Preventing catheter-associated

Preventing catheter-associated By Cheryl Dumont, PhD, RN, CRNI, and Janine Wakeman, BSN, RN Respondent profile D ENNIS KUNKEL M ICROSCOPY, INC. / P HOTOTAKE Approximately 20% of respondents had a BSN or higher degree. About 29% had an AD, 12% had an RN diploma, and 23% were students. Twenty-eight percent of respondents were certified in their nursing specialty. The specialty area represented most frequently was medical-surgical nursing (34%) and the most common work setting was a hospital (61%). Other work settings represented were long-term care (14%), home health (4%), office nurse (3%), and outpatient (2%). A few identified student clinical rotation, clinical research, and manufacturing as their work setting. Electron microscopy showing the inner surface of a urinary catheter colonized with Candida albicans, a yeast-like fungus. 24 l Nursing2010 l December www.nursing2010.com

2.8 ANCC CONTACT HOURS UTIs: Survey report CATHETER-ASSOCIATED urinary tract infections (CAUTI) are one of the 10 hospital-acquired conditions (HACs) considered never events because they re preventable and should never happen. The Centers for Medicare and Medicaid Services (CMS) won t reimburse a facility for CAUTI and other never events unless the condition was documented as present on admission. 1 Because many guidelines for preventing CAUTI are directly under nurses control, CAUTI is considered a nurse-sensitive indicator. Last spring, Nursing2010 conducted a survey in the journal and online to explore nurses knowledge of CAUTI prevention and the level of support they get from their facilities. This article reviews the results of the survey, discusses best practices, and provides evidence-based rationales. Challenges and opportunities Many nurses initial reaction to the CMS no-pay policy was dismay because of the extra burdens and pressure placed on them. But every cloud has a silver lining, and this one has two. First, the new policy puts a premium on quality care by focusing on best practices to deliver quality care. Our patients can only benefit from this. Second, because many aspects of HAC prevention are within the scope of nursing, the policy presents a unique opportunity for nurses to shine. Successful outcomes depend on consistent bedside implementation of evidencebased best practices. This is an opportunity to demonstrate, in outcomes and dollars, the value of nurses to their organizations. What survey results reveal One hundred seventy-eight nurses from across the country responded to our survey. This convenience sample represented 58% RNs, 12% LPNs/LVNs, and 23% students. No licensing status was identified for 7% of the sample. For more details, see Respondent profile. The mean score for participants was 64% correct. The scores reflect only correct answers; unanswered questions Coming to terms with acronyms Here s a quick reference for abbreviations used in this article: CAUTI: catheter-associated urinary tract infection CMS: Centers for Medicare and Medicaid Services CDC: Centers for Disease Control and Prevention HAC: hospital-acquired condition HAI: healthcare-associated infection were considered incorrect. The scores were normally distributed, forming a bell curve with a slight negative skew (tail to the left). The minimum score was 23% and the maximum, 92%. We found no differences in scores based on education, work setting, or licensing status. Likewise, we found no significant differences (statistical significance = p < 0.05) based on clinical specialty. However, nurses working in the ED (N = 10) and rehabilitation (N = 11) scored highest with means of 69%, standard deviation (SD) 8%, and 66%, SD 19%, respectively. Nurses working in intensive care (N = 10) scored lowest with a mean of 59%, SD 16%. This is an interesting observation, but these sample sizes are too small to make generalizations. It should also be noted that when looking at the percent correct and the response choices made for each question, most nurses chose the correct response for the most important questions and at least a partially correct response for many others. Responses to individual questions, correct answers, and rationales are presented in the following pages. Correct answers are highlighted in red. The percent of responses for each answer is found at the end of the row. Numbers have been rounded. Percentages don t always add up to 100% because not every participant answered every question. www.nursing2010.com December l Nursing2010 l 25

