BLOODSTREAM INFECTIONS are a major cause of morbidity and increased mortality in health care and are also attributed to an increased length of stay and escalating costs.1,2 Central line use is a major risk factor for bloodstream infections.1,3,4 More than 250 000 cases of hospital-acquired bloodstream infections associated with central lines occur annually within the United States, with only a reported 80 000 cases occurring in the intensive care unit (ICU) setting alone.5 This estimate highlights the fact that most bloodstream infections (BSI) occur in patients who are in units other than ICUs.2,4,6,7 An intervention that has recently garnered attention in decreasing bloodstream infections is the topical use of the antiseptic chlorhexidine gluconate (CHG) as a means to decrease the bacterial load on the skin of patients with central venous catheters or central lines. Many studies have analyzed its efficacy in the intensive care population; support for its use in the non-ICU population is increasing.8 The purposes of this quality improvement (QI) project were to implement daily chlorhexidine bathing in all adult medical-surgical units and evaluate the effectiveness of this practice change in reducing central line-associated bloodstream infections (CLABSI).
BACKGROUND
The associated costs of CLABSI were $33 000 to $75 000 per case in adult ICUs in 2009.4 This does not include the reduction in reimbursement of approximately $26 000.4 Extensive research has been conducted primarily in ICUs to identify the associated causes of CLABSI. One cause is the patient's own skin flora contaminating the catheter during insertion and migrating to the catheter tip.9,10 Colonization with multidrug resistant bacteria also increases the risk of infection of hospitalized patients.11 The Centers for Disease Control and Prevention (CDC), Society for Healthcare Epidemiology of America, and Infectious Disease Society of America have compiled evidence-based strategies to assist providers with implementation and prioritization of CLABSI prevention efforts. Strategies such as appropriate site selection, hand hygiene, maximum barrier precautions, insertion checklists, skin antisepsis, assessment of line necessity, staff education and training, and a line maintenance bundle (a group of interventions aimed at the safe handling and maintenance of central lines) are considered the gold standard in infection control and prevention.5,12,13 High infection rates across the country, however, demonstrate a need for a renewed focus on infection prevention.14 The focus of CLABSI prevention has now shifted to the use of supplemental interventions such as chlorhexidine bathing, antimicrobial-impregnated catheters, and chlorhexidine impregnated dressings, independent interventions that have shown promise in infection control and prevention.5,12,13
Chlorhexidine gluconate is a topical antiseptic widely used for both infection control and prevention. It is effective against a wide range of gram-positive and gram-negative bacteria, yeast, and molds. It acts by disrupting cytoplasmic membranes and remains active for hours after application.15 Studies have used preparations of both 2% to 4% CHG and 2% CHG impregnated cloths to decrease skin flora and prevent BSIs in patients with central lines in ICUs.3 Several studies have identified a reduction in CLABSI ranging from 32% to 87% with little to no adverse patient reactions.16-25 The use of 2% CHG bathing is supported by the CDC as a category II recommendation, suggested for implementation and supported by clinical or epidemiological studies or a theoretical rationale.5,26 Some experts believe efforts directed at postinsertion catheter use and care may have a greater impact outside the ICU-a setting where patients have more exposure to unjustified catheter days and less stringent maintenance of insertion-site dressing.27 As mounting evidence supports the use of CHG baths in patients with central venous catheters, an opportunity to further decrease BSI rates exists in the non-ICU population.2,4,6,7
METHODS
The prevention of CLABSI became a top priority for our facility in early 2011. After identifying an increased facility infection rate above the national average, a task force was formed to develop a plan to reduce CLABSI rates.28 The task force consisted of the chief nurse officer, nursing directors, nursing unit managers, infection control nurses, and bedside nurses. The unit managers selected bedside nurses who were highly engaged in process improvement and were members of the unit or hospital-based shared governance committee or had cared for a patient who developed a BSI. The task force used the Plan, Do, Check, Act model.29 The goal of the task force was to evaluate the facility's infection control and bloodstream infection prevention practices, compare practice to current CDC guidelines, develop changes in practice according to evidence-based practice, and formulate a plan for continuous improvement. Table 1 presents the specific steps of the process.
The facility has 946 licensed beds, 4 ICUs, and 8 medical-surgical units. There are 1091 nurses employed in the facility. Thirty-four nurses have obtained diploma education, 473 associate, 549 bachelor's, 32 master's, 2 doctorate in nursing practice, and 1 doctor of philosophy degrees. In addition, 253 have specialty certification. In 2012, the 8 medical-surgical units had 15 492 (counted as the number of patients with 1 or more central lines) while the 4 ICUs had 15 042 central line days. The number of CLABSI in the medical-surgical units during this time period was 20 (rate = 1.29), compared with 19 in the ICUs (rate = 1.26). National CLABSI median rates (per 1000 patients) for medical-surgical units range between 0.0 and 0.3 and between 0.0 and 2.8 in ICUs.30
CHANGE IN PRACTICE
First steps
The task force conducted a thorough review of the current CDC central line insertion and maintenance guidelines and compared them to facility practices.5 Several deficiencies were identified. First, the facility had implemented paper insertion checklists prior to this project, but the task force found the checklists were not used during emergent insertions, were incomplete, or not filed in the medical record. In addition, the current practice of line maintenance bundling, a term used to describe the care provided to a central line following insertion, was not a part of the medical record. Since transitioning to the electronic medical record 2 years earlier, documentation of compliance with central line site maintenance lacked consistency. The current process of using visual reminders, labeling the dressing or placing a sticker with the change date on the administration tubing, was inconsistent, and the electronic medical record lacked triggers to remind nurses of required dressing changes or tubing changes, increasing the risk of infection.
