1
Bloodstream Infection Prevention Project: A Multimodal Approach to Improve Compliance
Aurelia C. Ramos, DNP, RN-BC
Gloria L. Beriones, PhD(c), RN, NEA-BC
Abstract
Bloodstream infection is one of the deadliest hospital acquired infections that increases cost, length of hospital stay, mortality risk. The Bloodstream Infection Prevention Project is performance improvement project in two acute surgical care units of The Methodist Hospital in Houston, Texas to improve compliance and reduce the rate of central line associated blood stream infections with a long-term goals of zero. A multimodal education approach was implemented using the PDCA (plan-do-check-act) Process Model with underpinnings from John Hopkins CUSP/TRiP conceptual model. Staff nurses were required to attend an education session after completing a baseline survey followed by a skills and knowledge validation check-off. Postintervention compliance was measured through a daily four-week audit performed by the staff nurses on their patients. Containers were installed in the patient rooms to provide accessibility to basic supplies. Monthly CLABSI rate was monitored. Process and outcomes were analyzed and results were disseminated. Of the 55 staff nurses, 37 completed the baseline survey, 41 attended the education session, and 36 participated in the four-week daily audit. Postintervention compliance was lower than self-reported baseline compliance. However, a downward shift on the trajectory of CLABSI rates and a reduction on the mean CLABSI rate in Unit A from 2.42 to 0.91 and Unit B from 3.41 to 1.98 from 2011 to November 2012 are positive indicators of quality improvement. Adopting the CUSP/TRiP model to address quality and safety issues at the unit level is a pragmatic approach with the right leadership, support, resources, teamwork, persistent follow-up measures, and a rigorous system of tracking and reporting outcomes data.
Keywords: central line associated bloodstream infection prevention, multimodal education approach, evidence-based practice, performance improvement project, CUSP
Bloodstream Infection Prevention Project: A Multimodal Approach to Improve Compliance
The Bloodstream Infection Prevention Project implemented in two acute surgical care units at The Methodist Hospital in Houston, Texas is a performance improvement project that utilized the PDCA (plan-do-check-act) Process Model. The basic tenets of the CUSP (Comprehensive Unit-Based Program)/TRiP (Translating Research into Practice) concept developed by the John Hopkins Quality and Safety Research Group to address the safety issues of the institution at the unit level were adopted to provide the underpinnings of the project. Central line associated bloodstream infection (CLABSI) has been an ongoing issue on both units with observed noncompliance to policies and procedures on the care and maintenance of venous access. The multimodal education approach gleaned from a systematic review of effective educational interventions was implemented to improve compliance. Although postintervention compliance at month five was noted to be lower from baseline self-reported compliance, there were significant lessons learned that provided insight and direction on how to sustain the practice change initiative. A downward trajectory of the CLABSI rate and trend demonstrate that leadership and staff partnership, due vigilance, diligence, and attention to best practices can help prevent CLABSI.
Background
Central line associated bloodstream infection (CLABSI) is one of the deadliest hospital acquired infections that increases mean hospital length of stay by 12 days, mean cost of hospitalization by $18,432 (Halter, Debden, Kale, & Zack, 2010), and mortality risk by 12% to 25% (Centers for Disease Control and Prevention [CDC], 2011). Quality initiatives that implemented insertion, maintenance, and removal of central line bundles resulted to a significant reduction in the rate of CLABSI among hospitalized patients in the intensive care units (ICU) across the United States from 2001 to 2009 (CDC). However, the 2009 national CLABSI rate was notably higher in the inpatient acute care units and outpatient hemodialysis centers than the ICUs (CDC). As the use of central venous catheters (CVC) is becoming more indispensable in various health care settings, it is imperative that evidence-based strategies are incorporated into daily practice to prevent the deadly infection from harming at risk individuals and patient populations.
Problem Statement
Two 30-bed acute surgical care units (Unit A and Unit B) of The Methodist Hospital in Houston, Texas have adult patient populations often requiring long-term use of CVCs particularly peripherally inserted central catheters (PICC). Patients who undergo surgeries of the gastrointestinal system requiring total parenteral nutrition (TPN) postoperatively and those who develop surgical site infections needing long-term intravenous antibiotics are at higher risk for acquiring CLABSI. In 2011, the mean CLABSI rate per 1,000 central line days was 2.42 in Unit A and 3.41 in Unit B (see Figure 1).
Figure 1. There was an upward trajectory of CLABSI rate in Unit A and Unit B in the year 2011. Data were obtained from The Methodist Hospital 2011 Monthly Pillar Scorecard for Surgical/Transplant service lines.
