Central lines (or central venouscatheters) can provide manybenefits to patients such as

fluid resuscitation medication adminis-tration and hemodynamic monitoringBut these benefits bring several risksthe most common of which is centrallinendashassociated bloodstream infection(CABSI) The Centers for DiseaseControl and Prevention (CDC) esti-mates that 250000 CABSIs occur inhospitals each year with an attributablemortality of 12 to 25 for eachinfection1 In addition bloodstreaminfection rates are substantially higheramong patients with central lines thanamong those without central lines1

Due to the persistence of theseinfections the Centers for Medicare ampMedicaid Services (CMS) will nolonger pay health care organizations forthe extra costs associated with vascular

catheterndashassociated infections CMShopes to thereby motivate organiza-tions to prevent a repeat of the 29536vascular catheterndashassociated infectionsthat occurred with Medicare patients

in 20072

The Joint Commission approved anew National Patient Safety Goalrequirement for 2009 (NPSG070401)

Central LinendashAssociated Bloodstream Infections

Central LinendashAssociated Bloodstream Infections 1

PATIENT SAFETY PULSE YOUR PATIENT SAFETY NEWS

HHS Issues Action Plan to Prevent Health CarendashAssociated Infections 2

Strategies for Eliminating Catheter-Related Urinary Tract Infection 5

Preventing Home Fires Associated with Long-Term Oxygen Therapy 8

CONTENTS

The Joint Commission

Perspectives onTMPatient Safety

March 2009Volume 9 Issue 3

As of 2009 The Joint Commissionrsquos National Patient Safety Goals include a requirementdesigned to prevent CABSIs (Photo courtesy of the Federal Emergency Management Agency)

(continued on page 3)

Top 5 in the News

1Agency Advises Organizations

About Antiviral Drugs Patients who

have weakened immune systems

health care workers and emergency

services personnel should be pro-

tected with antiviral drugs throughout

an influenza pandemic according to a

recently released guideline by the US

Department of Health and Human Ser-

vices The guideline is available at

httpwwwpandemicflugov

2Study Smoking Cessation

Reduces Heart Attacks Heart

attack hospitalizations in the city of

Pueblo Colorado fell from 399 to 237

in an 18-month period after work-

places and public places were made

smoke-free according to the Centers

for Disease Control and Preventionrsquos

Morbidity and Mortality WeeklyReport

3Antibiotics Overprescribed for

Pediatric Patients Physicians tend

to overprescribe antibiotics for children

who have upper respiratory infections

according to a recent study in the

journal Ambulatory Pediatrics

4X-rays Help Prevent Surgical

Sponge Retention Requiring the

use of x-rays to detect surgical

sponges before the patient leaves the

surgical suite is more cost-effective

for hospitals than relying on sponge

counts by operating room staff

according to a recent study that

appeared in the journal Surgery

5Some Medical Errors Not Docu-

mented A recent study published

in the Annals of Internal Medicinefound that hospital patients reported

serious adverse events that were

never documented in their medical

records

wwwjcrinccom

Patient Safety PulseYour Patient Safety News

HHS Issues Action Plan to Prevent HealthCarendashAssociated Infections

Senior Editor Jim ParkerProject Manager Bridget ChambersManager Publications Paul ReisExecutive Director of Publications Catherine Chopp HinckleyContributors Meghan Pillow RNCatherine Rategan Kathy Vega

Subscription Information The Joint Commission Perspectives on PatientSafetyTM (ISSN 1534-5181) is published monthly(12 issues per year) by

Joint Commission ResourcesOne Renaissance BoulevardOakbrook Terrace IL 60181

Send address corrections to The Joint Commission Perspectives on Patient Safety Superior Fulfillment131 West First StreetDuluth MN 55802-2065

Annual subscription rates for 2009Domestic $319 for print and online $299 foronline only international $410 for print and online$299 for online only Back issues are $25 each(postage paid) To begin your subscription call800746-6578 fax orders to 218723-9437 or mailorders to Joint Commission Resources 16442 Col-lections Center Drive Chicago IL 60693

Editorial policy Reference to a name an organization a product or a service in The Joint

Commission Perspectives on Patient SafetyTM

should not be construed as an endorsement byJoint Commission Resources nor is failure toinclude a name an organization a product or aservice to be construed as disapproval

copy 2009 by The Joint Commission on Accreditationof Healthcare Organizations No part of this publi-cation may be reproduced or transmitted in anyform or by any means without written permission

Joint Commission Resources Inc (JCR) an affiliate of The Joint Commission has been designated by The Joint Commission to publishpublications and multimedia products JCR reproduces and distributes these materials underlicense from The Joint Commission

Visit us on the Web at httpwwwjcrinccom

The US Department of Health and Human Services (HHS) has estab-lished a set of five-year ldquonational prevention targetsrdquo designed to preventhealth carendashassociated infections (HAIs)

According to Centers for Disease Control and Prevention (CDC) estimatesapproximately 17 million HAIs occurred in US hospitals in 2002 the mostrecent year for which CDC data were available These infections were associatedwith an estimated 99000 deaths The CDC also estimates that HAIs lead to anestimated $20 billion in health care costs annually

The Joint Commissionrsquos National Patient Safety Goal 7 requires accreditedorganizations to take steps to reduce the risk of HAIs The goalrsquos five requirementsinclude provisions related to hand hygiene surgical site infections centrallinendashassociated bloodstream infections multiple-drug-resistant organisms andmanagment of identified HAI cases as sentinel events (For more information aboutthe National Patient Safety Goals visit httpwwwjointcommissionorg)

The HHSrsquos ldquoThe Action Plan to Prevent Health CarendashAssociated Infectionsrdquolists a number of areas in which HAIs can be prevented such as surgical site infec-tions According to HHS this document serves as a roadmap for how the federalgovernment will address HAIs as a public health issue The plan includes the creationof national benchmarks a set of prioritized recommended clinical practices aresearch agenda an information management strategy and a public communicationsplan intended to raise awareness of HAIs and prevention of HAIs The action planalso describes the agencyrsquos blueprints for collaboration with other federal agenciesand state tribal and local governments and organizations