1. Research indicates that on average, CAUTI increases a patient s length of stay by 2 days. 55% 10 days. 41% 1 month. 5% The best answer is 2 days; however, this is just an average and the impact of CAUTI is extremely variable and dependent on many factors. Urinary tract infections are not benign: they re potentially fatal and have been estimated by the CMS to result in costs as high as $451 million annually. 2-4 2. The most common type of healthcare-associated infection (HAI) is ventilator-associated pneumonia. 2% CAUTI. 93% central catheter-associated bloodstream infection. 3% surgical-site infection. 1% As most nurses knew, CAUTI is indeed the most common HAI, representing up to 40% of all HAIs. The National Healthcare Safety Network reported that the average rate of CAUTI is between 3.1 and 7.5 per 1,000 patient days (calculated as number of CAUTI number of patient days 1,000). 5 4. Evidence shows that silver alloy-coated indwelling urinary catheters reduce CAUTI risk in patients with urinary catheters for up to 2 weeks. 43% don t affect CAUTI incidence. 15% reduce CAUTI risk when catheters are in place for more than 2 weeks. 26% increase urethral irritation compared to other catheter types. 15% Studies on silver alloy coated urinary catheters demonstrate that they re effective in preventing CAUTI for the first 2 weeks of dwell time. Researchers have demonstrated that in hospital units, use of silver-coated urinary catheters reduced risk of CAUTI by 32%. 7 This suggests that silver alloy coated catheters may be of benefit in the acute care setting but have limited usefulness in longterm care. Antibiotic-impregnated catheters have been found to be effective in reducing incidence of CAUTI for only 7 days. 8-10 5. Which of the following is true about biofilm? It develops only on the outside of urinary catheters. 7% It provides shelter for bacterial growth. 60% It s a diagnostic criterion for CAUTI. 11% It enhances bactericidal activity. 22% 3. Which of the following is true? CAUTI risk increases 3% to 7% daily in the acute care setting with indwelling urinary catheter use. 5% CAUTIs comprise about 40% of all HAIs. 0.6% CAUTIs can lead to bloodstream infections. 4% All of the above. 90% As noted above, CAUTI represents 36% to 40% of HAIs and can lead to serious complications such as bloodstream infections. The risk of CAUTI increases 3% to 7% with each day of catheterization. When a catheter remains indwelling for a week, the risk of bacteriuria increases to 25%; at 1 month, the risk of bacteriuria is 100%. Although bacteriuria may not cause symptoms, it s the first step toward a CAUTI. From 10% to 24% of patients with bacteriuria will develop symptomatic CAUTI (fever, dysuria, urgency, frequency, suprapubic tenderness), and up to 3% will progress to bacteremia. 2,6 Approximately 17% of hospital-acquired bacteremias have been found to have a urinary source and carry an associated mortality of 10%. 5 Facts and figures 5 Biofilm is a coating of polysaccharides and microorganisms that develops on every indwelling medical device. Within the biofilm, microorganisms are highly resistant to antimicrobial treatment and bind tenaciously to the surface. The microorganisms living in biofilm are virtually impossible to eradicate without removing the catheter. 5 Biofilm may be composed of a single species or multiple species, depending on the device and its duration of use in the patient. Initially, urinary catheter biofilm may be composed of a single species, but longer exposures inevitably lead to multispecies biofilm. The biofilm polysaccharides have been visualized by scanning electron microscopy and The National Healthcare Safety Network reported CAUTI rates to be from 3.1 to 7.5 per 1,000 catheter days in acute care hospitals in 2006. The highest rates were found to be in burn ICUs and the lowest rates in medical-surgical ICUs. The most common organisms associated with CAUTI are Escherichia coli (21.4%), Candida (21%), Enterococcus (14.9%), Pseudomonas aeruginosa (10%), Klebsiella pneumonia (7.7%), and Enterobacter (4.1%). appear either as thin strands connecting the cells to the surface and one another, or as sheets of amorphous material on a surface. Most biofilm volume is actually composed of this extracellular polymeric substance rather than cells. Biofilm matrix may act as a filter, entrapping minerals or host-produced serum components. 11 26 l Nursing2010 l December www.nursing2010.com

