Central line-associated bloodstream infections (CLABSIs) are linked with negative consequences such as increased length of stay, increased mortality rate, and increased costs.1,2 Various hospital rating and ranking systems often include CLABSI as a measure of performance for defining overall quality of patient care. In fiscal year 2016, our level 1 large academic trauma center located in the southeastern United States experienced a 43% increase over prior year performance in CLABSI. Despite an overall increase in CLABSI, the hospital remained a top performer in the state when compared with other academic peers for standardized infection ratio calculation provided quarterly and annually by state surveillance for Healthcare-Associated and Resistant Pathogens Patient Safety Program.
This overall increase in CLABSI inspired hospital leaders to analyze performance to identify opportunities for improvement as well as develop strategies to reduce CLABSI. The first step was to garner support from key team members, followed by identification of an operational leader to serve as project champion. A failure mode effect analysis was conducted related to maintenance of central lines, and a line assessment was developed to review maintenance practices across the hospital. Intentional collaboration from multiple experts to ensure a seamless experience for frontline nursing staff is critical. To sustain improvement, the hospital adopted a quarterly sustainability assessment to evaluate performance and share results with leadership to drive follow-up actions. The aim of this article is to share our experience developing an innovative intervention to achieve and sustain highly reliable performance with maintenance practices of central line catheters.
INTERVENTIONS TO PREVENT CLABSI
Evidence-based practice guidelines for prevention of CLABSI developed by the Centers for Disease Control and Prevention include routine hand washing prior to catheter insertion or manipulation of catheter, sterile insertion with full barrier precautions (cap, mask, sterile gown, sterile gloves, and full sterile drape), use of 2% chlorhexidine solution with proper air drying prior to insertion, avoidance of femoral site for catheterization, and prompt removal of unnecessary catheters.3,4 Bell and O'Grady3 identified newer technologies such as disinfecting caps and needleless securement devices as effective prevention strategies for reducing CLABSI. Moreover, findings indicated clinical factors that may reduce CLABSI included catheter choice, catheter site selection, insertion technique, and proper catheter maintenance.
Identifying key team members and the initial assessment
An interprofessional team including frontline staff, infection control staff, physician leaders, and hospital operations leaders were identified as key team members in reducing CLABSI. This group of individuals spent time analyzing each CLABSI. A multidisciplinary team with representatives from quality, infection control, frontline staff, physician leaders, and hospital operations collaborated with the central line catheter supplier to conduct an independent assessment of central line practices across the hospital in July 2016. The initial assessment focused on 2 components of prevention including dressing maintenance of the central line catheter as well as critical skills to prevent CLABSI. All central lines on a given day were visually inspected with data collected on 10 items shown to prevent infection including dressing maintenance (6 items), chlorhexidine gluconate (CHG) disc presence (3 items), and a single item focused on catheter securement. The following day the team made 39 observations of simulated critical skills to prevent CLABSI. These skills included dressing change, blood draw, flush/medication administration, and hub maintenance. Following data analysis by the third-party vendor, identified opportunities included catheter securement and proper dressing maintenance (labeling of dressing, proper placement of CHG dressings, and dressings being occlusive without visible blood beneath the dressing). Further improvements were necessary in 2 of the 4 critical skills observed: dressing change and blood draw.
Preliminary results were shared with operational leaders and direct care nursing staff. These results inspired a refreshed commitment to improving performance, and operational leaders identified 2 project champions to partner with quality staff. This team orchestrated the reeducation of all nursing staff on proper central line catheter maintenance skills over the next 90 days. This was followed by a subsequent 1-day prevalence study focused on observing 100% of central lines on the day of assessment and then by simulated clinical skills for the 4 critical responsibilities (dressing change, blood draw, flush/medication administration, and hub maintenance). Unit champions trained by staff from the supply vendor in collaboration with organizational education and infection control staff were deployed to achieve reeducation of all nursing staff. Annual education practices were also reevaluated to ensure onboarding of new nurses included key information related to CLABSI prevention.
ACHIEVING RESULTS
February 2017 marked the completion of training efforts and a reassessment was conducted utilizing the same metrics as the initial assessment. Results indicated rapid improvement in catheter securement, dressing maintenance (labeling of dressing, proper placement of CHG dressings, and dressings being occlusive without visible blood beneath the dressing) as well as performance of simulated clinical skills for blood draw and flushing/medication administration. These promising results inspired operational leaders and quality staff to partner in the development of a quarterly assessment, replicating the metrics from the initial assessment, to be completed by hospital quality staff. This practice continues and an overall reduction in CLABSIs from fiscal year 2016 performance remains. A 57% reduction in overall CLABSIs occurred from fiscal year 2016 to 2017, and while performance increased in fiscal year 2018, a 15% reduction in performance from 2016 remained.
Sustainability of intervention
A team of approximately 10 individuals including quality staff, operational team members such as clinical nurse specialists, and unit champions coordinate to complete a quarterly reassessment of central line maintenance practices across the organization. The key to success with this intervention has been engaged nursing leadership to support and protect time for participation in this assessment.
CONCLUSIONS
Sustaining highly reliable performance within the health care landscape can be challenging. Successful strategies for improving patient outcomes, specifically central line-associated infections, are multifaceted and multidisciplinary. Meaningful communication of performance, paired with interventions aimed at observing clinical practice, provides a unique lens to further develop improvement strategies as well as strategies for sustaining positive results. Collaboration between clinical leaders, quality and infection control leaders, and direct care staff is necessary to initiate successful interventions and sustain reductions in CLABSIs.
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