Authors

  1. Pate, Kimberly DNP, RN, ACCNS-AG, PCCN-K
  2. Brelewski, Kiersten MSN, RN, AGCNS-BC, OCN
  3. Rutledge, Sarah R. MSN, RN, ACCNS-AG, CCRN, OCN
  4. Rankin, Veronica DNP, RN-BC, NP-C, CNL, NE-BC
  5. Layell, Jessica BSN, RN, CIC

Abstract

Background: Central line-associated bloodstream infections (CLABSIs) are an ongoing concern in health care, resulting in increased mortality, morbidity, length of stay, and additional costs to hospitals.

 

Local Problem: Despite intermittent improvements in CLABSI rates within our facility, long-term sustainment has been challenging.

 

Methods: This was a quality improvement project including a collaborative rounding approach supported by specialty nursing roles.

 

Interventions: In addition to implementing a variety of evidence-based interventions, the rounding team performed audits to assess performance and created focused education tools to address the identified opportunities within each individual unit.

 

Results: High levels of engagement as evidenced by increased audit completion resulted in CLABSI reductions. However, 2 peaks in CLABSI rates were associated with higher volumes of coronavirus disease (COVID-19) hospitalizations and decreased audits.

 

Conclusions: Despite challenges correlated with COVID-19, a collaborative rounding team promotes and enhances awareness of prevention methods and a culture of safety.

 

Article Content

The Centers for Disease Control and Prevention estimates that 5% of all hospital admissions result in a health care-associated infection. This results in approximately 722 000 infections, 75 000 deaths, and $28 billion to $33 billion in additional costs each year.1 The direct expenditure related to hospital-associated infections in North Carolina is estimated at $124 million to $348 million each year.1 As a common hospital-associated infections, central line-associated bloodstream infections (CLABSIs) occur when a vascular access device or line is placed in a large vein resulting in a pathway for organisms to enter the body either when placed or through inappropriate maintenance.

 

CLABSI data are submitted to the National Healthcare Safety Network (NHSN) to compute the standardized infection ratio (SIR), which compares the observed number of infections in the hospital with the predicted number of infections. The predicted number is an estimate based on comparative national data and considers certain risk factors such as hospital affiliation, size, and patient population. If the SIR is less than 1, the number of observed infections is less than the number of predicted infections. The national SIR for CLABSIs in 2019 was 0.69 for general acute care hospitals, with North Carolina exceeding this benchmark at an SIR of 0.922 and the target facility for this project at 0.92 as well.

 

CLABSIs result in increased mortality, morbidity, length of stay, and additional costs to hospitals.3 Of the 250 000 CLABSIs estimated in US hospitals, only about 80 000 occur in critical care units. Thus, increased infections occurring in non-critical care units may be associated with patients having central lines in place for extended periods of time. The assumption of infections occurring in established central lines supports the use of interventions to improve central line use and maintenance for infection prevention.4

 

AVAILABLE KNOWLEDGE

CLABSI prevention requires implementation of multifaceted programs, which are inclusive of performance assessment, education to impact the behavior of health care professionals, constructive feedback, and teamwork.3 Evidence-based practices often included in prevention bundles are disinfection of hubs (or the end of the central line that connects to the intravenous tubing), needleless connectors, and injection ports of the intravenous tubing before catheter access; changing transparent dressings routinely as well as when soiled, loose, or damp; and education of health care professionals.4 Many articles demonstrate a significant association between central line bundle compliance and decreased incidence of CLABSIs in critical care and non-critical care patients including neonates, children, and adults.3,5-8 O'Neil and colleagues4 demonstrated that CLABSI bundle implementation was associated with improvement in catheter dressing compliance but did not demonstrate a statistically significant decrease in CLABSI incidence. Successful, sustained CLABSI prevention programs had strong leadership support and ongoing monitoring. Despite evidence of success with CLABSI prevention bundles with leadership support, compliance with guidelines has been identified as a universal problem in health care.3 Noncompliance has been linked to increased acuity of patients, the onboarding of new staff, and complacency over time.9

 

