MEASURING ONCOLOGY NURSING-SENSITIVE PATIENT OUTCOMES: EVIDENCE-BASED SUMMARY

1. Outcome: Infections, Prevention of 2. Category: Safety (Preventable Adverse Event) 3. Definition:

An infection is the invasion of the body’s natural barriers by microscopic organisms—bacterial, fungal, viral, or parasitic—which multiply to create symptoms (Infectious Diseases Society of America, 2003). Prevention of infection thus includes activities by patients, physicians, nurses, and public health professionals aimed at reducing the likelihood of microbial invasion and multiplication. Reference for Definition Infectious Diseases Society of America. (2003). Facts about infectious diseases. Retrieved November 17, 2003, from Facts About Infectious Diseases

4. Integrative reviews and meta-analysis

Search Strategy These citations were retrieved following searches in CINAHL and MEDLINE, and at www.guidelines.gov for 2000–2003. Articles retrieved had to be flagged as “systematic reviews,” or “meta-analyses.” “Review articles” were retrieved, and those with a search strategy published in the document were retained for consideration. Papers and guidelines in this resource guide had to discuss infection or infection control and the role of registered nurses. Special emphasis is indicated (by an asterisk) on documents that address patients with cancer. Clinical articles, tutorials, and book chapters were excluded from analysis. Reviews Bohlius, J., Reiser, M., Schwarzer, G., Engert, A., Clark, O., Lyman, G., et al. (2003).

Granulopoiesis-stimulating factors in the prevention for adverse effects in the therapeutic treatment of malignant lymphoma. Cochrane Database of Systematic Reviews, 3, 3.

Bow, E. J., Laverdiere, M., Lussier, N., Rotstein, C., Cheang, M. S., & Ioannou, S. (2002). Antifungal prophylaxis for severely neutropenic chemotherapy recipients: A meta analysis of randomized-controlled clinical trials. Cancer, 94, 3230–3246.

Braunschweig, C. L., Levy, P., Sheean, P. M., & Wang, X. (2001). Enteral compared with parenteral nutrition: A meta-analysis. American Journal of Clinical Nutrition, 74, 534–542

Cornely, O. A., Ullmann, A. J., & Karthaus, M. (2003). Evidence-based assessment of primary antifungal prophylaxis in patients with hematologic malignancies. Blood, 101, 3365–3372.

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Epstein, J. B., & Chow, A. W. (1999). Oral complications associated with

immunosuppression and cancer therapies. Infectious Disease Clinics of North America, 13, 901-923.

Gotzsche, P. C. & Johansen, H. K. (2003). Routine versus selective antifungal administration for control of fungal infections in patients with cancer. Cochrane Library, 2.

Greene, J. N. (1996). Catheter-related complications of cancer therapy. Infectious Disease Clinics of North America, 10, 255–295.

Kanda, Y., Yamamoto, R., Chizuka, A., Hamaki, T., Suguro, M., Arai, C., et al. (2000). Prophylactic action of oral fluconazole against fungal infection in neutropenic patients: A meta-analysis of 16 randomized, controlled trials. Cancer, 89, 1611–1625.

Mank, A., & van der Lelie, H. (2003). Is there still an indication for nursing patients with prolonged neutropenia in protective isolation?. An evidence-based nursing and medical study of 4 years experience for nursing patients with neutropenia without isolation. European Journal of Oncology Nurings, 7(1), 17–23.

O'Grady, N. P. (2002). Applying the science to the prevention of catheter-related infections. Journal of Criicalt Care, 17(2), 114–121.

Pratt, R. J., Pellowe, C., Loveday, H. P., Robinson, N., & Smith, G. W. (2001). The epic project: developing national evidence-based guidelines for preventing healthcare associated infections. Journal of Hospital Infection, 47(Suppl.), S1–82.

Russo, P. (2000). Urologic emergencies in the cancer patient. Seminars in Oncology, 27, 284–298.

Saint, S., & Lipsky, B. A. (1999). Preventing catheter-related bacteriuria: Should we? Can we? How? Archives of Internal Medicine, 159, 800–808.