The agency has submitted a plan for public comment and plans to hold a seriesof public meetings about the plan A copy of the plan a schedule for these meet-ings and instructions for commenting on the plan can be found athttpwwwhhsgovophs PS

2 THE JOINT COMMISSION PERSPECTIVES ON PATIENT SAFETY March 2009

Top 5 in the News

1Agency Advises Organizations

About Antiviral Drugs Patients who

have weakened immune systems

health care workers and emergency

services personnel should be pro-

tected with antiviral drugs throughout

an influenza pandemic according to a

recently released guideline by the US

Department of Health and Human Ser-

vices The guideline is available at

httpwwwpandemicflugov

2Study Smoking Cessation

Reduces Heart Attacks Heart

attack hospitalizations in the city of

Pueblo Colorado fell from 399 to 237

in an 18-month period after work-

places and public places were made

smoke-free according to the Centers

for Disease Control and Preventionrsquos

Morbidity and Mortality WeeklyReport

3Antibiotics Overprescribed for

Pediatric Patients Physicians tend

to overprescribe antibiotics for children

who have upper respiratory infections

according to a recent study in the

journal Ambulatory Pediatrics

4X-rays Help Prevent Surgical

Sponge Retention Requiring the

use of x-rays to detect surgical

sponges before the patient leaves the

surgical suite is more cost-effective

for hospitals than relying on sponge

counts by operating room staff

according to a recent study that

appeared in the journal Surgery

5Some Medical Errors Not Docu-

mented A recent study published

in the Annals of Internal Medicinefound that hospital patients reported

serious adverse events that were

never documented in their medical

records

wwwjcrinccom

Patient Safety PulseYour Patient Safety News

HHS Issues Action Plan to Prevent HealthCarendashAssociated Infections

Senior Editor Jim ParkerProject Manager Bridget ChambersManager Publications Paul ReisExecutive Director of Publications Catherine Chopp HinckleyContributors Meghan Pillow RNCatherine Rategan Kathy Vega

Subscription Information The Joint Commission Perspectives on PatientSafetyTM (ISSN 1534-5181) is published monthly(12 issues per year) by

Joint Commission ResourcesOne Renaissance BoulevardOakbrook Terrace IL 60181

Send address corrections to The Joint Commission Perspectives on Patient Safety Superior Fulfillment131 West First StreetDuluth MN 55802-2065

Annual subscription rates for 2009Domestic $319 for print and online $299 foronline only international $410 for print and online$299 for online only Back issues are $25 each(postage paid) To begin your subscription call800746-6578 fax orders to 218723-9437 or mailorders to Joint Commission Resources 16442 Col-lections Center Drive Chicago IL 60693

Editorial policy Reference to a name an organization a product or a service in The Joint

Commission Perspectives on Patient SafetyTM

should not be construed as an endorsement byJoint Commission Resources nor is failure toinclude a name an organization a product or aservice to be construed as disapproval

copy 2009 by The Joint Commission on Accreditationof Healthcare Organizations No part of this publi-cation may be reproduced or transmitted in anyform or by any means without written permission

Joint Commission Resources Inc (JCR) an affiliate of The Joint Commission has been designated by The Joint Commission to publishpublications and multimedia products JCR reproduces and distributes these materials underlicense from The Joint Commission

Visit us on the Web at httpwwwjcrinccom

The US Department of Health and Human Services (HHS) has estab-lished a set of five-year ldquonational prevention targetsrdquo designed to preventhealth carendashassociated infections (HAIs)

According to Centers for Disease Control and Prevention (CDC) estimatesapproximately 17 million HAIs occurred in US hospitals in 2002 the mostrecent year for which CDC data were available These infections were associatedwith an estimated 99000 deaths The CDC also estimates that HAIs lead to anestimated $20 billion in health care costs annually

The Joint Commissionrsquos National Patient Safety Goal 7 requires accreditedorganizations to take steps to reduce the risk of HAIs The goalrsquos five requirementsinclude provisions related to hand hygiene surgical site infections centrallinendashassociated bloodstream infections multiple-drug-resistant organisms andmanagment of identified HAI cases as sentinel events (For more information aboutthe National Patient Safety Goals visit httpwwwjointcommissionorg)

The HHSrsquos ldquoThe Action Plan to Prevent Health CarendashAssociated Infectionsrdquolists a number of areas in which HAIs can be prevented such as surgical site infec-tions According to HHS this document serves as a roadmap for how the federalgovernment will address HAIs as a public health issue The plan includes the creationof national benchmarks a set of prioritized recommended clinical practices aresearch agenda an information management strategy and a public communicationsplan intended to raise awareness of HAIs and prevention of HAIs The action planalso describes the agencyrsquos blueprints for collaboration with other federal agenciesand state tribal and local governments and organizations

The agency has submitted a plan for public comment and plans to hold a seriesof public meetings about the plan A copy of the plan a schedule for these meet-ings and instructions for commenting on the plan can be found athttpwwwhhsgovophs PS

2 THE JOINT COMMISSION PERSPECTIVES ON PATIENT SAFETY March 2009

which requires organizations to imple-ment evidence-based guidelines toprevent CABSIs NPSG070401applies to short- and long-term centralvenous catheters as well as peripherallyinserted central catheter (PICC) linesThe elements of performance (EPs) forthis goal focus on four main points (1)educating staff patients and their fam-ilies regarding guidelines for preventingCABSIs (2) measuring compliancewith the guidelines and CABSI rates(3) maintaining aseptic technique dur-ing central line insertion and (4)properly maintaining the central lineand continuously evaluating the neces-sity of the central line

