Central Line Associated Blood Stream Infection (CLABSI) prevention has largely focused efforts on insertion in the intensive care setting (Loftus, 2015; Perin, Erdmann, Higashi & Sasso, 2016; Saguna & Hyzy, 2013). In addition to insertion practices, guidelines for maintenance practices are referenced in various organizations such as the American Society of Clinical Oncology (ASCO) clinical practice guideline, the Infusion Nurses Society (INS), and Society for Healthcare Epidemiology of America Society for Healthcare Epidemiology of America the Society for Healthcare Epidemiology for American (SHEA) (Gorski et al., 2016; Marschall et al., 2014; Schiffer et al., 2015).
Upon review of hospital-wide 2016 CLABSI cases, 88% of infections were occurring on day 5 or later post insertion. Infections that occur after day 5 post insertion may suggest are related to maintenance practices. Maintenance efforts became the focus for the inpatient acute care areas. Our medical oncology unit held the highest CLABSI rate and highest central line count outside the ICU. To identify the problem, our first step in February of 2017 was to initiate leader rounding. Two leaders would round one to two times a week to observe the dressing integrity and status of central lines. Inconsistent maintenance practice was identified as an area for improvement. In addition, nurses reported inconsistent implanted port needle access and dressing change practice.
It was evident that an educational approach was needed to improve maintenance practices. An educational approach has had success in similar units. An oncology department implemented a simulation based education program which resulted in improved CLABSI rates from 5.86 to 3.45 (Page, Tremblay, Nickolas, & James, 2016). Changing culture around the importance of maintenance practice by rounding was also a top priority to support sustainability of the education. One facility demonstrated central line maintenance sustainability with leader rounding implementation (Owings et al., 2018).
Description:
In 2017, our quality improvement initiative expanded to develop an interdisciplinary team on our 30-bed Medical Oncology unit consisting of Registered Nurses from the IV team and Medical Oncology unit, an Infection Preventionist (IP), the Patient Care Manager (PCM), the Patient Care Supervisor (PCS), and the medical-surgical Clinical Nurse Specialist (CNS). The team worked to develop an educational plan for all RNs on the Medical Oncology unit. The education plan consisted of filming a video to demonstrate accessing a port and applying dressing correctly, developing a port access procedure, providing tips for maintaining aseptic technique for access, standardizing practice for dressing change indications, and establishing a timeframe for all nurses to demonstrate an implanted needle access and dressing application. The educational plan was mandatory for all nurses who access implanted ports on the Medical Oncology unit. Education occurred in 4th quarter of 2017.
Weekly rounding on all central line patients started before implementation of the educational plan and continued throughout and after. The IP maintains a consistent expectation of maintenance for central lines by rounding one to two times a week with either the PCM, PCS, or CNS. Leader rounding allows for identification of improvement, immediate follow up with bedside nurses including immediate attention to inadequate maintenance practices, and follow up with other departments as needed for maintenance care deficits. Rounding also provided an acute awareness to maintenance practices by creating an open culture for nurses to ask questions, report concerns, and/or anticipate maintenance care needs for patients. This proactive communication between leaders and bedside nurses has identified further areas of improvement outside of the Medical Oncology unit.
Findings:
Dressing compliance was measured as either needing a dressing change or not during leader rounding. In 2017, 16% of dressings needed a leader to request a change. From January through June in 2018, leaders only identified 6% of dressings that need changing at the point of rounding two times a week. Between 2017 and 2018 (January to June) over 500 central lines were rounded on. The CLABSI rates on the medical oncology unit decreased from 1.06 (2017) to 0.63 (Jan-June 2018).
Conclusions:
Simulation based nursing education in combination with routine leader rounding to monitor the consistency in practice and to provide on the spot coaching has decreased CLABSI rates on the Medical Oncology unit. Engaging bedside nurses in the planning and implementation of interventions as well as implementing a leader monitoring and surveillance program is an effective way to reduce CLABSI.