Researchers have shown that CLABSI bundle compliance is sustained by auditing and rounding processes. Auditing may occur in a variety of formats including peer-to-peer, collaborative processes with infection preventionists and other members of the interdisciplinary team, and incorporation with leader rounding.9-18 A quality improvement (QI) project implementing a collaborative, systematic approach to proper line maintenance was found to be effective in reducing CLABSI rates, with rates reduced from 3.9 per 1000 days in 2011 to 0.3 per 1000 patient-days in 2014 in a neonatal intensive care unit.18 Kamishibai cards are a performance improvement strategy that provides real-time compliance data and correction of bundle elements that have not been completed. This strategy has been demonstrated as a practical auditing tool to sustain evidence-based practices to reduce health care-associated infections and to promote communication between leadership and staff. By implementing Kamishibai cards in a standardized auditing process, Shea and colleagues13 demonstrated a decrease in CLABSI rates from 1.83 in 2015 to 0.0 in 2018. Monitored bundle adherence with compliance of 95% or more in the critical care units was associated with significantly lower CLABSI rates.12 Despite this evidence, pediatric researchers found that only 35% of critical care units achieved greater than 95% adherence with insertion and maintenance bundles over a 2-year period.19

 

Layne and Anderson15 demonstrated that collaboration between clinical leaders, quality and infection control leaders, and direct care staff is essential to initiate and sustain outcomes with a successful CLABSI prevention initiative. The initiatives in the articles reviewed were supported by a variety of staff members including direct care nurses, nursing leaders, and physicians.4,9-11,14,15,17,18 Utilization of a consistent team15,17,18 and education to ensure standardization of the review of the central lines by the auditing teams contributed to successful CLABSI prevention interventions.4,9,10,11,14 To our knowledge, a collaborative initiative involving the clinical nurse specialist (CNS) and clinical nurse leader (CNL) roles to prevent CLABSIs has not been explored.

 

SPECIFIC AIMS

The purpose of this QI initiative was to implement an innovative CLABSI rounding team supported by the master's prepared nursing roles of CNS and CNL and infection preventionists. Through combined expertise and focus on central lines, a standardized assessment of clinical practice related to central line maintenance was performed, and identified deficiencies were then addressed with targeted interventions.

 

METHODS

Setting

After obtaining support and buy-in from facility leaders including the chief nurse executive, service line Assistant Vice Presidents, and unit nurse managers, the QI initiative was implemented in an 874-bed, level 1 trauma and academic medical center in Charlotte, North Carolina. A team of master's prepared nurses including 3 CNSs, 1 CNL, and an infection preventionist was assembled as leaders of the core team. A convenience sample of patients with central lines on non-critical care units was used.

 

Theoretical framework

Lewin's20 Theory of Planned Changed was used as the theoretical framework for this QI project. By identifying both driving and restraining forces, it is possible to understand why individuals and the organization behave as they do in addition to what forces would need to be weakened or strengthened to produce change. Essentially, the theory consists of 3 phases: unfreezing (problem is identified, causes are determined, and resources are mobilized); change (developing a plan of action, soliciting buy-in from key stakeholders, and implementing targeted interventions); and refreezing (sustaining change and building it into the organizational culture).20

 

Intervention

This project was submitted for ethical approval at the project facility, and approval to proceed as QI was obtained. The core team used evidence-based literature, common deficiencies from Infection Prevention audits, and feedback from bedside nurses engaged in CLABSI work to build an audit tool. By optimizing technology, the tool was built in the Microsoft Forms platform, which can be accessed from any browser on any device. Strengths of using this format include protection against unintentional deletion or altering of collected information when being accessed by multiple individuals and flexibility in how audits were performed such as use of a cell phone or tablet instead of the traditional paper tool.

 

Audit components were built to capture areas of opportunity rather than simple compliance. For example, the integrity of the central line was not answered as simply compliant or noncompliant; instead, the options in the audit tool assess if the dressing was clean, dry, and intact as well as appropriately labeled. The audit tool consisted of 10 components including type of line, antimicrobial disk compliance, cleanliness of needleless connectors, presence of alcohol caps, compliance with labeling of tubing, presence of sluggish or clotted lines, completion of a daily chlorhexidine bath, and appropriate assessment of central line necessity. In addition, names of the nurses, nursing assistants, and attending providers were collected to allow for identifying trends, ensuring accountability, and identifying individuals who would benefit from targeted education.

 

Auditing was implemented initially in select surgical and oncology units in June 2020 to allow the core team to pilot the tool. Audits then quickly expanded throughout all non-critical care units in the facility with the recruitment of additional master's prepared nurses to create the CLABSI rounding team (see Supplemental Digital Content, Table 1, available at: http://links.lww.com/JNCQ/A949). Exclusions were the critical care and maternity units, as they had identified CLABSI prevention processes in place. Performing audits within routine work areas allowed the CLABSI rounding team to provide real-time feedback and coaching to nurses, nursing assistants, and patients. Identifying trends was also made easier with the creation of an electronic dashboard in Microsoft Power BI, which provided a centralized place to store data. Audit results entered into the Microsoft Form were automatically transferred over and backed up twice daily, allowing additional data security. An added benefit was the ease of access for all staff members from bedside nurses to senior leadership. The dashboard also allowed for sorting of data by unit, service line, and specific time periods; furthermore, data were presented in a variety of visual aids.

