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Prevention of Central Line-Associated Bloodstream Infection (CLABSI)

Rina Patel

Grand Canyon University

Dr. Isiguzo

08/19/2019

Prevention of Central Line-Associated Bloodstream Infection (CLABSI)

Abstract

PICOt Question

In hospitalized adult patients, how does an educational program on central line management compare to no educational program in the prevention of central line-associated bloodstream infections?

Background information and significance

CLABIS is an infection of a patient’s blood stream when bacteria or germs enter the

central line. A central line is a catheter placed in the large vein of a patient, especially

around the groin, neck or chest. It helps in drawing blood, giving ill patients medications or

fluids. Sometimes, bacteria’s can enter the central line and enter the patient’s bloodstream

resulting in an infection. The infections are serious but can be treated successfully.

According to the Centers for Disease Control and Prevention (2016), there are

approximately 41,000 CLABIS every year in the U.S. hospitals. Therefore, assessment,

recognition and treatment of CLABIS will help ensure the achievement of favorable patient

outcome.

States have developed practices to help prevent this infection. However, educating nurses

on nurse management of the central line and the patient are the most important factors in the

management of the central line. This involves ensuring preventative measures and a no-

touch aseptic technique in managing the central line (Centers for Disease Control and

Prevention, 2016). Using insertion bundles and maintenance checklist can help to

standardize central line care and reduce incidences of CLABIS. Nurses can follow the

local hospital policy on the management of the central line as well as educate patients on

management. Therefore, nurses play an essential role in central line management and

prevention of CLABIS.

by using educational initiative could decrease the rate of catheter-associated bloodstream

infection. mandatory education program offered to ICU nurses and physicians. it was

developed by a multidisciplinary task force to highlight correct practices for the prevention

of catheter-associated bloodstream infection.

In this program, they included 10-page self-study module on risk factors and practice

modifications involved in catheter-related bloodstream infections and in-services at

scheduled staff meetings for their staff. Seventy-four episodes of catheter-associated

bloodstream infection occurred in 7,879 catheter-days in the 24 months before the

introduction of the education program.

Following implementation educational of the intervention, the rate of catheter-associated bloodstream infection decreased to 41 episodes in 7,455 catheter days. The estimated cost savings secondary to the decreased rate of catheter-associated bloodstream infection for the 24 months following the introduction of the education program was between $103,600 and $1,573,000.

Significance of the study

Educational intervention main focused on the education of health-care providers on the

prevention of catheter-associated bloodstream infections. it may lead to a dramatic

decrease in the incidence of primary bloodstream infections. Education programs may lead

to a substantial decrease in medical-care costs and patient morbidity attributed to central

venous catheterization when implemented as part of mandatory training.

Cather-associated infections are preventable when nurses and healthcare providers are

provided with training or education so that they acquire skills necessary for the prevention

of these infections. Education programs help in equipping nurses and healthcare providers

with the knowledge needed to implement evidence-based practices such as preventing

inappropriate short-term catheter use; ensuring that there is timely removal of the catheters;

and ensuring that there is catheter care during placement. Nurses and healthcare providers

are also expected to adopt practices related to the observation of the hygienic protocols

and use of antiseptic barrier caps as opposed to manual alcohol while improving the safety

of the catheter from microorganisms.

Once the practices are implemented, there will be a reduction in the hospital stay by the

patients and this, in turn, will help in the reduction of healthcare costs. There will also be

a reduction in the reported cases of infection. Therefore, the evaluation of the success of

the capstone project will be based on comparing the rate of infection after the

implementation of the proposed intervention (education program) to the previous rate

before the commencement of the implementation. If there is a reduction in the rates of

catheter-associated infections, then it implies that the proposed intervention of the capstone

project worked effectively in ensuring that the infection rate is reduced. However, is the

rate of infection continues to increase or remained unchanged, and then the intervention is

considered to be ineffective and cannot help in reducing catheter infection rates.

Based on this study, the aim was to compare the effectiveness of the educational program

on the central line management with no educational program in the prevention of the

central-line associated bloodstream infections. The episodes of infections related to

catheter bloodstream infections were witnessed in 7,879 catheter days for 24 months

before the program. Following the implementation of the education program, the incidences

of infection reduced by 41 in 7,455 catheter days. The healthcare cost saved during that

period was approximated to be between $ 103,600 and $ 1, 573, 000 for the 24 months.

