward circular motion, says Mitchell. "Allow the skin to dry with the desired prep solution on it, as indicated by the manufacturer of the solution," she says. "Insertion technique should be such that the gloved finger of the nurse does not touch the site, to avoid contamination."

Clean and dress decubitus ulcers appropriately.

"Clean from the inner wound to the outer boundaries to avoid contamination of the central wound by outside skin flora," says Mitchell. "Utilize a hospital-approved skin cleaner to remove dry or dead tissue. Then, cover the wound with a dressing that will promote healing and reduce additional contamination."

Always wear gloves when accessing any peripheral or central venous ports.

Swab the ports that are to be accessed with alcohol/chlorohexidine solution pads to disinfect, says Mitchell. "Use only new, sterile syringes and tubing to avoid contamination," she says. (See related stories on peripheral IV insertion, alternatives to invasive procedures, central line education for ED nurses, and reducing the use of central lines and urinary catheters, below.)


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

  • Hillary R. Mitchell, RN, BSN, CEN, Clinical Coordinator, Emergency Department, Methodist Hospital of Sacramento (CA). Phone: (916) 423-5933. E-mail: Hillary.Mitchell@chw.edu.
  • Mary M. Pelton, RN, CEN, Emergency Department, Carteret General Hospital, Morehead City, NC. E-mail: mmpelton@CCGH.org.
  • Alexandra Penzias, RN, MEd, MSN, CEN, Clinical Nurse Educator, Department of Emergency Medicine, Tufts Medical Center, Boston. Phone: (617) 636-5357. E-mail: apenzias@tuftsmedicalcenter.org.
  • Amy Tyler, RN, BSN, CEN, Staff Development Specialist, Emergency Department & Clinical Decision Unit, Christiana Care Health System, Wilmington, DE. Phone: (302) 733-1030. E-mail: AmTyler@Christianacare.org.

Use these tips for peripheral IV insertion

Mary M. Pelton, RN, CEN, an ED nurse at Carteret General Hospital in Morehead City, NC, gives these recommendations for ensuring aseptic technique with peripheral intravenous (IV) insertion:

Cleanse the skin liberally with ChloraPrep.

"This is a proven way to prevent infection," says Pelton. "Prepackaged IV start packs with ChloraPrep in the kit can ensure its use. Be aware of debris, and ensure its removal prior to IV insertion."

Consider your insertion site.

"If the patient is flexing his elbow frequently, do your best to avoid that site," says Pelton. "Avoid extremities that already have sores, swelling, or injuries present."

Before initiating an IV, consider the purpose and extent of that IV to avoid multiple attempts.

"For example, a young patient receiving IV fluids will do well with a large bore antecubital site if you anticipate fluid resuscitation and discharge," says Pelton. "However, an elderly patient who you anticipate will be admitted will do well with a forearm site. There is less chance of infiltration or removal, due to no joint involvement."

Clinical Tip

You might not need invasive procedure

Consider these alternatives to invasive procedures when appropriate, says Amy Tyler, RN, BSN, CEN, staff development specialist for the ED and Clinical Decision Unit at Christiana Care Health System in Wilmington, DE:

  • Instead of inserting a nasogastric (NG) tube to deliver activated charcoal, provide emotional support and encouragement or add flavoring.
  • Obtain a urine sample on an incontinent patient using straight catheterization, rather than inserting an indwelling catheter.
  • Ask your most skilled nurse try to insert a peripheral intravenous line before resorting to a central line.

NPSG requires you to obtain education on central lines

Emergency department is not off the hook

Has your ED implemented The Joint Commission's requirements to prevent health-care associated infections? As of Jan. 1, 2010, you need to be in full compliance with this National Patient Safety Goal (NPSG), but ED nurses might be disregarding the important role they play in meeting this goal.

"The ED is a stopping point for most patients on their way to the floors, units, or home," says Hillary Mitchell, RN, clinical coordinator for the ED at Methodist Hospital of Sacramento (CA). "Practices consistent with NPSG compliance are sometimes let go, for the sake of moving onto the next critical patient presenting to the triage desk."

The NPSG requires you to prevent central line-associated bloodstream infections, and it requires that everyone involved in these procedures be educated about this topic.

Rhonda Morgan, RN, MSN, CEN, CNRN, CCNS, APN, vice president of clinical services and former emergency department director at Wellmont Health System in Kingsport, TN, says, "Many central lines are placed, accessed, and cared for in the ED. Many organizations already have this in place for inpatient areas, but it is no longer an option. It must reach all areas in which these procedures take place."

Morgan advises EDs to implement the Institute for Healthcare Improvement's central line "bundle" to meet the NPSG requirement. This bundle gives practices for hand hygiene, optimal site selection, maximal sterile barrier technique, chlorhexidine skin prep, and evaluation for line necessity. (For more information about this tool, go to www.ihi.org. Select "Topics" and "Critical Care." On the right side of the page, select "Central Line Bundle.")

