Catheter-related bloodstream infections (CRBSIs) are a significant healthcare problem; nearly 250,000 infections occur annually, and mortality is 12.3%.1 Studies suggest that following best practices in CRBSI prevention could save more than 20,000 lives each year, with an associated cost savings of $18.2 billion.2 The primary strategy for preventing these infections is optimal hub care, including hub disinfection and appropriate hand hygiene; however, evidence suggests that nurses do not consistently practice appropriate hub disinfection techniques.3,4 This study sought to determine whether packaging an alcohol swab and prefilled flush together impacted hub-scrubbing behaviors among medical-surgical nurses.

Identifying the problem

Needleless connectors were introduced to prevent healthcare worker exposure to bloodborne pathogens, providing safe access for I.V. medication administration, fluid infusion, or blood draws.5 However, there has been a significant increase in the reports of CRBSIs after implementation.5 Although safer for healthcare workers, needleless connectors provide a portal of entry into the bloodstream for microorganisms, increasing the potential for infection. When venous access is necessary, the best way to prevent hospital-acquired bloodstream infections is to optimize hub care.3

Literature review

Previous research and quality improvement efforts have established that nursing compliance with hub scrubbing is poor, ranging from 6% to 51%.6-8 Another study reported that 56% of the RNs surveyed did not feel it was necessary to disinfect the hub of the I.V. catheter.9 Surveillance at the study institution demonstrated inconsistencies between nursing practice and the policy of hub scrubbing before each use and between each intermittent medication administration or blood draw.

However, the issue is not lack of knowledge, since studies have demonstrated that additional education has failed to decrease the incidence of CRBSIs to the preneedleless device baseline.6,10 Instead, process may be a significant contributing factor. It is possible that if nurses do not have the necessary supplies when accessing an I.V. hub, they do not take the extra steps to obtain the supplies. For example, in evaluating the effectiveness of alcohol disinfection caps for CRBSI prevention, packaging the cap and the normal saline flush together improved compliance with cap utilization and reduced CRBSI rates over introducing the cap alone.8,11

In the study organization, prefilled normal saline flushes and alcohol swabs are available on units in multiple locations. The current process depends on the nurse to bring both the flush and alcohol swab to the bedside when accessing a needless connector. This study evaluated the rate of hub scrubbing before and after introduction of a product containing both a normal saline flush and alcohol swab (combined product) in the same package to determine if this would improve policy compliance.

Methodology

The system's institutional review board approved this prospective control study. Researchers observed nurses on four medical-surgical units of two hospitals within a community-based health system administering I.V. medications, fluids, or flushes. After baseline data collection (Phase 1), the combined product was introduced at Hospital A and observations were repeated (Phase 2). Hospital B served as the control. Researchers compared rates of scrubbing compliance at both facilities (as a percentage) to determine if the new product had a positive effect.

The study included the orthopedic and general surgical units because of the frequency of I.V. medication administration on these units. Nurses were observed on all shifts, and each nurse was observed no more than twice per phase until the necessary sample size was reached. Based on an estimated scrubbing rate of 50%, and the population of nurses available, the study targeted a sample size of 25 observations per unit to detect a 20% difference in hub-scrubbing behaviors.

During observations, each opportunity to disinfect was recorded as "scrub" or "no scrub." For the purposes of this study, scrub duration was not evaluated. Rather, any use of an alcohol swab prior to access was a scrub.

Results

Researchers analyzed data with statistical software. A total of 67 observations comprised Phase 1 (Hospital A = 33; Hospital B = 34), and 69 in Phase 2 (Hospital A = 36, Hospital B = 33). During Phase 1, nurses followed policy in 88% of observations for Hospital A (n = 29) and 82% for Hospital B (n = 28). After introducing the flush/scrub combination product, the scrub rate in Hospital A increased to 97% (n = 35). The scrub rate also increased in Hospital B (88%, n = 31). No statistically significant difference was observed between the intervention units at baseline (p = 0.73), or after introduction of the combination product (p = 0.6). No statistically significant improvement was observed in hub scrubbing in Hospital A after introduction of the combination product (p = 0.19) or Hospital B (p = 0.26).

Rates of scrubbing after the initial hub scrub were low. In total, there were 90 instances where a second scrub was indicated, and 50 for a third. The second scrub was completed in 28% (n = 25) of opportunities, and nurses completed a third scrub 24% of the time (n = 12).

Discussion

This study sought to determine if the combination product would increase the rate of hub scrubbing among medical surgical nurses. The results did not support the hypothesis. This suggests that the process of seeking appropriate supplies for short peripheral venous catheter care is not the only factor driving noncompliance with hub scrubbing. The fact that scrubbing improved on all units during the course of the study lends support to the notion that any improvement, statistically significant or not, was unrelated to the combination packaging. Overall improvement could be related to ongoing system focus and educational efforts to decrease CRBSI, increased nurse awareness of observer presence, or nurse awareness of observer purpose.

There were several study limitations. First, baseline hub-scrubbing rates of 82%-88% were higher than anticipated or previously reported in the nursing literature, and during random audits at our institution.6-8 The high baseline rates meant that the sample size calculations based on a scrubbing rate of 50% were not correct. Given a baseline hub-scrubbing rate of 88%, the sample size was not sufficient to detect a statistically significant change, even with the improved hub-scrubbing rate of 97% on the intervention units. Given these rates of hub scrubbing, the ideal sample size would have required 134 observations on each unit.

Second, participating nurses were aware that data collectors were observing their I.V. medication administration, though they did not know what data they were collecting. Still, the presence of an observer may have skewed the results, resulting in a Hawthorne effect. There was no possible design to eliminate the observer effect in this setting. Because of this, and the fact that compliance improved across all units, researchers decided to end the study despite the insufficient sample size.

Implications for practice

Nurses can help reduce CRBSIs in many ways. Utilizing an appropriate antiseptic in scrubbing short peripheral venous catheter hubs can minimize contamination and reduce both the risk of catheter contamination and incidence of CRBSI.10 It is critical that nurses recognize this is a basic and essential infection control practice, and that each nurse reflect on when and why he or she may have missed an opportunity to scrub the hub.

Measuring compliance with hub scrubbing is challenging and requires direct observation. However, the physical presence of a direct observer can skew the result of any validation process. It is important for organizations to identify accurate methods for auditing policy compliance. Reimbursement structures that pay for performance and penalize poor outcomes could assist in motivating healthcare providers to drive safety strategies. Organizations could also work with patients and families to heighten awareness and involve the patient in speaking up about his or her I.V. catheter care.

Implications for research

Although this study did not show a statistically significant increase in hub scrubbing compliance, there are many more opportunities to study CRBSI prevention. This study should be replicated with a larger sample size and designed to decrease or eliminate the potential observer effect on nurse performance. Qualitative research should be undertaken to understand why a nurse would skip catheter hub scrubbing. This is essential to effective infection control interventions.

This study showed poor compliance with subsequent hub scrubbing. While this was cause for concern, no research-based evidence exists to support the importance of these subsequent scrubs. Therefore, researchers could also study whether a second and/or third scrub is efficacious in reducing CRBSIs.

Conclusion

The results of this study demonstrate a significant need for further research. Because CRBSIs are such a significant but preventable problem in healthcare, healthcare organizations and nurses must work together to identify and implement new interventions to protect patients and ensure effective infection control.

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