Literature Review and Supporting Evidence

Many literature search is conducted based on the database like EBSCO host,Pubmed,

ProQuest, google scholar, CINAHL, CLABSIs is becoming a major healthcare concern

since it increases the rate of mortality, morbidity, and the hospital cost for the individuals

who are being readmitted and have to stay longer with the healthcare facility while

receiving healthcare services. Even though the precise effective approach of reducing

CLABSIs remains unclear, the education of the healthcare providers has been proven to be

effective in providing evidence-based prevention strategies to reduce it. According to

Manouher (2016), education is helping in the reduction of CLABSIs among hemodialysis

patients. The study showed that there was a reduction in the rate of infection by 18.1 at the

baseline and this reduced to 6.5 percent following the implementation of the education

program (Manouchehr, 2016). Adriana et al (2014) also studied the long-term impact of the

education programs on the prevention of CLABSIs within the surgical intensive care units.

The study took around 18 months and it involved the ICU visits by the healthcare providers

from the disease control board that directly interacted with the patients while teaching them

how to help in the reduction of the CLABSIs. Following the implementation of the

program, there was a reduction in the rate of CLABSI infections by 66 percent (Adriana,

Priscila, Erique, Cassia, Clara, & Arlete, 2014).

Theoretical Model of Framework

Using a mandatory education program to nurses in Intensive care unit will help in the reduction of central line bloodstream infections rate. Educating nurses on CLABIS will help reduce the number of deaths resulting from this infection. Most studies that examine the effects of educational interventions have been done in institutions or units with combined interventions. In my project, the diffusion of innovation theory will provide the framework for this project (CDC, 2016). The theory provides that an individual will adopt any innovation depending on how they understand the features of a particular guideline. This understanding affects the compliance of clinicians. A new guideline is seen as a practice or idea that results in positive patient outcome.

This framework would involve pre and post intervention studies for a period of five years in 3 adult ICUs in a tertiary hospital with 50 beds. There will be a 15 minutes lecture on 10 important points on the guidelines of the CDC in CLABIS prevention to the ICU staff on all shifts (CDC, 2016). The lecture is followed after six months by providing these workers with questionnaires to assess their understanding of the 10 points provided.

The theory involves four stages: the knowledge phase, persuasive stage, decision stage, and adoption stage. The knowledge phase would involve learning about innovation. Achieving a low rate of CLABIS is possible but maintaining zero rates can be challenging. Implementing evidence-based measures in catheter care can lead to a reduction of CLABIS rate in the ICU. According to Erdei et al. (2015), CLABIS is the infection of the bloodstream as a result of a central line. The study involved the exclusion criteria that included infants in NICU with positive blood culture that was viewed as contaminant. From the study, it was evident that using standardized care practices like checklists and CLABIS bundles resulted in a reduction in CLABIS rate in 2012. However, the rate increased in 2013, but through several interventions the rate reduced (Erdei et al. 2015). Also, providing nurses with high quality training was a key driver in the success of CLABIS prevention. According to the CDC, a report showed a decrease in CLABIS by 46% in the intensive care unit from 2008-2013. However, there is still an estimated 30,000 infections happening in intensive care units in the United States (CDC, 2016).

The persuasion stage involves creating positive or negative attitudes towards innovation. The education project will provide recommendations on reduction of CLABIS rate in ICU to zero or maintaining this rate low by using new practices like changing intravenous medications to oral administration (CDC, 2016). Teaching patients on how to maintain a central line will help in the reduction of CLABIS rate also. This recommendation will be presented to the medical group of practitioners during the monthly meetings.

The decision stage will determine the acceptability of the recommendations into the education system. The final stage will be characterized by acceptability or rejection of mandatory education program. The guideline will be more accepted if promoted by a respected peer.

For this project, the main framework to be used is Diffusion of Innovation Theory by

Rogers that provides that an individual adopts any innovation by an understanding of the

features of the particular guideline. This can affect the clinician’s compliance. A new

practice is seen as an idea that will lead to positive patient outcome. The theory has four

phases: adoption stage, persuasion stage, decision stage and acceptability stage. Using this

framework the team will work towards introduction of education program to nurses in ICU.

A study by Erdei et al. (2015) showed that providing high quality training to nurses could

help reduce the rate of CLABIS. Through the stages of this framework, introducing

mandatory education program for nurses would involve bring the idea to the medical group

committee for adoption, persuading the committee to build a positive attitude towards the

idea, the committee deciding on the applicability of the idea, and finally accepting the idea.

In summary, reducing CLABIS rate to zero has been a challenge in the United States for years. Even with the CDC and local hospitals implementing guidelines for maintenance and reduction of CLABIS the rate remains high. However, implementing a mandatory education program for ICU nurses will help lead to success in reduction. The diffusion of innovation theory will help in the adoption of this project into the health system in the United States. The theory involves four stages.

