A central line-associated bloodstream infection (CLABSI) is a prominent issue in the healthcare field, most commonly seen in intensive care units (ICU). The CDC reports an estimated 41,000 deaths caused by CLABSI each year in the U.S. Many researchers across the world have studied on how to best prevent these infections from occurring. Most of the studies consisted of improving hand hygiene, proper aseptic technique, donning sterile gloves and gowns, etc. Placing these guidelines into practice have shown a significant drop in CLABSI rates. The proposed solution of this paper is to create core measures that are standardized throughout all healthcare settings across the country. These core measures would be standard practice while inserting a central line as well as maintaining its integrity. These core measures would not only standardize care, but it would also save lives.
Identify the Problem
Central line-associated bloodstream infection is a preventable complication that leads to poor patient outcomes, prolonged inpatient stays, increased healthcare costs, and higher patient mortality. The goal is to reduce the incidence of CLABSI by eliminating or reducing risk factors such as insertion at internal jugular or femoral vein, low nurse-patient ratios, additional infections, insertion for longer than 72 hours, and the use of stopcocks.
Relevant People and their Roles
The people involved in Central Line-Associated Bloodstream Infection are healthcare workers, patients, and their families. Healthcare workers follow the guidelines for proper and careful sterile central line insertion. They practice and adhere to evidence-based guidelines for the maintenance of central lines. The healthcare workers also remove central lines from a patient as soon as they are no more needed. (Haddadin et al., 2020). Patients and families have a vital role to play as they are responsible for notifying healthcare workers if they notice central line dressing is dirty, wet, and coming off. They should only touch the central line after performing hand hygiene and always make sure healthcare workers perform hand hygiene before touching a patient. (Moyle, S. 2020).
Population Mostly Affected
The patients affected by Central Line-Associated Bloodstream Infection are mostly people with chronic illnesses such as malignancy gastrointestinal tract disorders, hemodialysis, pulmonary hypertension. Also, central venous catheter immune-suppressed patients, for example, patients with organ transplant, diabetes and vascular diseases. Besides are malnourished patients, total parenteral nutrition, extremes of age, burns (loss of skin integrity), Patients with multiple invasive procedures, and those with prolonged hospitalization before line insertion and patients on antibiotic therapy. (Moyle, S. 2020).
Rationale/Motivation for Accomplishing the Task & Why It Needs Change
CLABSI is responsible for lengthening hospital stays, increasing hospital readmission rates, and making the cost of care more expensive. By being diligent in our sterile technique while caring for patients with central lines, we can prevent these consequences of infection. Each year in the U.S., there are an estimated 100,000 deaths from healthcare-associated infections, and one-third of the fatalities are from CLABSI, according to the Joint Commission (Columbia University School of Nursing, 2013). By using better sterile technique and infection control, we could save the lives of many patients as well as save them the burden of extra healthcare costs associated with a prolonged hospital stay.
Ideas already considered or attempted and their results
There are several interventions that health professionals have utilized to prevent the occurrence of a CLABSI. First, and the most important, is hand hygiene. This method is the most convenient, the most cost-effective, and prevents the transmission of pathogens. The WHO came up with a strategy that includes the five elements called the “Five Moments for Hand Hygiene.” The five moments include before touching the patient, before performing any procedures, after exposure to body fluid, after touching the patient, and after touching the patient’s surroundings (Myatra, S.N). Next, studies have found that using full-barrier precautions are effective as well. This consists of sterile gloves, gown, large sterile body drape, face mask, and cap/hat (Stream Infection). Other methods for preventing a CLABSI include the use of chlorhexidine to disinfect the skin prior to the intervention, avoiding the use of the femoral vein for catheters, and removing unnecessary catheters.
Possible Solution Alternatives
A central line-associated bloodstream infection (CLABSI) is an extremely prevalent issue among ICUs across the nation. The Centers for Disease Control and Prevention estimates about 41,000 central line-associated bloodstream infections each year. Although this is a common issue, there are several ways that healthcare professionals can avoid such infections. Some ways to prevent these infections from occurring would be strict hand hygiene, applying appropriate skin antiseptic, ensuring the skin prep has completely dried before inserting the central line, and using all five maximal sterile barrier precautions (sterile gloves, sterile gown, cap, mask, and large sterile drape).
