INTRODUCING STATISTICS FOR THE DNP

This academic Doctor of Nursing Practice (DNP) project is a quality evaluation of an evidence-based central line associated bloodstream infection (CLABSI) reduction program at a surgical intensive care unit (SICU). Acquisition of CLABSIs affects thousands of patients every year, costing $300 million to $2.3 billion annually, and has a mortality rate of about 10-30%. Without a protagonist approach for nursing interventions and processes, indwelling time (catheter duration) can increase, leading to colonization of microorganisms and further CLABSIs as well as demise of ICU patients. The practice-focused question was: Will a retrospective evaluation of a quality improvement initiative involving an evidence-based CLABSI reduction program demonstrate reductions in CLABSI rates in the SICU? The purpose of this project was to determine if leveraging hospital support for an infection prevention program using a recommended CLABSI bundle protocol would impact quality outcomes. Evaluation involved a chi-test to show all bundle components had a value of p < . 001, except handwashing, which did not show a statistically significant change. This study resulted in evidence-based research regarding education and appropriate interventions to produce best outcomes for patients. With adequate leadership support and direction, staff were able to understand the importance of CLABSI protocols and making changes in their practice in order to produce quality outcomes.

Background

Approximately 28,000 people die each year from central line bloodstream infections (CLABSIs; (Alshahrani et al., 2023). T A Surgical Intensive Care Unit (SICU) embedded in a large academic teaching hospital located in the southeast region of the United States has 18 beds with a patient population composed of general and postoperative cancer patients. Preventing surgical site infections and not acquiring CLABSIs is a high priority during intensive care of these patients. However, the SICU has large numbers of CLABSI infections. Various factors contribute to this increase. The pandemic led to heightened monetary gain opportunities for ICU nurses who were willing to travel, which resulted in the loss of about 50% of core staff. This loss of experienced nurses led new graduate nurses into critical care. To backfill experienced staff, the organization turned to travel nurses. Onboarding orientation for travel nurses never incorporated skillsets involving CLABSI prevention practices. There was an assumption these nurses already had requisite skillsets to address CLABSIs.

Reason for Quality Evaluation of the Practice Change

In late 2022, hospital leadership challenged the SICU and infection control department to address high hospital-acquired infection rates in order to improve patient safety and outcomes. This challenge led to new ways of addressing nursing onboarding orientation, and the need for an evidence-based CLABSI reduction program. This program was developed and implemented in January 2023, and all nursing staff were required to participate. This project was initiated to evaluate the impact of the CLABSI reduction program on infection rates and changes to nursing practice in the SICU.

Project Purpose

The project question was: Will a retrospective evaluation of a quality improvement initiative involving an evidence-based CLABSI reduction program demonstrate a reduction in CLABSI rates in the SICU? The purpose of this quality improvement evaluation project was to evaluate reducing CLABSI rates and maintaining best practices for CLABSI prevention using the recommended CLABSI bundle regarding nursing care in the SICU.

Assessment of the Site

Organizational strengths of the facility included a fully engaged leadership team who wanted objective evidence of results of this CLABSI reduction program. The SICU also had full cooperation from participating staff nurses and SICU advanced practice providers. There were opportunities for better nurse retention in terms of increased stability. The main threat was continual mid-level leadership changes, which challenged consistent implementation of nursing practice changes in the SICU.

Summary of Evidence

Evidence to support the quality evaluation project came from literature on program sustainability and evidence from the staff education program on CLABSI reduction (see Table 1). CLABSI reduction programs starts with use of key components of the CLABSI bundle. Sustainability of successful CLABSI programs requires leadership support, cultures of safety, availability of resources, and appropriate nurse to patient ratios (Mossburg et al., 2020; Phillips et al., 2021; Pozzobon et al., 2023). Sustainability of these programs must also involve appropriate and continual education (Dyk et al., 2021).

Table 1

Summary of Evidence

Project Development

Planning and Design

Evaluation outcome variables for this project were CLABSI rates and adherence to the CLABSI bundle protocol. While reviewing data with an infection control preventionist, two distinct time frames were identified to conduct this evaluation. The first time frame lasted 3 months prior to the start of the CLABSI reduction program, from October to December 2022. The second time frame was between October and December 2023, which was after implementation of the program.

Implementation

CLABSI rates for the SICU were easily identified via the infection control department. Data were retrieved to show the number of CLABSI infections each quarter given total number of infections during a particular year. To examine adherence to CLABSI bundle protocols, a daily central line care and maintenance audit tool (see Appendix A) was developed based on recommended evidence-based practices involving the CLABSI reduction program (see Appendix B). The daily central line care and maintenance audit tool was used by SICU leadership and infection control to determine daily compliance with CLABSI bundle protocols. Information in daily reports included number of patients with central lines in the SICU. The leadership team used the daily central line audit tool while making direct observations of patients. Items that were marked as no during rounds required immediate followup with primary nurses with the expectation that there would be instantaneous corrective action taken.

Daily compliance was checked at random for at least 2 to 3 days during the week based on number of patients in the unit with central lines. The daily central line care and maintenance audit tool was used for deidentified patient data and completion of the compliance bundle for patients.