Methods/ Design/Sampling

The question being addressed in this capstone study is related to the effectiveness of educational programs on healthcare providers as compared to no education in the prevention of infections. The independent variable, in this case, is the educational program on the healthcare providers while the dependent variable is the reduction or prevention of these infections. The criteria for the evaluation of the study outcome will be based on the determination of the infection rates during the process of implementing the intervention (educational program to the healthcare providers on the means of prevention infections). When there is a reduction in the rates of infections as compared to the previous case before the implementation of the intervention, then it implies that the educational program positively worked towards a reduction in the infection. If the no change or an increase in the rate of infection following the implementation of the program, then it means that the program never worked effectively to help in preventing the incidence of the infections.

The manual reports related to the rate of infection before the implementation of the intervention is recorded. The education program is then implemented and the latest outcome regarding the infection rates is compared to the previous outcomes taken before the implementation process. The outcome before and after the implementation process will be compared to determine whether the proposed intervention help in the reduction of infections

Research strategies used to answer the question and their importance to the evaluation of the question posed

Before commencement on the education program, the previous data on the infections were recorded. There was an obligatory education plan provided to the ICU nurses and physicians. The education program was developed by the multidisciplinary task force to help in highlighting the effective and correct practices that need to be adopted to help in preventing infections. A ten-day self-study module on the risk factors as well as modification of practices associated with infections and in-services during staff gatherings was used. During the training, the new practices taught, for example, adoption and implementation of hygienic protocols and use of antiseptic barrier caps were implemented. The rate of infections was taken daily for 24 months. The outcome of the intervention program was then compared to the previous data before the implementation of the intervention program. The positive outcome related to the decrease in the incidence of infection will be an indication that an educational program is working effectively in the reduction of infections.

How Data will be collected

Data will be collected based on the quasi-experimental study in the ICU units before and after the implementation of the intervention. The data recorded before the commencement of the program will be compared to the data from the implementation of the intervention program. Data from the study will be collected daily and recorded in the patient health record tools to monitor the changes. This activity will take place for 24 months and the activity will be mainly based in the ICU units where nurses and physicians are working. The data collected during the program will tally the names and the diseases. The validity of the data will be improved through monitoring the implementation process and recording of the infection-related data on the patient health record tools to be used for the final tally. Data collection methods are suitable to research strategy, type of data, and objective of the study since the suitability of the method influences the overall outcome of the study thus making the study to be considered valid.

Analysis of the data

Data from the study will be analyzed suing percentage to determine the rates of infections after the implementation of the proposed intervention. The percentage of the data will be based on comparing the data before and after the implementation program. Data will be presented in tables to show the trend in the infection rates based on the use of the proposed intervention.

Methods/ Design/Sampling

Research strategies used to answer the question and their importance to the evaluation of the question posed

How Data will be collected

Analysis of the data

Proposed Interventions

The success of the education program as an intervention to help in the prevention of CLABSIs depends on the willingness of the healthcare factors to cooperate in the training program, the readiness of the hospital management to support the training program, the availability of the resources. The success of the program depends on the commitment of the infection control team and healthcare providers to help in the coordination of the overall program. They also help in ensuring that there is governing leadership within the units to help in the maintenance of the levels of practice quality. The materials needed for the education program must be provided by the management tom ensure that the implementation team is successful in their work.

The expected outcomes

Nurses and other healthcare providers play important roles in the maintenance of the

catheters as well as producing a desire healthcare outcome at the ICU. Nurses and

healthcare providers are responsible for acquiring suitable knowledge as well as practices

of catheter care and prevention of catheter-associated infections. However, there is a lack

of knowledge in handling patients with ICU and this exposes patients to catheter-associated

infections. Through the implementation of an education program, nurses and healthcare

providers are provided with knowledge which is important in undertaking or implementing

the evidence-based practices to help in the reduction of catheter-associated infections.

The first expected outcome is the skilled ICU nurses and patients who are well trained in

the use of central line bundles. The rate of CLABSI infection is also expected to be lower

following the implementation process. Another anticipated result is the decrease in the

reported cases of mortality and morbidity. There will be a reduction used by the facility to

fight CLABSI and reduction of hospital costs to the patients and their families due to a

reduction in the number of hospital stays.

Anticipated Conclusions

Nurses and physicians have to go through a compulsory educational program in order to gain adequate knowledge about the appropriate practices required to manage Central line bloodstream infections (CLABIS). The main goal of every nurse and physician is to provide quality care for patients by reducing the risk of infections and ensuring they receive the right treatment. Due to this, nurses and physicians fully support the project which is aimed at improving the quality of care.