Shelton, B. K. (2003). Evidence-based care for the neutropenic patient with leukemia. Seminars in Oncology Nursing, 19, 133–141.

van de Wetering, M. D., & van Woensel, J. B. (2003). Prophylactic antibiotics for preventing early central venous catheter Gram positive infections in oncology patients. Cochrane Database System Review, 2, CD003295.

Warren, J. W. (1997). Catheter-associated urinary tract infections. Infectious Disease Clinics of North America, 11, 609–622.

Wilson, B. J. (2002). Dietary recommendations for neutropenic patients. Seminars in Oncology Nursing, 18, 44–49.

Worthington, H. V., Clarkson, J. E., & Eden, O. B. (2003). Interventions for preventing oral candidiasis for patients with cancer receiving treatment. Cochrane Library, 2. Zitella, L. (2003). Central venous catheter site care for blood and marrow transplant recipients. Clinical Journal of Oncology Nursing, 7, 289–298. Clinical Journal of Oncology Nursing

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Reviews With Abstracts Bohlius, J., Reiser, M., Schwarzer, G., Engert, A., Clark, O., Lyman, G., et al.

(2003). Granulopoiesis-stimulating factors in the prevention for adverse effects in the therapeutic treatment of malignant lymphoma. Cochrane Database of Systematic Reviews, 3, 3.* Systematic Review. PubMed Abstract

Bow, E. J., Laverdiere, M., Lussier, N., Rotstein, C., Cheang, M. S., & Ioannou, S. (2002). Antifungal prophylaxis for severely neutropenic chemotherapy recipients: A meta analysis of randomized-controlled clinical trials. Cancer, 94, 3230–3246.* Meta-analysis PubMed Abstract

Braunschweig, C. L., Levy, P., Sheean, P. M., & Wang, X (2001). Enteral compared with parenteral nutrition: A meta analysis. American Journal of Clinical Nutrition 74, 534 542.* Meta-analysis PubMed Abstract

Cornely, O. A., Ullmann, A. J., & Karthaus, M. e (2003). Evidence-based assessment of primary antifungal prophylaxis in patients with hematologic malignancies. Blood 101, 3365 3372.* Systematic Review PubMed Abstract

Epstein, J. B., & Chow, A. W. (1999). Oral complications associated with immunosuppression and cancer therapies. Infectious Disease Clinics of North America 13, 901–923.* Comprehensive Literature Review PubMed Abstract

Gotzsche, P. C., & Johansen, H. K. (2003). Routine versus selective antifungal administration for control of fungal infections in patients with cancer. Cochrane Library, 2.*Systematic Review Cochrane Abstract

Greene, J. N. (1996). Catheter-related complications of cancer therapy. Infectious Disease Clinics of North America, 10, 255–295.* Comprehensive Literature Review PubMed Abstract

Kanda, Y., Yamamoto, R., Chizuka, A., Hamaki, T., Suguro, M., Arai, C., et al. (2000). Prophylactic action of oral fluconazole against fungal infection in neutropenic patients. A meta-analysis of 16 randomized, controlled trials. Cancer, 89, 1611–1625.* Meta analysis PubMed Abstract

Mank, A., & van der Lelie, H. (2003). Is there still an indication for nursing patients with prolonged neutropenia in protective isolation? An evidence-based nursing and medical study of 4 years experience for nursing patients with neutropenia without isolation. European Journal of Oncology Nursing, 7(1), 17–23.* Systematic Review and Intervention Research PubMed Abstract

O'Grady, N. P. (2002). Applying the science to the prevention of catheter-related infections. Journal of Critical Care, 17, 114–121. Systematic Review PubMed Abstract

Pratt, R. J., Pellowe, C., Loveday, H. P., Robinson, N., & Smith, G. W. (2001). The epic project: developing national evidence-based guidelines for preventing healthcare associated infections. Journal of Hospital Infection, 47(Suppl.), S1-82. http://www.epic.tvu.ac.uk. Systematic Review PubMed Abstract

Russo, P. (2000). Urologic emergencies in the cancer patient. Seminars in Oncology 27, 284-298.* Comprehensive Literature Review PubMed Abstract

