Central line-associated bloodstream infections (CLABSIs), which are defined by the Centers for Disease Control and Prevention (CDC) as primary bloodstream infections that occur within 48 hours of central venous catheter insertion and cannot be attributed to another source, are well known to substantially increase morbidity, length of stay, and health care costs for hospitalized patients.1 Although initiatives undertaken throughout the United States reduced CLABSI incidence by 44% between 2008 and 2012, acute care hospitals reported 30,100 CLABSIs to the CDC's National Healthcare Safety Network in 2012.2 The mortality rate associated with CLABSIs is estimated to be between 12% and 25%,3 and a single CLABSI incident raises health care costs an additional $22,885 to $29,330.4
|Figure. A nurse demonstrates application of an alcohol cap to an unused central line port. Photos by Seth M. Reed.|
In March 2011, the CLABSI rate within the 30-bed acuity adaptable critical care unit (AACCU) at Geisinger Medical Center in Danville, Pennsylvania, which had remained at zero per 1,000 catheter days for five months, suddenly jumped to 3.97 per 1,000 catheter days. Geisinger Medical Center is a rural, level 1 trauma center with approximately 500 inpatient rooms. Geisinger's AACCU is unique in that it serves the hospital's cardiothoracic, vascular, and coronary intensive care patients, while absorbing overflow from the adult medical-surgical ICU. Because the clinical staff are prepared to care for patients at all levels of acuity, patients in the AACCU are able to stay in the same room throughout their hospital stay. At the time the CLABSI rate spiked, a single AACCU champion (that is, a staff RN who worked full-time on the unit and was an expert in central line research and practice guidelines) was assigned to oversee all central line-related interventions, ensuring that practice within the unit was consistent with the Geisinger system, in addition to working 36 to 40 patient care hours per week. If tasks related to central lines were not completed during patient care hours, the champion would be compensated for additional hours with prior approval from management. The single champion model had been in effect since March 2010, when the unit transitioned from a cardiac-cardiothoracic ICU to an AACCU. In March 2011, when the CLABSI rate suddenly increased, the unit's first champion was in the process of handing over responsibilities to a new champion.
The rise in the CLABSI rate prompted a reassessment of the role of the unit champion and the unit's central line care initiatives. The unit's clinical nurse specialist (CNS; one of us, AJB) and the new champion (one of us, SMR) suggested to the AACCU nurse manager that the daunting workload of a single champion working simultaneously as a full-time nurse may have contributed to the rise in the unit's CLABSI rate. Another probable factor, also associated with the unit's reliance on a single central line champion, came to light when the unit educator and management team reviewed past CLABSI rates and found that they increased when the champion role was transferred from one staff member to another, allowing for a discontinuity in central line practice. Typically, a single RN would hold the champion position for one to two years, but it could take several months for the new champion to become familiar with the role and competent in the position.
To identify practice deficiencies, in March 2011, the new unit champion and the CNS began collaborating with infection control practitioners, reviewing medical records and conducting observational rounds during which they collected central line care adherence data and taught staff best practices. Between March 2011 and March 2012, a total of 12 infections occurred, three in January alone, causing the unit's infection rate to remain elevated at 3.58 per 1,000 catheter days. Surprisingly, the review of medical records showed no specific trend in causative organisms or central line insertion technique, although there were inconsistencies in the documentation and timing of dressing changes. Direct observation by the champion and infection control staff confirmed that nursing staff demonstrated proper technique and competency in the process but also engaged in practices that may have contributed to the infection spike.
For example, unit nurses were inconsistent in applying aseptic technique prior to accessing central line ports. The standard of care was to scrub the hub for 15 seconds with an alcohol prep pad prior to making any connections, but observational rounds showed actual scrub times to be notably shorter. In addition, the staff did not consistently wash hands and change gloves before manipulating central lines, and some staff members wore nail polish or nail extensions, in violation of institution policy. Adherence data were not calculated for these deficiencies, but deviance in these areas of central line care was noted. The champion brought these findings to the attention of the unit's CNS and unit management to seek guidance on further action. Recognizing that the increase in the CLABSI rate was alarming and the single champion's tasks were overwhelming, the new champion and the CNS suggested to management that, rather than rely on a single champion, the unit develop a champion team program. The program's objective was to reduce the CLABSI rate and improve care in the AACCU by promoting and sustaining best practices in central line care through staff education, professional mentoring, and interdisciplinary collaboration. This article describes how the unit significantly reduced the CLABSI rate by implementing a central line champion team program and identifies the major components of such a program.
