¶ … Evidence-Based Solution to Reducing Incidence The goal of this assignment is to increase my ability to appraise and synthesize evidence to provide experience a logical argument in support of a proposal for practice change, and to provide experience in designing a detailed implementation and evaluation plan for my project. I need to discuss my project plan with you.

An evidence-based solution to reducing incidence of hospital acquired infections through indwelling medical devices

Hospital-acquired or nosocomial infections are the fourth leading cause of disease in developed countries. The increased insertion and implanting of prosthetic or indwelling medical devices is a leading cause of these infections since the introduction of a foreign body significantly reduces the body's immunity and decreases the number of bacteria needed to produce an infection. Prosthetic or indwelling medical devices such as urethral catheters, suprapublic catheter, nasogastric tubes, hemodialysis catheters, central venous catheters, and tracheostomy tubes are associated with higher risk of hospital acquired or nosocomial infections. These devices are consistently associated with increased risk of infection or colonization with multi-drug resistant bacteria such as Staphyloccocus aureus, enterococcus spp. And other gram-negative bacteria that produce extended spectrum beta-lactamases

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(Chu et al., 2005; Legras et al., 1998; Raad et al., 2005)

. The most common and significantly life-threatening infections, based on frequency and severity are those associated with procedures such urinary tract infection in catheterized patients, pneumonia as a result of intubation of patients and bacteremia as a result of intravascular catheters. Often clinicians and nurses practicing the recommended practices in order to be the front line in prevention efforts can prevent these infections.

Data from Harrington, Carrillo, and Thollaug (2000)

shows that in long-term care patients has reduced from slightly over 8.5% in 1991 to under 5% in 2010. The prevalence of feeding tubes in these patients has also decreased in the same period from 4.4% in 1991 to 3.1% in 2008. The patterns in long-term care patients suggest good trends. However, the same cannot be said of post-acute care patients where there is an increase in use of indwelling medical devices. In a recent survey, it was shown that approximately 12% of patients admitted across five states had an indwelling urinary catheter.

Reports from studies in the U.S. show that there are approximately two million nosocomial infections and 90,000 associated deaths each year. In the year 2000, the U.S. Centers for Disease Control and Prevention estimated that hospital acquired infections led to over 5 billion U.S. dollars in costs to the health system. This figure, obviously, does not take into account the huge cost of treating these infections and the disabilities that they cause

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(National Nosocomial Infections Surveillance (NNIS) System, 1991)

. Another estimate provided by Health care managers, clinicians, clinical epidemiologists and hospital administrators, all argue that nosocomial infections are largely preventable as infected medical devices are a frequent cause of hospital-acquired infections. They also contribute substantially to in-hospital mortality and morbidity Digiovine, Chenoweth, Watts, & Higgins, 1999

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. The crude mortality rate because of hospital-acquired infections is often quoted to range from 15 to 80% depending on the population and hospital environment Smith, Meixler, & Simberkoff, 1991.

Attempts to assess attributable mortality in patients are futile since most patients who require indwelling medical devices are often sicker and at greater risk of death than the other patients are Kollef et al., 2005

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. Statistics from different studies show that at least 50% of all cases of hospital-acquired infections are attributed to indwelling medical devices Safdar, Crnich, & Maki, 2001

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The cause-effect relationship of indwelling medical devices and nosocomial infections can be traced to Elek and Conen (1957)

who state that the number of bacteria that is needed to produce an infection when a foreign body is introduced decreases significantly. This is because microorganisms can access the body through many different pathways and therefore disruption of the integrity of the body's defense mechanisms such as the skin by implanting medical devices creates a direct and indirect link for microorganisms to access the body's respiratory and urogenital tracts, cerebrospinal space and bloodstream.

Data from about 500,000 patients in a report published by the National Nosocomial Infection Surveillance system suggest that 97% of the patients with urinary catheters suffer from nosocomial or hospital-acquired infections and that 87% of patients with intravenous central lines acquire nosocomial infections National Nosocomial Infections Surveillance (NNIS) System, 2002.

The situation is worsened by developments in medical and surgical practices that require increased usage of indwelling medical devices of different kinds since they are associated with better therapeutic...