Saint, S., & Lipsky, B. A. (1999). Preventing catheter-related bacteriuria: Should we? Can we? How? Archives of Internal Medicine, 159, 800–808. Systematic Review PubMed Abstract

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Shelton, B. K. (2003). Evidence-based care for the neutropenic patient with leukemia. Seminars in Oncology Nursing, 19, 133–141.* Systematic Review PubMed Abstract

van de Wetering, M. D., & van Woensel, J. B. (2003). Prophylactic antibiotics for preventing early central venous catheter. Gram positive infections in oncology patients. Cochrane Database System Review, 2, CD003295.* Systematic Review PubMed Abstract

Warren, J. W. (1997). Catheter-associated urinary tract infections. Infectious Disease Clinics of North America. 11, 609–622. Comprehensive Literature Review PubMed Abstract

Wilson, B. J. (2002). Dietary recommendations for neutropenic patients. Seminars in Oncology Nursing, 18, 44–49.* Systematic Review PubMed Abstract

Worthington, H. V., Clarkson, J. E., & Eden, O. B. (2003). Interventions for preventing oral candidiasis for patients with cancer receiving treatment. Cochrane Library, 2. Systematic Review Cochrane Abstract

Zitella, L. (2003). Central venous catheter site care for blood and marrow transplant recipients. Clinical Journal of Oncology Nursing, 7, 289–298.* Comprehensive Literature Review, Primary Survey PubMed Abstract

5. Guidelines and standards

Boyce, J. M., & Pittet, D. (2002). Guideline for hand hygiene in health-care settings. Morbidity and Mortality Weekly Report, 51(RR-16), 1–48.

Centers for Disease Control and Prevention. (2000). Guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients: Recommendations of CDC, the Infection Disease Society of America, and the American Society of Blood and Marrow Transplantation. Morbidity and Mortality Weekly Report, 49(RR-10), 1–126.

Centers for Disease Control and Prevention. (2002). Guidelines for the prevention of intravascular catheter-related infections. Morbidity and Mortality Weekly Report, 51(RR-10), 1–33.

Haisfield-Wolfe, M. E., & Rund, C. (1997). Malignant cutaneous wounds: A management protocol. Ostomy Wound Management, 43(1), 56–58.

Mangram, A. J., Horan, T. C., Pearson, M. L., Silver, L. C., Jarvis, W. R., & the Hospital Infection Control Practices Advisory Committee. (1999). Guideline for prevention of surgical site infection, 1999. Infection Control and Hospital Epidemiology, 20, 247–278.

National Comprehensive Cancer Network. (2002). Clinical practice guidelines:Fever and neutropenia. Retrieved December 15, 2003, from Clinical Practice Guidelines: Fever and Neutropenia

Ozer, H., Armitage, J. O., Bennett, C. L., Crawford, J., Demetri, G. D., Pizzo, P. A., et al. (2000). 2000 update of recommendations for the use of hematopoietic colony-stimulating factors: evidence-based, clinical practice guidelines

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American Society of Clinical Oncology Growth Factors Expert Panel [comment]. Journal of Clinical Oncology, 18, 3558–3585.

Singapore Ministry of Health. (2002). Prevention of infections related to peripheral intravenous devices. Retrieved November 17, 2003, from Prevention of Infections Related to Peripheral Intravenous Devices

Tablan, O. C., Anderson, L. J., Arden, N. H., Breiman, R. F., Butler, J. C., McNeil, M. M., et al. (1994, March 26, 1996). Guideline for prevention of nosocomial pneumonia. Retrieved November 17, 2003, from Guideline for Prevention of Nosocomial Pneumonia

6. Tools to measure oncology nursing sensitive patient outcome: prevention of

infection.

Protocol for the Diagnosis of Catheter-Related Infections (Blot, Nitenberg, & Brun-Buisson, 2000).

This article reviews the literature and summarizes a study conducted to compare various diagnostic tools for catheter-related infections. Briefly summarized, the authors suggest

1) Paired blood cultures: one obtained peripherally, the second set obtained from the distal port of the catheter

2) The peripheral culture should be obtained first. Both sets should contain the same volume of blood for comparison.

