EXPERIENCES IN PRACTICE
Luis Enrique Estévez-Cruz,1 Masiel Rodríguez-Sánchez,2 Liliana Mejía-Ángeles,1 Elizabeth Casimiro-Hernández,1 Thalía Sharannin Cid-Tafoya,1 María Eugenia Ramos-Rayón1
1Clínica de Catéteres; 2Dirección de Enfermería, Quimioterapia Ambulatoria. Hospital de Oncología, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Distrito Federal, México
Correspondence: Luis Enrique Estévez-Cruz
Received: April 16th 2015
Judged: June 24th 2015
Accepted: July 22nd 2015
Infections associated with healthcare are a major patient safety problem due to its impact on morbidity and mortality. One of the top three causes of infection is related to vascular lines. Although its use is essential in emergency services, intensive care, and inpatient services, it carries the risk of catheter-related bacteremia (CRB). In this regard, there are standards, protocols, programs, clinical practice guidelines and manuals; as well as the recommendations issued by international organizations like the Infusion Nurses Society (INS) and the Center for Disease Control and Prevention (CDC). With these references, the integration of Intravenous Therapy Equipment (ITE), implementing improvement strategies and operationally practical interventions, as well as the collaboration of professionals involved in the process, makes for favorable results to benefit cancer patients with vascular devices.
Keywords: Intravenous administration; Catheters; Bacteremia
Healthcare-associated infections are a major patient safety problem for their impact on morbidity and mortality, increasing the length of hospital stay, long-term disability, increased resistance of microorganisms to antimicrobials, additional financial burden on the health system, and the cost implications for patients and their families.1-3
One of the top three causes is infection related to vascular lines. Although their use is essential in emergency, intensive care, and inpatient services for the infusion of medications, blood products, and treatments such as parenteral nutrition and antineoplastics, this carries the risk of catheter-related bacteremia (CRB) as one of the most serious adverse events associated with inpatient care.4,5 In high-income countries, the incidence of bacteremia is 3.5 (CI = 95%, 4.1-2.8) per 1000 central catheter days in adult intensive care units.4,6 On the other hand, in developing countries rates have been reported whose dimension is 19 times higher than those recorded in Germany and the United States.3 In the latter, 80,000 bacteremias occur in patients with central venous catheters (CVC), which result in 28,000 deaths each year.7,8
According to what was reported by the IMSS Coordinación de Vigilancia Epidemiológica,8 in the area of CRB in 2013, the overall rate was 2.4 per 1000 catheter days.
Among the institutional actions to take for the prevention and reduction of nosocomial healthcare-associated infections is the Institutional model for the prevention and reduction of nosocomial infections (Modelo Institucional para Prevenir y Reducir las Infecciones Nosocomiales, MIPRIN),8 which focuses on risk and process improvement through the application of checklists, including some aimed at the reduction of the CRB from installation, healing, and monitoring measures in patients with CVC.
In this regard, there are references at a national level such as NOM-022SSA3-2012,9 in which the conditions for the administration of infusion therapy in Mexico are specified; the Protocol for the Standardized Management of Patients with Peripheral, Central, and Permanent Catheters (Protocolo para el Manejo Estandarizado del Paciente con Catéter Periférico, Central y Permanente),9 Programa de Bacteriemia Cero;10,11 and Clinical Practice Guidelines for the Prevention, Diagnosis and Treatment of Infections Related to Vascular Lines (Guía de Práctica Clínica para la Prevención, Diagnóstico y Tratamiento de las Infecciones Relacionadas a Líneas Vasculares).4 Among international agencies there are the Infusion Nurses Society12 and the Center for Disease Control and Prevention.13
In the Unidad Médica de Alta Especialidad (UMAE) Hospital de Oncología of the Centro Médico Nacional Siglo XXI of Instituto Mexicano del Seguro Social (IMSS), of all adult patients admitted to medical or surgical treatment, between 85 and 90% require a peripheral or central vascular device. According to the requirement of infusion therapy this may be temporary or permanent, and based on the mode of treatment, the patient is hospitalized or treated on an outpatient basis. The need for one or more vascular devices, coupled with the base condition and concomitant diseases and immune competence status, places cancer patients in a state of greater vulnerability.
