Central Line Associated Bloodstream Infection (CLABSI), a significant cause of morbidity and mortality in hospitalized patients, has been identified as a never event (CDC NHSN, 2013). The Centers for Medicare and Medicaid Services no longer reimburse for CLABSI-associated costs of care as an incentive to improve the quality of care and reduce healthcare costs (Kuhn, 2008). In countries with limited resources, rates of healthcare-associated infections including CLABSI are three to five time higher than those in the U.S., and CLABSI reduction has been identified as a priority for the International Nosocomial Infection Control Consortium (Rosenthal, Maki, & Graves, 2008). Many CLABSI prevention initiatives focus on sterile insertion technique and are limited to ICU settings or specific patient populations (Berenholtz et al., 2004; Southworth, Henman, Kinder, & Sell, 2012; McMullan et al., 2013). Despite initial efforts to reduce rates in ICUs and high-risk patients, CLABSIs continued to be an area of concern for our organization. In FY12, our goal was to reduce our institution-wide CLABSI rate by at least 10% through a multidisciplinary initiative that focused on the standardization of practices across the continuum of patient care. In FY13, our objective was to sustain low CLABSI rates via targeted education and reinforcement of successful clinical practices.
The CLABSI taskforce included leaders and staff from nursing, infection prevention, patient safety, supply chain, clinical documentation, and providers. Subjects were all hospitalized neonatal, pediatric, and adult patients with a CLABSI by the CDC definition between July 2011 and June 2013. CLABSI rates were calculated and communicated to each patient care unit on a monthly basis. In FY12, a “Scrub the Hub” protocol for accessing and maintaining central lines was taught via computer based training (CBT) and reinforced with 1:1 return demonstration for all registered nurses (RNs) from clinics, procedural areas, inpatient units, emergency departments, and home health services. The same protocol including CBT and return demonstration was added to monthly orientation for newly hired nurses across the institution. Custom-built standardized kits for central line insertion and dressing changes were adopted for each patient population and type of line. Providers were educated on proper line placement via CBT, followed by simulation validation for designated housestaff. The procedure for central line placement was modified to include both an “observer” and an “inserter”, with sterile technique highlighted and audited. An electronic checklist tool requiring documentation by both the observer and inserter was implemented.
In FY13, monthly unit-specific CLABSI rates were reported across the medical center in adult and pediatric hospitals. Each CLABSI case underwent a collaborative quality review by representatives from infection prevention, nursing unit staff and managers, providers, and ancillary staff involved in central line maintenance. Specific gaps in care and opportunities for improvement were identified. These included targeted re-education for nursing staff on units with higher CLABSI rates and 1:1 return demonstration as needed to validate skills for accessing and maintaining central lines. Providers were encouraged to reassess each patient’s need for a central line daily and to remove central lines as soon as no longer required. The “Scrub the Hub” protocol was reviewed during annual nursing competency sessions for nursing staff and continued during monthly new hire orientation. CBT training on central line placement was required as part of orientation for all incoming housestaff in FY13 and monthly simulation validation sessions are ongoing.
In FY12, 1452 RNs from all patient care areas across the institution completed the CBT and 1:1 return demonstration of skills for accessing and maintaining central lines. A total of 559 providers completed the CBT on proper central line placement, including 368 residents, 61 fellows, and 130 faculty members. Eighty-five housestaff (62 residents, 23 fellows) from the departments of medicine, surgery, emergency medicine, anesthesia, critical care, and pediatrics participated in the simulation validation sessions.
In FY13, multidisciplinary quality reviews were performed for all 26 CLABSI cases. Timely and unit-specific data improved the awareness of nursing staff and managers and renewed their responsibility for CLABSI prevention. Increased attendance and participation from all practitioners involved in each case helped identify actionable items, such as the need for re-education on standardized practices, improvements in documentation, and changes to local systems. During annual competency sessions in FY13, 698 nurses from medical-surgical and critical care units were re-validated on the on the “Scrub the Hub” protocol. In addition, 317 newly hired nurses underwent training with successful return demonstration. A total of 217 new housestaff completed the CBT on proper line placement as part of FY13 orientation, and 96 have participated in the simulation validation exercise.
Institution-wide CLABSI rates decreased from 1.06/1000 central line days in FY11 to 0.6/1000 central line days in FY12 (p = 0.01). In FY13, the annual rate further decreased to 0.5/1000 central line days (p < 0.001 compared to FY11). The CLABSI rate was reduced by 43% from FY11 to FY12 and an additional 17% from FY12 to FY13. The mean number of monthly CLABSI cases was 4.5 in FY11 (range 1-9), 2.6 in FY12 (range 1-8), and 2.2 in FY13 (range 0-5). Since the inception of our multidisciplinary team approach in July 2011, an overall reduction in CLABSI rates of greater than 50% has been achieved and sustained across the medical center in all patient populations.
Clinical education coupled with institution-wide standardization of procedures and supplies led to a statistically significant decrease in CLABSI from FY11 to FY12, reducing rates by 40% to surpass our initial goal. In contrast to other CLABSI prevention initiatives limited to the ICU setting, our multidisciplinary approach spanned all patient care areas in adult and pediatric hospitals. An early focus on uniform protocols for central line access and maintenance with education and return demonstration helped drive success. Readily accessible supply bundles for central line placement and dressing changes in all patient care areas streamlined workflows. Modifying the central line insertion procedure to include an observer empowered nursing staff to ensure proper sterile technique and improved communication with providers. Provider education and simulation validation on proper central line placement were critical to address gaps in knowledge and skills for housestaff.
In FY13, the communication of unit-specific data across the institution increased transparency regarding our CLABSI rates. Quality reviews of each case were instrumental in bringing all practitioners together to identify areas for improvement. Feedback informed interventions that generated clinical impact for specific nursing units and patient populations. Investment at the individual and unit levels was particularly valuable in preventing CLABSIs and sustaining low rates across the medical center. We learned that training for newly hired nurses and housestaff, while essential, must be supplemented with continuing education and validation to maintain skills for all practitioners involved in central line care.
Elements critical to the success of our institution-wide 50% reduction in CLABSI rates included the multidisciplinary team approach, standardization of supplies and practices, and support at every level of patient care and leadership. Our methodology could be readily adopted by other national and international organizations challenged with patient safety and quality improvement initiatives such as CLABSI reduction.
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