6. According to the CDC, CAUTI is diagnosed when the patient develops a fever. 2% the catheter develops biofilm. 1% the patient develops signs and symptoms of infection, bacteriuria, and leukocyturia. 35% all of the above. 62% To create a reliable and valid database and benchmark for the incidence of CAUTI, everyone must use the same definition when identifying and diagnosing this infection. The CDC has issued specific criteria that must be met before the diagnosis of CAUTI can be made. These criteria include the following: 12 Patient had an indwelling urinary catheter at the time of or within 48 hours before specimen collection. Patient has at least one of the following signs or symptoms with no other recognized cause: fever (>38 C), urgency, frequency, dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness. A urine culture is positive: greater than or equal to 10 5 CFU/mL (CFU = colony forming unit) with no more than two species of microorganisms, which would suggest specimen contamination. All patients with indwelling medical devices will have some degree of biofilm, and fever can occur for many reasons. Asymptomatic bacteriuria isn t classified as a CAUTI. 7. Which of the following reduces the incidence of CAUTI? routine catheter irrigation with 0.9% sodium chloride solution 0% catheterization only when indicated and prompt catheter removal 78% antibacterial ointment application to urethral meatus 0.6% all of the above 21% Only one intervention listed above decreases the incidence of CAUTI based on the evidence: reducing urinary catheter days.8 Catheter irrigation, instillation of antimicrobial solutions into the catheter or drainage bag, and antibiotic ointments applied to the urinary meatus have not been shown to decrease CAUTI. Some evidence indicates that routine meatal care with soap and water (good hygienic care) may reduce the incidence of CAUTI, especially in patients who are incontinent of stool. 5,13 8. Signs and symptoms of CAUTI include fever of 100 F (38 C) or more. 0% new-onset flank or suprapubic tenderness. 1% change in urine char acteristics. 2% worsening of mental or functional status. 4% all of the above. 93% Signs and symptoms of CAUTI can develop early on, before the patient becomes seriously ill. Pediatric patients younger than 1 year may exhibit hypothermia (<36 C). CAUTI should be immediately suspected if a patient with any of these signs and symptoms has an indwelling urinary catheter or has had one removed in the last 48 hours. 12 9. Components of the CAUTI prevention bundle (evidence-based practice guidelines) include staff education about catheter management. 0.6% regular monitoring of CAUTI incidence. 0% frequently changing the urinary drainage bag. 0% all of the above. 21% only the first and second choices above. 76% Key components of the CAUTI prevention bundle include education and monitoring patients for CAUTI. Assure that only properly prepared staff perform urinary catheterization. A system of regular surveillance and feedback on unit specific CAUTI rates is recommended. Change drainage bags and catheters based on clinical indications such as infection, obstruction, or compromise of the closed system. Changing drainage bags at routine or fixed intervals isn t recommended. 14 10. All of the following are accepted indications for urethral catheterization except acute urinary retention or obstruction. 6% to accurately measure urinary output in critically ill patients. 4% patient comfort after administration of a diuretic. 88% to assist healing of open perineal wounds in incontinent patients. 2% According to the CDC, appropriate indications for indwelling urinary catheterization are: acute urinary retention or bladder outlet obstruction accurate measurement of urine output in critically ill patients selected perioperative situations; for example, for urologic surgery, when intra-operative monitoring of urine output is needed, and when large-volume infusions or diuretics during surgery are anticipated patient requires prolonged immobilization (unstable spine or pelvic fractures) www.nursing2010.com December l Nursing2010 l 27

to assist in healing of open sacral or perineal wounds in incontinent patients end-of-life care. Patient comfort (except during end-of-life care) and convenience aren t appropriate uses for indwelling urinary catheters. 5 Again, remember to remove the urinary catheter as soon as possible. 11. Evidence shows that using sterile insertion technique is the most effective measure for preventing CAUTI. true/80% false/20% Sterile technique is required for insertion of an indwelling urinary catheter in the hospital setting, but clean technique can be used for intermittent catheterization in non-acute settings. By itself, sterile technique on insertion doesn t prevent CAUTI. Prevention of CAUTI depends on knowledge of causes, proper care techniques, and early catheter removal. 14 The fact that 80% of participants chose the incorrect answer to this question is interesting but not surprising. Because healthcare professionals have so much trouble with hand hygiene, The Joint Commission has made Meeting Hand Hygiene Guidelines part of its National Patient Safety Goals. 15 As nurses, we re taught the importance of strict sterile technique, but we seem to forget that there are many days of care and opportunity for infection after the initial insertion. Perhaps we ve had sterile technique drummed into us in campus learning labs at the expense of some of the basics. 