Archive | 2021
Improve the Risk of Central Line-Associated Bloodstream Infections with Central Line Dressing Changes through a Team Approach
Abstract
Practice Problem: Central Line Associated Bloodstream Infections (CLABSI) are a preventable hospital acquired infection which contributes to patient morbidity, mortality and rising healthcare costs. PICOT: The PICOT question that guided this project was: In adult inpatients with central venous catheters, does the use of a two-person dressing change team, compared to a single person procedure, decrease the rate of central line associated bloodstream infections over the course of 8 weeks? Evidence: The prevention of CLABSI is most effective when multifaceted line maintenance bundles are implemented and adherence to these bundles nears 100% (Schreiber et al. 2018). Intervention: A two-person, evidence-based dressing change procedure was implemented for all central line dressing changes, known as the sterile buddy. The role of this additional bedside nurse was to assist the dressing change through an extra set of hands and to provide real-time sterile technique feedback to the primary nurse. Outcome: The intervention did not lead to a statistically significant change in the rate of CLABSI, however there was a reduction in the overall number of observed CLABSI compared to both the prior year and the 6 months preceding to the intervention. Conclusion: The implementation of a sterile buddy was an effective intervention that resulted in a decline in the total of CLABSI, and although not statistically significant, resulted in an estimated cost savings of $56,000 when compared to the year prior and an estimated cost savings of $112,000 when compared to the 6 months preceding the intervention. CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTION 3 Does a Sterile Buddy for Central Line Dressing Changes Reduce the Rate of Central LineAssociated Bloodstream Infections? Hospital-acquired conditions (HAC) are those that a patient develops while undergoing treatment in the hospital for another disorder and include both hospital acquired infections (HAI) and injuries. These conditions that cause harm to the patient, are classified under patient safety and adverse events, and are considered preventable with the application of current evidencebased practice (Agency for Healthcare Research and Quality, 2019). HAC result in increased cost during a patient’s hospital stay, as well as, in future healthcare encounters that may not have been necessary, prior to the onset of the HAC (Kandilov et al., 2014). Central line-associated bloodstream infection (CLABSI) is one of five HAIs which are reported to the Centers for Disease Control and Prevention’s National Healthcare Safety Network (Centers for Medicare & Medicaid Services, 2020). Current evidence-based practice supports the use of a CLABSI maintenance bundle with key components that include hand hygiene, cap and tubing changes every 72 hours, chlorhexidine skin antisepsis, and transparent dressing changes every 7 days (Agency for Healthcare Research and Quality, 2018c). Despite implementation of the evidencebased CLABSI maintenance bundle, CLABSI continues to be prevalent within the DNP practice site. The purpose of this project is to address the concern of CLABSI through an evidence-based, quality improvement project that proposes the implementation of a 2-nurse team that consists of a primary nurse and secondary nurse, or sterile buddy, for central line dressing changes. Significance of the Practice Problem CLABSIs are a significant burden to not only the healthcare system, but also to patients, as they contribute to thousands of deaths and billions of dollars in added costs to the United States healthcare system (Centers for Disease Control and Prevention, 2011b). When compared CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTION 4 to other HAIs such as, catheter-associated urinary tract infections, ventilator-associated pneumonia, and surgical site infections, CLABSIs are associated with the highest number of preventable deaths and have the highest cost impact (Umscheid et al., 2011). Annually in the United States, there are an estimated 41,000 CLABSI in hospitalized patients with an associated mortality rate of 10%-20% (Centers for Disease Control and Prevention, 2011b). Furthermore, there is an average prolonged hospitalization period of 7 days and an increase in medical costs of $28,000 or more per occurrence (Agency for Healthcare Research and Quality, 2018b). The average annual cost to Centers for Medicare & Medicaid Services (CMS) from CLABSI is $19,246,293.15 (Sankaran et al., 2020). In response to rising healthcare costs, CMS developed the Hospital-Acquired Condition Reduction Program, which penalizes facilities with rates of HACs in the 75 percentile, or worst performing quartile, by 1% each year (Centers for Medicare & Medicaid, 2019). This consequence has led to incentivizing healthcare facilities to make a change in how they prevent CLABSI and other HAIs. In addition to the challenges that healthcare facilities face with CLABSIs, patients are also affected at the individual level with symptoms consisting of fever, pain, and redness around the insertion site (Centers for Disease Control and Prevention, 2011a). Severe illness due to CLABSI may also occur with patients manifesting signs of sepsis such as hypotension, hemodynamic instability, lethargy, fatigue, and altered mental status, which can be alarming and distressing to the patient and their family members, especially if the clinical course has been complicated and perilous. Treatment of a CLABSI may include additional invasive procedures, testing, and up to 14 days of parenteral antibiotics, which all result in pain or discomfort to the patient (Haddadin et al., 2020). CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTION 5 The majority of CLABSI can be prevented with correct insertion, skin antisepsis, and adherence to evidence-based central line maintenance (Johns Hopkins Medicine, n.d.). The Centers for Disease Control and Prevention provides guidelines and tools for the healthcare community to follow, from the time of insertion through removal, to help decrease the rate of CLABSI (Centers for Disease Control & Prevention, 2011a). In order to improve the quality and safety of patient care, implementation of evidence-based clinical practice guidelines is crucial. However, adherence to clinical practice guidelines across hospitals in the United States varies with implementation rates between 20% and 100%. In addition to increasing awareness, focusing on changing practice patterns at the bedside through multifaceted and multidisciplinary interventions, is the most effective strategy to combat rates of CLABSI (The Joint Commission, 2012).