The sponsors are responsible for proving the financial resources required for the project. They fully support the project because CLABIs have been a key health care issue notonly in the United States but globally. They therefore want to be part of developing a solution to this problem.

Stakeholders who will be interested in the results

· Medical institutions.

· Governments institutions.

· Physicians and nurses.

· Research institutions.

The first step in promoting stakeholder participation is identifying the needs and interests of the stakeholders. The more one understands about each stakeholder the more one can efficiently influence them. It is important that the needs and interests of the stakeholders are taken into account while developing the objectives of the overall project. The next step is ensuring that the stakeholders are aware of all thedetails regarding the project. There should be effective communication channels to ensure that all the stakeholders receive the messages sent. The third strategy is utilizing intrinsic motivation. Stakeholders like to feel valuable in something and also they often want to have some sense of control (Pandi-Perumal, 2015). I will foster intrinsic motivation by engaging the stakeholders in the decision making process.

Assessment of whether skilled ICU nurses and physicians are effectively working towards

ensuring that the rates of CLABSIs infections are reduced will be done through looking at

whether there is a reduction in the number of patients who have been admitted with similar

complications i.e. CLABSIs. When there is a reduction in the healthcare costs being used

to treat CLABSIs related infection will reveal the effectiveness of the program and that

ICU nurse and physicians are now skilled to help in controlling such infections (Salama,

Jamal, Al Mousa, & Rotimi, 2016).

Barriers from stakeholders

The stakeholders may have different opinions and interests and this will be a key barrier while conducting the project. It is important that all stakeholders have common goals and objectives as the project starts and progresses to ensure conflicts do not emerge. Some nurses and physicians may not be willing to undergo a compulsory educational program which is the foundation for this project. In case some of them don’t, it will be impossible to accurately determine the effect of educational initiatives in managing CLABIs.

Strategies to gain support from the stakeholders

The first step is identifying the stakeholders and their interests. The second step is

developing a power interest grid. This entails determining the power and interest of the

stakeholders on the project. Through this, I will understand where I should focus my

attention and communication. For the stakeholders that have high power and low interest

they will require attention and being nurtured (Bourne, 2016). For those who have high

power and high interest they will need to keep on being motivated in order for them to see

the benefits of the program.

Possible Limitations

Barriers that might tamper with the successful implementation of the education program as an intervention to control and prevent CLABSIs include high job turnover combined with the absence of the ongoing education system for the nurses and doctors following the implementation. Another barrier is related to a lack of commitment from healthcare providers. Another barrier is limited to no resources to ensure that the required materials are purchased. Another barrier is the lack of commitment from the hospital management to support the program by giving time for the program to take place and failure to provide funds to purchase the required materials.

Resources needed

· Insertion and maintenance bundles

· Inpatient and outpatient register

· Alcohol for sterilization

· Central line bundles

· Waste segregation manual

· Pens

· Notebooks

Possible Implication to Practice

There will be regular meetings between the infection control office and the ICU nurses and physicians. The meeting will be aimed at implementing and coordinating the CLABSI prevention bundles, when and how to use alcohol for sterilization, how to follow the waste segregation manual, and how to record the reported cases of CLABSI during the intervention period. There will be an overview introduction regarding the use of central line bundles to help in the control of the CLABSIs. The introduction on this topic will be performed by the control team which will take around 30 minutes every week. The infection control office will be responsible for designing the overall CLABSI prevention bundles as well as the working programs and adjusting them as per the feedback provided during the meetings. The training related to the use of the bundles will be provided to the ICU nurses and physicians. The group will be providing their feedbacks related to the bundle's use of adherence.

The infection control team or office will be performing weekly monitoring on the hand hygiene while comparing it to the guidelines provided by the World Health Organization. This will be aimed at measuring whether the guidelines are being followed. This office will also be monitoring the CLABSI events and whether the ICU nurses and physicians are complying with the demand of using the bundles. Checklists related to the insertion and maintenance bundles of CLABSI prevention will be done and this will be done by the ICU nurses and physicians (Zellmer, Zimdars, & Safdar, 2016).

The implementation program will be headed by the infection control office that is having experience in the maintenance of the liaison with the health and safety officers, infection control representatives from the government, and other regulatory bodies. This office will be guiding the ICU nurses and physicians on the daily activities and meeting activities throughout the implementation program.