12. Evidence shows that use of smaller-diameter catheters and catheter stabilization devices improves patient comfort. true/84% false/15% Using the smallest-bore catheter that will adequately drain the bladder is recommended to prevent bladder neck and urethral trauma. While this recommendation isn t based on strong evidence, such as a randomized controlled trial, it s supported by a weaker but valid type of evidence expert opinion. Indwelling urinary catheters should be secured after insertion to prevent urethral traction and movement that could damage the urethral lining. 5 13. The strongest predictor of CAUTI is patient age. 1% latex urinary catheter use. 1% length of catheter dwell time. 89% failure to use an antiseptic solution during catheter care. 8% The length of time a urinary catheter is in place is the strongest predictor that CAUTI is likely to develop. No evidence has shown that use of antiseptic solutions or catheter material has any effect on CAUTI. 5 Analyzing current practices The remaining questions on the survey dealt with identifying practices occurring in organizations across the country. We found that the policy for frequency of catheter care varies, but the most common frequency reported was routinely twice a day and after each bowel movement. Most institutions (74%) are following the CDC recommendation to clean the external catheter and perineal area with soap and water only (74%). 5 According to the CDC s guidelines, cleaning the meatal surface during daily bathing or showering is appropriate. 5 Forty-eight percent of respondents reported that their institutions don t use antimicrobial-impregnated catheters. Only 15% responded that they do use antimicrobialimpregnated catheters, but many participants (36%) said they don t know. Only 37% of respondents said their institution had a care bundle for urinary catheter insertion and care/cauti prevention. This improved slightly when analyzing results from those who work in a hospital: Among hospital-based respondents, 43% responded yes, they had a prevention bundle for CAUTI. But even in the hospital setting, 57% reported that either they didn t have a prevention bundle or they didn t know if they had one. This presents an opportunity to teach staff about proactive and evidence-based care. We ll discuss the CAUTI care bundle in detail below. Other evidence-based best practices are use of a catheter removal reminder system and urinary catheter securement devices. In this survey, 45% of hospital-based respondents and 38% of others reported using catheter removal reminders. This is another opportunity for improvement, as prolonged urinary catheter dwell time is the number one predictor of CAUTI. Sixty-four percent of respondents reported using urinary catheter securement devices. Blodgett (2009) identified 11 studies demonstrating benefits of using a reminder system to reduce duration of indwelling catheters. These systems can be physical reminders, such as stop orders, checklists, and discussion in rounds; virtual reminders using electronic medical record prompts; and combinations of both methods. 16 Another recent meta-analysis concluded that urinary catheter reminders and stop orders appear to reduce the rate of CAUTI and should be strongly considered to enhance the safety of hospitalized patients. 17 28 l Nursing2010 l December www.nursing2010.com

Monitoring CAUTI rates Nearly 58% of respondents overall and 66% of those working in hospitals reported that their organizations monitor CAUTI rates, and 10% reported they don t. It may be that many respondents just aren t aware of the monitoring. Most respondents (78% overall and 76% in hospitals) reported they don t know the CAUTI rate in their organization. Institutional support is needed to provide the structure that allows nurses to participate in teams to prevent CAUTI. Providing information about CAUTI rates to all staff involved in caring for these patients is an essential strategy for preventing CAUTI. Engaging staff in improving CAUTI rates is extremely difficult if they don t know it s a problem and can t track progress. Graphs or run charts posted on the staff bulletin board are very helpful. A system of surveillance and a dedicated interdisciplinary team, including champions at the bedside, is highly recommended. 2 Applying the CAUTI care bundle A care bundle is a collection of guidelines and interventions that, when consistently followed, have been shown to improve outcomes. Research has shown that improved outcomes depend on all elements of the bundle being applied, not just some. 18 The following bundle strategies are recommended by the CDC for prevention of CAUTI. 