Resident Physicians as Champions in Preventing Device-Associated Infections

Patients may be exposed to multiple devices (PVCs, CVCs, UCs, and ventilators) at any time. We underscore the importance of collaboration among the interprofessional team to create a safer environment for patients. Engagement of the interprofessional team at the hospital level is essential to improve patient safety and reduce hospital-acquired infections and other safety events. Team members may include resident physicians, attending physicians, nurse leaders, staff nurses, infection preventionists, respiratory therapists, and ancillary personnel.

RPs play an essential role as champions for device safety by promoting best practices, identifying barriers, and developing solutions with various stakeholders. Modeling behaviors to minimize device risk is crucial.

The goal is for every RP to own the process of evaluating the daily need and risk of all invasive devices as part of their patient care.

Resident Physicians as Champions

Successful champions are those who believe in safety efforts, have recognition and respect from and for their co-workers, and are early adopters of change. RPs play a pivotal role in patient management and safety in U.S. teaching hospitals. They are likely to be very involved in the decision to use invasive devices, place them, and decide on the duration of use.

The Clinical Learning Environment Review (CLER), RPs, and safety: The recently implemented CLER underscores the importance of both quality and safety in the RP’s learning environment. CLER   was established by the Accreditation Council for Graduate Medical Education and is designed to provide institutions with periodic feedback that addresses patient safety, health care quality, care transitions, supervision, duty hours and fatigue management and mitigation, and professionalism for resident training. The seven pathways of the safety components include education on patient safety, promotion of a culture of safety, resident and fellow experience in patient safety investigations, and monitoring of resident, fellow, and faculty engagement in patient safety.

In addition to learning disease management and methods to optimize clinical outcomes, RPs are expected to learn, promote, and enhance safe care. Part of the RPs’ training is to be educated on best practices. Examples include appropriate indications for devices, proper placement techniques, maintenance, and regular evaluation of device risk and necessity. Engaging their faculty, nurses, and other supporting services will improve the RPs’ learning experience, solidify their approach to safety, and favorably influence other health care workers’ behaviors.

RPs have the opportunity to be the quality and safety champions for every patient they care for by integrating patient safety and disease management into the daily workflow of clinical care. Integration of concepts and tools from Team Strategies to Enhance Performance and

Patient Safety (TeamSTEPPS^®) and the Comprehensive Unit-based Safety Program (CUSP) provide the RP with strategies for addressing patient issues. Some of the RP (as a champion) functions include—

Leading Teams

Team leaders are well-informed team members who make decisions and take actions. Team leaders establish the goals of the team and help maintain its focus. The RP can—

• Monitor the plan of care and the surrounding situation to better anticipate the patients’ and staffs’ needs
• Facilitate information sharing among team members by—
  • Sharing patient stories about where harm was averted
  • Explaining the significant risks associated with devices
  • Providing examples of poor patient outcomes related to not following best practices
  • Conducting a brief at the beginning of a shift to communicate with team members the goals for each patient and the plan of care
  • Convening a huddle to communicate adjustments to a plan of care
• Encourage team members to assist one another when needed
• Facilitate conflict resolution
• Model effective teamwork

Coaching

Coaches play a critical role in the success of patient safety implementation and sustainment efforts. The RP can—

• Build consensus among key stakeholders to support use of best practices
• Observe and provide feedback to staff
• Offer support when challenges are encountered
• Facilitate sustained motivation for the implemented changes
• Identify barriers to implementing best practices
• Develop solutions by partnering with other stakeholders

Communicating

Effective communication skills are vital for patient safety and interplay directly with leading teams and coaching. Failure to communicate effectively significantly increases the risk of error. The RP can—

• Use the check-back method to verify and validate information is exchanged in the way in which it is intended
• Implement a patient handoff to ensure continuity of care is maintained
• Utilize a standard framework for communicating pertinent patient information such as Situation-Background-Assessment-Recommendation (SBAR)  

Situation Monitoring

Situation monitoring is a way for team members to be aware of what is going on around them, enabling individuals to adapt to changes in the situation. The RP can—

• Maintain the focus on patient safety through reducing device risk
• Observe actions of fellow team members to gain an accurate understanding of the care environment