After considering the problems inherent in relying on a single champion to ensure best practices in central line care, the unit CNS and the central line champion conducted a literature review of evidence-based practice in central line care, reducing CLABSIs, and the use of champion teams to reinforce best practices in various contexts. The review revealed that champion teams (as opposed to single champions) have been used successfully in wound-ostomy care and have been highly effective in reducing hospital-acquired pressure ulcers.5-8 Although there are fewer published studies on the use of champion teams in central line care, studies have found the team approach beneficial in reducing CLABSIs.9-11 Based on these findings, in January 2012 the unit CNS and the central line champion drafted the framework for an AACCU-based central line champion team and presented it to unit management, who determined that a champion team would provide the best model for ensuring quality central line care and reducing CLABSIs in the AACCU. Because the AACCU allows patients to remain in the same room throughout their hospital stay, champion team members would be able to follow the progression of central line care and outcomes across a variety of patient populations with multiple levels of acuity and comorbidity.
In March 2012, a central line champion team, representing both day and night shifts, was recruited and assembled, with the current unit champion taking on the role of team leader and orienting the two new champion recruits. The champion team leader familiarized the other members with the champion role and how to intervene appropriately, while simultaneously acting as a resource for the team and all other unit staff. To reinforce collegiality between the champion team and staff, it was determined that the team leader and team members would always be RNs from the unit. An additional resource for the team was the AACCU CNS, whose research expertise was helpful in ascertaining the productivity and validity of champion team interventions. Acting as a mentor, the CNS met with the team to develop an initial action plan and assist in developing the program methodology and the roles of the team leader and members (see The Role of Central Line Champions).
|Figure. No caption available.|
Key intervention components. At the core of the champion team program was a champion-led rounding process with follow-up supplementation in a variety of media formats designed to provide staff and patient education, ensure adherence to standards of care, and thereby promote optimal central line care throughout the AACCU.
Planning educational topics. Each month, the champions met in four-hour blocks to develop a new educational topic to incorporate into champion-led bedside rounds over the course of the month. Initially, education focused on raising awareness of and ensuring adherence to central line bundle principles and enforcing use of a central line insertion checklist based on recommendations from the CDC and the Infusion Nurses Society (see Figure 1).1, 12 The central line bundle principles are well known as effective strategies for reducing central line infections, but maintaining best practices consistently within a health care system or nursing unit can pose a significant challenge. To remind nurses to use proper aseptic access technique, champions placed a "scrub the hub" sign around the clocks in all patient rooms, highlighting 15-second intervals, and hung signs in staff restrooms and on staff bulletin boards reinforcing the central line bundle principles. The practice of placing hand hygiene signs in the windows of all rooms occupied by patients with central lines had been initiated prior to the assembly of the central line champion team and was continued. These signs not only reminded nurses to wash their hands and don clean gloves before providing central line care, but also reinforced the practice of scrubbing the hub for 15 seconds.
|Figure 1. The central line insertion checklist used in the Geisinger Medical Center's acuity adaptable critical care unit. CHG = chlorhexidine gluconate; N/A = not applicable.|
During the monthly champion team meetings, members
|Figure. The champion team placed a "scrub the hub" sign around the clocks in all patient rooms to remind nurses to use proper aseptic access technique.|
* reviewed literature reflecting changes in guidelines and evidence, AACCU medical records, and data trending.
* collaborated with the unit CNS and infection control.
* planned for additional multidisciplinary central line meetings.
If extra time was required beyond the scheduled four hours, it would be granted at the discretion of the operations manager, who played a critical role in sustaining the project's progression and success.
Champion-led rounding. The three champions alternated in conducting rounds either once or twice weekly, depending on the complexity of the topic and time constraints on the rounding champion and unit staff. As the project moved forward, the educational emphases of the rounds was based on previous bedside observations, findings from medical record reviews, the implementation of new policy or practice guidelines, or concerns brought to the champion team by unit personnel.