To ease organizations into the tran-sition of preventing CABSIs The JointCommission has included a one-yearphase-in period with expectations forplanning developing and testingprogress at three six and nine monthsin 2009 Full implementation of thegoal is expected by January 1 2010across an entire organization (not justin intensive care units [ICUs]) Thisarticle outlines tips for complying withthe EPs under NPSG070401 andreducing CABSIs (Organizations canalso reference ldquoPreventing Catheter-Related Bloodstream Infectionsrdquo whichwas published in the May 2008 issue ofThe Joint Commission Perspectives onPatient Safety Subscribers can accessthat article here httpwwwingentaconnectcomcontentjcahojcpps20080000000800000005art00004

Educate providers onevidence-based practices forpreventing CABSIs Both theUniversity of Pittsburgh MedicalCenter (UPMC) Presbyterian inPittsburgh and BJC Healthcare Systemin St Louis have developed Web-basededucation modules for physicians whoinsert central lines and nurses who

assist with insertion and maintain thecentral line ldquoThe central line insertioncourse uses Web-based didactic trainingand a simulation centerrdquo says CarleneA Muto MD MS medical directorof Infection Control and HospitalEpidemiology at UPMC Presbyterian(Find out more about UPMCrsquos educa-tion module athttpwwwwiserpitteduappscoursescourseviewaspcourse_id=3131) BJC Healthcare also developededucational modules for preventinghealth carendashacquired infections includ-ing CABSIs (see httpwwwapicorgfor more information)

Good marketing of required policiesand procedures can improve providercompliance The Greater CincinnatiHealth Council created a slogan ldquo2 Minutes to Save a Liferdquo to helpproviders remember the interventionsinvolved in the central line insertionbundle3 These interventions includeuse of alcohol-based hand gel (10 sec-onds) maximum sterile barriersincluding sterile gloves large steriledrape sterile gown mask with faceshield and hat (50 seconds) applica-tion of chlorhexidine-based antiseptic(30 seconds) and appropriate dryingtime for antiseptic (30 seconds)

Involve patients andfamilies in CABSI preven-tion strategies Along with basichand hygiene techniques patientsshould be told the following to helpprevent a CABSI4bull If the bandage at the insertion site

comes off or becomes wet or dirtytell your nurse or physicianimmediately

bull Inform a nurse or physician if the areaaround your catheter is sore or red

bull Ensure that health care providerswash their hands before entering theroom and disinfect the injectionport before accessing the central line

bull Do not let family and friends whovisit touch the catheter or the tubing

The Society for HealthcareEpidemiology of America (SHEA) pro-vides an educational flyer that can begiven to patients to help them getinvolved in preventing CABSIs (seehttpwwwshea-onlineorgAssetsfilespatient20guidesBSIpdf )

Follow establishedguidelines from the CDC orother professional organiza-tions when developingpolices and procedures Thegold standard for evidence-based prac-tice guidelines for preventing CABSIsis Guidelines for the Prevention ofIntravascular Catheter-Related Infectionswhich the CDC published in20021ldquoWe are updating the guidelinesright now and they should be ready bythe spring of 2009rdquo says Naomi POrsquoGrady MD medical directorProcedures Vascular Access andConscious Sedation Services CriticalCare Medicine Department NationalInstitutes of Health BethesdaMaryland ldquoAntibiotic and antisepticimpregnated catheters will probably geta stronger rating than they did in theoriginal guideline there will be a con-tinued emphasis on education andtraining including the use of chlorhex-idine instead of betadine and there isan expanded section on the use of posi-tive pressure valvesrdquo says OrsquoGrady

Although the EPs underNPSG070401 support the CDCguidelines there are some guidelinesfor maintaining the catheter that arenrsquotspecifically included in the goalincluding the following1bull Replacing transparent central line

insertion site dressings every sevendays or whenever the dressingbecomes damp loose or visiblysoiled (Gauze dressings can also beused without an increased risk forinfection but these dressings have tobe changed every two days and asneeded)

TIP

TIP

TIP

wwwjcrinccom THE JOINT COMMISSION PERSPECTIVES ON PATIENT SAFETY March 2009 3

Central LinendashAssociated Bloodstream

Infections (continued from page 1)

(continued on page 4)

Patient Safety Editorial Advisory Board

bull Replacing IV administration tubingsets every 72 to 96 hours Howeverwhen a fluid that enhances microbialgrowth is infused through the tubing(such as lipid emulsions and bloodproducts) the tubing should bechanged every 24 hours (Tubingused to administer propofol shouldbe changed every 6 to 12 hours)

bull Capping all stopcocks when not in use

Measure compliancewith CABSI preventionguidelines as well as CABSIrates and report back tostakeholders Organizationsshould measure unit-specific incidenceof CABSIs (in terms of CABSIs per1000 catheter days) and report thedata to nurses physicians and leader-ship on a regular basis5 To correctlyperform surveillance for CABSIsorganizations should consult theCDCrsquos Outline For Healthcare-Associated Infections Surveillance athttpwwwcdcgovncidoddhqppdfnhsnOutlineForHAISurveillancepdf

Most hospitals measure CABSI rateson ICUs but not all have the resourcesto measure CABSI rates for their entireorganization ldquoSome of our smallerhospitals do surveillance in non-ICUpatient care areas but itrsquos resourceintensive because these patients arespread out all over the hospitalrdquo says

Keith F Woeltje MD PhD medicaldirector for Infection Prevention atBJC Healthcare System in St LouisldquoOur data suggest that there are at leastas many patients outside the ICU withcentral lines as there are inside theICU Therefore if we had only focusedon ICU patients we would havemissed half if not more of central lineinfectionsrdquo To help reduce the work-load involved with measuring CABSIsoutside ICUs BJC Healthcare Systemis automating surveillance by evaluatingelectronically available data on patientswho have inserted central lines positiveblood cultures and positive culturesfrom other sites of the body ldquoThesedata donrsquot give a completely accurateNational Healthcare Safety Network[NHSN]ndashstyle CABSI rate but they dohelp us follow infection rate trends overtime and focus on the units that needincreased educationrdquo says Woeltje

Use a catheter checklistfor central line insertions TheNHSN provides a central line insertionchecklist at httpwwwcdcgovncidoddhqpforms57125_CLIP_BLANKpdf ldquoAn organization shouldfollow the checklist and ensure that thephysician inserting the central line iscompleting all the appropriate stepsrdquosays Woeltje

