Influence of a multifaceted intervention on central line days in intensive care units: results of a national multisite study

Development and implementation of a clinical decision support system-based quality initiative to reduce central line-associated bloodstream infections

Background

Central venous lines (CVLs) are frequently utilized in critically ill patients and confer a risk of central line-associated bloodstream infections (CLABSIs). CLABSIs are associated with increased mortality, extended hospitalization, and increased costs. Unnecessary CVL utilization contributes to CLABSIs. This initiative sought to implement a clinical decision support system (CDSS) within an electronic health record (EHR) to quantify the prevalence of potentially unnecessary CVLs and improve their timely removal in six adult intensive care units (ICUs).

Methods

Intervention components included: (1) evaluating existing CDSS' effectiveness, (2) clinician education, (3) developing/implementing an EHR-based CDSS to identify potentially unnecessary CVLs, (4) audit/feedback, and (5) reviewing EHR/institutional data to compare rates of removal of potentially unnecessary CVLs, device utilization, and CLABSIs pre- and postimplementation. Data was evaluated with statistical process control charts, chi-square analyses, and incidence rate ratios.

Results

Preimplementation, 25.2% of CVLs were potentially removable, and the mean weekly proportion of these CVLs that were removed within 24 hours was 20.0%. Postimplementation, a greater proportion of potentially unnecessary CVLs were removed (29%, p < 0.0001), CVL utilization decreased, and days between CLABSIs increased. The intervention was most effective in ICUs staffed by pulmonary/critical care physicians, who received monthly audit/feedback, where timely CVL removal increased from a mean of 18.0% to 30.5% (p < 0.0001) and days between CLABSIs increased from 17.3 to 25.7.

Conclusions

A significant proportion of active CVLs were potentially unnecessary. CDSS implementation, in conjunction with audit and feedback, correlated with a sustained increase in timely CVL removal and an increase in days between CLABSIs.

Teaching-Learning Programs to Prevent and Control Infections Related to Long-Term Central Venous Access Device in Cancer Patients: A Systematic Review

OBJECTIVES

To evaluate the effectiveness of teaching-learning programs for cancer patients and/or their caregivers or family in preventing and controlling infections associated with long-term central venous access devices.

DATA SOURCES

This systematic review used the CINAHL, Cochrane Library, EMBASE, LILACS, and MEDLINE via PubMed portal, Scopus, and Web of Science. Google Scholar was used for the gray literature search. The included studies were analyzed, and the obtained data were qualitatively synthesized. The risk of bias was assessed using Cochrane tools: RoB 2 and ROBINS-I. The certainty of the evidence was evaluated using the GRADE. The review protocol was registered in PROSPERO (CRD42021267530).

CONCLUSION

The teaching-learning programs were implemented through theoretical-practical and theoretical dimensions in five and two studies, respectively. The risk of bias in the studies was low, moderate, severe, and high in one, three, two, and one of them, respectively. The certainty was very low. Teaching-learning programs on central venous access devices care for cancer patients and/or their caregivers or families could be effective in reducing infection rates.

IMPLICATIONS FOR NURSING PRACTICE

This systematic review addressed the teaching-learning programs for preventing and controlling infections associated with long-term central venous access devices. We identified that the most programs were effective in reducing the infection rates. The results may influence the clinical practice of oncology nurses, and consequently, the educational strategies and methods provided not only to these patients but for caregivers and families.

The effect of the multimodal intervention including an automatic notification of catheter days on reducing central line-related bloodstream infection: a retrospective, observational, quasi-experimental study

BACKGROUND

A central venous catheter (CVC) is an important medical device, but it could be preceding infection and the risk of central line-associated bloodstream infection (CLABSI). CLABSI is a common healthcare-associated infection but results in high cost and mortality; therefore, various efforts to reduce CLABSI have been attempted.

METHODS

This is a retrospective, observational, quasi-experimental study in the intensive care unit (ICU) of a single tertiary care hospital. We reviewed and analysed the data of CLABSI rates and days from the insertion to the removal of the temporary CVC between January 2018 and June 2021 with transient periods over 9 months. Sequentially, all patients with the CVC in the ICU underwent the following interventions: maximal barrier precaution, automatic notification of catheter days and 2% chlorhexidine gluconate bathing. A segmented regression analysis of interrupted time series was conducted to compare the CLABSI rates before and after the introduction of multimodal interventions. During study periods, the impact of interventions on CLABSI was evaluated using multivariate logistic regression analyses.