Another identified issue was not having a standardized central line insertion cart with all the necessary supplies. The task force learned that the medical-surgical units did not stock central line insertion supplies due to cost constraints. However, waiting for the supplies was time consuming; it delayed treatment and increased the risk of infection if clinicians did not use the recommended protective equipment. A central line insertion cart would address these issues. Compliance with hand hygiene was also an ongoing concern at the facility. Surveillance identified a compliance rate of only 68% when all units and disciplines were included. This was surprising as hand sanitizer holders were situated in highly visible and accessible places within patient care areas, and hand hygiene was part of the new employee orientation as well as a component of the yearly online educational requirement of all clinical employees.
The task force's review revealed 5 concerns: (1) there was inconsistent use of the central line preinsertion checklist, particularly when placement was emergent; (2) central line bundling was not part of the electronic medical record so there were no triggers to remind nurses of upcoming required tasks; (3) central line maintenance was documented inconsistently; (4) there was lack of access to a standardized central line insertion cart with all the necessary supplies; and (5) compliance with hand hygiene was an issue. Through the work of the task force, both insertion checklists and line maintenance bundle triggers were added to the electronic medical record within a month, allowing the nurses to receive reminders for upcoming tasks and to aid in tracking compliance.
To address the lack of available supplies, central line insertion carts were assembled and stationed in each of the 3 nursing towers within the facility. Each cart was stocked with all the equipment needed to insert central lines according to practice guidelines. A process was instituted for restocking the cart after catheter insertion, enabling the proper expensing of the procedure and replacement of the cart to the respective unit housing the cart. With the assistance of the marketing department, the facility printed informational brochures reinforcing the importance of hand washing. The brochures were provided to all patients who were admitted to the facility in an effort to educate and increase health care provider compliance with the infection prevention process.
Once these interventions were in place, a root-cause analysis was performed on any infection identified. As infections were identified, cases were reviewed by the task force and the involved staff caring for the patient on a weekly basis. Each analysis evaluated the compliance with prescribed interventions and identified care practices requiring improvement in a blame-free environment.
Next steps
Six months after these interventions were in place, a review of literature identified the use of CHG bathing as a supplemental strategy for the prevention of CLABSI. The strategy was brought to the task force for review, and it was decided the intervention would be trialed in 1 of the 3 adult ICUs. Following a 3-month trial of using a prepackaged 2% CHG bathing product, the practice was implemented in all adult ICUs. Twelve months before the initial trial, the Cardiac ICU had 2.6 infections per 1000 patient days. During the trial, their rate was 0.33 infections per 1000 patient days. The Medical ICU had a rate of 0.75 infections per 1000 patient days prior to the trial, which decreased to 0.33 infections during the trial. The Surgical ICU had a rate of 0.83 infections per 1000 patient days (nontrauma population) prior to the trial and 0.33 infections during the trial. The addition of CHG baths necessitated a change in the facility central line policy. The policy was updated to include the bathing protocol in the adult ICUs. During the same time period, the use of CHG impregnated catheter caps was also introduced in the ICUs.
Shortly thereafter, the focus of the task force turned to the medical-surgical nursing units. Only 4 of those units had an infection rate below the national benchmark during 2011.30 On the basis of the lower cost of the CHG bathing product compared to the CHG impregnated caps, ease of use, and the potential for a large impact on infection rates, the task force decided to forgo implementing the CHG impregnated caps and that the next step needed to be implementation of the CHG bathing process in the medical-surgical units.
CHG bathing process
The daily CHG bathing process was introduced in all of the medical-surgical units for patients who had a central line. The facility chose to use prepackaged wipes that were impregnated with a 2% CHG solution at a cost of $5.77 for each package. As this was something most patients would have been unfamiliar with, nursing staff were coached on how to explain the new procedure to patients and their families. To maximize the effectiveness of CHG bathing and to ensure consistency between staff, step-by-step instructions of the bathing procedure were taught in the mandatory staff inservice programs and provided on a laminated card that they could refer to during the bath. The inservices were attended by all registered nurses and nurses' aides. Steps included using soap/shampoo and water to clean the face, hair, and genital area rather than the CHG wipes and then to cleanse the patient's body from jaw line to feet. One cloth was to be used for each of the 6 body areas: neck, shoulder, and chest; upper extremities; abdomen; right lower extremity; left lower extremity; and back and buttocks. Skin was not to be rinsed and needed to air dry completely.