During rounds, champions assessed the practices of nurses caring for patients who had a central line or whose central line had been removed within the past 48 hours. They tried to observe central line insertions, dressing changes, or other central line maintenance, subsequently providing nurses with constructive criticism or praise. If no central line care was being performed at the time, the champion assessed the central line site to ensure an intact dressing and proper selection of dressing type for the particular catheter. Assessments focused on the following parameters:
* central line dressings
* IV tubing and add-on devices
* central line sites
* practitioner enforcement of hand hygiene
* central line maintenance
* prompt removal of unnecessary lines and femoral access
Champions provided instruction on a one-to-one basis, away from the bedside, with nurses who were given an opportunity to receive feedback and ask questions.
During rounds, champions attempted to meet with each nurse working on the unit, including those not caring for a patient with a current or recently removed central line. Since this was not always possible, they maintained a logbook documenting which nurses received instruction on each topic. Any nurses who were missed during a scheduled round were targeted for future instruction. To supplement rounding instruction, the champions created handouts that highlighted the educational points of each round and showed current CLABSI rates. Handouts were placed in each nurse's mailbox for mandatory review and e-mailed to all unit staff. In time, the champions followed up with slide-show presentations and demonstration videos on topics that were incorporated into annual competency reviews, such as central venous pressure and arterial transduction, central line dressing changes, arterial line dressing changes, and proper asepsis for central line access.
Patient education. Champion-led rounds also incorporated patient education on the purpose of the champion team, general principles of central lines, how patients can protect their central lines, and why a central line is preferable over peripheral IV access. Patients were instructed to protect their central line sites from contamination by
* preventing anyone other than authorized care providers from manipulating the devices.
* avoiding exposing the site to dirty surfaces, saliva, or food.
* ensuring that all caregivers wash their hands and don clean gloves before manipulating the central line.
* notifying staff members immediately if the dressing appeared to be loose or if they had any discomfort or noticed any drainage at the site.
The champion team member could maintain a therapeutic patient interaction, answering questions from the patient and family, while assessing central lines and associated equipment. Each patient assessment lasted about five minutes, as did each interaction with a patient's RN. If each nurse cared for two patients with central lines, a rounding session could last up to 15 minutes, and weekly rounds took about two hours to complete.
Data collection. Champions used forms developed and managed by the CNS to collect data during rounds. The forms allowed champions to record staff adherence to central line care guidelines as well as the number of nurse and patient interactions observed during rounding and any perceived barriers to interaction or situations that facilitated interaction-information that was used to identify areas of possible improvement in the rounding process. Trends in subpar care practices were used to direct future literature reviews and guide education plans for the following month. If a problem, such as improper technique or nonadherence to hand hygiene protocol, was specific to a particular staff member, the staff member was consulted and instructed in correcting the problem. Adherence data were used as a means of assessing progress on a month-to-month basis.
Interdisciplinary collaboration was essential to achieving success. Many people outside the AACCU have a significant effect on central line care, and related policies were under review. Many of the central lines cared for in the AACCU are initially inserted by anesthesia staff in the operating room, for example, including nearly all catheters placed during open-heart surgery. Instead, pulmonary artery catheters could be inserted by cardiology, cardiothoracic surgery, or critical care medicine personnel at the bedside. The team leader thus served a pivotal role in introducing new champions to the director of nursing for critical care; the critical care medical director; the director of IV therapy; central line representatives on other units; and key personnel in anesthesia, cardiothoracic surgery, cardiology, and critical care medicine.
To foster communication and teamwork across these various disciplines, one or two champions attended monthly, system-wide, central line committee meetings, which provided an opportunity to share beneficial findings that would ultimately produce standardized practice based on current evidence. The director of nursing for critical care, together with the critical care medical director and the director of infection control, presided over the meetings, and IV therapy staff assumed responsibility for drafting policy. In July 2012, the committee released a new central line policy, reflecting the collective needs of the health care system, including
* an emphasis on the practice of drawing blood from a closed system, using central lines only in the absence of arterial or peripheral venous access.
* standardization of central line insertion carts.
* improved dressing-change kits.
* use of alcohol caps for unused central line ports.
* use of chlorhexidine-impregnated dressings.