However, as suggested by Chambless, Hunt, & Stewart, 2006(Locci, Peters, and Pulverer (1981)
, these plastic devices are easily colonized with fungi and bacteria leading to infections. Multi-resistant nosocomial bacteria and fungi can colonize the inner and outer surfaces of catheters and proliferate at a rate of up to half a centimeter per hour. Therefore, a thick biofilm can be formed within 24 hours )

Antibacterial resistance also affects the incidence and prevalence of nosocomial infections. Many patients in hospitals receive antibacterial drugs. This widespread use of antibacterial medication increases the resistance of bacteria to the medication. This makes the drugs to be less effective or completely ineffective against bacteria and resistant strains of bacteria are borne. These become endemic in hospitals leading to emergence of hospital-acquired infections.

Preventive measures

Reducing use of indwelling medical devices

The most important part of the debate regarding nosocomial infections is that they are preventable. The Infectious Disease Society of America emphasizes the importance of limiting the use of indwelling urinary catheters to defined clinical situations. In their argument, the society suggests that by restricting the use of urinary catheters to situations that have no other available options, the number of hospital-acquired urinary tract infections can be decreased considerably. To facilitate this reduction in use of urinary catheters, the society suggests solutions such as use of condom catheters, which are external collecting devices, intermittent catheterization and use of incontinence pads Hooton et al., 2010

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. Other proposed alternatives are anti-infective catheters which reduce the rates of bacteriuria in patients with short-term urinary catheters though do not help much in patients with chronic prosthetic urinary catheters Maki & Tambyah, 2001()

Use of percutaneous endoscopic gastrostomy tubes should also be checked to prevent hospital-acquired infections. When using percutaneous endoscopic gastrostomy tubes, it is considered standard care to conduct cephalosporin-based prophylaxis to reduce the risk of peristomal wound infection Lipp & Lusardi, 2009

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. Other practices that have been shown to be effective in minimizing catheter contamination are use of protective sheaths during placement of transoral tubes. Transabdominal insertion of tubes is considered to reduce risk of peristomal wound infection considerably Maetani et al., 2003.

However, this is often not done because of wrong perceptions of higher risk associated with deflation.

When using intravascular catheters, the Healthcare Infection Control Practices Advisory Committee of the Centers for Disease Control and Prevention and the Society for Healthcare Epidemiology of America have received guidelines for preventing intravascular device infections. The two bodies support evidence that minimizing contamination of the intravascular device hub and its contents help to reduce infections at these sites Marschall et al., 2008

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. They also state that clinical or nursing staff should ensure that catheters are removed when they are no longer needed to ensure that providers adhere to these recommended hygiene practices always. Whenever the port is being accessed, it is also important to ensure that the septum of the connector is swabbed with an antiseptic liquid Cookson et al., 1998

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When using tracheostomy devices, one simple way of preventing infection is minimizing of sedation and providing as much quality oral care as possible to patients. Patients with long-term indwelling tracheostomy devices should be provided with an individualized treatment plan that takes care of any secretions in the airway and humidity. This ensures that there is adequate humidity to prevent insippation and mucosal injury that leads to infection Solomon, Wobb, Buttaro, Truant, & Soliman, 2009

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. While cleaning airway secretions, staff should ensure hand hygiene and use of sterile gloves when manipulating the tracheostomy device. Weaning of these patients and eventual decannulation has the highest impact on reducing risk of infection at tracheostomy sites Scheinhorn, Chao, Hassenpflug, & Gracey, 2001()

Hospital programmes

At the hospital level, it is important for administrators to set up a widespread hospital program to help prevent nosocomial infections. These programs will often focus on training and refresher courses for clinical and nursing staff on the current best practice based on available evidence in order to promote good health care, appropriate sterilization and isolation practice, and epidemiological surveillance of hospital-acquired infections. One such program is the infection control committee which provides a platform for input from different stakeholders within the hospital such as clinicians, nurses, pharmacists, and support staff such as supply and maintenance, housekeeping and human resources departments. This committee should be tasked with improving the effectiveness of hospital programs to prevent nosocomial infections. They do this by reviewing monitoring and surveillance reports,…