3) The time to positivity (the time between obtaining culture and a positive result) should be compared for set obtained by the catheter versus peripherally. If the culture obtained by the catheter is positive first, the difference between the two is greater than 120 minutes, and colonization is focused within the catheter, catheter related infection should be strongly suspected.

Protocol for Obtaining Blood Cultures from Central Venous Catheters and

Peripheral Sites (Penwarden & Montgomery, 2002) This article documents a literature-based protocol which was reviewed and endorsed by clinicians to standardize blood culture procedures in a single institution. The highlights include

1) Obtaining cultures within 30 minutes of the order 2) One peripheral set of blood cultures obtained at the first fever 3) One set of cultures from each lumen of a central venous catheter, with no

blood discarded 4) Subsequent cultures drawn from central lines only. Only one set of central line cultures are obtained once the fever has occurred outside the initial 48-hour period

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7. References related to instruments to measure outcome

Blot, F., Nitenberg, G., (2000). New tools in diagnosing catheter-related infections. Supportive Care in Cancer, 8, 287–292.

Penwarden, L. M., & Montgomery, P. G. (2002). Developing a protocol for obtaining blood cultures from central venous catheters and peripheral sites. Clinical Journal of Oncology Nursing, 6, 268–270. Clinical Journal of Oncology Nursing

8. Summary of key evidence that nursing interventions influence prevention of

infection and gaps in current evidence base

Recommendations specific to patients with cancer are marked with an asterisk. The recommendations summarized below are at a level consistent with strong recommendations supported by well-designed experimental, clinical, or epidemiological studies. Other important recommendations with a less rigorous support base may be found in the source documents. The interventions are clustered into five domains. A. Hygiene

• Handwashing is the single most important nursing intervention to prevent infection. This may be accomplished with antimicrobial soap and water.

• When hands are not visibly soiled, alcohol-based handrubs that come in contact with all surfaces of the hand are acceptable substitutes.

• Avoidance of urinary catheterization is recommended. If not clinically feasible, intermittent catheterization—using sterile technique and a closed drainage system—is preferred to continuous catheterization.

• For patients who require long-term catheterization, suprapubic catheters may be considered.

• Insertion and care of urinary catheters should be routinely documented. • Prevention of infection in malignant cutaneous wounds is best achieved

when the wound is (1) irrigated thoroughly between dressing changes, (2) debrided of necrotic material, and (3) dressed appropriately to absorb exudate.*

• Neutropenic patients with cancer should have frequent oral care (toothbrushing and gentle flossing as tolerated). Oral rinses should be “palatable,” and antimicrobial rinses should be considered when gingivitis or poor hygiene is noted.*

B. Intravenous Therapy

• Selection of intravascular catheter type and site for insertion should consider the risk of complications related to the planned type and duration of IV therapy.

• Placement of permanent or semipermanent catheters should be avoided when patients are functionally or quantitatively neutropenic.*

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• Insertion of central venous catheters should take place using full barrier precautions (i.e., sterile field, caps, gowns, masks, sterile gloves).

• Catheters, regardless of site, should always be placed aseptically. • 2% chlorhexidine preparation is the preferred cleansing agent of catheter

sites. • Catheters should be removed promptly when deemed unnecessary. • Injection ports and diaphragms of multidose vials should be cleansed with

70% alcohol prior to accessing. • Catheter dressings should be replaced promptly when damp, soiled, or

loosened. • IV administration sets, extensions, and secondary sets should be replaced

no more frequently than 72 hours, unless infection is suspected or documented.

C. Nutrition/Gastrointestinal

• When clinically appropriate, enteral nutrition is preferred to the parenteral route in the cancer patient population.*

• Appropriate dietary restrictions for the neutropenic cancer patient include (1) fruits and vegetables well washed with tap water, and (2) Avoidance of raw and/or unwashed meat, eggs, fish, and shellfish.