Use a standardizedsupply cart that includes all

the materials needed toinsert central lines asepti-cally Organizations need to make iteasy for providers to comply with evi-dence-based practices This meansplacing the tools and materials neededto prevent CABSIs at their fingertipsMost likely the supply cart should con-tain the following items central venouscatheter chlorhexidine large steriledrape sterile gown and gloves maskwith face shield hat syringes with salineflush 1 lidocaine sutures hemostatsscalpel blade and a dressing kit

Ensure proper maintenance of central linesProviders who access central lines mustensure that the dressing and adminis-tration tubing is changed according tothe guidelines and that catheter hubs orinjection ports are scrubbed with alcoholbefore the port is accessed15 ldquoWe haveempowered patients to stop providersfrom accessing central lines if providersdonrsquot wash their hands or access theport correctlyrdquo says OrsquoGrady ldquoIn addi-tion when a CABSI occurs we try todetermine if the infection occurred atthe time of insertion or much laterwhich would indicate that the infectionresulted from a maintenance problemand that further education for thosewho maintain central lines is neces-saryrdquo adds OrsquoGrady

TIP

TIP

TIP

TIP

wwwjcrinccom4 THE JOINT COMMISSION PERSPECTIVES ON PATIENT SAFETY March 2009

Central LinendashAssociated Bloodstream

Infections (continued from page 3)

(continued on page 11)

Bonnie M BarnardMPH CIC QualitySpecialist St PeterrsquosHospital Helena Montana

Diane D Cousins RPhVice President Center forthe Advancement of PatientSafety United StatesPharmacopeia

Hedy Cohen RN MSVice President Institute forSafe Medication Practices

Kathy Connolly RNMSEd CPHRM

Assistant Vice PresidentRisk Management PremierInsurance ManagementServices Inc

Nilda Conrad MBACPMSM CPCSPresident NationalAssociation of Medical StaffServices

David Fuller Senior SpaceSystems and OperationsEngineer and AssociateFellow of the AmericanInstitute of Aeronautics andAstronautics

Suzanne Graham RNPhD Director of PatientSafety California RegionsKaiser Permanente

Robert S Lagasse MDVice ChairmanDepartmentof Anesthesiology AlbertEinstein College ofMedicine amp MontefioreMedical Center New York

Jeannell M MansurRPh PharmDFASHP Practice LeaderMedication Safety JointCommission Resources

David Marx Head ofPaediatric GastroenterologyTeam University HospitalCzech Republic

Deborah Nadzam PhDRN FAAN PracticeLeader Patient SafetyJoint CommissionResources

Rita Shane PharmDFASHP DirectorPharmacy Services andAssistant Dean ClinicalPharmacy UCSF School ofPharmacy Cedars-Sinai

Medical Center LosAngeles

Paula Spears DNScRN Corporate DirectorProfessional Practice andAdvancement MethodistLe Bonheur HealthcareMemphis

Sherry Umhoefer RPhMBA Vice PresidentQuality and ComplianceMcKesson MedicationManagement

wwwjcrinccom THE JOINT COMMISSION PERSPECTIVES ON PATIENT SAFETY March 2009 5

Urinary tract infections (UTIs)are the most common hospitalndashacquired infections

and 80 of these infections can beattributed to indwelling urinarycatheters (UCs)1 The insertion of aUC is a common intervention inhealth care organizations and up to25 of patients will have a UC atsome time during their hospital stay2

Most commonly the adverse outcomeof UCs is a UTI but bacteremia andsepsis may occur in a small proportionof infected patients1 Furthermore UCscan cause restricted mobility which cancontribute to delayed recovery andincreased risk for pressure ulcers3

Due to the persistence of UTIs theCenters for Medicare amp MedicaidServices (CMS) will no longer payhealth care organizations for the extracosts associated with catheter-associatedurinary tract infections (CA-UTIs)CMS hopes to therby motivate organi-

zations to prevent a repeat of the12185 CA-UTIs that occurred inMedicare patients in 20074 In addi-tion The Joint Commissionrsquos NationalPatient Safety Goal 7 requires organiza-tions to take steps to prevent healthcarendashacquired infections

This article aims to provide healthcare organizations with tips and strate-gies for inserting UCs only whennecessary reducing the risk for UTIwhile a catheter is in place and forremoving UCs as soon as they are nolonger necessary to a patientrsquos care Itmay be helpful to review the figure onpage 7 which presents a decision treeregarding the use of UCs while read-ing through the following tips andstrategies

Insert a UConly when necessary Studiesshow that at least 40 of patients have indwelling UCs for unjustified

reasons5 ldquoFocusing on whether thepatient truly needs the catheter is thenumber-one intervention to preventinfectionsrdquo says Susan M SlavishBSN MPH CIC consultantJoint Commission Resources The onlypatients who should have UCs insertedinclude those with the following condi-tions or needs36

bull Urinary tract obstructionretentionbull Neurogenic bladder dysfunctionbull Urinary incontinence in patients

who are at risk for major skinbreakdown or who need to protect anearby operative site

bull Bladder irrigation or instillingmedications

bull Measurement of accurate inputs andoutputs in critically ill patients (forexample patients with hypoxemiahypotension or congestive heartfailure or patients who needinotropic support or repeatedadministration of diuretics)

bull Fluid challenge in patients withacute renal insufficiency

bull Preoperative catheter insertionbull Comfort care for terminally ill

patientsStaff education can go a long way

toward reducing the number of unnecessary UCs ldquoPeople need tounderstand what a UC is meant forand what potential complications canoccur from using itrdquo says Slavish

Donrsquot forget automaticstop orders One emergencydepartment (ED) used a ldquojust-in-timerdquo education method whereinurinary catheter indication sheet wasattached to each catheter insertionkit7 Providers filled out the indicationsheet prior to UC insertion the sheetrequired them to circle a reason for

TIP

Strategies for Eliminating Catheter-Related Urinary Tract Infection

(continued on page 6)