Strategies that facilitate the implementation of the proposed

The effective strategies for the facilitation of the proposed intervention will be through the full collaboration of the team. It will also be based on the provision of feedback on the areas that brought some challenges. The challenges will be discussed during the meetings. The implementation program is expected to take place for 90 working days whereby the parties involved will actively take part in the implementation activities.

During the implementation of the education program towards reduction of CLABSIs

infections, the expected outcomes are the reduction in the rate CLABSIs infections, skilled

healthcare providers especially ICU nurses and physicians with regard to the use of the

central line bundles, and reduction in the mortality and morbidity rates (Salama, Jamal, Al

Mousa, & Rotimi, 2016).

These outcomes are aimed at reducing the cases of hospitalization and increasing

healthcare costs. Therefore, assessing the role of these outcomes is important in ensuring

that necessary changes are made in case the outcomes are not effectively working towards

the reduction of hospitalization with CLASBIs. Assessing the role of the outcomes helps in

ensuring that improvement to the proposed interventions is made. It also helps in ensuring

that the key players towards the implementation of the intervention program are assessed in

terms of their commitment and readiness to bring change while relying on the proposed

intervention (Salama, Jamal, Al Mousa, & Rotimi, 2016).

References

CDC, (2016, January). Blood stream infection events. Central line associated bloodstream Infection and non-centrally line associated blood stream infection. Device Associated Module BSI, 4-1- 4-32. Retrieved from www.cdc . Com

Erdei, C., McAvoy, L., Gupta, M., Pereira, S., & McGowan, E. (2015). Are zero central line associated blood stream infection rates sustainable? A 5-year perspective. Pediatrics, 135(6), 1485-1491. http://dx.doi.org/10.1542/peds.2014-2523

The Effect of an Education Program on the Incidence of Central Venous Catheter-

Associated Bloodstream Infection in a Medical ICU.Warren D.K., Zack J.E., Mayfield

J.L., Chen A., Prentice D., Fraser V.J., Kollef M.H. (2014) Chest, 126 (5) , pp. 1612-

1618

Bourne, L. (2016). Stakeholder relationship management: a maturity model for organisational implementation. Routledge.

Pandi-Perumal, S. R., Akhter, S., Zizi, F., Jean-Louis, G., Ramasubramanian, C., Edward Freeman, R., &Narasimhan, M. (2015). Project stakeholder management in the clinical research environment: how to do it right. Frontiers in psychiatry, 6, 71.

Kurt, R. H., Louis, N., Dagna, O. C., William, J. W., & Peter, J. P. The long term effect of a program to prevent central line-associated bloodstream infections in the surgical intensive care unit. Clinics, 67 (8), 969-970.

Warren, D. K., Zack, J. E., Mayfield, J. L., Chen, A., Prentice, D., Fraser, V. J., et al. (2014). The Effect of an Education Program on the Incidence of Central Venous Catheter-Associated Bloodstream Infection in a Medical ICU. Chest, 126 (5), 1612-1618.

Salama, F. M., Jamal, W., Al Mousa, H., & Rotimi, V. (2016). Implementation of central venous catheter bundle in an intensive care unit in Kuwait: effect on central line-associated bloodstream infections. Journal of Infection and Public Health, 9 (1), 34-41.

Centers for Disease Control and Prevention (2016).‘Central Line-associated Bloodstream infections’, Healthcare-associated Infections, CDC, Atlanta, GA. Retrieved from: https://www.cdc.gov/hai/bsi/bsi.html .

Erdei, C., McAvoy, L., Gupta, M., Pereira, S., & McGowan, E. (2015). Are zero central line associated blood stream infection rates sustainable? A 5-year perspective.Pediatrics, 135(6), 1485-1491. http://dx.doi.org/10.1542/peds.2014-2523

Aloush, S. M., & Alsaraireh, F. A. (2018). Nurses' compliance with central line associated blood stream infection prevention guidelines. Saudi medical journal, 39(3), 273–279. doi:10.15537/smj.2018.3.21497

Adriana, P., Priscila, O., Erique, M., Cassia, F., Clara, L., & Arlete, G. (2014). The long term effect of a program to prevent central line-associated bloodstream infections in the surgical intensive care unit. Clinics, 67 (8), 969-970.

Manouchehr, A. (2016). Evaluation of the effectiveness of an educational intervention to reduce central line-associated bloodstream infections among hemodialysis patients. American Journal of Infection Control, 44 (12), 1703-1704.

Zellmer, C., Zimdars, P., & Safdar, N. (2016). The usefulness of patient education materials for central line-associated bloodstream infection prevention. International Journal of Infection Control, 12, 1-5.