Capping Off Central Line-Associated Bloodstream Infections
Hospital acquired infections, including central-line associated bloodstream infections (CLABSIs), result in several yearly deaths. CLABSIs originate extraluminally from inadequate skin decontamination prior to insertion or intraluminally from inadequate decontamination of the catheter hub during port access. With intraluminal contamination, risk for CLABSIs increase for all patients with each subsequent port access. Prevention bundles have improved insertion practices and reduced CLABSI rates, however prevention of intraluminal contamination using alcohol impregnated caps, on all central lines, will further reduce mortality, cost, and infection rates. Their use will replace scrubbing-the-hub technique while providing continuous and consistent protection. A review of literature obtained through EBSCO and Google Scholar, including peer-reviewed research studies published in 2013-2018, supported the use of continuous passive disinfectant caps. The intervention resulted in a decrease in: colony forming units, CLABSI rates by 40%, hospitalization related costs, and patient length of stay. It improved nursing satisfaction, and prevented potential deaths. Studies only reporting results for a pediatric or neonatal population were filtered from the search query and were not used. Although evidence based, possible constraints in implementing this proposal is lack of funding, resistance to change, and staff non-compliance.
Introduction
Healthcare-associated infections (HAI) occur while patients undergo medical treatment. Patients acquire these infections in various healthcare settings including: hospitals, long-term care facilities, dialysis centers, ambulatory surgery centers, and outpatient care facilities. Approximately 722,000 yearly acute care HAIs occur in the United States, which account for about 75,000 yearly patient deaths. Of the 722,000 HAIs, approximately 71,900 are bloodstream infections (BSI), including central-line associated infections (CLABSIs). CLABSIs cost an estimated $45,814 per case, making this the most costly HAI. One way to reduce their long-term cost is by implementing alcohol impregnated caps on all central lines. The Stetler model provides a step-by-step process to aid in this endeavor by: identifying the problem, reviewing the literature, evaluating evidence feasibility, delineating implementation plan, and evaluating outcomes. Finally, disseminating results ensures evidence based practice propagation.
Preparation
The high incidence of CLABSI rates at this facility became apparent through data obtained via the California Department of Public Health (CDPH) and health consumer reports (CR). CDPH’s latest 2016 report records a total of five CLABSI cases at this facility; this is higher than the 2015 national average. Similarly, CR states that between 04/01/2016 and 03/31/2017, this facility reported four CLABSI cases to Centers for Medicare and Medicaid Services (CMS). This according to CR, is 84% worse than the national rate. To prevent CLABSIs, it is necessary to stop the chain of infection. Protecting the portal of entry, is one way healthcare workers can interrupt the chain link. Currently, facility policy to protect the portals of entry includes scrubbing-the-hub of all central line catheters for 15 seconds prior to access. Evidently, this is an insufficient intervention.
A review of the literature obtained through Google Scholar and EBSCO reported consistent results after implementing disinfectant caps in relationship to contamination rates, infection rates, costs, and preventable deaths. A common misconception among some healthcare organizations, is that additional training for nurses on scrubbing technique will decrease microorganism count and make the need for disinfectant caps obsolete. Contrary to this notion, a level 3, multiple experimental group design research study, found no significant difference in Staphylococcus aureus colony forming unit count following an intervention in which two separate operators scrubbed the hubs for 15 seconds with a wipe containing 2% chlorohexidine gluconate in 70% isopropyl alcohol. Additionally, when comparing contamination rates between cap use and scrubbing intervention, a statistically significant higher decontamination rates resulted in the cap group versus the scrub group at each intervention point, on Day 1, Day 3, and Day 7. This in vitro design study enabled researchers to control confounding variables, hence yielding more reliable results. A separate level 4, multiphase, prospective, quasi-experimental study, implemented at 3 facilities, reaffirmed the cap’s effectiveness in the clinical setting versus scrubbing-the-hub. The phases progressed from scrubbing-the-hub, to implementing a new alcohol impregnated cap, and finally reinstituting scrubbing-the-hub. Contamination rates from Phase 1 to Phase 2 decreased from 12.7% to 5.5%. Moreover, after reinstituting the scrub-the-hub intervention, contamination rates increased from 5.5% to 12.0%.
A more clinically significant result is the effect these disinfectant caps have on infection rates. In a level 4, prospective, observational disinfectant cap study, conducted on all central and peripheral lines at a Methodist Hospital’s 3 intensive care units, researchers found a 43% BSI (bloodstream infection) rate drop for peripheral intravenous (IV) lines and a 49.3% BSI rate drop for central lines. Combined, this meant a 50.0% reduction in BSIs. Although this proposal’s aim is not peripheral IVs, the future implications are promising. This research is clinically relevant to this proposal, in that it if results are consistent, implementing caps could mean a 49% decrease to the facility’s 84% higher than national average CLABSI rates. In another quasi-experimental, short interrupted time series intervention study conducted in a 430 bed, level 1 trauma center, researchers found a larger than 40% decrease in CLABSIs after implementing disinfectant caps on all peripheral and central lines. Consistently, infection rate improvement is nearly similar in both studies, further supporting the reliability in these results.
In 2008, CMS discontinued reimbursements for additional care accrued by ‘never events’, under which CLABSI is classified. As a result, healthcare facilities face increasing liability and costs. Fortunately, disinfectant caps help reduce these costs. In a cost benefit analysis conducted by Wright et al. (2013), caps cost the team $60,233 during their multiphase experiment. In return, this intervention helped avoid 21 infections, 4 deaths, and freed up 13 new admissions. Likewise, Merrill et al. (2014) calculated a decrease in CLABSI related costs from $1 million per year to $575,000 per year. After accounting for the additional supply costs, this translated into $282,840 savings per year. Additionally, this intervention yielded a theoretical decrease of 68 patient hospital days and prevented one potential death.