A study was conducted in an adult critical care unit for which the researchers adapted an ‘insertion bundle’ and a ‘maintenance bundle’ when caring for central lines. The insertion phase bundle included proper hand hygiene, optimum site for insertion of catheter, proper skin preparation with chlorhexidine and maximal sterile barriers during insertion. The maintenance bundle included hand hygiene, sterile dressing change and aseptic accession of the central line with periodic review for the line in place. The study showed to have a significant reduction of CLABSI rates by 73% after implementing these practices (Victor et al., 2019). Another study was conducted in the Asia Pacific region implementing CLABSI prevention protocols in the ICU setting. Again, their study focused on ‘bundles’ that consisted of proper techniques in order to best prevent CLABSI from occurring. Their study showed a successful reduction to zero or close to zero incidences of CLABSIs occurring (Ling et al., 2016). Another study was conducted in Israeli medical-surgical ICUs. Their approach was based on second-tier prevention practices including 14 prevention measures in CLABSI prevention. Their study showed a reduction in CLABSI rates and each additional measure that was implemented showed a 19% decrease of CLABSI occurrence (Ben-David et al., 2019). Lastly, a study was conducted at Vanderbilt University in an outpatient adult hematopoietic cell transplantation program regarding CLABSIs. This study more specifically looked at the likelihood of this specific patient population to contract a central line infection. The study reported a 9% incidence of CLABSI in their outpatient setting and that gram-positive cocci was the most common cause of a CLABSI (McDonald et al., 2018).
As seen above, the incidence of CLABSI can be greatly reduced as long as strict aseptic technique is implemented. Some solution alternatives to even further reduce the prevalence of CLABSIs as a whole would be to implement core measures as a nationwide standard of care. This is the same idea as the bundles that were previously mentioned in the research articles, however these core measures would be unanimous throughout all hospitals. Some implications that would be listed in these core measures would be strict hand hygiene, proper cleansing of the skin using chlorhexidine, the use of sterile gloves, sterile gown, cap, and masks when inserting the catheter, proper site for insertion of the catheter, and guidelines written out for antibiotics for prophylactic treatment. With these guidelines in place, the incidence of CLABSIs occurring in the United States, and even worldwide, could be greatly reduced or even non-existent.
In order to reduce the incidence of Central Line Associated Bloodstream Infections in the hospital setting a CLABSI care bundle will be implemented. The care bundle will include a series of patient cares that are mandatory for nurses and other healthcare professionals to perform with any patient that has a central line. These interventions will ensure that staff are utilizing best practices and understand their role in the prevention of bloodstream infections. The care bundle is going to include guidelines for five main practices including, hand hygiene/aseptic technique, catheter site dressing regimens, daily skin cleansing with 2% chlorhexidine, and monitoring CLABSI surveillance criteria (Beardsley, 2016).
First, the bundle will include guidelines for hand hygiene and aseptic techniques. Hand washing with soap and water or alcohol-based hand rubs must be performed prior to insertion and any time the healthcare team is touching the insertion site or the patient (Myatra, 2019). Sterile gloves must be worn during catheter insertion, accessing the port, and when changing the dressings (Myatra, 2019). Performing hand hygiene and utilizing sterile gloves is essential in preventing the introduction of pathogens to the catheter insertion site.
There are several factors that each hospital has to consider in order for their goals to be met. First, is the goal easy to implement? In terms of hand hygiene and surgical asepsis, there are hand sanitizer dispensers outside of every room. There are sinks with soap to wash hands thoroughly before and after procedures. Along with this, kits are provided in the supply closet for aseptic procedures. Next, the hospital would need to continue to purchase kits, hand sanitizer and soap, and training and education. Nursing staff compliance would require that everyone is sanitizing/ hand washing before and after entering a patient’s room, use proper aseptic technique, and attend education and training. Lastly, the long-term effects will have to be considered to evaluate how well the interventions are working. Continuous data should be collected on each unit. Goal setting will also be necessary for the unit to keep a record of how well they are preventing this type of infection.
