For patients with cancer, it’s hard to believe any health condition could be scarier or deadlier than the tumor cells in their bodies. But infection—whether from compromised immune systems or cancer treatment itself—is a life-threatening safety issue many patients may face. It’s such a concerning and prevalent issue, the Joint Commission declared infection prevention a national safety goal in 2013, and many reimbursement programs no longer pay for preventable, hospital-acquired infections. 

Oncology nurses, as hands-on patient care advocates, are in a key position to step up and lead infection prevention efforts at their workplaces. 

Preventing Central Line Infections in Transplant Recipients

ONS member Richard Miller, RN, BSN, OCN®, an advanced clinical nurse and chemotherapy infusion nurse at University Hospitals Case Medical Center Seidman Cancer Center in Cleveland, OH, developed an interest in decreasing central line–associated blood stream infections (CLABSI) because of his patient population. “As a bedside nurse on a bone marrow transplant unit, I became very aware of the seriousness of our immune compromised patients being exposed to infection. The combination of high-dose chemotherapy with extended hospital stays puts these patients at high risk for developing infections. The use of sterile technique and proper hand hygiene are extremely important for nursing staff who are working with this compromised population.”

Is Your Patient at Risk for Necrotizing Fasciitis?

A growing number of case studies in the literature report an increasing incident of patients with cancer who have developed necrotizing fasciitis. This condition, sometimes known as a flesh-eating disease, is a rare, progressive, bacterial infection of subcutaneous tissue. 

Common Early Symptoms of Necrotizing Fasciitis

  • Sudden, severe pain in the affected area
  • Fever, nausea, vomiting, fatigue, and other flu-like symptoms
  • Redness, heat, swelling, or fluid-filled blisters in the skin over the affected area
  • Scaling, peeling, or discolored skin over the affected area
  • Cool, pale extremities
  • High or very low temperature and chills
  • Lightheadedness
  • Low blood pressure, especially when standing
  • Low or absent urine output
  • Palpitations
  • Rapid heart rate
  • Restlessness, agitation, lethargy, or confusion
  • Shortness of breath
  • Skin rash or discoloration

At his hospital, it is standard for all transplant recipients to have central lines placed. Miller addressed the risk of CLABSI by developing a project that incorporates further infection prevention methods. “I began to look at our institution’s central line dressing practice and started researching to see if there were better options being used at other hospitals,” he explains. “I found that a dressing with an impregnated chlorhexidine gluconate gel patch was showing promising results.” 

According to Miller, incorporating the product into their central line care took a collaborative effort. “I began meeting with vendors, hospital managers, the infection control committee, and the purchasing department to explore the possibility of trialing a new dressing. As the meetings progressed, interest in the product grew from a division-level trial to a system-wide change. After approximately a year of discussions and planning, we began to educate the bedside nursing staff and prepared to make a system-wide change. “

Miller shares that the “change greatly affected our institution’s CLABSI rates. Over the six-month period following implementation of the dressing change policy, our institution showed as much as a 48% reduction in its CLABSI rates. This also put us below the national benchmark for five out of those six months. Infection prevention and patient safety was what drove this system-wide change. ”

Preventing Urinary Tract Infections From Catheters

Catheter-associated urinary tract infection (CAUTI) is the most common healthcare-acquired infection in the United States. ONS member Debra Rodrigue, MA, RN-BC, a clinical nurse specialist at Memorial Sloan-Kettering Cancer Center (MSKCC) in New York, NY, explains why urinary catheters can be hazardous. “The duration of catheterization is the most important risk factor for the development of infection. For each day a catheter is present, the risk of developing an infection increases by 3%–7%. Therefore, in one week the risk is at 25%–50%, and by day 20, the risk is at 100%. 

“Because most patients at MSKCC have weakened immune systems, one of our goals is to develop effective ways of preventing serious infections among patients whose immune systems are weakened by cancer treatments and diagnoses. Putting in place a standard of care for the prevention of CAUTI is one way we can decrease their risk.”

Debra Rodrigue, MA, RN-BC

Rodrigue and colleagues Nora Love, MSN, RN, CURN, OCN®, and Ellie Dougherty, MA, CNOR, CIC, were part of a task force that developed an evidence-based standard of practice for the prevention of CAUTI. They also designed an educational program focusing on CAUTI prevention to ensure all inpatient nursing staff received comprehensive, evidence-based information on all aspects of Foley catheter care. In addition to hands-on demonstrations of proper catheter insertion, the program included a lecture series that reviewed proper catheter insertion technique, explicit criteria for appropriate catheter insertion, practice variations for male and female patients, pediatric guidelines, and routine maintenance items. The lectures were enhanced with clinical scenarios and case studies to illustrate key points. 

“We worked closely with our nursing informatics department to develop a nurse-driven discontinue algorithm, an evidence-based plan of care, electronic patient education documentation, electronic catheter insertion order sets, and electronic nursing documentation,” Rodrigue explains. “We also updated our supplies to reflect current standards. After implementing all of these elements, we feel that our nursing staff is now better prepared to care for our patients with indwelling urinary catheters.”

This successful education program has resulted in a significant decrease in hospital-wide CAUTI rates. According to Rodrigue, “When comparing the first and second quarters of 2012 to 2013, there has been a 31% reduction in the number of CAUTI. We expect to continue this decline once all of the elements of the initiative are fully implemented.” 

Reimbursement’s Influence on Infection Prevention Programs

Both Miller and Rodrigue say that the current economic climate played a role in these projects. “Because CAUTI is a national patient safety goal and a Center for Medicare and Medicaid Services never event, which means it is preventable if standards are followed, we no longer will receive reimbursement for our CAUTIs. As a nonprofit organization, this would greatly affect our budget and operating costs,” Rodrigue says. 

Miller says that his hospital had a similar approach for central line infections. “I was aware that readmissions for hospital-acquired infections were no longer going to be reimbursable by Medicare. This fact may have contributed to the speed at which our large institution was able to implement the CLABSI prevention project at the bedside.”

Front-Line Care Providers Are Key to Infection Prevention

Rodrigue and Miller stress how important it is to have bedside nurses involved in infection prevention measures from the start. Rodrigue’s group included front-line care providers in the educational program, which increased buy-in from bedside nurses. “Using our council structure was a key component in this effort,” she says. “From the beginning of the project, we included materials management and nursing informatics to help with a realistic timeline for the implementation of appropriate supplies and electronic documentation. Products need to be tested and approved by users and departments involved, and all of these efforts take time.”

“Front-line oncology nurses have a unique understanding of the challenges surrounding the provision of safe patient care to our immune compromised patients,” Miller says. “We have the ability to advocate for small changes that may promote drastic improvements in our patients’ outcomes.”

You Tell Us! How has your institution worked to reduce either CAUTI or CLABSI?