Comparative Evaluation/Decision Making
The literature reviewed consistently reported a reduction to contamination rates, infection rates, costs, and preventable deaths. All literature presented is peer-reviewed, and within five years or less. Some literature retrieved during the review dealt only with the pediatric and neonatal population and as a result, was not used. Most of the results presented in this proposal resulted from an adult population, however Merrill et al.’s (2014) results includes all patients from newborn to elderly. Two of four studies presented included medical/surgical unit results similar to this proposal’s population. As previously mentioned, the results consistently reported similar findings, demonstrating the reproducibility of these results. The major constraint to this proposal is monetary, however long-term savings were evident after conducting a financial analysis. Based on the literature and on the high CLABSI rates at this facility, it is recommended that it implements a trial of using alcohol impregnated caps on all central lines in the medical/surgical floor for a renewable period of one year.
Translation/Application
For change implementation, it is helpful to consider Kotter’s eight step change model. To create a sense of urgency, one can share this hospital’s CLABSI rate findings and review of the literature with stakeholders, starting with the medical/surgical unit manager. If the unit manager accepts the need for change, moving forward one can present the proposal and form a coalition with the medical/surgical unit manager, materials management, finance department, and nursing staff. The next step is to develop a vision, in this case the vision is the resolution strategy to implement disinfectant caps. To help communicate this vision, one can reach out to the disinfectant cap product representative and schedule an in-service meeting in which the product representative will present the product to the stakeholders. If all stakeholders agree to move forward and provide funding, the product representative will also present and educate the nursing staff on the use of the disinfectant cap during the monthly staff meeting. The plan will include delegating to materials management the order and stocking of new disinfectant caps for central lines in the medical/surgical floor. To eliminate any possible obstacles, certified nursing assistants will hang disinfectant cap strips on IV poles belonging to patients with central lines. The nursing staff will identify patients with central lines and obtain a baseline blood culture per doctor’s orders. The information technology team will upload new patient education created by the unit manager, on the use of disinfectant caps. The unit manager will also develop a “satisfaction score card” for a monthly anonymous feedback evaluation from the staff. To consolidate gains, the unit manager will present monthly graphs showing CLABSI rates and provide positive reinforcement through the use of praise and quarterly “you make a difference” awards to compliant nurses. Finally, before anchoring change, the nurse manager will evaluate outcomes and make decisions about the future of the proposal.
Evaluation
Evaluating outcomes following interventions allows one to objectively determine if the results support or negate the continued implementation of said intervention. In order to systematically evaluate the outcomes of a proposal, one must first identify the main objectives it set out to accomplish. There were three main objectives in the implementation of alcohol impregnated caps on all central lines, in an adult medical surgical unit. The objectives were to reduce primary blood stream infections rates, increase nursing staff satisfaction, and decrease potential hospital costs related to the care of CLABSIs. To evaluate the first objective one can track laboratory confirmed CLABSI cases pre- and post- intervention and calculate the incidence rate of CLABSI cases during the trial run. To evaluate the second objective one can track staff compliance rates to intervention via daily audits conducted by charge nurses during their grand rounds, track staff satisfaction or reasons for resistance to change via monthly e-mail questionnaire, and track the patient CLABSI education provided by the nurse upon discharge. To evaluate the final objective, one can track the cost of the intervention with the help of the materials management department, conduct a cost-benefit analysis, and determine net return.
Dissemination
The next step after implementing an intervention and evaluating outcomes is dissemination of findings. Disseminating outcomes is a nurse’s professional responsibility as it helps propagate information that can help improve patient outcomes. It is estimated that it takes about 9 years for evidence based interventions to be fully adopted by healthcare facilities and it takes about 17 years for 14% of research results to benefit patient populations. Finding dissemination can occur within the facility, but should also occur outside the facility as well.
Within the facility, one will first present findings to the medical/surgical nursing unit via a poster presentation during a staff meeting. Light refreshments will be provided as a way of thanking staff members for their cooperation. Nurses will receive encouragement to share findings with their colleagues and nursing friends. Beyond this, findings will also be shared with the intensive care unit manager during a scheduled appointment meeting. One will also seek permission to present findings to this unit during a staff meeting. Another stakeholder in this intervention is infection control, therefore findings will be presented and confirmed with the director using data sheets. One will seek permission to set up a booth during the annual education fair as part of the infection control presentation. For a house-wide dissemination of findings, one will collaborate with the communications department to include outcomes in the quarterly facility newsletter.
Outside of the facility, one will call local rural hospitals and present previous research findings along with the outcomes of this proposal to their infection control managers. One will also contact the local directors of nursing programs seeking permission to present outcomes to students during skills lab day via power-point and/or poster presentation. To reach a greater audience, results will be shared via YouTube slideshow presentation, and through slide shares.
Summary / Conclusion
To summarize, the goal of this proposal is to increase awareness about CLABSIs and to present an additional way to reduce rates. This proposal suggests using alcohol impregnated caps on all central lines in a medical/surgical unit for a period of one year. This intervention is meant to reduce primary blood stream infections rates, increase nursing staff satisfaction, and decrease potential hospital costs related to the care of CLABSIs. Previous evidence demonstrated consistent results in the reduction of contamination rates, infection rates, costs, and preventable deaths. Along with the evidence and the urging need to implement new interventions to reduce the high incidence rates of CLABSI at this facility, it is highly encouraged to move this proposal forward.
