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Improved central line care reduced bloodstream infections
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Simple measures may be all that is needed to decrease rates of central line-associated bloodstream infections, according to data presented at the 2014 Annual Conference of the Association for Professionals in Infection Control and Epidemiology.
Infection preventionists at three hospitals reported successful ways that prevented bloodstream infections associated with central line catheters. Many facilities follow a bundle of best practices to reduce risk factors during the insertion of a central line, but experts admit that continuous and safe maintenance of the line is difficult.
“Sharing successful process improvement strategies for catheter maintenance is essential to continuing efforts to prevent these serious bloodstream infections,” Association for Professionals in Infection Control and Epidemiology (APIC) 2014 President Jennie Mayfield, BSN, MPH, CIC, said in a press release. “For patients with long lengths of stay, maintenance-related issues become very important. As these examples demonstrate, each health system needs to review its own data and work as a team with front-line caregivers to tailor interventions that will be successful at their institution.”
A trio of abstracts addressed the challenge of keeping bacteria from entering the bloodstream through a central line.
Task force proves effective in Texas hospital
Infection preventionists at Texas Health Dallas, an 800-bed facility, noticed an increase in hospital-wide central line-associated bloodstream infections (CLABSI) in 2011. In response to the increase, they assembled a task force to assess infection data and recommend improvement strategies. A gap analysis, utilizing observational audits, identified inadequate catheter maintenance; specifically, employees were not consistently scrubbing the hub with alcohol for the required 15 seconds before accessing the line, according to Barbara Danielson, RN, BSN, CIC, study researcher and infection prevention manager at Texas Health Dallas.
The task force included members of the infection prevention department and hospital employees. They tried a range of evidence-based strategies to improve line maintenance, but did not see improvement in CLABSI rates until alcohol-impregnated port protectors, which had already been used successfully in the hospital’s neonatal ICU, were introduced.
In November 2012, infection preventionists received approval from hospital administration to use the disinfecting caps on every patient, for every port, on every unit. In 10 months, CLABSI rates decreased by 68%. By adding a simple device to other evidence-based measures, Texas Health Dallas prevented 17 CLABSIs during the first 10 months for a total cost savings of $410,000. In addition, by eliminating the need to scrub the hub, the hospital calculated an annual time savings of 144 nurse hours.
“We did this in a very systematic fashion,” Danielson said in a press release from APIC. “We involved a team and went through the necessary steps to show that this was the intervention that we needed.”
To maintain compliance with use of the alcohol-impregnated port protectors, the infection prevention team educated nurse managers and front-line providers, conducted weekly audits, and made sure the port protectors were readily available at every point-of-use. It took 5 months to reach their goal of 85% of patients having 100% of their connector hubs and ports covered.
“The alcohol-impregnated port protectors represent one way to protect the line and keep it in a constant state of disinfection, but there’s a lot more involved than just adding a cap,” Danielson said. “You have to stay on top of the process.”
Illinois hospital goes beyond scrubbing the hub
Loyola University Medical Center in Maywood, Ill., also saw a significant improvement in CLABSI rates after routine use of disinfection caps on all connector hubs and access ports.
The infection prevention team at Loyola University Medical Center, which has 140 ICU beds, aimed to identify the best ways to decrease colonization beyond scrubbing the hub. The researchers conducted a three-arm study comparing disinfection caps with an intense scrub-the-hub intervention vs. standard care. At the end of the study, both the scrub-the-hub and the disinfection caps interventions reduced CLABSI significantly.
During the last 3 months of the study, the team discovered that 80% of the infections that occurred in the scrub-the-hub arm were related to a significant drop-off in adherence to scrubbing the hub for the required 15 seconds.
“It became clear that relying solely on the scrub-the-hub method may not be sustainable for many staff,” Marcelina M. Wawrzyniak, MSN, RN, study researcher and infection preventionist at Loyola University Medical Center, said in a press release. “The alcohol-impregnated caps, by comparison, were very well received due to their ease of use. Our study shows that long term, they have a sustained, positive impact on CLABSI reduction.”
Results of a 2-year follow-up study also presented at the APIC meeting revealed that the Loyola researchers found a 68% decrease in the overall number of CLABSIs. A total of 59 CLABSIs occurred during the 12-month standard care period compared with 23 CLABSIs during the 12-month intervention period; alcohol-impregnated disinfection caps were used on all central line access ports during this time.
Using a recent analysis published in JAMA Internal Medicine, which estimated the cost of CLABSIs at $45,814 per infection, prevention of these additional 36 CLABSIs reduced CLABSI-related costs by more than $1 million during the intervention year, according to Jorge Parada, MD, MPH, FACP, FIDSA, professor of medicine at Loyola University Chicago Stritch School of Medicine.
“It was vital to get C-suite support for this intervention,” Parada said in the release. “By demonstrating that implementing this method to reduce CLABSI would not only yield improved patient outcomes, but also an improved bottom line, it was a no-brainer for our leadership.”
Pittsburgh hospital moves back to basics
A 250-bed community hospital in Pittsburgh had success in reducing CLABSIs with use of a “back-to-basics” approach.
After a decision in August 2012 to halt use of the alcohol-impregnated caps previously used on central lines, an increase occurred in the number of CLABSIs at University of Pittsburgh Medical Center (UPMC) St. Margaret hospital. This led the infection prevention team to institute a back-to-basics approach to the maintenance of central lines, according to Jenny Bender, MPH, BSN, RN, CPH, study researcher and infection preventionist at UPMC St. Margaret.
The team rolled out a variety of educational tools, including videos, talking points, printed pocket cards and postcards, as well as an extensive online manual accessible on the facility’s intranet. These tools covered topics such as scrubbing the hub, proper labeling, dressing and tubing change requirements and techniques.
The toolkit was released in May 2013 and the facility saw zero CLABSIs through November.
“Sometimes, people can become a bit too reliant on products, like we were with the alcohol caps,” Bender said in a press release. “Our staff got so used to having them and letting them do the work for us that we became too relaxed with our good nursing care, when it comes to maintaining a line. As a team, we were able to retrain and re-introduce good practices back into our everyday routine to improve our patient outcomes.”
The basic steps of maintaining a safe central line include: 1) conduct hand hygiene before accessing the line; 2) determine if the line is still needed, and if not, obtain an order to have it removed; 3) assess and document the condition of the line; 4) scrub the hub for 15 seconds; 5) conduct line flushing; and 6) change the dressing and tubing according to protocol.
“Basic line care should always be the first defense against bloodstream infections,” Bender said. “This demonstrational study shows that going back to the basics can in fact make a difference in infection prevention.”
For more information:
Bender J. #417.
Danielson B. #419.
Wawrzyniak MM. #418. All abstracts presented at: APIC 2014; June 7-9, 2014; Anaheim, Calif.