To address the high rate of CLABSI on both units, it was crucial to identify the factors that led to the poor outcome. Albeit the desired long-term outcome is zero CLABSI, incorporating the care and maintenance bundles of CVC and PIV will hardwire the best practices across various types of venous access. Based on observation, noncompliance among the staff nurses to the institution’s policies and procedures and best practices was evident. The staff argued there were not enough nurses on the units to meet competing patient needs/demands and job expectations. Amidst the staffing crisis, the challenge was not just to improve the knowledge and skills of the staff nurses, but also to change the current practice, attitudes, beliefs, and behaviors towards adherence to evidence-based practices to achieve zero CLABSI.
Literature Review
Etiology of CLABSI
Hospital acquired bloodstream infections are preventable if nurses diligently comply with best evidence-based practices. The two most common preventable causes of bloodstream infection are organisms from the patient’s skin or organisms from the skin of the healthcare providers who insert, access, and manipulate the CVCs (Gorki, 2010). When the skin is not properly disinfected prior to insertion, an organism could attach to the tip of the catheter and be pushed through the skin into the bloodstream that can cause an extraluminal infection usually within the first seven days after line placement (Ryder, 2006). Manipulation of the infusion system, which includes intravenous fluid or medication administration, flushing or accessing the hubs, and changing intravenous administration sets without regard to aseptic technique could cause intraluminal bloodstream infections that usually occur seven days after line placement (Ryder, 2006). Evidence shows that scrubbing the crevices and septum of the hubs/valves with a twisting motion as if juicing an orange for 15 seconds is effective in sterilizing access ports prior to each use (Moureau & Dawson, 2010). A study at Rady Children’s Hospital in San Diego, California showed that blood culture specimens obtained from access ports inoculated with commonly found organisms in the clinical setting did not show any organisms when scrubbed for 15 seconds with friction by either alcohol or chlorehexidine gluconate and isopropyl alcohol (CHG/IPA) wipes, while those that were not disinfected did (Halter et al., 2010).
The Keystone ICU Project
As quality and safety take center stage in the 21st century healthcare landscape, successful quality initiatives to improve processes and outcomes are shared within the healthcare community and duplicated to broaden the evidence base. One such program is the Keystone ICU Project that was launched to tackle the safety issue of CLABSI across participating Michigan ICUs. The project successfully decreased the rate of CLABSI in 100 ICUs by more than 60% from baseline, maintaining and sustaining a median infection rate of zero at 18 and 36 months postintervention (Pronovost et al., 2010). The project adopted the framework developed by the John Hopkins Quality and Safety Research Group that comprised of three essential elements: (1) CUSP, (2) TRiP, and (3) a rigorous system to measure, report, and improve outcomes (Goeschel, 2011).
The Comprehensive Unit-Based Program (CUSP) was developed to empower staff nurses to identify and address safety issues at the unit level targeting both the adaptive (changing attitudes, beliefs, and behaviors) and technical (improving knowledge and skills) work necessary to effect a change (Pronovost et al., 2005). The CUSP was aimed at promoting a culture of safety and teamwork within the units and the institution, which also showed a reduction of the nursing turnover from 9% preintervention to 2% postintervention (Pronovost et a., 2005). The steps involved were staff education about the science of safety; identification of safety issues; assigning a senior executive leader to every unit; recovering and learning from mistakes through monthly discussions; and the use of a goal checklist that was completed daily during interdisciplinary rounds to facilitate and help move patients to the next level of care (Goeschel, 2011).
Although there is a robust amount of research-based evidence on best practices to improve outcomes, there is a large gap in the number of years before this evidence is translated into practice. The TRiP (Translating Research into Practice) concept narrows this gap by hastening the implementation of the best available empirical evidence to practice. The TRiP process began with the appraisal of existing evidence to identify appropriate interventions that were more focused on clinical behaviors rather than technology and with the least burden to implement (Goeschel, 2011). Five interventions implemented in the project were hand washing, full barrier precaution, use of chlorhexidine as the skin antiseptic, avoiding the femoral site, and the removal of catheters when no longer indicated (Pronovost et al., 2010). Prior to implementation, barriers were identified and addressed to facilitate the implementation process. Once evidence-based clinical behaviors were identified, baseline behaviors were measured and interventions were implemented while monitoring the process throughout the project (Goeschel, 2011). The third vital element was a rigorous system to measure and report CLABSI data to improve outcomes. (Goeschel, 2011).
