Patient Safety Report

Journal 2 Dawn Papeika and Debbie Dombroski
The impetus of our project was initiated after a healthcare professional requested a port protection device be applied to a patient's accessed infusaport during transport to Temple University Hospital (TUH). This triggered an investigation into the current policy being used at TUH. Upon review of current institutional policies it was discovered that Curos disinfecting port protectors were being used on "All patients, All lines, All the time" (AAA) in order to prevent central line associated bloodstream infections (CLABSI). Further research into proper maintenance and care of IV's and CDC guidelines in order to meet 2016 National Patient Safety Goals ( NPSG) revealed that current practices may not
CUSP is comprised of the 4 E's: Engage, Educate, Execute and Evaluate. The discovery of the CUSP toolkit thrilled both of us, knowing this basic tool will provide a framework for our safety project. We were enlightened through research review that neglected human factors were placing our immunocompromised patients at risk of infection. We will share the evidenced-based practices along with fact sheets on central line associated bloodstream infection in order to engage our coworkers in the importance of following guidelines. The main focus of the project is to educated our colleagues on the importance of proper disinfection of needleless connector hubs in order to prevent bloodstream infection. The execution of our plan will encompass the use of staff meetings which will include educational videos, facts , and poster presentation along with a "QUIFLE". The idea of a "QUIFLE" was enticing to us and we decided it would be an interesting way to engage our coworkers. Evaluation of the success of our project will be done through post intervention
Cognitively, we have learned a great deal about the importance of proper care of IV's. We did not realize the significant risk of bacterial infection that can occur from the hub of a connector or from areas of blood accumulation around luer locks. Although we did have prior knowledge of fibrin sheaths in portacaths, we did not fully understand the risk of bacterial growth within the sheath. Affective learning has occurred in that we now understand the science behind the standards and the importance of adherence to protocols. We are excited and compelled to share this information with our colleagues. We have, however, discovered some inconsistency in TUH policy concerning flushing of ports: the use of Heparin is not always recommended due to possible heparin induced thrombocytopenia and the policy states to use 20ml NS and heparin to flush ports after drawing blood, but also states to use 10ml of NS to flush ports after drawing blood. We have determined that our needle connectors are neutral displacement and therefore Heparin use is not always necessary. We plan to discuss this with our preceptor and determine if policy updates are needed. The technique of scrubbing the connector and allowing dry time is one example of the physical learning that has taken place through this project. We hope that throughout the development of this project we can create a