• Outcomes related to other dietary restrictions popular in clinical care are not supported by the literature.*

D. Environment

• No systematic evidence exists for the practice of protective isolation of the neutropenic patient with cancer. Such measures may be substituted with aggressive hygienic measures.*

• Neutropenic patients with cancer should not be in contact with fresh flowers or plants.*

E. Chemoprevention

• To prevent oral candidiasis in the cancer patient, the use of prophylactic antifungals which are entirely or partially absorbed in the gastrointestinal tract (e,g.. fluconazole, clotrimazole) are preferable to nonabsorbed agents (nystatin) *

• Prophylactic anti-infectives are indicated in specific clinical situations* Allogeneic bone marrow transplantation, against

• Mycoses: Fluconazole, Itraconazole, Amphotericin B. • Herpes Simplex: Acyclovir, Famciclovir, or Valacyclovir • Pneumocystis carinii: trimethorprim-sulfamethoxazole

Acute leukemia undergoing induction, against • Mycoses: Fluconazole, Itraconazole, Amphotericin B. • Herpes Simplex: Acyclovir, Famciclovir, or Valacyclovi

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• Pneumocystis carinii: trimethorprim-sulfamethoxazole (acute lymphocytic leukemia only, and throughout therapy).

• Colony-stimulating factors may play a role in preventing infection for patients

with malignant lymphoma undergoing chemotherapy.

Gaps in current evidence base 1. Prevalence and Patterns: While the Centers for Disease Control and Prevention

conducts extensive prevalence studies in hospital-acquired infections, the prevalence of infection in the outpatient setting is not well known. Further, while infection incidence is reported in the cancer research literature, seldom are incidence data aggregated to understand a more complete picture of the true “risk” of infection for the population of patients with cancer.

2. Assessment/Measurement: Infection control standards and standardized infection

reports are advocated by the Centers for Disease Control and Prevention. While some authors have attempted to standardize culture techniques in the cancer patients, these initiatives are largely restricted to blood culture. The optimal schedule for nursing assessment of patients for infection is not known, nor is the frequency of obtaining cultures.

3. Mechanisms/Etiology: Surveillance activities to ascertain the source of infection is

strongly advocated by the Centers for Disease Control and Prevention. What is less clear from the literature is how the receipt of surveillance data changes clinical practice and ultimately, patient outcomes.

4. Correlates: Systematic reviews have yet to incorporate emerging concepts of risk

assessment for infection in the cancer patient. Given the multitude of research activities aimed at validating infection risk assessment tools, this area should be a high priority target for future reviews. Further, the impact of advanced cancer stage on infection prevention activities has been understudied.

5. Management/Nursing Interventions: While this template identified practices

associated with decreased infection risk for patients, far less is known about how specific nursing activities alter the risk of infection in the cancer patient. For example, it would be helpful to understand whether systematic nursing assessments performed at regular intervals, or nurse-led patient teaching would be useful in identifying early-stage and precursors to infection for cancer patients.

6. Diverse Populations: None of the literature reviewed addressed cultural/ethnic

diversity of the patient sample. Expert reviews of this summary suggested an important area for further research are the differences in patient needs based upon geographic location. Infection control in the elderly has been targeted in the general medical literature, but with less specificity in cancer. While reviews and studies often take special exception to the neutropenic or hematopoietic stem cell populations, less attention is paid to specific tumor types, or patients receiving specific modalities. Evidence is sparse for important infection control activities in solid tumor population

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9. Recommendations

Practice There are definable activities, highlighted above, which reduce the risk of infection to cancer patients. Clinicians, managers, and educators should reflect upon how these activities coincide with their current clinical practice, and initiate the appropriate steps to reconsider their current practice when indicated. Clinicians must also remain current on the research literature concerning new agents for prevention of infection; these new agents do not emerge immediately in systematic reviews, but may be vital advances in clinical practice. Education Nurse educators have a responsibility to understand the systematic review process and newest trial data on interventions to educate both new and seasoned staff in the latest interventions. Educators should also help nurses interpret surveillance data, and the applicability of research findings to their clinical populations. Research Multi-center, experimental or quasi-experimental designed studies are necessary to consider the interventions that possess theoretical support but lack empirical support. Examples include scheduling and content of nursing assessments, appropriate oral rinsing agents, frequency and technique of cultures, general skin care, and the effectiveness of nurse-led patient teaching in preventing the occurrence of ameliorating the experience of infection. Policy Infections and their treatment are responsible for considerable morbidity and economic expenditures. The federally-sponsored research that addresses interventions to prevent infection is scant. Targeted research funding may lead to the development of interventions that save lives and costs. Investments in data resources to share surveillance data may also aid clinicians in targeted assessment and prevention strategies.