Multimodal Education Approach
Cherry, Brown, Neal, and Shaw (2010) conducted a systematic review of literature to determine the features of structured educational interventions that were most effective in improving compliance with the aseptic insertion and maintenance of CVCs. Of 9,968 articles reviewed, 47 met the criteria for inclusion. Findings of the review that were relevant to practice included the following:
Educational interventions appear to have the most prolonged and profound effect when used in conjunction with audit, feedback and availability of new clinical supplies consistent with the content of the education provided. Educational interventions will have a greater impact if baseline to best practice is low. Repeated sessions, fed into daily practice, using practical participation (such as the use of demonstration, video education, use of similar or self-study materials) appear to have a small, additional effect on practice change when compared to education alone. Active involvement from healthcare staff, in conjunction with provision of formal responsibilities and motivation for change, may change healthcare worker practice. Dissemination of information through peers or higher management may have a small effect on practice change (Cherry et al., 2010, p. 198).
Policies and procedures are evidence-based imperatives that serve as guidelines for the standards of care. However, they become obscure or least important as nurses juggle time to meet demanding job expectations, increase patient satisfaction, and improve documentation, communication, and quality outcomes without incurring any overtime. From this perspective, the multimodal education approach is a pragmatic strategy to improve compliance and practice outcomes.
Intervention
The intervention for the bloodstream infection prevention project was a multimodal education approach gleaned from the Cherry et al. (2010) systematic review of literature, with underpinnings from the John Hopkins CUSP/TRiP concept and the PDCA (Plan-Do-Check-Act) Process Model as the framework. A baseline survey was developed to identify (1) self-reported practice/compliance on the care and maintenance of CVC; (2) perceived barriers to compliance; (3) perceived solutions; (4) if accessibility of basic CVC care supplies (alcohol wipes, CHG/IPA wipes, needleless valves, sterile red caps, and intravenous tube labels) in patient rooms will help; (5) perceived levels of importance and willingness to adhere to policies and procedures; and (6) perceived levels of confidence to make the necessary changes in practice (see Appendix A, Baseline Survey). A checklist of basic knowledge and skills on the care and maintenance of CVC was used to validate knowledge and skills after the education session (see Appendix B, CVC Care and Management Check-off). The audit tools used to measure postintervention compliance with CVC and PIV care and management were also developed from an existing audit tool used by the units (see Appendix C, CVC and PIV Care and Management Checklist).
All full time and part time staff nurses of both units were required to attend a 30-minute education session given individually or in groups proceeded by knowledge and skills validation check-off. The topics covered in the education session were cause and cost of hospital acquired blood stream infections; policies and procedure on the care and maintenance of CVC and PIV access (i.e. CVC and PIV bundles); and the proper way to obtain blood culture specimens to prevent blood culture contamination and misdiagnosis. Emphases were placed on components of the standards of care where noncompliance was observed the most (i.e. scrubbing the hubs of both CVC and PIV lines; changing CVC dressings of patients admitted to the institution with central lines; changing CVC dressings 24 hours after insertion and whenever occlusion was compromised; scrubbing CVC insertion sites with CHG/IPA scrub using a back-and-forth motion as recommended by the manufacturer versus circular motion (CareFusion, 2012); changing PIV lines every three days to prevent localized infections; changing administration sets every three days being mindful of aseptic techniques; flushing unused ports with the appropriate amount of normal saline with a turbulent push-pause technique every eight hours to prevent occlusion; labeling insertions sites appropriately to enhance communication among healthcare providers caring and maintaining the various types of venous access; and the proper way to obtain blood cultures to avoid blood culture contamination and misdiagnosis.
Table 1.
Central Venous Catheter (CVC) and Peripheral Intravenous (PIV) Catheter Bundles
CVC Bundle / PIV Bundle1. Wash hands
2. Assess site for signs of infection
3. Assess need for CVC
4. Remove lines when no longer indicated
5. Change PICC line and CL dressings every week per institution’s policy
6. Change implanted VAD dressings twice a week per institution’s policy
7. Change implanted VAD needle every seven days
8. Label dressings with date of insertion, date of dressing change, and initial
9. Scrub the hubs with CHG/IPA wipes for 15 seconds prior to access
10. Flush with 10ml NS after every use (20 ml for implanted VAD), every eight hours if not used, and with 20ml NS after blood draw or transfusion
11. Change and label administrations sets every three days using aseptic technique
13. Change needless valves with every tubing change, when blood specimen is drawn, and as needed
12. Change and label IV solutions at least every 24 hours / 1. Wash hands
2. Assess site for signs of infiltration and/or infection
3. Change PIV lines every three days per institution’s policy
4. Use sterile transparent dressing over the insertion site
5. Label the site with date and time of insertion, size of the needle, and initial
6. Flush with NS after every use or every eight hours if not used
7. Change and label administration sets every three days per institution’s policy
8. Change and label IV solutions at least every 24 hours
Note: CL = central line; VAD = venous access device; CHG/IPA = chlorhexidine gluconate and isopropyl alcohol; NS = normal saline; IV = intravenous