STRATEGY 1

inserting the catheter (similar to thelist of reasons above) or describe a dif-ferent reason for ordering the UC ifthey could not find it in the preap-proved list The UC indicationchecklist helped these ED providersthink twice about inserting a UCThereafter the total number ofcatheters inserted decreased and thenumber of appropriate UCs wentfrom 37 to 517

Be open toalternatives to inserting UCsldquoA lot of times catheters are used morefor convenience than for necessityrdquosays Keith F Woeltje MD PhDmedical director for InfectionPrevention at BJC Healthcare Systemin St Louis Even though it may beeasier to care for patients when theyhave UCs in place the increased riskfor infection negates the benefit of timesaved by the catheter Health careproviders should reconsider insertingUCs in patients who (1) cannot com-municate their need to void (2) areincontinent and arenrsquot at risk for majorskin breakdown (3) are hemodynami-cally stable and (4) have urinaryretention but can be managed withbladder scans and intermittentcatheterization5 Care providers can usethe following alternative interven-tions12bull Incontinence pads placed on beds

and chairs (use diapers only when apatient is ambulating)

bull Regular toileting roundsbull Intermittent catheterizationbull External catheters (for men)bull Bladder scans to check for post-void

residualsbull Suprapubic catheters

Follow guide-lines to reduce the risk of

CA-UTIs when catheters arein use When providers decide that aUC is necessary to a patientrsquos care theymust ensure that the catheter is wellmaintained to further reduce the risk ofinfection Woeltje and Slavish offer thefollowing tips for reducing the risk ofCA-UTIs when caring for a patientwho has a UC bull Use aseptic technique and sterile

equipment when inserting a UCbull Secure catheter tubing to the

patientrsquos leg so that the catheterdoesnrsquot continuously move up anddown causing irritation andallowing bacteria to move up intothe bladder

bull Maintain a closed drainage systemndash Use clean technique when

emptying the collecting bag andprevent the drainage spigot fromtouching the measuring container

ndash Obtain urine samples byaspirating urine from thesampling port only after cleansingthe port with disinfectant

ndash Do not disconnect the catheterand drainage tube unless thecatheter must be irrigated

bull Use a separate measuring containerfor each patient when draining urinefrom the collecting bag to avoidspreading infections from room toroom

bull Keep the collecting bag below thelevel of the bladder at all times toprevent inadvertent backflow ofurine into the bladder (especiallywhen the patient is beingtransferred)

bull Clean the perineal area and urinarycatheter tubing routinely

bull Use antimicrobial catheters inpatients who are at high risk forUTIs (including patients who mightrequire a UC for a long period oftime)

Remove UCsimmediately when they areno longer indicated Because theduration of catheterization is the mostimportant risk factor for developinginfection it is imperative that providersremove catheters as soon as they are nolonger needed1 In addition at least40 of patients who have a UC inplace longer than seven days candevelop a UTI extending their hospitalstay three more days6 ldquoI think the twobiggest reasons that providers leavecatheters in longer than necessary isthat they forget about the catheter andthe patientrsquos care is more convenientwith a catheterrdquo says WoeltjeldquoSometimes I see patients who can getout bed on their own but theircatheter is still inrdquo

STRATEGY 4

STRATEGY 3

STRATEGY 2

wwwjcrinccom6 THE JOINT COMMISSION PERSPECTIVES ON PATIENT SAFETY March 2009

Strategies for Eliminating Catheter-Related

Urinary Tract Infection

(continued from page 5)

The Centers for Medicare amp Medicaid Services consider CABSIs to be ldquonever eventsrdquo

wwwjcrinccom THE JOINT COMMISSION PERSPECTIVES ON PATIENT SAFETY March 2009 7

Use automatic stoporders to remind providersto remove UCs after a certainnumber of days ldquoIf you canbuild stop orders into the ordering sys-tem then the institution canautomatically remind people to thinkabout removing cathetersrdquo saysSlavish For example a study per-formed at a VA medical center

evaluated a computerized reminderthat prompted physicians either toremove or continue a UC 72 hoursafter UC insertion This study foundthat the reminder shortened the dura-tion of catheterization by three dayswithout affecting the recatheterizationrate2 ldquoIf organizations donrsquot haveaccess to a computerized system theycan build in a reminder system to daily

rounds by always looking at the appro-priateness of invasive lines and thereadiness for those lines to beremovedrdquo adds Slavish

Woeltje explains that a provider atBarnes-Jewish St Peters Hospital in StPeters Missouri went through all theoperative order sets to make sure thatany time there was an order for a

Patient is admitted to the health care

organization

Decision Point Is there a need to insert a urinary

catheter (See Strategy 1)

NO YES

Goal met Successful

prevention of CA-UTI

Increased risk for CA-UTI

Can an alternative to a urinary

catheter be used instead

(See Strategy 2)

NO

YES

Follow guidelines for reducing the risk of CA-UTIs

when urinary catheters are used (See Strategy 3)

Assess the need for urinary catheters daily

Decision point Can the catheter be removed

(See Strategy 4)

NO

YES

Goal Reduced risk for CA-UTI

Figure Decision Tree for Using Urinary Catheters

CA-UTI =catheter-associated urinary tract infection

(continued on page 11)

TIP

Copyright Joint Commission Resources 2009

wwwjcrinccom8 THE JOINT COMMISSION PERSPECTIVES ON PATIENT SAFETY March 2009

Preventing Home Fires Associated with Long-TermOxygen Therapy

Lester grew up in the tobaccofields of Kentucky startedsmoking when he was 12 and

has been smoking ever since By thetime he was admitted to the Burn Unitat his local hospital at age 75 he was inthe advanced stages of chronic obstruc-tive pulmonary disease (COPD) Worseyet although hersquod been advised not tosmoke near the concentrator he feltunable to go without nicotine forlonger than 15 minutes at a time