RESULTS

A total of 76,504 patient-days, 28,312 catheter days and 66 CLABSI cases were reviewed in ICU-hospitalised patients. As additional interventions, the CLABSI rate declined from 3.1 per 1000 CVC days to 1.2 per 1000 CVC days in post-interventions. In the pre-intervention and post-intervention periods, 4146 patents had one more short-term CVC. In the multivariate logistic regression analyses, multimodal intervention was one of determinants reducing CLABSI rates (odds ratio (OR), 0.52 [95% confidence interval {CI}, 0.28-0.94]). Indwelling time of CVC over 10 days was the risk factor for CLABSI rates (OR, 6.27 [95% CI, 3.36-12.48]). Of the three interventions, the automatic notification of catheter days was associated with decreased median monthly total CVC days and duration of CVC days per patient.

CONCLUSIONS

Multidisciplinary and evidence-based interventions could lead to a decrease in the CLABSI rates. Moreover, the automatic notification of catheter days of the electronic medical healthcare system has shortened the time of indwelling CVC.

Reducing Central Line Associated Bloodstream Infections (CLABSIs) by Reducing Central Line Days

Purpose of Review

While reducing unnecessary days present of central venous catheters (CVCs) is part of central line associated bloodstream infection (CLABSI) best practices, there is limited information regarding compliance with this recommendation as well as addressing barriers to compliance.

Recent Findings

Significant work has been directed towards daily audits of necessity and improving communication between members of the medical team. Other critical interventions include utilization of the electronic health record (EHR), leadership support of CLABSI reduction goals, and avoiding CVC placement over more appropriate vascular access.

Summary

Institutions have varied approaches to addressing the issue of removing idle CVCs, and more standardized approaches in checklists as well as communication, particularly on multidisciplinary rounds, will be key to CVC removal. Utilization of the EHR for reminders or appropriate documentation of necessity is a factor. Avoidance of placing a CVC or appropriateness of the CVC is also important to consider.

A systematic review and meta-synthesis of policy intervention characteristics that influence the implementation of government-directed policy in the hospital setting: implications for infection prevention and control

Background

Government-directed policy plays an important role in the regulation and supervision of healthcare quality. Effective implementation of these policies has the potential to significantly improve clinical practice and patient outcomes, including the prevention of healthcare-associated infections. A systematic review of research describing the implementation of government-directed policy in the hospital setting was performed with the aim to identify policy intervention characteristics that influence implementation.

Methods

A systematic search of four electronic databases was undertaken to identify eligible articles published between 2007 and 2017. Studies were included if published in the English language and described the implementation of government-directed policy in a high-income country hospital setting. Data on policy and implementation were extracted for each article and interpretive syntheses performed.

Results

A total of 925 articles were retrieved and titles and abstracts reviewed, with 69 articles included after review of abstract and full text. Qualitative synthesis of implementation data showed three overarching themes related to intervention characteristics associated with implementation: clarity; infrastructure; and alignment.

Conclusion

Better understanding and consideration of policy intervention characteristics during development and planning will facilitate more effective implementation although research describing implementation of government-directed policy in the hospital setting is limited and of variable quality. The findings of this study provide guidance to staff tasked with the development or implementation of government-directed policy in the hospital setting, infection prevention and control professionals seeking to maximise the impact of policy on practice and improve patient outcomes.

Safety Checklist Implementation Did Not Reduce Central Venous Catheter Duration in Pediatric Cardiac ICU Patients

The Center for Disease Control recommends prompt removal of nonessential central venous catheters (CVCs) to reduce the risk for central line-associated bloodstream infections. Safety checklists have been trialed to reduce nonessential CVC days, but pediatric studies are lacking. Our specific aim was to detect >10% reduction in mean CVC duration after implementation of a safety checklist addressing CVCs in our unit.

Methods

All patients admitted to the Congenital Cardiovascular Care Unit at New York University Langone Medical Center who had a CVC placed between January 1, 2012, and December 31, 2017, were included. We implemented a checklist addressing CVC use in our unit on June 7, 2013, and modified it on March 10, 2016. We analyzed quarterly mean CVC duration and postsurgical CVC duration over the study period using statistical process control charts.

Results

We placed 778 CVCs for 7,947 CVC days during the study period. We noted special cause variation from Q4 2013 to Q2 2014 and a centerline shift in mean CVC duration from 8.91 to 11.10 days in Q1 2015. In a subgroup analysis of the 657 lines placed in surgical patients, there was a centerline shift in mean CVC duration from 6.48 to 8.86 days in Q4 2013.