10. Links

Agency for Healthcare Research and Quality (AHRQ), AHRQ Quality Indicators:

http://www.qualityindicators.ahrq.gov/ Currently, three sets of indicators are available to measure quality: Inpatient

Quality, Patient Safety, and Prevention Quality. The latter two sets include various measures of infection. This website includes techniques to measure these indicators in hospital claims data.

The Centers for Disease Control and Prevention: http://www.cdc.gov In addition to frequent updates to the guidelines cites above (Surgical Site

Infection, Handwashing, Catheter-related infection), the National Nosocomial Infections Surveillance System (provides information on how to measure and compare infection rates): http://www.cdc.gov/ncidod/hip/SURVEILL/NNIS.HTM

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Evidence Based Practice in Infection Control (EPIC): http://www.epic.tvu.ac.uk Specific areas of foci are long term urinary catheters, patients receiving enteral

feeding, and patients with central venous catheters. Infectious Diseases Society of America: http://www.idsociety.org Clinical guidelines are available for treatment of specific organisms, sites, and

patient populations. These are mostly centered around appropriate drug therapies. Multinational Association of Supportive Care in Cancer:

http://www.cancerworld.org/MASCC/default.asp The activities and findings of the Infection Study Group are reported here, focused

on predictive models of outcomes for patients with febrile neutropenia to target prophylaxis.

National Center for Nursing Quality: http://www.nursingquality.org The repository for the National Database of Nursing Quality Indicators (NDNQI), in

which nosocomial infection is currently under exploration as a nurse-sensitive outcome measure in acute care settings. No infection-related outcome measures have been endorsed in non-acute care settings.

National Quality Forum: http://www.qualityforum.org Endorsed 39 performance measures to reflect hospital care quality, including

measurement techniques. Three of which, urinary catheter-related urinary tract infection, central line catheter-related blood stream infection, and ventilator-assisted pneumonia, are related to infection.

University of Iowa Center for Nursing Classification & Clinical Effectiveness:

http://www.nursing.uiowa.edu/centers/cncce/ Included in the nursing outcomes classification (NOC) is Infection Severity and

Immune Status. 11. Current Research

ONS Foundation-funded research

http://www.ons.org/research/funding/Projects/index.shtml “Neutropenic Diet for Leukemia Patients”, Alison E. Gardner, PhD, RN, MD Anderson

Cancer Center “Neutropenia Outcomes: Nursing Staffing and Environment Effects”, Christopher R.

Friese, MS, RN, AOCN®, University of Pennsylvania NIH-funded research http://crisp.cit.nih.gov/

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No relevant studies were retrieved from the CRISP database using the keywords cancer, prevent, and infect. The following studies were identified after a search using nurs, infect, and prevent, as keywords: “Oral Care and Respiratory Pathogen Colonization,” Ozan Akca, PI, 1R03DE014879 “Backrest Position and Oral Health – Effect on VAP [Ventilator-Associated

Pneumonia]”, Mary Grap, PI, 1R15NR004730 “Prompts for Handwashing Effectiveness,” Stephen S. Lane, PI, 1R43NR008099 “Home Hygiene Intervention,” Elaine Larson, PI, 1R01NR005251 “Statewide Efforts to Improve Care in Intensive Care Unit,” Peter J. Pronovost, PI,

1UC1HS014246

Author Christopher R. Friese, RN, MS, AOCN®, Pre-Doctoral Fellow & American Cancer Society Doctoral Scholar, Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing

Last Updated: July 7, 2004

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