HAIs 'Not Just a Nursing Problem'

Nurses cannot prevent hospital-acquired infections by themselves. What's needed is a nurse-led interdisciplinary team-based approach, says the author of a study on infection prevention.

A study from researchers at the Columbia School of Nursing shows that the mere presence of infection-prevention policies isn't enough to keep infection rates down. It also shows that although hospital-associated infections are nursing-sensitive outcomes, it's not just up to nurses to ensure that IP policies are being followed.

The authors of the study, published in the American Journal of Infection Control, write that their research is the "largest survey of acute care hospital infection prevention and control programs reported to date." Among the study's major and somewhat damning, findings:

• Central line-associated bloodstream infections (CLABSI): 92% of ICUs had a policy for an insertion checklist, but only 52% of the healthcare professionals were seen to adhere to that policy
• Ventilator-associated pneumonia (VAP): 74% of ICUs had a ventilator bundle checklist, but only 52% of those treating patients adhered to it
• Catheter-associated urinary tract infection (CAUTI): 27% of ICUs had a policy for a nurse-assisted catheter insertion, but only 22% were seen to observe that practice

Nurses have long been linked to infection control and prevention. Other research has even shown that nurse staffing hours and certifications can lead to reductions in certain HAIs.

"Some of these things are really [linked to] nursing," says Patricia Stone, PhD, MPH, RN, FAAN, Centennial Professor of Health Policy at Columbia University School of Nursing, and the study's lead author. But just because HAIs are a nursing-sensitive outcome, doesn't mean that nurses alone bear the responsibility for them.

"It takes a team, it takes top leadership, it takes everyone on the same page," Stone says. "It's not just a nursing problem."

For instance, with CLABSI prevention, optimal catheter site selection is critical, but nurses aren't responsible for that. With VAP, "the bedside nurse doesn't order the ulcer-prevention drugs," Stone says.

This isn't an attempt to pass the buck. Rather, it is showing that an interdisciplinary approach is needed, and that nurses clearly aren't solely responsible for "nurse-sensitive outcomes."

That said, Stone says nurse leaders can and should take the lead on making sure that an interdisciplinary team is adhering to IP policies, and establishing such policies when there aren't any in place.

"Nurses are very much part of the team, but [HAIs] should be considered an interdisciplinary problem," she says. "Nurses should be leading the team."

And if the organization doesn't have policies? Then nurse leaders should speak up and "say why we don't?" If nurse leaders know existing policies aren't being adhered to, they need to acknowledge and get to the bottom of it.

"Don't accept that, as [saying] we're too busy…we need to figure out why," Stone says.

Nurse leaders can and should take a critical look at what resources are needed to help healthcare providers adhere to IP policies every time.

"Do they have the cart for central line insertion? Do they have the resources like portable bladder ultrasounds?" Stone says. "Are they sure that people understand what needs to be done and why it needs to be done?"

Infection prevention presents unique challenges because it is, in many ways, a moving target, Stone says. Other events, such as patient falls, have a clear causation such as slippery floors, or not enough people helping a patient with ambulation. But it's not always clear when and how infections begin. It's not easy to trace the origins of an infection, and an infection might appear a day or two after the event that caused it.

"You don't see the organism," Stone says. "It happens later. You just can't pin it to one event. I think not being able to establish the one event that's causal makes people think, 'Everything I'm, doing is OK.'"

That is precisely why certified infection preventionists, strong policies, interdisciplinary checks and balances, and leaders who are willing to lead the charge against HAIs are needed.

"It comes from nursing leadership, it comes from medical leadership, it comes from hospital leadership," Stone says. "Physicians don't like to be told what to do by the nurses, and nurses don't like to be told what to do by the physicians. Having that interdisciplinary core team involved in infection prevention is important."