Conclusions

Our study demonstrated an unexpected increase in mean CVC duration after the implementation of a safety checklist designed to decrease nonessential CVC days. Additional studies are needed to identify the ideal method to detect and remove nonessential CVCs and reduce the risk of preventable harm.

Impact of a Central-Line Insertion Site Assessment (CLISA) score on localized insertion site infection to prevent central-line-associated bloodstream infection (CLABSI)

OBJECTIVE

To assess the impact of a newly developed Central-Line Insertion Site Assessment (CLISA) score on the incidence of local inflammation or infection for CLABSI prevention.

DESIGN

A pre- and postintervention, quasi-experimental quality improvement study.

SETTING AND PARTICIPANTS

Adult inpatients with central venous catheters (CVCs) hospitalized in an intensive care unit or oncology ward at a large academic medical center.

METHODS

We evaluated CLISA score impact on insertion site inflammation and infection (CLISA score of 2 or 3) incidence in the baseline period (June 2014-January 2015) and the intervention period (April 2015-October 2017) using interrupted times series and generalized linear mixed-effects multivariable analyses. These were run separately for days-to-line removal from identification of a CLISA score of 2 or 3. CLISA score interrater reliability and photo quiz results were evaluated.

RESULTS

Among 6,957 CVCs assessed 40,846 times, percentage of lines with CLISA score of 2 or 3 in the baseline and intervention periods decreased by 78.2% (from 22.0% to 4.7%), with a significant immediate decrease in the time-series analysis (P < .001). According to the multivariable regression, the intervention was associated with lower percentage of lines with a CLISA score of 2 or 3, after adjusting for age, gender, CVC body location, and hospital unit (odds ratio, 0.15; 95% confidence interval, 0.06-0.34; P < .001). According to the multivariate regression, days to removal of lines with CLISA score of 2 or 3 was 3.19 days faster after the intervention (P < .001). Also, line dwell time decreased 37.1% from a mean of 14 days (standard deviation [SD], 10.6) to 8.8 days (SD, 9.0) (P < .001). Device utilization ratios decreased 9% from 0.64 (SD, 0.08) to 0.58 (SD, 0.06) (P = .039).

CONCLUSIONS

The CLISA score creates a common language for assessing line infection risk and successfully promotes high compliance with best practices in timely line removal.

Interventions to reduce unnecessary central venous catheter use to prevent central-line–associated bloodstream infections in adults: A systematic review

Objective

To identify, describe, and evaluate interventions to reduce unnecessary central venous catheter (CVC) use to prevent central-line–associated bloodstream infections (CLABSIs) in adults.

Design

Systematic review.

Methods

The review has been registered in PROSPERO, an international prospective register of systematic reviews. We searched PubMed, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), and the Cumulative Index to Nursing and Allied Health (CINAHL) from inception until August 28, 2018, to collect experimental and observational studies. We included all studies that implemented interventions to reduce unnecessary CVC use, defined as interventions aimed at improving appropriateness, awareness of device presence, or prompt removal of devices.

Results

In total, 1,892 unique citations were identified. Among them, 1 study (7.1%) was a randomized controlled trial, 9 studies (64.3%) were quasi-experimental studies, and 4 studies (28.6%) were cohort studies. Furthermore, 13 studies (92.9%) demonstrated a decrease in CVC use after intervention despite different reporting methods, and the reduction rate varied from 6.8% to 85%. Also, 7 studies (50.0%) that reported the incidence of CLABSI described a reduction in CLABSIs ranging from 24.4% to 100.0%. Data on secondary outcomes were limited, and results of the descriptive analysis showed 70%–84% compliance with these interventions, less catheter occlusion, shorter duration of hospitalization, and cost savings.

Conclusions

Interventions to reduce unnecessary CVC use significantly decrease the rate of CLABSI. Healthcare providers should strongly consider implementing these interventions for prevention of CLABSI in adults.

Are quality improvement collaboratives effective? A systematic review

Background

Quality improvement collaboratives (QIC) have proliferated internationally, but there is little empirical evidence for their effectiveness.

Method

We searched Medline, Embase, CINAHL, PsycINFO and the Cochrane Library databases from January 1995 to December 2014. Studies were included if they met the criteria for a QIC intervention and the Cochrane Effective Practice and Organisation of Care (EPOC) minimum study design characteristics for inclusion in a review. We assessed study bias using the EPOC checklist and the quality of the reported intervention using a subset of SQUIRE 1.0 standards.