 

Using a Plan-Do-Study-Act model, the rounding team met biweekly to review CLABSI events, evaluate the monthly SIR, and report on the trends identified during audits, which prompted discussion and further action planning. Action planning included targeted staff and patient education to address identified trends (see Supplemental Digital Content, Table 2, available at: http://links.lww.com/JNCQ/A950). For example, 2 trends were patient refusal of chlorhexidine baths and performing only partial treatments when self-performed. In collaboration with the facility health literacy committee, members of the rounding team developed an educational flyer outlining the importance and correct process for a head-to-toe chlorhexidine treatment.

 

All supporting tools for this project, especially those to address identified trends, were stored on a facility intranet webpage in a CLABSI-reduction tool kit. Supporting documents were saved in an editable format, allowing members of the rounding team to easily modify them to meet individual unit needs. The webpage served the additional purpose of providing direct links to both annual infection data and the CLABSI dashboard. The rounding team routinely updated nurse managers and senior leaders on progress and trends, especially when specific individuals were identified as needing formal accountability.

 

Measures

To evaluate the impact of the CLABSI rounding team and the interventions implemented on the basis of the identified deficiencies, the overall non-critical care and individual unit SIRs were monitored monthly. In addition, all individual CLABSI events were reviewed. Rounding team engagement also was assessed through completion of audits, with consideration given to the utilization rates of central lines and the number of available resources for auditing within each service line.

 

RESULTS

The CLABSI rounding process officially began in June 2020, with an SIR of 2.747 in the previous month of May 2020. As the CLABSI rounding process continued with a systematic progression to spread throughout the non-critical care units, the CLABSI SIR consistently remained below this rate. The SIRs for the remainder of 2020 were 0 in June, 0 in July, 1.844 in August, 0.424 in September, 1.873 in October, 1.18 in November, and 1.132 in December (see Supplemental Digital Content, Figure, available at: http://links.lww.com/JNCQ/A951). The most frequently identified deficiencies were inconsistencies in chlorhexidine bathing, line labeling not performed to policy standard, confusion regarding responsibility for dialysis lines, lack of awareness of policy for discontinuing central lines, and unnecessary accessing of ports.

 

A variety of interventions were developed and implemented to systematically address the identified deficiencies (see Supplemental Digital Content, Table 2, available at: http://links.lww.com/JNCQ/A950). However, the SIR demonstrated a steep increase to 3.343 in January 2021, which correlated with an increase in the average daily census of patients hospitalized with coronavirus disease (COVID-19) (see Supplemental Digital Content, Figure, available at: http://links.lww.com/JNCQ/A951) as well as a decline in the number of audits being completed by the CLABSI rounding team. The average daily census of COVID-19 patients was not collected prior to September 2020 for comparison (Figure). As the surge abated, the CLABSI SIR decreased as well for the next 5 months, with the following SIRs in 2021: 0.914 in February, 0 in March, 0 in April, 1.03 in May, and 1.245 in June. This decline in SIR again correlated with an increased number of audits being performed (Figure) as well as the implementation of the attestation and CLABSI bedside reporting tool. Then, in July 2021, the SIR once again increased to 3.153, and this was sustained into September. Initially, the number of COVID-19-positive patients did not demonstrate a correlation. Then, the number of COVID-19 patients quickly increased again in August and September (see Supplemental Digital Content, Figure, available at: http://links.lww.com/JNCQ/A951). The number of audits also decreased in June and July (Figure), with the units showing sustained progress in SIR reduction completing the most audits.

  
Figure. CLABSI SIR a... - Click to enlarge in new windowFigure. CLABSI SIR and number of audits. CLABSI indicates central line-associated bloodstream infections; SIR, standardized infection ratio.

DISCUSSION

Although the SIR did not demonstrate a consistent decline with ongoing sustainment, the CLABSI rounding process demonstrated significant potential, offering tremendous learning opportunities for the CLABSI rounding team. The lower SIRs seemed to correlate to the months with the most active engagement of the CLABSI rounding team and completion of the highest volume of audits. As the average daily census of COVID-19 patients increased, the focus was shifted to handle the surge of patients and higher acuity.