The catheter site dressing regimens will include procedures for how and when to change the dressings. Nurses will utilize standard dressing change kits that include everything needed to maintain a sterile field and successfully replace the dressing. The site will be dressed with a sterile, transparent, semipermeable dressing in order to allow for frequent visual inspection of the insertion site. The dressing will remain in place for seven days or until the site becomes damp, loosened, or visibly soiled (Ling, 2016).
There is significant research indicating that bathing the patients once daily with 2% chlorhexidine reduces the risk of CLABSI (Swan, 2016) . The care bundle will require that nurses or unlicensed assistive personnel assist the patient in bathing using the chlorhexidine wipes and document the care each day.
Finally, the care bundle will include incremental assessments for CLABSI criteria. Once per shift, nurses will assess and document the patient’s vital signs, appearance of the insertion site, and any signs/symptoms of systemic infection (Beardsley, 2016). Additionally, blood cultures should be drawn every 2–4 days to assess for presence of pathogens (Beardsley, 2016). This information will be utilized to monitor for trends and identify CLABSIs early in the infectious disease process.
In order to implement this intervention, nurses will need to assess and document the patient’s vital signs, appearance of the insertion site, and any signs/symptoms of systemic infection. They will also need to collect blood cultures, which should be drawn every 2–4 days to assess for presence of pathogens. The only thing they will need to pay for are cultures and other lab tests. Nurses will have to complete all assessment data and documentation in order to be compliant. To assess the long-term effects, nurses will need to monitor patients for infections.
The most important step to implement the proposed solution is educating and training the staff on the specifics of the care bundle. A pre and post intervention observational study found that an education program aimed at teaching healthcare professionals about preventing CLABSIs lead to a significant decrease in rate of bloodstream infections (Shimoyama, 2017). The nursing staff will be trained on insertion and maintenance of the central line, effective infection control measures, and how to accurately perform each procedure included in the care bundle. Staff will initially be educated through in-service training, where they will be provided education regarding the rates of CLABSI, the new policies and procedures, step by step instructions for how to perform the cares, and rationale behind the actions. The staff will provide return demonstrations after the inservice training, which will be re-evaluated periodically in the future to reinforce the teaching.
For this alternative, the ease of implementation may be difficult. It may be challenging for everyone to attend all of the required training. Therefore, planning is needed to execute this well. The hospital would need to hire instructors or volunteers to train all of the nursing staff. As well as conference rooms big enough to hold this type of training. The cost for education and training will mostly come from hiring an instructor and getting equipment to practice with. In order for the staff to be compliant, there should be multiple days and times available for employees to attend. Along with this, providing incentives may encourage everyone to attend. In order to assess the long-term effects, the hospital can reward the unit for lasting a certain number of days without instances of a CLABSI. They can keep score on a white board and update it each day or week.
Resistance to change is expected when implementing new procedures, so in order to achieve staff approval and acceptance of the CLABSI bundle, the change must be planned and collaborative. Utilizing Lewin’s Change Theory, the first step in implementing the CLABSI bundle would be to create awareness among staff regarding the frequency and severity of CLABSI incidences (Lewin, 1951). Many healthcare professionals have a common priority of striving for positive patient outcomes and maintaining patient safety, so bringing awareness to the issue of CLABIs will initiate the unfreezing stage of the change theory. In this stage, the group is convinced to change when concern is elicited, which creates discontent and a desire for change (Marquis, 2021). Change agents, including managers and leaders, will be responsible for making staff aware of the problem and creating discontent with the rate of CLABSI incidence, thus generating a desire for change.
In the movement stage of Lewin’s Change Theory, gradual change will begin to be implemented (Lewin, 1951). The most valuable strategies to utilize at this stage is the rational-empirical strategy and utilizing a collaborative process. The rational-empirical strategy recognizes that a major source of resistance to change is lack of knowledge, therefore, by educating staff on the rationales behind each intervention and how their actions directly influence their patient’s CLABSI risk, they will be less likely to resist the change and adherence to the care bundle will be increased (Marquis, 2021). Collaborating with the staff on implementing the change means giving the staff a voice in the process. If stakeholders are a part of the change, introducing new policies and procedures will have a greater adherence rate compared to if changes are mandated from authority figures (Marquis, 2021).