Data Collection

Data from this daily central line care and maintenance audit tool were stored in the infection control databank and retrieved upon request. For each month, 10 audits were reviewed, leading to a total of 30 audits prior to the CLABSI reduction program and 30 audits after program implementation for a total of 60 patient audits ( n = 60). Outcomes for each month were transferred using pre and post data collection tools (see Appendix C). During analysis of the CLABSI protocol, the bundle was disassembled to highlight particular concerns involving CLABSI prevention.

Results

SICU Central Line Infection Rates

The SICU had nine infections during 2022 (see Appendix D). During Q1 of 2023, the SICU started the CLABSI reduction education program and quickly went to zero CLABSIs starting in Q2. The SICU has remains CLABSI-free for three consecutive quarters.

CLABSI Bundle Compliance

Post evaluation results showed a notable significant increase in terms of compliance (see Appendix E). A chi-square test was performed to understand the relationship between compliance and reduction of CLABSI infections (see Table 2). Between October and December, 2022, chlorhexidine gluconate (CHG) baths were completed with an overall compliance rate of 41.6%. Compared to Q4 in 2023, CHG compliance was at 100%. Chi-square test results showed a statistically significant change ( N = 60; X2 [1], = 0.707, p < .001) in the sample. There were 30 charts each from preintervention and postintervention phases. Intact dressings showed a compliance rate of 43.3% for Q4 in 2022, as compared to a compliance rate of 96.6% during 2023. Chi-square test results were also statistically significant (N=60; X2(1) = 0.681, p <. 001). Prior to implementation of the education program, compliance rates for dated dressings was 23.3%, which changed to 91.6% after implementation ( N = 60; ( X2(1), = 0.681, p < . 001). A scrub the hub approach to decreasing infections showed a compliance rate of 20% in 2022 which changed to 100% in 2023, With Chi- Square test results showing ( N = 60; X2(1), = 0.845, p < . 001). Hand hygiene continued to be struggle for the team with a 68% compliance rate in 2022 which increased to 72% in 2023, with p < . 273. Handwashing did not show a statistically significant change.

Chi-square analysis of these six indicators demonstrated no one component of the CLABSI bundle was more prevalent than the other. During analysis of effectiveness of education, the all or none group showed a 73.3% rate of completing all six components of the CLABSI bundle after education as compared to preimplementation at 0%.

Table 2

Chi-Test Results

Analysis

This qualitative inquiry (QI) evaluation demonstrated the CLABSI reduction program was effective as evidenced by 0% CLABSI rates for Q2-4 during 2023. This trend started immediately after implementation of the CLABSI reduction program and was maintained for three quarters.

QI evaluation was used to identify contributing factors to success of the QI improvement project that was aimed at reducing CLABSI rates. Implementation of bundles is the best practice to help prevent hospital-acquired infections (Gupta et al., 2021; Odada et al., 2023; Randall et al., 2021). Slight improvements with hand hygiene could result from nursing staff understanding the importance of hand hygiene prior to education.

Evidence-based research also shows pillars for successful programs rest on organizations being reliable in terms of leadership commitment, cultures of safety, and process improvement (Phillips et al., 2021; Pozzobon et al., 2023). The SICU had comprehensive leadership involvement from the C-Suite, which included the Chief Nursing Officer at the local unit level as well as physicians, nurses, unit leaders, unit educators, and infection control specialists.

To facilitate better dialogue regarding safety, the SICU took a nonpunitive approach to self-reporting and being fully transparent in terms of error reporting. Lu et al. (2022) identified to establish patient safety and quality outcomes, organizations must focus on improving their processes and workflows to remove factors that can contribute to errors. The necessity of keeping central lines was discussed, and if patients no longer needed vasopressors and/or parental nutrition for 48 hours, the central line was removed.

Limitations

The unit had staff turnover rates, and paperwork was required to verify new staff had been through the education program. Another limitation involved the hierarchical structure of the facility. Some nurses seemed timid when speaking to colleagues about unsafe practices that had the potential to contribute to CLABSI. Lastly, daily central line care and maintenance audit tool had time constraints due to being cumbersome, requiring significant time for observation, and need for immediate feedback when completing the tool.

Impact on Organization

The SICU has a fiduciary responsibility to ensure best outcomes while keeping costs of healthcare under control. This project has helped put into perspective the importance of evidence-based practice and nursing excellence in the SICU. The hospital recognizes next steps in acknowledging guidance and commitment it takes to implement and support good quality initiatives. It is in its final stages for applying for magnet status. This will assist with recruitment and retention of high-quality nurses . The hospital also recognizes the need for standardization of practices across all ICUs and during onboarding orientation.

Importance Beyond the Local Site

The hospital system is comprised of 11 hospitals and is the largest clinically integrated system in Georgia with more than 600 intensive care beds. Standardization of practice within the hospital system can lead to to patient safety and positive patient outcomes by expanding this CLABSI reduction program.

Conclusion

This study has reinforced the necessity for collaborative approaches to reducing CLABSI infections that involve all healthcare providers, from front line staff to nursing leadership. Overall findings indicate evidence-based practice can be linked to quality outcomes and lead to sustainable results over time. Results of this QI evaluation project have proven to be successful in terms of sustainability of CLABSI reduction programs.