So when Lester lit a cigarette in theoxygen-enriched environment createdby his concentrator the ensuingflames burned his mouth and nose aswell as the skin on his face He recov-ered after several weeks of inpatienttreatment but Lesterrsquos physician wasreasonably certain that unless herefused to prescribe home oxygen forLester there was a good chance thathis patient could ignite the home heshared with his daughter and threegrandchildren the next time he triedlighting a cigarette

Lester is a fictitious character typicalof nearly 1 million patients in theUnited States who receive long-termoxygen therapy through the Medicareprogram most of them due to smoking-related lung conditions1

Some patients try to continue smokingwhile using oxygen As anyone familiarwith basic chemistry can tell you thecombination of oxygen and fire posesserious risks of property damage hor-rific pain injury disfigurement and anightmarish death Often the victimsinclude not only the smokers them-selves but their family membersfriends neighbors and firefighters

Reading the NumbersCOPD is the fourth leading cause ofdeath in the United States and isamong the leading causes of disability1

In another decade COPD will likelymove up becoming the third leadingcause of death around the world2

Smoking is the cause of 80 to 90of COPD At least 12 million adults

have been diagnosed with COPD inthe United States and approximately119000 adults die each year as a resultof the disease3 In 2002 caring forCOPD patients cost an estimated$321 billion3 Home oxygen therapy isnow the standard of care for treatingCOPD patients Today more than800000 individuals in the UnitedStates receive oxygen therapy anannual cost of $18 billion4 The JointCommissionrsquos National Patient SafetyGoal Requirement NPSG150201requires organizations to take steps toprevent home fires associated withpatientsrsquo long-term oxygen therapyAnd on March 20 2001 the JointCommission issued the Sentinel EventAlert ldquoFires in Home Care Settingsrdquoregarding oxygen hazards

Smoking cessation is key to patientsafety during long-term oxygen ther-apy In addition the following stepscan help prevent fires in an oxygentherapy patientrsquos home1 Do not use oil grease aerosol

sprays or petroleum jellyndashbasedproducts on or near oxygenequipment

2 Keep oxygen equipment away fromopen flames or heat sources

3 Provide adequate ventilation and donot cover concentrators

4 Educate patients on the safe use ofthe equipment and about fire safetyand prevention

5 Equip the patientrsquos home with firesafety devices such as extinguishersand smoke detectors

A Physicianrsquos ViewpointMichael White MD head of theinpatient clinic in the adult burn unitat Detroit Receiving Hospital treatsone or two patients a month who areon home oxygen therapy and who have

wwwjcrinccom THE JOINT COMMISSION PERSPECTIVES ON PATIENT SAFETY March 2009 9

burned themselves while smoking ldquoIsuspect that number will graduallyincrease as the population agesrdquo Whitesays ldquoAbout half of them are repeatoffenders who have undergone repeatadmissions but havenrsquot been able tostop smoking Once their burns havehealed we donrsquot continue to treat themrdquo

And yes he and his colleagues dorecommend strongly to their patientsthat they quit smoking ldquoBut we canrsquotfollow them homerdquo he says ldquoFor thosewho donrsquot stop smoking they tend toslide back into their addiction Itrsquosoften one of the few pleasures theyhave in liferdquo The average age of Whitersquospatients is around 66 his oldest patientis 79 Most have additional medicalissues besides COPD Most haveunhealthy lungs to begin with and halfof those patients die from diseases suchas lung failure and comorbiditiesldquoThose are the ones for whom quittingis difficultrdquo White says ldquoSo they keepcoming back I donrsquot have a good handleon what outpatients do I may prescribethem a nicotine patch but I donrsquot havea good way of following up on themrdquo

According to White trying to getthese patients to quit is the job of theirprimary care physician ldquoSometimes theirfamily gives them cigarettesrdquo he saysldquoWe see the hard-core of the hard-coresmokers even though theyrsquove been toldby their primary physician not tosmoke Sometimes the Veterans HealthAdministration has given them a tra-cheotomy tube and they continue tosmoke through the tube A lot ofpatients hope that if theyrsquore carefulnothing will happen Some of them gooutside to smoke or go to anotherroom Others have trouble leaving theiroxygen supply for even a few minutesand the oxygen is still in the atmospherewhen they smoke Thatrsquos when theyrsquoremost likely to trigger a home firerdquo

A Social Workerrsquos ViewpointErin Terkoski MSW LMSW is aclinical social worker on the burn unit

and works closely with White She seesthe same patient population andadvises patients following their treat-ment for acute burns ldquoWe see themwhen they have an injury related totheir smoking Often they see a pulmo-nologist or some other specialist otherthan their primary care doctorSometimes theyrsquore treated by a pulmo-nologist andor monitored by a homecare agency after theyrsquore released especially if theyrsquore on home oxygendelivered by a durable medical equip-ment agencyrdquo

According to Terkoski the homecare agency is responsible for handlingthe oxygen safety training at a patientrsquoshome ldquoThe hospital is a nonsmokingfacility so we donrsquot do any safety train-ing here If we have oxygen delivered tothe patientrsquos beside the agency thathandles the delivery also does the train-ing before the patient is releasedrdquo Ifthe patient returns for a checkup anditrsquos clear that theyrsquove been smoking athome while on oxygen the clinicalstaff and social work staff address theproblem with the patient ldquoEven if thepatient understands the issue of homeoxygen and smoking that doesnrsquot meanthey will change their behavior at homeWe canrsquot force them they may indeedgo home and continue to smoke Itrsquos just

like your doctor telling you that youmust exercise Your doctor canrsquot gohome with yourdquo

Has a health professional everrefused to prescribe home oxygen for aknown smoker ldquoYes a health profes-sional has refused to prescribe homeoxygen for an indigent patient whorsquos aknown smoker if he or she is clearlynoncompliantrdquo says Terkoski ldquoThemajority of our patients are homelessand have a history or drug and alcoholuse These patients may require homeoxygen or home antibiotics The hospi-tal may pay for antibiotics and if apateint requires home oxygen andwonrsquot use the oxygen correctly and itrsquosevident that the oxygen isnrsquot benefitingthem andor is endangering them andothers itrsquos up to our department torefuse to pay for the oxygen intendedto be sent home with the patientrdquo