"Don't deviate from evidence-paced practice, guidelines, and bundles," Morgan says. "Make these hardwired actions and standard practice."

Additionally, The Joint Commission guidelines call for a standardized cart that includes all necessary equipment and all sterile barrier supplies. "This creates consistency and accessibility in a 'one-stop shopping manner,'" says Morgan.

At Tufts Medical Center in Boston, ED nurses use a dedicated central line cart. "This contains all of the supplies necessary for the insertion of a central line, including all precautionary gear — mask, gown, gloves, hair and shoe coverings," says Alexandra Penzias, RN, MEd, MSN,CEN, clinical nurse educator for the Department of Emergency Medicine. [The list of the cart's contents is included.]

Insert 'many fewer' central lines, catheters

They're often not necessary

Urinary catheters often are inserted in the ED to obtain a urine specimen or for bladder drainage and measurement; however, in some cases, they are inserted too often.

Not all patients who are incontinent need an indwelling catheter, according to Mary M. Pelton, RN, CEN, an ED nurse at Carteret General Hospital in Morehead City, NC. "Straight catheterization for a urine sample will prevent the occupation of the catheter, which can be a medium for bacteria growth," says Pelton. "It is not above an ED nurse to frequently assess the patient for incontinence and provide peri-care. Indwelling catheters should be considered when monitoring of intake and output is essential to good nursing care."

However, says Hillary Mitchell, RN, clinical coordinator for the ED at Methodist Hospital of Sacramento (CA), "in the ED, many times a patient who is incontinent of urine and/or stool will have a catheter placed for the convenience of the nurse. It allows the nurse to not have to go in and help the patient utilize the bedpan or assist them with getting to the bedside commode. Not only is this invasive procedure not necessary, sterile technique is compromised in the name of time."

ED nurses need to stop inserting urinary catheters in a nonzindicated situation, says Rhonda Morgan, RN, MSN, CEN, CNRN, CCNS, APN, vice president of clinical services and former emergency department director at Wellmont Health System in Kingsport, TN. "Urinary tract infections account for 32% of hospital-acquired infections," she says. "Many of these are related to indwelling urinary catheters."

Morgan says indications for a urinary catheter are obstruction or gross hematuria, urological diagnostic studies or surgery, neurogenic bladder, Stage 3 or 4 sacral decubiti in the incontinent patient, palliative care at the patient's request, and close monitoring for urinary output.

Indwelling urinary catheters are not indicated for incontinence, immobility, obtaining urinary specimens, or usual monitoring of urinary output, says Morgan. "The practice of inserting many fewer urinary catheters in the ED will be a practice change, but one that will positively impact this very common healthcare-acquired infection," she says.

Limit to sickest patients

At Tufts Medical Center's ED in Boston, Foley catheter insertion is limited to certain key populations. These are trauma patients, critical care patients, and patients requiring bladder irrigation.

"We have limited the insertion of Foley catheters to only our sickest patients requiring hourly monitoring of urine output. And, we have removed the insertion and removal of Foley catheters from the scope of the technician and returned it to the hands of nursing," says Alexandra Penzias, RN, MEd, MSN, CEN, clinical nurse educator for the Department of Emergency Medicine.

In addition, a physician order is required for Foley catheter insertion, and only nurses who have demonstrated competency are permitted to insert catheters.

Fewer patients are receiving urinary catheters due to increased risk of urinary tract infections, says Stephen R. Francz, RN, BSN, clinical manager of the ED at AtlantiCare Regional Medical Center City Campus in Atlantic City, NJ. However, fewer urinary catheters means the more frequent use of a bedpan, he says. For example, elderly patients who present in heart failure with limited mobility and poor skin turgor who are receiving diuretics to initiate dieresis require the use of a bedpan frequently, Francz says. "This requires additional nursing resources and assistance," he says. "In a situation like this, the emergency care team adjusts by reallocating staff to an area to assist a patient with frequent needs."

At AtlantiCare's ED, Foley catheters and central lines are used primarily for patients who present in shock and those who need end organ perfusion measurement, large volumes of fluids, or blood products. "We also use the catheters to measure the effectiveness of fluid resuscitation," says Francz.

Morgan says that a central line is indicated for administration of medications not recommended for a peripheral line, total parental nutrition, hemodynamic monitoring, repeated administration of blood products, poor peripheral access, and administration of sclerosing agents. "Central lines are not indicated for convenience of the health care provider or intermittent medication administration," she says.

At Signature Healthcare Brockton (MA) Hospital, the frequency of central lines placed in the ED has decreased significantly. "There is a significant decrease in the use of femoral lines altogether," Kate Mac Kinnon, RN, CEN, nurse manager for emergency services. "Infection rates are closely monitored and shared with staff."