Mutual Support

Mutual support provides a safety net to help prevent errors, increase effectiveness, and minimize individual pressure. The RP can—

• Engage in dialogue with the members of the care team as a means to provide feedback and establish patient care goals
• Foster a climate that allows for open communication about unsafe situations

Incorporating Device Evaluation Into Daily Work

Resident Physicians

RPs should incorporate the presence of invasive devices (PVCs, CVCs, UCs, or ventilators) into their daily patient care, including the evaluation of risk and necessity. The evaluation of devices should be similar to the evaluation of respiratory or cardiac function, or the evaluation of the daily laboratory values. Including this in daily patient evaluation highlights the importance of promptly addressing device utilization and any safety issues related to device use.

The two main unit types in the hospital are ICUs and non-ICUs. Device use is higher in the ICU setting due to the severity of illness, which translates to a potentially greater risk of safety events in that environment.

There are at least two opportunities every day for RPs to evaluate devices for use and risk. The first opportunity is during morning patient evaluation. The junior RP typically does this as part of clinical care, during evaluation of any changes in condition, review of medications, vital signs, and laboratory results. During patient evaluation, any device which is no longer necessary or which poses a high risk for infection or complications should be considered for removal.

The other opportunity is during daily team or multidisciplinary rounds. This occurs in the presence of the attending physician or intensivist, the nursing staff, and other supporting services. Creating an environment that supports situation monitoring will enable the team to anticipate and predict the needs of the patient and fellow team members.

During rounds, the senior RP may act as the champion by asking questions such as, “Are there any devices in use? Is there a continued need for the device? Do we have any safer alternatives?”

This mutual understanding provides team members with a common understanding of who is responsible for what task and what information is necessary to guide care decisions, which creates accountability at the individual and team level. For example, a CVC placed in the femoral area or inserted without asepsis or under suboptimal conditions (i.e., “emergently placed”) needs to be removed promptly, thereby eliminating the risk whenever possible. The senior RP makes sure all RPs involved in placing CVCs adhere to complete barrier precautions, ensuring aseptic insertion. Intubated patients should be evaluated daily for readiness to wean from the ventilator and extubation. Finally, the senior RP will trigger the questions during multidisciplinary rounds about whether there are appropriate indications for continued UC use in patients who show signs of improvement. If a senior RP is not part of the multidisciplinary team, the attending physician needs to ask the questions about these devices (CVCs, ventilators, PVCs, and UCs).  In that case, the RP should communicate with the attending about device use and indications before multidisciplinary rounds.

Supporters of Resident Physicians

Engaging members of the interprofessional team will help sustain the effects and success of the device evaluation initiative. An actively involved team is essential to spread the intervention and sustain the gains.

Intensivists and attending physicians (or faculty) ensure that RPs are supported in their role to reduce device risk. They oversee the RPs’ performance and education, and they are the “captain of the ship” and have the ultimate responsibility for care. Participating in the daily rounds, the intensivist or other faculty needs to evaluate all CVCs, ETs, PVCs, and UCs as part of the routine daily care.

The nurse leader (nursing director or manager) partners with the different stakeholders and addresses the processes that ensure the risk of infection is reduced in the unit. For example, the nurse leader will evaluate the competencies of the nursing staff who place and maintain PVCs and UCs. Other examples include evaluations of compliance with infection risk reduction strategies (e.g., use of low-risk catheters, dressing intactness, head-of-bed elevation).

Nurses are responsible for placement of PVCs and UCs and maintenance of all devices, including CVCs and ventilators. Nurses are very important in supporting compliance with correct processes and practices.

1. CVC placement: The nurse documents that the operator placing the CVC complies with all the steps of the central line checklist (i.e., adherence to complete barrier precautions). S/he will maintain situation awareness during the CVC insertion, stop the procedure if there is a break in sterile technique, and assert the proper technique to reduce risk.
2. PVC placement: PVC placement is generally a nursing function. Compliance with all of the steps to ensure that the procedure is done aseptically is very important to reduce risk.
3. Maintenance of venous catheters: CVCs and PVCs are accessed multiple times daily. With each access there is a risk of introducing organisms. Ensuring appropriate line care and dressing intactness are nursing functions that are important to reduce infection risk.
4. UC placement: Nurses or technicians (with the nurse’s oversight) may place UCs. Compliance with proper insertion technique is important to reduce the risk.
5. UC maintenance: Nurses and technicians maintain the UCs. Compliance with proper maintenance (keeping the system closed with a securement device) is important to reduce the risk of introducing organisms.
6. Ventilator maintenance: The ICU nurse maintains the closed ventilator system of intubated patients. In addition, the ICU nurse should champion oral care-related work and keep the head of the bed elevated to reduce the risk of aspiration (lower risk of VAP).