Although implementing the CHG baths was the primary intervention, simultaneous support strategies were implemented to maximize quality outcomes. Those 4 strategies included staff education, making sure there was strong leadership support, ensuring availability of resources, and increasing staff awareness and accountability.
Support strategies
Prior to implementing CHG bathing in the medical-surgical units, comprehensive education was provided to all nursing staff. One-hour education sessions were held on each unit for each shift and consisted of a review of the product, the rationale underlying the practice, an explanation and demonstration of the technique, and a competency examination. This content was also integrated into new employee orientation sessions and was added as a component of the yearly skills competency check-off. The task force identified the need for strong leadership support to solidify the QI process. In the past, staff did not receive feedback when patients developed infections on their respective nursing units. Unit leaders would be required to share the process improvement results with their staff, and quality measures such as CLABSI rates would become a part of annual evaluations of all nursing leadership, from the nursing unit manager to the chief nurse officer.
Implementing CHG bathing would require additional supplies for each unit. The units' operational budgets were adjusted to accommodate the increased cost of stocking CHG wipes, and units with higher insertion rates were provided with additional central line insertion carts. To increase staff awareness and accountability of their role in prevention of BSI, direct care nursing staff would be included in root cause analysis investigations. Beyond increasing each participating nurse's awareness of the specific CLABSI occurrence, "lessons learned" could be taken back to the individual units as another means to educate and engage staff in the QI project.
In addition, "visibility walls" have been placed in public areas on individual nursing units as a method to increase staff and public awareness of nursing sensitive indicators and support the culture of transparency. Each unit places its unit-specific results for quality initiatives such as falls, pressure ulcers, patient experience, catheter-associated urinary tract infections, and CLABSI on the wall. National benchmarks and unit results are displayed in easy-to-read graphs. Early evaluation of this strategy has revealed that the visibility wall has become a source of pride for staff and that they have developed a growing awareness and accountability for their role in improving outcomes. Ongoing compliance efforts include daily review of the medical records and auditing for documentation of chlorhexidine bathing and central line care.
RESULTS
Eight months into this project, formal tracking of the standardized infection ratio for each medical-surgical unit continues to be monitored. Earlier interventions such as staff education (use of preinsertion checklists, charting line maintenance, and hand hygiene); electronic medical record triggers; and central line insertion supply carts remain in place. Ongoing medical record audits assure CHG bathing compliance. Since implementing CHG baths, a downward trend in the overall number of central line infections in the medical-surgical units has been observed. Over this 8-month period, 8 CLABSIs have been recorded (a rate of 0.52 infections per 1000 patient days), compared to a total of 17 (a rate of 1.46 infections per 1000 patient days) over the previous 12 months. Table 2 presents CLABSI rates for the pre- and post-CHG implementation for the 8 medical surgical units participating in the process improvement project.
DISCUSSION
Throughout the implementation project, the task force has continued to review each case of central line infection and identified areas for continued improvement. Issues identified with recent infections include inconsistencies in line maintenance practices, inadequate hand hygiene, and variability of unit auditing practices. A standardized process by which each unit audits compliance of the central line maintenance and bathing practices is currently being developed and will be included in the facility central line policy. A renewed and vigilant focus on hand hygiene has also been identified as a priority.
Results from this QI project suggest that the implementation of CHG baths for non-ICU patients with central lines is an effective practice change. The occurrences of CLABSI in these units decreased more than 50% over the previous year. This experience demonstrates the value of using a QI process that identifies problems, aids in developing a comprehensive plan that includes all major stakeholders, and builds a process for ongoing evaluation with a means for disseminating the results to staff, patients, and facility visitors.
The multidisciplinary task force used a comprehensive review process to identify issues that may have contributed to the high CLABSI rates and worked to address those issues prior to introducing CHG baths on the medical-surgical units. This first step helped build a comprehensive system that would augment the introduction of CHG baths. Supporting strategies included staff education, garnering strong leadership support in implementing the bathing process, and providing continuous feedback of the results to staff. In addition, addressing the need for supplies for not only the baths but also for central line insertions led to the resolution of a longstanding barrier to consistent utilization of preinsertion checklists. The addition of specific triggers and documentation of line maintenance tasks to the electronic medical record improved the completeness and consistency of nursing documentation.
The goal of preventing CLABSI has challenged health care providers to develop innovative and comprehensive evidence-based practices. With this goal in mind, the facility accepted the challenge and identified a need in a susceptible population. Facilities need to systematically evaluate their care practices and ensure that high standards are being achieved regardless of the patient's location in the facility. The process described in this article can be useful to others in undertaking similar QI projects at their facilities where adverse outcomes call attention to a need for change, but no direct and standardized application process exists.
REFERENCES