The final stage of the implementation process is refreezing. This stage will include continuous reinforcement of the policy and the rationales (Lewin, 1951). Maintaining change is an ongoing process, so staff will be continuously evaluated for adherence to the care bundle and commitment to reducing CLABSI risk. The most important strategy to utilize in this stage is continuous support of staff; if staff is motivated to maintain the implemented change, it will take three to six months for the care bundle to be accepted as part of the system (Marquis, 2021).
A potential barrier to the implementation of the solution is lack of adherence to the care bundle. Potential foreseeable reasons for low adherence are time constraints for nurses providing patient care. Lack of time for nurses may lead to lapses in procedure. For example, nurses that are overworked may not properly perform hand hygiene, may not have time to give the patient a chlorhexidine bath, or may continue to use a contaminated sterile field. To address this concern, appropriate staffing levels will be enforced to prevent elevated patient-to-nurse ratios, which will reduce lack of adherence due to time constraints.
In providing a solution to the plan, the researcher utilized a qualitative analysis. The study was conducted in a surgical intensive care unit with the patient to nurse ratio, which happened to be 3:1. The study included: a pre-intervention period of 9 months, an intervention period of 6 months, and a post-intervention period of 9 months (Park, SW. et al. 2017). During this period, individuals monitored for CLABSI for three years after the post intervention period of 9 months. Also, the infection control office intervened and had minimal intervention. Lastly, while dressing the catheter site, transparent semipermeable dressing or sterile gauge was used and changed every two days and one week if not indicated.
During the intervention, 2% chlorhexidine and 70% alcohol were used to disinfect the site and minimize contamination, and hand hygiene was monitored weekly. At the end of every month, the department received the report. Also, all the nurses core knowledge was assessed with 20 questions and was conducted three times during the intervention period. The physicians and residents learned the insertion procedure, and there was a checklist based on what they missed. There were regular team meetings between the infection control office and the SICU to implement and monitor the CLABSI prevention bundles. The infection control designed a program to work on based on frequent meetings.
A comparison and analysis of the CLABSI incidence rates during the intervention period with the baseline were determined. CLABSI reduced from 6.9 during the pre-intervention period to 2.4 and 1.8 in the intervention and post-intervention period. Compliance to each component in the insertion bundle reached 100% in five months, and adherence to the element with the maintenance bundle was able to achieve 100% in the second month. Furthermore, the awareness of core knowledge about CLABSI prevention practices during the intervention period of 6 months increased with scores of 15.8 in the first month which indicates that the educational method and monitoring was effective in implementing CLABSI prevention bundles for a short time (Park, SW. et al. 2017). With the data collected and the core knowledge questions, it would reveal the areas where the healthcare team lacks understanding when it comes to the prevention of CLABSI. Qualitative and quantitative questionnaires should allow the healthcare team to state some of the reasons behind CLABSI occurrences and how they can prevent them. There is a need for adequate resources to support the healthcare team’s training and monitoring of hand hygiene and central line procedures.
Nursing Recommendation for Future Research
The research personnel should focus on the type of research method they are using. Qualitative and quantitative data need to be evaluated further to develop the procedure that describes the prevention of CLABSI. Even though each hospital has its policy regarding infection control, collecting data might differ from hospital to hospital as they operate differently. Some hospitals have a central line team that takes care of central line procedures, while some do not have. For research to effectively monitor and assess the healthcare team’s knowledge, one should know how a hospital under study operates.
There are different purposes and levels of validity in research methods; a study’s results should show strong evidence. Research personnel should have in mind that qualitative and quantitative research methods are more beneficial. Using the qualitative research method helps to bring out the importance of studying an individual holistically. Quantitative research would help to generate data and analyze them. It can help in explaining the importance of data collection and help in measuring the results statistically. More research is needed in nursing before the consequences of choosing evidence-based practice can come into reality.