14 Insert catheters for appropriate indications only. Leave catheters in place only as long as needed. Ensure that only properly trained persons insert and maintain catheters. Insert catheters using sterile technique and sterile equipment (in acute care settings). Following sterile insertion, maintain a closed drainage system. Maintain unobstructed urine flow. Practice hand hygiene and standard precautions (in addition to other transmission-based precautions as appropriate) according to Healthcare Infection Control Practices Advisory Committee (HICPAC) guidelines. Consider the quality of evidence Like many other practices in medicine and nursing, the evidence for best practice in prevention of CAUTI is identified as Category IB or lower. Category IB is defined as a strong recommendation supported by low-quality evidence suggesting net clinical benefits or harms, or an accepted practice supported by low to very low quality evidence. There are too few practices with a Category IA rating (meaning a strong recommendation supported by high-to-moderate quality evidence suggesting net clinical benefits or harms). Strong evidence for many nursing and Lowering the risk of CAUTI with bladder scanning The CDC guideline recommends various strategies to reduce the risk of CAUTI, including intermittent (rather than chronic indwelling) catheterization for patients with spinal cord injuries and those with bladder emptying dysfunction. The guideline recommends that clinicians consider using a portable ultrasound bladder scanner to assess urine volume in patients undergoing intermittent catheterization to reduce unnecessary catheter insertions. If ultrasound bladder scanners are used, ensure that indications for use are clearly stated, nursing staff are trained in their use, and equipment is adequately cleaned and disinfected in between patients. Further research is recommended in the use of bladder scanners in patients with oliguria to reduce unnecessary catheter insertions or irrigations (in catheterized patients). 5 medical practices is lacking due to multiple variables and ethical considerations. The recommendation categories identified as the highest priorities by HICPAC are as follows: 5 appropriate urinary catheter use (including prompt removal when no longer needed) sterile insertion of urinary catheters proper urinary catheter maintenance. These three recommendation categories are clearly within the scope of nursing. Nurses can implement many interventions to fulfill these recommendations. For example, to help ensure appropriate urinary catheter use, nurses in our facility keep the urinary drainage bag hanging on the side of the bed facing the door. This serves as a reminder system: Every day when the clinical team rounds, they see the drainage bag and are reminded that the patient still has an indwelling urinary catheter. The visual reminder prompts them to consider whether it can be removed. Better evidence: You can help Many recommendations require further research to establish better evidence for practice; for example: determining which catheter materials are optimal use of antiseptics and antimicrobials alternatives to indwelling urethral catheters and bag drainage use of portable ultrasound in patients with low urine output to reduce unnecessary catheterizations (see Lowering the risk of CAUTI with bladder scanning). www.nursing2010.com December l Nursing2010 l 29

Each of these potential research topics is amenable to interdisciplinary research. Prevention of CAUTI is truly a nurse-sensitive indicator. Nurses should be leading as well as participating in ongoing efforts to attain zero CAUTI. REFERENCES 1. Centers for Medicare and Medicaid Services. Hospital-acquired conditions (present on admission indicator). 2010. http://www.cms.gov/ HospitalAcqCond/06_Hospital-Acquired_Conditions.asp#TopOfPage. 2. Institute for Healthcare Improvement. Prevent catheter-associated urinary tract infections. 2009. http://www.ihi.org/ihi/programs/improvementmap/ PreventCatheterAssociatedUrinaryTractInfections.htm. 3. Leithauser D. Urinary tract infections. Association for Professionals in Infection Control and Epidemiology, Inc. 2005;25:1-15. 4. Reilly L, Sullivan P, Ninni S, Fochesto D, Williams K, Fetherman B. Reducing foley catheter device days in an intensive care unit: using the evidence to change practice. AACN Adv Crit Care. 2006;17(3):272-283. 5. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for prevention of catheter-associated urinary tract infections 2009. http://www. cdc.gov/hicpac/cauti/001_cauti.html. 6. Saint S. Clinical and economic consequences of nosocomial catheter-related bacteriuria. Am J Infect Control. 2000;28(1):68-75. 7. Karchmer TB, Giannetta ET, Muto CA, Strain BA, Farr BM. A randomized crossover study of silver-coated urinary catheters in hospitalized patients. Arch Intern Med. 2000;160(21):3294-3298. 