Infection prevention plays a consulting and facilitating role to support the effort. Infection preventionists are considered content experts in infection prevention and play a role in educating physicians, nurses, respiratory therapists, and other disciplines on following standard processes and reducing infection risks. They may consider unannounced audits to evaluate compliance with processes of care. They use various sources of information to review outcomes, compare to benchmarks of care, and identify potential areas for improvement as well as share feedback with the team regularly.

Respiratory care: The respiratory care leader will work with respiratory therapists to support evaluating the intubated patients for the possibility of weaning and readiness to extubate, in addition to promoting mechanisms to keep the ventilator closed system intact.

Other physicians: All physicians need to evaluate their patients daily for the presence of and need for devices. The structure of ICUs differs depending on the hospital. Some hospitals have a closed ICU, where the intensivist is key to implement changes, but others are open ICUs. In open ICUs, many physicians may be able to affect patient care. Hospitalists or other attending physicians play a very important role in daily device evaluations outside of the ICU. They will advocate for the use of lower risk devices or removal of unnecessary devices. Urologists may play a supporting role especially in discouraging unnecessary UC use (urologists are important stakeholders who end up addressing many noninfectious adverse outcomes of the UC).

Other supporting services: Other supporting services may help the effort to reduce device risk by encouraging health care workers to evaluate need. For example, wound care nurses and physical therapists would discourage UC use to reduce the risk for immobility and falls. The intravenous therapy team may help identify areas for improvement related to venous catheters and support nursing education. Respiratory therapists may trigger assessments for weaning of mechanical ventilation. Supply chain personnel can help with product selection.

Figure 3 below summarizes how the RP as a safety champion interacts with other stakeholders (or supporters) to reduce device infection risk in the different units.

Figure 3. Interaction between RP and other stakeholders

Differences Between the Units

Intensive Care Units

ICUs have high prevalence of device use (CVCs, UCs, and ventilators). Equally important is the use of PVCs in the ICUs, although often PVCs are not given much attention because surveillance is not required for PVCs. Many ICUs may have dedicated teams responsible for the care of the patients (“closed units”). Often, multidisciplinary rounds function to evaluate risk reduction efforts and device need. RPs, an integral part of the multidisciplinary rounds, may function as the champions to evaluate the device risk and need and promptly remove devices that are no longer needed. Additional stakeholders,

including the intensivists, nurses, other physicians and ancillary services, may play the role of the RP supporters.

Non-Intensive Care Units

The non-ICU setting usually represents 70–80 percent of the inpatient units. Although the prevalence of device use (CVCs, UCs) is lower than in the ICU, it is still significant in determining total device days. In addition, the non-ICU typically does not have physicians who are responsible for individual units (as opposed to the ICU). At some hospitals, unit-based multidisciplinary rounds may not include physicians. The RP should ensure that non-ICU patients are evaluated for device safety as part of their routine care. This includes evaluating the device risk and necessity.

Other Units To Evaluate

Other units where devices are placed and maintained include the ED and the OR. Up to 50 percent of admissions to the hospital are through the ED, and PVCs are universally placed there. In addition, short-term CVCs may also be placed, many of them under suboptimal conditions. The ED, too, represents an area where large numbers of UCs are placed, and many of them may not be appropriately indicated. ED process improvements may positively affect patient outcomes hospitalwide. When working with the ED, engaging both physician and nurse leaders is essential to success. RPs in the ED can ensure both device appropriateness and proper insertion.

The OR represents another area where CVCs and UCs are commonly placed. Ensuring appropriate use of UCs and proper insertion techniques for both CVCs and UCs is important to reduce the risk. For interventions in the OR, engaging the surgical RPs, the attending surgeons, and anesthesiologists will help improve care and outcomes.