Furthermore, nursing research should implement qualitative research as the analysis is an open-ended question and would help nurses express themselves and make their voice matters. Thereby, improves the quality of nursing care and provides insight into patients’ experience better. Nurses need to get involved in decision making as they are in the position to advocate for patients’ needs.
Beardsley, A. , Bogue, T. , Nitu, M. & Cox, E. (2016). 785. Critical Care Medicine, 42(12), A1549. doi: 10.1097/01.ccm.0000458282.84462.12.
Ben-David MD, Debby(2017). The Association between Implementation of Second-Tier Prevention Practices and CLABSI Incidence: A National Survey. Retrieved February 01, 2021, from https://pubmed.ncbi.nlm.nih.gov/31339089/
Ling, M. L., Apisarnthanarak, A., Jaggi, N., Harrington, G., Morikane, K., Thu, L. T. A., Ching, P., Villanueva, V., Zong, Z., Jeong, J. S., & Lee, C. (2016). APSIC guide for prevention of central line associated bloodstream infections (CLABSI). Antimicrobial Resistance & Infection Control, 5(1), 16–16. https://doi.org/10.1186/s13756-016-0116-5
McDonald, M. K., Culos, K. A., Gatwood, K. S., Prow, C., Chen, H., Savani, B. N., Byrne, M.,
Kassim, A. A., Engelhardt, B. G., Jagasia, M., & Satyanarayana, G. (2018). Defining Incidence and Risk Factors for Catheter-Associated Bloodstream Infections in an Outpatient Adult Hematopoietic Cell Transplantation Program. Biology of Blood & Marrow Transplantation, 24(10), 2081–2087. https://doi-org.libproxy.gmercyu.edu/10.1016/j.bbmt.2018.04.031
Moi Lin Ling, Anucha Apisarnthanarak, Namita Jaggi, Glenys Harrington, Keita Morikane, Le Thi Anh Thu, Patricia Ching, Victoria Villanueva, Zhiyong Zong, Jae Sim Jeong, & Chun-Ming Lee. (2016). APSIC guide for prevention of Central Line Associated Bloodstream Infections (CLABSI). Antimicrobial Resistance and Infection Control, 5(1), 1–9. https://doi.org/10.1186/s13756-016-0116-5
Myatra S. N. (2019). Improving Hand Hygiene Practices to Reduce CLABSI Rates: Nurses Education Integral for Success. Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine, 23(7), 291–293. https://doi.org/10.5005/jp-journals-10071-23200
Park, SW., Ko, S., An, Hye-sun.(2017). Implementation of central line-associated
bloodstream infection prevention bundles in a surgical intensive care unit using peer tutoring. Antimicrob Resist Infect Control 6, 103. https://doi.org/10.1186/s13756-017-0263-3
Swan, J. T., Ashton, C. M., Bui, L. N., Pham, V. P., Shirkey, B. A., Blackshear, J. E., Bersamin, J. B., Pomer, R. M., Johnson, M. L., Magtoto, A. D., Butler, M. O., Tran, S. K., Sanchez, L. R., Patel, J. G., Ochoa, R. A., Jr, Hai, S. A., Denison, K. I., Graviss, E. A., & Wray, N. P. (2016). Effect of Chlorhexidine Bathing Every Other Day on Prevention of Hospital-Acquired Infections in the Surgical ICU: A Single-Center, Randomized Controlled Trial. Critical care medicine, 44(10), 1822–1832. https://doi.org/10.1097/CCM.0000000000001820
Shimoyama, Y., Umegaki, O., Agui, T., Kadono, N., Komasawa, N., & Minami, T. (2017). An educational program for decreasing catheter-related bloodstream infections in intensive care units: a pre- and post-intervention observational study. JA clinical reports, 3(1), 23. https://doi.org/10.1186/s40981-017-0095-4
Victor, P. C., Ramakrishnan, K., Hanifa, M., Easow, J. M., & Venugopal, J. (2020, February 05). An Intervention Based Prevention of Catheter Associated Blood-Stream Infection in Adult Critical Care Unit, J Pure Appl Microbiol., 2019; 13(4):2209–2214. https://doi.org/10.22207/JPAM.13.4.34