And what about patients who arehomeless ldquoSome of our patients arehomelessrdquo says Terkoski ldquoAnd if theyleave our hospital for a shelter andtherersquos nowhere to keep a concentratorthat has to be plugged in to an electri-cal outlet our case managers have todecide whether itrsquos advisable to give

(continued on page 10)

Smoking cessation is a key part of preventing fires associated with home oxygen therapy

wwwjcrinccom10 THE JOINT COMMISSION PERSPECTIVES ON PATIENT SAFETY March 2009

them oxygen equipment to take withthem especially if they have no elec-tricity and especially if they must leavethe shelter during the dayrdquo

The Bottom Line on Preventing FiresAccording to Terkoski the companythat supplies the oxygen equipment isresponsible for teaching the patient touse the home oxygen equipment wherever they call homemdashand to use it safely ldquoUltimately people who donrsquothave dementia and who are oxygenpatients need to understand that if theycontinue to smoke they need to shutoff the oxygen and go outside to smokein a well-ventilated area and avoidcooking near an open flamerdquo

Finally says Terkoski the requirementin most communities is that patients areresponsible for contacting their local firedepartment to get safety equipment on afirst-come first-served basis

References1 Madison JM Irwin RS Chronic obstructive

pulmonary disease Lancet 352467ndash473 1998

2 Pauwels RA Global initiative for chronic obstructivepulmonary diseases (GOLD) Time to act Eur Respir J18 291ndash292 2001

3 National Heart Lung and Blood Institute ChronicObstructive Pulmonary Disease 03ndash5229 2003

4 OrsquoDonohue WJ Jr Plummer WJ Magnitude ofusage and cost of home oxygen in the United StatesChest 105301-302 1995

PS

Preventing Home Fires Associated with

Long-Term Oxygen Therapy

(continued from page 9)

Call for Papers

Are you or your organizationworking on a project or policy toimprove patient safety

Why not share your ideas andresults with your colleaguesnationwide

If you have a paper you would liketo submit for potential publicationin Perspectives on Patient Safety please send us an e-mail atpatientsafetyjcrinccom

The Patient Safety Blog

Readers no longer have to wait a

whole month for new information

from Perspectives on Patient Safety

Beginning soon the editor will be

posting to a blog on the Joint

Commission Resources Web site

(httpwwwjcrinccom) that will

provide supplemental information

to the articles in the newsletter and

other news

Whatrsquos more this blog gives you

the reader an opportunity to give

your feedback about the newsletter

and voice your opinions on the

issues discussed in the blog and

in print

See the blog at

httpwwwjcrinccomblog2008

1211greetings

National Patient Safety Goal 15

The organization identifies safety risks inherent in its patient population

Requirement NPSG150201

The organization identifies risks associated with home oxygen therapy such as

home fires

Rationale for NPSG150201

Many sentinel events reported by home care programs to The Joint Commission

were due to a fire in the patientrsquos home In each case when patients were

injured or killed as a result of a home fire home oxygen was in use

Elements of Performance for NPSG150201

1 The home safety risk assessment includes the presence or absence and

working order of smoke detectors fire extinguishers and fire safety plans

and a review of all medical equipment

2 The organization provides education to the patient and family regarding the

findings of the home safety risk assessment possible interventions causes

of fire and fire prevention activities

3 The organization assesses the patientrsquos level of comprehension of and

compliance with fire prevention activities and reports any concerns to the

patientrsquos physician

wwwjcrinccom THE JOINT COMMISSION PERSPECTIVES ON PATIENT SAFETY March 2009 11

perioperative UC there were also ordersto remove the catheter after surgery

In addition to implementing thesetips and strategies organizations shouldcollect data on the number of sympto-matic CA-UTIs (numerator) and thenumber of patients with catheters inplace each day (denominator) ldquoThegoal is to limit catheter use to drivedown the number of catheter infec-tionsrdquo says Woeltje ldquoBut recognizethat infection rates are expressed as thenumber of CA-UTIs per 1000catheter days So as you reduce thedenominator by decreasing the use ofinappropriate catheters the infectionrates may not decrease as much becauseyoursquore only putting catheters in thepatients who really need them andthose patients are most likely at highrisk for UTIrdquo

References1 Lo E et al Strategies to prevent catheter-associated

urinary tract infection in acute care hospitals Infect

Control Hosp Epidemiol 29 (Suppl 1)S41ndash50 Oct2008

2 Saint S et al Preventing hospital-acquired urinarytract infection in the United States A national studyClin Infect Dis 46243ndash250 Jan15 2008

3 Apisarnthanarak A et al Initial inappropriate uri-nary catheters use in a tertiary-care center Incidencerisk factors and outcomes Am J Infect Control35594ndash599 Nov 2007

4 Department of Health and Human Services Changesto the hospital inpatient prospective payment systemsand fiscal year 2008 rates Fed Regist Aug 19 2008httpwwwregulationsgovsearchindexjsp (accessedDec 1 2008)

5 Robinson S et al Development of an evidence-basedprotocol for reduction of indwelling urinary catheterusage Medsurg Nursing 16(3)157ndash161 Jun 2007

6 Weitzel T To cath or not to cath Nursing38(2)20ndash21 Feb 2008

7 Gukola RM Smith MA Hickner J Emergencyroom staff education and use of a urinary catheterindication sheet improves appropriate use of Foleycatheters Am J Infect Control 35589ndash593 Nov 2007PS

Remove nonessentialcatheters immediately Thelonger central lines remain in patientsthe more the risk for CABSIsincreases15 ldquoYou can use electronicdocumentation systems to promptnurses and physicians to considerwhether a patientrsquos central line is neces-saryrdquo says Woeltje ldquoIf a patient nolonger needs IV medications or theirperipheral access has improved itrsquosprobably time to remove theircatheterrdquo

References1 Centers for Disease Control and Prevention (CDC)