Results

Of the 220 studies meeting QIC criteria, 64 met EPOC study design standards for inclusion. There were 10 cluster randomised controlled trials, 24 controlled before-after studies and 30 interrupted time series studies. QICs encompassed a broad range of clinical settings, topics and populations ranging from neonates to the elderly. Few reports fully described QIC implementation and methods, intensity of activities, degree of site engagement and important contextual factors. By care setting, an improvement was reported for one or more of the study’s primary effect measures in 83% of the studies (32/39 (82%) hospital based, 17/20 (85%) ambulatory care, 3/4 nursing home and a sole ambulance QIC). Eight studies described persistence of the intervention effect 6 months to 2 years after the end of the collaborative. Collaboratives reporting success generally addressed relatively straightforward aspects of care, had a strong evidence base and noted a clear evidence-practice gap in an accepted clinical pathway or guideline.

Conclusions

QICs have been adopted widely as an approach to shared learning and improvement in healthcare. Overall, the QICs included in this review reported significant improvements in targeted clinical processes and patient outcomes. These reports are encouraging, but most be interpreted cautiously since fewer than a third met established quality and reporting criteria, and publication bias is likely.

Frequency of change of chlorhexidine-impregnated gel dressings for central venous catheters in critically ill patients

Abstract Objectives: To identify the frequency of change of chlorhexidine-impregnated gel dressings applied in central venous catheter insertion sites, describe reasons for dressing changes, and identify the amount of dressings used per adult patients admitted to an intensive care unit. Methods: Descriptive study consisting of daily record of occurrence evaluation, reason for dressing change and quantity used per patient, between April and December 2014. Descriptive statistical analysis was used. Results: A total of 159 dressings were applied at the insertion site of 64 central venous catheters whose mean frequency of dressing changes was 3.04 days. The mean number of dressing per patient was 3.1, but 83 unscheduled changes occurred before 7 days of stay, due to detachment, wetness, soiling, and loss of dressing. Conclusion: The frequency of dressing changes was less than seven days, resulting in greater quantities of dressings per patient. Detachment was the most common reason for unscheduled dressing changes.

Prevention of central venous line associated bloodstream infections in adult intensive care units: A systematic review

BACKGROUND

In adult Intensive Care Units, the complexity of patient treatment requirements make the use of central venous lines essential. Despite the potential benefits central venous lines can have for patients, there is a high risk of bloodstream infection associated with these catheters.

AIM

Identify and critique the best available evidence regarding interventions to prevent central venous line associated bloodstream infections in adult intensive care unit patients other than anti-microbial catheters.

METHODS

A systematic review of studies published from January 2007 to February 2016 was undertaken. A systematic search of seven databases was carried out: MEDLINE; CINAHL Plus; EMBASE; PubMed; Cochrane Library; Scopus and Google Scholar. Studies were critically appraised by three independent reviewers prior to inclusion.

RESULTS

Nineteen studies were included. A range of interventions were found to be used for the prevention or reduction of central venous line associated bloodstream infections. These interventions included dressings, closed infusion systems, aseptic skin preparation, central venous line bundles, quality improvement initiatives, education, an extra staff in the Intensive Care Unit and the participation in the 'On the CUSP: Stop Blood Stream Infections' national programme.

CONCLUSIONS

Central venous line associated bloodstream infections can be reduced by a range of interventions including closed infusion systems, aseptic technique during insertion and management of the central venous line, early removal of central venous lines and appropriate site selection.

Using Incentives to Improve Resource Utilization: A Quasi-Experimental Evaluation of an ICU Quality Improvement Program

OBJECTIVES

Healthcare systems strive to provide quality care at lower cost. Arterial blood gas testing, chest radiographs, and RBC transfusions provide an important example of opportunities to reduce excess resource utilization within the ICU. We describe the effect of a multifaceted quality improvement program designed to decrease the avoidable arterial blood gases, chest radiographs, and RBC utilization on utilization of these resources and patient outcomes.

DESIGN

Prospective pre-post cohort study.

SETTING

Seven ICUs in an academic healthcare system.

PATIENTS

All adult ICU patients admitted to study ICUs during consecutive baseline (n = 7,357), intervention (n = 7,553), and follow-up (n = 7,657) years between September 2010 and August 2013.