* other equipment updates.
The new policy empowered nurses to enforce use of the AACCU's central line insertion checklist and to stop any procedure that deviated from protocol. The champion team served as the primary liaison between the central line community, AACCU staff, and AACCU management.
To address concerns related specifically to central lines in patients undergoing cardiothoracic surgery, every two months the champions met with the system's director of anesthesia, the unit's operations manager and chief cardiothoracic nurse anesthetist, as well as with a cardiothoracic surgery team member and a clinical nurse educator (CNE). The champion team leader developed the meeting agenda and presided over this meeting with input from all involved. Any interest in new products or concerns regarding current interventions communicated in the meeting was conveyed by the champion team to the system-wide committee or other proper authority. Likewise, the champions briefed members of this unit meeting on pertinent discussions within the system-wide meeting. From time to time, product representatives were invited to unit meetings for product demonstrations and education; if there was interest in a product, communication between the champion and representative would continue, with the approval of management.
Staff orientation. To orient all unit staff to the changes in equipment and procedures as part of the new policy, the champions enlisted the help of the AACCU's CNEs and career enhancement program RNs. Combining expertise in clinical education, familiarity with current research, and institutional policy on central line care, the three groups worked together to distribute central line policy education materials and track the progress of their delivery.
Ethical considerations in planning this quality improvement initiative focused primarily on maintaining confidentiality (patient and provider) and avoiding disruption of patient care during bedside rounds. To evaluate the effectiveness of interventions, it was necessary to obtain potentially identifiable patient information, but this information was provided on a strict need-to-know basis. Only the medical records of patients with central line infections were reviewed, with deidentified data subsequently analyzed by the newly appointed champion team members and infection control personnel. All involved in the review process were mindful of the need to maintain confidentiality, and any discussion of medical records occurred only in appropriate meetings. The same consideration was given to unit staff when evaluations revealed practice deficiencies. Corrective instruction was provided in a confidential manner and involved only the new champion team members and the specific staff member whose practice was deficient, unless special circumstances, such as gross negligence, warranted the inclusion of unit management.
To avoid disrupting patient care, champions conducting bedside rounds interacted with a patient only after obtaining the approval of the patient's nurse and never while the nurse was providing care. All staff members were given printed information on the purpose of the champion teams and the champion-led rounds before the rounding program was initiated, and were informed of scheduled rounds by e-mail. Patients were informed of the champion team's intentions and of their right to refuse team member presence at any time.
Evaluating outcomes. The unit's CLABSI rate was used as the primary measure of outcomes and program success. In addition, direct observation of practice, interactive educational sessions with staff members, and medical record reviews continued throughout program implementation to identify positive and negative aspects of the program and central line care on the unit.
Prior to March 2011, any positive blood culture triggered a review of the patient's medical record by an infection control practitioner, who identified CLABSIs based on CDC criteria. Nonidentifying information, including system-wide CLABSI rates and central line days, were made available in the form of tables and graphs to all staff throughout the health care system. During the AACCU review period, from March 2011 to March 2012, confidential patient information related to individual infections was accessible only to the reviewing team, which consisted of infection control, the CNS, and the single unit champion. Once the champion team program was established in March 2012, this information was accessible to the whole team, who would review the patient's medical record for possible contributing factors, using a standardized chart review form provided by the infection control department. Findings were further reviewed by infection control practitioners and used to reevaluate champion team interventions and educational topics.
The quantitative outcome measure used to evaluate the champion team program was the CLABSI rate in the AACCU. After the sudden CLABSI spike in March 2011, the rate over the following 13 months averaged 3.58 per 1,000 catheter days. (Monthly rates ranged from zero to over 10 per 1,000 catheter days.) With the assembly of the champion team in early March 2012, education and rounding began immediately. In the 25 consecutive months spanning April 2012 through April 2014 (5,959 catheter days), two CLABSIs occurred on the unit-one in August 2012 and one in July 2013, representing 23 months with no CLABSIs and an overall rate of 0.34 per 1,000 catheter days (see Figure 2). The first of the two CLABSIs occurred in a patient with eight separate central lines placed during hospitalization and was noted 30 days after admission and initial line placement. No failure in adherence could be attributed to this infection, which was associated with comorbid conditions and the patient's immunocompromised state. The second CLABSI occurred in a patient admitted for emergent repair of a type A aortic dissection in whom a triple-lumen central venous catheter was placed intraoperatively. Owing to extreme diaphoresis in the postoperative period, the patient required multiple dressing changes, which may have contributed to the development of the CLABSI.
