Decreasing Central Line–Associated Bloodstream Infections in the Non-ICU Population

Self-Reported versus observed audit: Measuring CHG bathing compliance

Measuring compliance with the appropriate chlorhexidine gluconate (CHG) bathing process through direct observation audits can be helpful in sustaining this important practice; however, capturing this data may be difficult. This study reports the differences between observed and self-reported CHG bathing process compliance audits. The difference between mean observed and self-reported compliance was not significant (p = .06), indicating that self-reported compliance may be an accurate, easy to obtain proxy measure for CHG bathing process compliance.

Results of the CHlorhexidine Gluconate Bathing implementation intervention to improve evidence-based nursing practices for prevention of central line associated bloodstream infections Study (CHanGing BathS): a stepped wedge cluster randomized trial

BACKGROUND

Central line-associated bloodstream infections (CLABSIs) result in approximately 28,000 deaths and approximately $2.3 billion in added costs to the U.S. healthcare system each year, and yet, many of these infections are preventable. At two large health systems in the southeast United States, CLABSIs continue to be an area of opportunity. Despite strong evidence for interventions to prevent CLABSI and reduce associated patient harm, such as use of chlorhexidine gluconate (CHG) bathing, the adoption of these interventions in practice is poor. The primary objective of this study was to assess the effect of a tailored, multifaceted implementation program on nursing staff's compliance with the CHG bathing process and electronic health record (EHR) documentation in critically ill patients. The secondary objectives were to examine the (1) moderating effect of unit characteristics and cultural context, (2) intervention effect on nursing staff's knowledge and perceptions of CHG bathing, and (3) intervention effect on CLABSI rates.

METHODS

A stepped wedged cluster-randomized design was used with units clustered into 4 sequences; each sequence consecutively began the intervention over the course of 4 months. The Grol and Wensing Model of Implementation helped guide selection of the implementation strategies, which included educational outreach visits and audit and feedback. Compliance with the appropriate CHG bathing process and daily CHG bathing documentation were assessed. Outcomes were assessed 12 months after the intervention to assess for sustainability.

RESULTS

Among the 14 clinical units participating, 8 were in a university hospital setting and 6 were in community hospital settings. CHG bathing process compliance and nursing staff's knowledge and perceptions of CHG bathing significantly improved after the intervention (p = .009, p = .002, and p = .01, respectively). CHG bathing documentation compliance and CLABSI rates did not significantly improve; however, there was a clinically significant 27.4% decrease in CLABSI rates.

CONCLUSIONS

Using educational outreach visits and audit and feedback implementation strategies can improve adoption of evidence-based CHG bathing practices.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03898115 , Registered 28 March 2019.

Culture of Safety: Impact on Improvement in Infection Prevention Process and Outcomes

Purpose

Safety culture is known to be related to a wide range of outcomes, and measurement of safety culture is now required for many hospitals in the U.S.A. In previous reviews, the association with outcomes has been limited by the research design and strength of the evidence. The goal of this review was to examine recent literature on the relationship between safety culture and infection prevention and control-related (IPC) processes and healthcare-associated infections (HAIs) in U.S. healthcare organizations. We also sought to quantitatively characterize the challenges to empirically establishing these relationships and limitations of current research.

Recent Findings

A PubMed search for U.S. articles published 2009–2019 on the topics of infection prevention, HAIs, and safety culture yielded 448 abstracts. After screening, 55 articles were abstracted for information on purpose, measurement, analysis, and conclusions drawn about the role of safety culture in the outcome. Approximately ½ were quality improvement (QI) initiatives and ½ were research studies. Overall, 51 (92.7%) concluded there was an association between safety culture and IPC processes or HAIs. However, only 39 studies measured safety culture and 26 statistically analyzed safety culture data for associations. Though fewer QI initiatives analyzed associations, a higher proportion concluded an association exists than among research studies.

Summary

Despite limited empirical evidence and methodologic challenges to establishing associations, most articles supported a positive relationship between safety culture, improvement in IPC processes, and decreases in HAIs. Authors frequently reported experiencing improvements in safety culture when not directly measured. The findings suggest that associations between improvement and safety culture may be bi-directional such that positive safety culture contributes to successful interventions and implementing effective interventions drives improvements in culture. Greater attention to article purpose, design, and analysis is needed to confirm these presumptive relationships.