8. Johnson JR, Kuskowski MA, Wilt TJ. Systematic review: antimicrobial urinary catheters to prevent catheter-associated urinary tract infection in hospitalized patients. Ann Intern Med. 2006;144(2):116-126. 9. Lee SJ, Kim SW, Cho YH, et al. A comparative multicentre study on the incidence of catheter-associated urinary tract infection between nitrofurazonecoated and silicone catheters. Int J Antimicrob Agents. 2004;24(suppl 1):S65-S69. 10. Parker D, Callan L, Harwood J, Thompson D, Wilde M, Gray M. Nursing interventions to reduce the risk of catheter-associated urinary tract infection. Part 1: Catheter selection. J Wound Ostomy Continence Nurs. 2009;36(1):23-34. 11. Donlan RM. Biofilms and device-associated infections. 2001. http://www.cdc. gov/ncidod/eid/vol7no2/donlan.htm. 12. Centers for Disease Control and Prevention. Catheter-associated urinary tract infection (CAUTI) event. 2009. http://www.cdc.gov/nhsn/pdfs/ pscmanual/7psccauticurrent.pdf. 13. Willson M, Wilde M, Webb ML, et al. Nursing interventions to reduce the risk of catheter-associated urinary tract infection: part 2: staff education, monitoring, and care techniques. J Wound Ostomy Continence Nurs. 2009;36(2):137-154. 14. Healthcare Infection Control Practices Advisory Committee (HICPAC). CAUTI guideline fast facts. 2010. http://www.cdc.gov/hicpac/cauti_fastfacts. html. 15. The Joint Commission. NPSG Chapter Outline and Overview: Hospital. 2010. http://www.jointcommission.org/nr/rdonlyres/cee2a577-bc61-4338-8780-43f132729610/0/npsgchapteroutline_final_hap_2010.pdf. 16. Blodgett TJ. Reminder systems to reduce the duration of indwelling urinary catheters: a narrative review. Urol Nurs. 2009;29(5):369-378. 17. Meddings J, Rogers MA, Macy M, Saint S. Systematic review and metaanalysis: reminder systems to reduce catheter-associated urinary tract infections and urinary catheter use in hospitalized patients. Clin Infect Dis. 2010;51(5):550-560. 18. Robb E, Jarman B, Suntharalingam G, Higgens C, Tennant R, Elcock K. Using care bundles to reduce in-hospital mortality: quantitative survey. BMJ. 2010;340:c1234. Cheryl Dumont is director of nursing research and vascular access team at Winchester Medical Center, Winchester, Va. Janine Wakeman is a staff nurse, medical/surgical intensive care unit at Winchester Medical Center. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NURSE.0000390665.67826.56 > < For more than 21 additional continuing education articles related to preventing hospital-associated conditions, go to Nursingcenter.com/CE. Earn CE credit online: Go to http://www.nursingcenter.com/ce/nursing and receive a certificate within minutes. INSTRUCTIONS Preventing catheter related UTIs: Survey report TEST INSTRUCTIONS To take the test online, go to our secure Web site at http://www.nursingcenter.com/ce/nursing. On the print form, record your answers in the test answer section of the CE enrollment form on page 32. Each question has only one correct answer. You may make copies of these forms. Complete the registration information and course evaluation. Mail the completed form and registration fee of $24.95 to: Lippincott Williams & Wilkins, CE Group, 2710 Yorktowne Blvd., Brick, NJ 08723. We will mail your certificate in 4 to 6 weeks. For faster service, include a fax number and we will fax your certificate within 2 business days of receiving your enrollment form. You will receive your CE certificate of earned contact hours and an answer key to review your results. There is no minimum passing grade. Registration deadline is December 31, 2012. DISCOUNTS and CUSTOMER SERVICE Send two or more tests in any nursing journal published by Lippincott Williams & Wilkins together by mail, and deduct $0.95 from the price of each test. We also offer CE accounts for hospitals and other healthcare facilities on nursingcenter. com. Call 1-800-787-8985 for details. PROVIDER ACCREDITATION Lippincott Williams & Wilkins, publisher of Nursing2010 journal, will award 2.8 contact hours for this continuing nursing education activity. Lippincott Williams & Wilkins is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. Lippincott Williams & Wilkins is also an approved provider of continuing nursing education by the District of Columbia and Florida #FBN2454. This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP 11749 for 2.8 contact hours. Your certificate is valid in all states. The ANCC s accreditation status of Lippincott Williams & Wilkins Department of Continuing Education refers only to its continuing nursing educational activities and does not imply Commission on Accreditation approval or endorsement of any commercial product. 30 l Nursing2010 l December www.nursing2010.com