Therefore, at the end of 2012 the implementation of a specific service for the care of patients with vascular devices was undertaken, which was completed with the opening of the Clínica de Catéteres the February 26, 2013, under the Dirección de Enfermería. This clinic has the following purposes:
The planning and implementation of Clínica de Catéteres included physical space requirements for conducting procedures, waiting room for patients and families, supplies, installations, and equipment, as well as the needs analysis from a situational diagnostic of the epidemiological profile of patients. Among the features identified are medical diagnosis, treatment modality, time of CVC placement, and complications associated with infusion therapy, which can be prevented with early assessment and placement of CVC.
Intravenous therapy teams from both shifts received theoretical and practical training from an external clinical consultant, as well as visits to catheter clinics at the Instituto Nacional de Cancerología and the Unidad Médica de Alta Especialidad Hospital de Infectología del Centro Médico Nacional La Raza of IMSS.
Once the training on intravenous therapy equipment and service infrastructure was completed, coordination and management areas for the operation of the service of Clínica de Catéteres were established, 365 days a year in morning and afternoon shifts (Figure 1).
Figure 1. Management and Coordination Areas of Clínica de Catéteres
Following the project of Clínica de Catéteres, nursing staff of the hospital areas related to the direct care of patients with vascular devices were trained on nursing care in vascular access, allowing nursing talent and skills to be identified and with that to strengthen the ITT to implement educational strategies with staff of priority services and impact the timely evaluation of patients and the requirements of vascular devices.
From the evaluation of the first year of Clínica de Catéteres, the next step was to approach a project to improve care entitled "Safety and security in the care of the vascular device in cancer patients." The project was approved for implementation in afternoon shift at a joint meeting with the ITT of the morning and evening shifts, the clinical coordinator, the director of nursing, the deputies of nursing in the morning and evening shifts, base doctors in the specialties of Medical Oncology, Hematology and Surgery, Social Work teams, and the coordinator of medical assistants. After approval of the project, the implementation was spread and shared with the nursing staff of the three shifts.
In 2013, a total of 444 patients were treated, 261 (59%) were hospitalized patients and 183 (41%) outpatients (Figure 2). The procedures most commonly performed were 4443 catheter site healings (32%) and 2778 CVC heparinizations (20%); with less frequency there were 309 patient reviews (2%) by the ITT to decide the type of ideal catheter; ITT intervention in the installation of percutaneous catheters (PICC) in 82 cases should also be noted (Figure 3).
Figure 2. Patients seen by type of care at Clínica de Catéteres (N = 444). Source: Clínica de Catéteres database (February to December 2013)
Figure 3. Procedures performed by the ITT on inpatients and outpatients at Clínica de Catéteres (N = 13,931). CVC = central venous catheter; PICC = peripherally inserted central catheter; RX = X rays; ITT = intravenous therapy team
The training by the ITT was instrumental in this first year of operation of Clínica de Catéteres, because not only were nurses from inpatient services trained (30%), but also patients (32%), family (34%) and medical staff (4%) were also included (Figure 4).
Figure 4. People who received training in Clínica de Catéteres by the ITT (N = 1200). ITT = intravenous therapy team
The process flow of patient care and monitoring by the ITT in the Clínica de Catéteres service is part of the refinement and clarification of the process, as a result of collaborative work, communication, and coordination of all involved to benefit cancer patients with vascular devices (Figure 5).
Figure 5. Process of care and patient follow-up by ITT in the Clínica de Catéteres. Source: prepared by Luis Enrique Estevez Cruz, Clínica de Catéteres, UMAE Hospital de Oncología, Centro Médico Nacional Siglo XXI. TSI = intravenous therapy team; PRN = per necessary reason