Effect of a Systemwide Approach to a Reduction in Central Line-Associated Bloodstream Infections

BACKGROUND

Unit-based initiatives were deployed independently creating silos in practice variability across the system with little impact on reduction of central line-associated bloodstream infections (CLABSI).

PROBLEM

The goal was to decrease CLABSI systemwide by establishing standardized evidence-based practice (EBP) procedures to advance nursing practice.

APPROACH

A new innovative method, the Ferrari Method for Practice Standardization, enhanced the quality infrastructure by merging EBP and lean methodology to translate nursing innovations into practice. Leveraging a culture of shared decision making to support autonomy, as well as collaborating interprofessionally, allowed the organization to standardize and sustain CLABSI prevention.

OUTCOMES

The Ferrari Method for Practice Standardization successfully reduced CLABSI rates by 48% over a 1-year improvement cycle. Eight standardized EBP clinical procedures were developed and implemented across the organization.

CONCLUSION

The implementation of the Ferrari Method for Practice Standardization swiftly moves new knowledge into clinical practice to improve outcomes. Using standardized improvement methodology, it eases the interprofessional approval processes, maximizes autonomy, and focuses on quality care.

Preventive bundles to reduce catheter-associated bloodstream infections in neonatal intensive care

This systematic survey includes a total of 27 studies published between 2002 and 2016 on the benefit of preventive bundles for the prevention of central-line associated bloodstream infections (CLABSI) in neonatal intensive care. These studies are mainly cohort studies or studies analyzing an interrupted time series before and after intervention. The studies showed heterogeneity in terms of endpoint definitions (CLABSI), details of the implemented measures, and evidence of a publication bias favoring the use of of preventive bundles. The cumulative analysis showed a statistically and clinically significant benefit of preventive bundles to avoid CLABSI in neonatal intensive care.

Enhanced central venous catheter bundle for pediatric parenteral-dependent intestinal failure

BACKGROUND

Central line-associated bloodstream infections (CLABSIs) cause substantial morbidity and increase antimicrobial use and length of stay among hospitalized children in the United States. CLABSI occurs more frequently among high-risk pediatric patients, such as those with intestinal failure (IF) who are parenteral nutrition (PN) dependent. Following an increase in CLABSI rates, a quality improvement (QI) initiative was implemented.

METHODS

Using QI methodology, an enhanced central venous catheter (CVC) maintenance bundle was developed and implemented on 2 units for pediatric PN-dependent patients with IF. CLABSI rates were prospectively monitored pre- and postimplementation, and bundle element adherence was monitored. Enhanced bundle elements included chlorhexidine-impregnated patch, daily bathing, ethanol locks, 2 nurses for CVC care in a distraction-free zone, peripheral laboratory draws, bundling routine laboratory tests, and PN administration set changes every 24 hours.

RESULTS

Adherence to enhanced bundle elements increased to >90% over 3 months. CLABSI rates averaged 1.41 per 1,000 central line days preimplementation compared with 0.40 per 1,000 device days postimplementation (P = .003), an 85% absolute reduction in CLABSI rates over 12 months.

CONCLUSIONS

Patients with IF are at an increased risk for CLABSI. Enhanced CVC maintenance bundles that specifically target prevention practices in this population may be beneficial.

Assessing nurses' adherence to a central line maintenance care checklist on a pediatric inpatient unit

Adherence to evidence-based central line maintenance practices remains a challenge, particularly in complex patient populations. Using an evidence-based observational checklist, areas of nonadherence were identified and a focused educational intervention was developed, resulting in improved adherence across all aspects of the central line maintenance care bundle.

Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their central line-associated bloodstream infection (CLABSI) prevention efforts. This document updates “Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Challenges in Hospital-Associated Infection Management

Maintaining a successful unit-based continuous quality improvement program for managing hospital-associated infections is a huge challenge and an overwhelming task. It requires strong organizational support and unit leadership, human and fiscal resources, time, and a dedicated and motivated nursing staff. A great deal of effort goes into implementing, monitoring, reporting, and evaluating quality improvement initiatives and can lead to significant frustration on the part of the leadership team and nursing staff when quality improvement efforts fail to produce the desired results. Each initiative presents its own unique set of challenges; however, common issues influence all initiatives. These common issues include organization and unit culture, current clinical practice guidelines being used to drive the initiatives, performance discrepancies on the part of nursing staff, availability of resources including equipment and supplies, monitoring of the data, and conflicting quality improvement priorities.

Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their central line-associated bloodstream infection (CLABSI) prevention efforts. This document updates “Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.