INTERVENTIONS

A multifaceted quality improvement program including provider education, audit and feedback, and unit-based provider financial incentives targeting arterial blood gas, chest radiograph, and RBC utilization.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the number of orders for arterial blood gases, chest radiographs, and RBCs per patient. Compared with the baseline period, unadjusted arterial blood gas, chest radiograph, and RBC utilization in the intervention period was reduced by 42%, 26%, and 17%, respectively (p < 0.01). After adjusting for potentially relevant patient factors, the intervention was associated with 128 fewer arterial blood gases, 73 fewer chest radiographs, and 16 fewer RBCs per 100 patients (p < 0.01). This effect was durable during the follow-up year. This reduction yielded an approximate net savings of $1.5 M in direct costs over the intervention and follow-up years after accounting for the direct costs of the program. Unadjusted hospital mortality decreased from 7% in the baseline period to 5.2% in the intervention period (p < 0.01). This reduction remained significant after adjusting for patient factors (odds ratio = 0.43; p < 0.01).

CONCLUSIONS

Implementation of a multifaceted quality improvement program including financial incentives was associated with significant improvements in resource utilization. Our findings provide evidence supporting the safety, effectiveness, and sustainability of incentive-based quality improvement interventions.

Nursing Activity Score for estimating nursing care need in intensive care units: findings from a face and content validity study

AIM

To re-evaluate the face and content validity of the Nursing Activity Score currently adopted in evaluating activities that best describe workloads in intensive care units and their weight in describing average nursing time consumption.

BACKGROUND

The Nursing Activity Score calculates the amount of nursing time that each patient will require over the next 24 hours. It has been widely used around the world since its first validation in 2003. However, no re-evaluation of its validity with regard to the advancements achieved in intensive care units nursing care has been documented to date.

METHOD

A research project was undertaken from 2012 to 2015, aimed at critically evaluating and validating this tool in the current context of Italian intensive care units nursing care. The 23 items were translated forward and backward into the Italian language, then a panel of 10 experts in critical care evaluated the face validity. Content validity was evaluated through focus groups involving seven critical care expert registered nurses.

FINDINGS

The Nursing Activity Score instrument has been considered as not fully adequate to measure current intensive care units nursing activities and their weightings have been considered not fully adequate to score average nursing time consumption. From the content validity process, lack of adequacy has emerged with respect to the concept of nursing care underpinning the tool, the interventions included, its capability to predict the nursing resources needed, advancements achieved in intensive care units nurses' roles and competences, and the contextual factors that may influence consumption of nursing time.

CONCLUSIONS

Development of the Nursing Activity Score tool both conceptually and in its structure, in view of the innovations that have occurred in the context of intensive care units, is necessary to continue to have a common tool to help clinicians and managers to capture accurately and compare nursing care required by patients in critical care settings.

IMPLICATIONS FOR NURSING MANAGEMENT

There is a need to revise the Nursing Activity Score tool, enabling its use in estimating nursing workloads in current Italian intensive care units practice. A taskforce of clinical nurses and nursing managers, capable of protecting the valuable original Nursing Activity Score project and to advance its further development is recommended.

Eliminating Infections in the ICU: CLABSI

Central line-associated bloodstream infections (CLABSI) are one of the leading causes of death in the USA and around the world. As a preventable healthcare-associated infection, they are associated with significant morbidity and excess costs to the healthcare system. Effective and long-term CLABSI prevention requires a multifaceted approach, involving evidence-based best practices coupled with effective implementation strategies. Currently recommended practices are supported by evidence and are simple, such as appropriate hand hygiene, use of full barrier precautions, avoidance of femoral lines, skin antisepsis, and removal of unnecessary lines. The most successful and sustained improvements in CLABSI rates further utilize an adaptive component to align provider behaviors with consistent and reliable use of evidence-based practices. Great success has been achieved in reducing CLABSI rates in the USA and elsewhere over the past decade, but more is needed. This article aims to review the initiatives undertaken to reduce CLABSI and summarizes the sentinel and recent literature regarding CLABSI and its prevention.

Quality Improvement Process in a Large Intensive Care Unit: Structure and Outcomes

Quality improvement in the health care setting is a complex process, and even more so in the critical care environment. The development of intensive care unit process measures and quality improvement strategies are associated with improved outcomes, but should be individualized to each medical center as structure and culture can differ from institution to institution. The purpose of this report is to describe the structure of quality improvement processes within a large medical intensive care unit while using examples of the study institution's successes and challenges in the areas of stat antibiotic administration, reduction in blood product waste, central line-associated bloodstream infections, and medication errors.