|Figure 2. The rates of central line-associated bloodstream infections (CLABSIs) in the acuity adaptable critical care unit at Geisinger Medical Center from February 2011 through April 2014. Following the March 2012 start of the central line champion team, the overall CLABSI rate decreased from 3.58 per 1,000 catheter days over the previous 13 months to 0.34 per 1,000 catheter days over the following 25 months.|
In addition to substantially reducing the unit's CLABSI rate, the central line champion program has proven invaluable in educating staff and maintaining competency when equipment, policy, or procedures change. The champions serve as the primary communicators between product representatives and staff, make informed recommendations to management concerning additions to unit or institutional inventory, and are easily accessible, in person or by e-mail, when concerns arise about central lines or related equipment.
Limitations include budgetary constraints, which may make it difficult to gain managerial support and implement the program-despite anticipated cost savings based on expected CLABSI reduction. The meetings and group work represent additional paid hours and may occasionally take champions away from patient care during their normally scheduled hours. In addition to their patient care pay, champions must be compensated for attending monthly four-hour team meetings, representing 12 paid hours for a three-member team; monthly hour-long, system-wide interdisciplinary meetings, representing one to two paid hours for the one or two champions who attend; and hour-long unit interdisciplinary meetings held every two months to address cardiothoracic surgery concerns, representing zero to two paid hours in a given month for the one or two champions who attend. Champion-led rounds represent an additional eight to 16 paid hours per month. The total monthly hours of a three-member champion team could range from 21 to 32 hours of regular or overtime pay for a full-time staff RN, depending on how the champions' time is factored into patient care hours in addition to their champion responsibilities. These figures may seem alarming, but maintaining a CLABSI rate of zero for a substantial period of time significantly reduces cost, as well as patient morbidity and mortality. The cost of implementing a champion team program seems reasonable, then, given that CLABSIs are estimated to raise health care costs by $22,885 to $29,330 per incident4 and are associated with a mortality rate of 12% to 25%.3
There are also limitations associated with the champion-led rounding process, as finding the time to receive one-on-one instruction from a champion can be difficult for nurses working on a busy unit. Although our champions found that nurses were frequently unable to participate in a scheduled champion-led rounding session, they were usually able to participate at a later point during the round and could be reminded to check the educational materials provided by both mail and e-mail. Likewise, it was necessary for the champions to be very efficient to complete unit rounding within two hours. During rounds, champions thus encouraged the sharing of knowledge between staff members who received direct instruction and those who did not. Similar efficiency was required during team and interdisciplinary meetings in order for all to receive the greatest benefit in the time allotted.
The ultimate benefit of instituting a central line champion team in the AACCU was the reduction seen in the CLABSI rate. The team approach, however, has also optimized the identification of problems through observation and medical record review, allowing champions to provide positive feedback while addressing educational needs and nonadherence in real time through champion-led rounds, and has improved interdisciplinary collaboration and standardization of care in the AACCU. The approach has fostered a sense of teamwork among unit staff and management, with staff encouraging each other to promote best practices and putting a greater emphasis on central line care during orientation.
The CNS continues to mentor the champion team and provide guidance to new champions. Since the team program was initiated in March 2012, champion team leaders have tended to remain in the role for one year, although no set limit has been established. In May 2013, when the 2012 champion team leader moved on to graduate school, he promoted a new leader from within his team (one of us, TJA) and recruited a new member to maintain the core number of three. Interventions continue to focus on consistency with national standards and maintaining zero central line infections. Interdisciplinary collaboration has been preserved, and best practice initiatives remain up to date through team meetings and literature reviews. Staff education and competency is continually evaluated and tailored appropriately in response to trending problems reported on rounding forms, staff response to interventions, and outcomes reflected by CLABSI data. Central line champion teams similar to the one described here may help other hospital units reduce CLABSI rates by promoting best practices, staff competency, team mentoring, and cultural change.