Guidelines for the prevention of intravascularcatheter-related infections Morb Mortal Wkly Rep511ndash26 Aug 2002 httpwwwcdcgovmmwr

previewmmwrhtmlrr5110a1htm (accessed Dec 22008)

2 Department of Health and Human Services Changesto the hospital inpatient prospective payment systemsand fiscal year 2008 rates Fed Regist Aug 19 2008httpwwwregulationsgovsearchindexjsp (accessed Dec 1 2008)

3 Render ML et al Evidence-based practice to reducecentral line infections Jt Comm J Qual Patient Saf32253ndash260 May 2006

4 Society for Healthcare Epidemiology of America(SHEA) Frequently Asked Questions (FAQs) aboutCatheter-Associated Bloodstream Infectionshttpwwwshea-onlineorgAssetsfilespatient20guidesBSIpdf (accessed Dec 3 2008)

5 Marschall J Strategies to prevent central linendashassociated bloodstream infections in acute care hospitals Infect Control Hosp Epidemiol 29(Suppl 1)S22ndashS30 Oct 2008

PS

Central LinendashAssociated Bloodstream Infections (continued from page 4)Access The JointCommission Perspectiveson Patient Safety Online

1 Go to

httpwwwingentaconnectcom

2 On the right side of the screen

under ldquoNeed to registerrdquo click

ldquoSign up hererdquo

3 On the ldquoPersonal Registrationrdquo

page complete all the required

fields Create your own user

name and password Click

ldquoRegisterrdquo

4 On the next screen you will

see the following text ldquoYou may

now personalize features under

lsquoMy Ingentarsquordquo Click ldquoActivating

Personal Subscriptionsrdquo and

then click the ldquoAddrdquo tab

5 Find the publication to which

you subscribe Using the

ldquoPublisher Namerdquo section click

ldquoJrdquo to find ldquoJoint Commission

Resourcesrdquo and then find the

entry for The Joint CommissionPerspectives on Patient Safety

6 Check the small box to the left

of the Patient Safety title

7 In the larger box to the right of

the title enter your subscription

number Your subscription num-

ber is your last name and your

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Smith12345)

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number box

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be sent through Ingenta to be

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After you have registered you can

access Patient Safety directly at

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contentjcahojcpps

Strategies for Eliminating Catheter-Related Urinary Tract Infection(continued from page 7)

TIP

wwwjcrinccom

NON-PROFIT

ORGANIZATION

US POSTAGE

PAIDPERMIT NO 68

Dundee IL

Volume 9 Issue 3 March 2009Send address corrections toThe Joint Commission Perspectives on Patient SafetySuperior Fulfillment131 W First StDuluth MN 55802-2065800746-6578

The Essential Guide for Patient Safety Officers co-published withthe Institute for Healthcare Improvement (IHI) is acomprehensive and authoritative repository of essential knowledgeon patient safety The book is geared to help patient safety leaderscreate a culture of safety plan oversee and implement new safetypractices and improve safety-related management and operationsThe book is applicable to community hospitals teachinghospitals health care systems ruralcritical access hospitals andambulatory care settings The editorsauthors are Allan FrankelMD principal Lotus Forum Inc Washington DC andfaculty IHI Michael Leonard MD physician leader of patientsafety Kaiser Permanente Oakland California and faculty IHITerri Simmonds RN CPHQ director IHI and CarolHaraden PhD vice president IHI

This book provides bull Core knowledge and insights for patient safety leaders

clinicians and change agents bull Strategies and best practices for day-to-day operational issues bull Ways to integrate quality and safety functions bull Strategies for patient safety strategies and initiatives bull Tools checklists and guidelines to assess improve and monitor

patient safety functions bull Detailed case studies from other health care organizations and

patient safety leaders bull Discussions on identifying and meeting the patient safety needs

at organizations with differentresources

The Essential Guide for Patient Safety Officers

For more information or to order this publication please visit our

Web site at httpwwwjcrinccom or call our toll-free Customer

Service Center at 877223-6866

Our Customer Service Center is open from 8 AM to 8 PM EST

Monday through Friday

Item Number PSOH08Price $7500

Co-published by JCR and IHINEW

Joint Commission Perspectives on Patient Safety

March 09 Patient Safety Abstracts

Central line-Associated Bloodstream Infections

Central lines (or central venous catheters) can provide many benefits to patients such as

fluid resuscitation medication administration and hemodynamic monitoring But these

benefits come at the cost of several risks the most common of which is a central line-

associated bloodstream infection (CABSI) The Centers for Medicare amp Medicaid

Services (CMS) will no longer pay health care organizations for the extra costs associated

with vascular catheter-associated infections

Strategies for Eliminating Catheter-Related Urinary Tract Infection

Urinary tract infections (UTIs) are the most common hospital-acquired infection and

80 of these infections can be attributed to an indwelling urinary catheter (UC) The

insertion of a UC is a common intervention in health care organizations and up to 25

of patients will have a UC at some time during their hospital stay Most commonly the

adverse outcome of UCs is a UTI but bacteremia and sepsis may occur in a small

proportion of infected patients Furthermore UCs can also cause restricted mobility

which can contribute to a delayed recovery and an increased risk for pressure ulcers

Preventing home fires associated with long-term oxygen therapy

Nearly 1 million patients in the United States receive long-term oxygen therapy through

the Medicare program most of them due to smoking-related lung conditions Some

patients try to continue smoking while using oxygen This poses serious risks of property

damage horrific pain injury disfigurement and death Often the victims include not

only the smokers themselves but their family members friends neighbors and

firefighters The Joint Commissionrsquos National Patient Safety Goal Requirement

NPSG150201 requires organizations to take steps to prevent home fires associated with

patientsrsquo long-term oxygen therapy

patients try to continue smoking while using oxygen This poses serious risks of property

damage horrific pain injury disfigurement and death Often the victims include not

only the smokers themselves but their family members friends neighbors and

firefighters The Joint Commissionrsquos National Patient Safety Goal Requirement

NPSG150201 requires organizations to take steps to prevent home fires associated with

patientsrsquo long-term oxygen therapy