 

Key contributors to the periods of success of this project between the COVID-19 surges included collaboration and active engagement from nursing experts including the CNS and the CNL, standardization of CLABSI-reduction processes, frontline staff buy-in, and leadership support. First, the CNS and the CNL intentionally partnered with each other as well as the infection preventionists to support this project. While the infection preventionists provided expertise on CLABSI prevention, both the CNS and CNL roles provided advanced knowledge and skills, clinical leadership and empowerment, and the ability to integrate evidence-based practice at the bedside, while creating interventions to achieve set goals.21 The CNS is an advanced practice registered nursing role that is prepared to serve as a specialist at the macrosystem level or within a system of care that crosses many areas where nursing practice is demonstrated.22 The CNL serves as an advanced generalist within a microsystem to oversee care delivery throughout the continuum and focuses on care quality at the point of care.23 While the CNS and CNL roles have a similar focus on patient safety and care quality, they are perfectly suited to work collaboratively24 and in a cohesive, complementary relationship.25 The body of evidence supporting the impact of the CNS and CNL roles on quality outcomes is growing.23,25,26

 

In this project, CNSs led the efforts in creating the initiative, teaming up with information services to build an innovative electronic dashboard, partnering with Infection Prevention, and creating a process that would directly address opportunities identified at a macrosystem level. CNLs were then able to help coach, mentor, and oversee clinical practice within the microsystem at the point of care by providing real-time coaching and feedback with the CNSs and Infection Prevention nurses to help change practice. By partnering the master's prepared CNS and CNL roles with infection preventionists, a team of consistent, highly engaged individuals performed all audits, limiting subjectivity and variability as well as improving outcomes for patients.

 

Buy-in from frontline staff was an additional key to success. This buy-in was facilitated by streamlining CLABSI improvement efforts through a clear process and not adding to the workload. Standardized education occurred with each CNS or CNL who joined the core team to limit variability in process. The perception of audits by staff had to be changed from simply data collection to the provision of real-time education and creation of a culture of change. Routine meetings allowed for the sharing of common trends in the audits, and the core rounding team worked collaboratively to create interventions to address each trend.

 

Additional buy-in from key stakeholders including nurse managers, senior nursing leaders, and physician leadership supported a successful CLABSI improvement effort. Support from our chief nurse executive and the Assistant Vice Presidents of each service line aided in establishing CLABSI reduction as a high priority for the facility as a whole and facilitated a common vision among nursing and non-nursing leaders. Their assistance was key in supporting the implementation of bedside shift report tool and supporting secondary audits. In addition, trends among teammates identified through the rounding process allowed for individual coaching or counseling by unit leaders as appropriate. There were also instances where some identified trends could be traced back to other departments or individual providers, allowing for further collaboration with areas such as Interventional Radiology and the emergency department to further improvement efforts. Support from physician leadership was imperative in addressing provider-related concerns such as site selection (eg, femoral vein) or orders to access implanted ports for general use during hospitalization.

 

Limitations of this project include only occurring at a single facility, a limited time frame for assessing the association between audit compliance and CLABSI rates, and challenges presented by the COVID-19 pandemic. Facilities with different resources including the absence of the CNS and CNL roles may encounter challenges implementing such an initiative. In addition, other CLABSI prevention efforts were occurring during the same time period in the project facility. This included the transition from chlor-hexidine disks to chlorhexidine-impregnated transparent dressings and shifting from disinfecting caps/port protectors to chlorhexidine and isopropyl alcohol wipes. Further evaluation is needed to determine whether the results can be sustained in the long term beyond the COVID-19 pandemic and whether this collaborative auditing process could be used to reduce other hospital-acquired conditions such as catheter-associated urinary tract infections.

 

CONCLUSIONS

Hospital-associated infections such as CLABSIs are mostly preventable, and prevention bundles have been successful in lowering CLABSI rates when performed consistently. The implementation of a collaborative rounding team inclusive of specialty nursing roles such as the CNS, CNL, and infection preventionists is an innovative method to promote the use of evidence-based prevention bundles and to standardize practice through consistent coaching and mentoring. Success was evidenced by the correlation between an increased number of audits and a reduction in CLABSI rates between COVID-19 surges. Using a collaborative rounding team promotes and enhances awareness and a culture of safety. The quality and effectiveness of patient care were also enhanced through a standardized auditing process, transparency of the process, and both personal and peer accountability. To sustain such practices and maintain successful QI efforts, leadership support is required as well as buy-in of frontline nurses.

 

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central line bundle; infections; nursing; quality improvement