At the Infusion Nursing Society (INS) meeting in May 2009 a panel discussion was held to address methods of reducing central line-associated bloodstream infections (CLABSI). This article presents results experienced by clinicians in their continuing efforts to reduce CLABSIs and to improve patient outcomes at their facilities. These statements are in no way intended to be product endorsements.
Debbie Campbell, MSN, RNC, CCRN
Our journey started in 2004 when we had a CLABSI rate that our team was not satisfied with, even though it was about average for a PICU. In 2008 we lowered our CLABSI rate to 0.42. I’m a firm believer that there is not one thing that causes a reduction. The PICU is a complex environment. The national average (NHSN mean) for CLABSI rates in the PICU is 6.6. Our rates are now much lower than the national average. Our first step was to look at the IHI Central Line Bundle (CLB) and we “pediatricized” it and adopted it into our PICU. We reeducated on hand hygiene, increased our number of audits, employed a “secret shoppers” program to watch and report on nursing practice, and we implemented a swabable, positive displacement needleless connector. In addition we worked on occlusion management and used alteplase when clots began to form. We also joined the National Association of Children’s Hospitals and Related Institutions (NACHRI) collaborative. We developed and implemented the standardized bundle that is related to insertion but with greater emphasis on sustaining maintenance practices. Most of our maintenance practices came from CDC and INS guidelines. We took the usual steps such as sterile insertion, daily assessment of line necessity and education on hand hygiene. We also implemented standardization for catheter site care with a pre-packaged dressing change kit and standardization of practice for tubing changes which requires all IV tubing sets to be changed in the cleanest manner possible. For cap changes we use cap change kits and standardized this process as well. Any tube or cap with blood exposure is changed every 24 hours. Additionally, we spent a lot of time on scrub the hub practice because we found that the policy to scrub the hub with alcohol or in some cases CHG exists, but actual practice often does not reflect the policy. Our auditing actually counted how long people were scrubbing and it very rarely met the standard of 15 seconds with a 15-second dry time. Utilizing the swabable needleless access device, which allows for complete and thorough disinfection, made gaining compliance with our “scrub the hub” campaign easier. We utilized educational programs, e-mails and posters to remind staff of our initiative and rewarded each success. Currently, our CLABSI rate is .42 and we are still improving. The implementation of new and improved products and standardized kits and the ability to sustain the practices we added resulted in a significant CLABSI rate reduction.
Karen Anderson, MT, CIC
Our facility started an initiative to reduce bloodstream infection rates in 2007. At that time the rate in our four adult ICUs was 2.5 per 1,000 catheter days. In 2008, we reduced the CLABSI rate to 1.3. Three of the adult ICUs have been at zero for over 15 months. From 2007 to 2008, we had a 36 percent reduction in CLABSI house-wide, and the rate reduction for the largest ICU was 48 percent. We have worked hard to reduce the total number of central line days through daily line assessment.
Reducing the number of line days has helped reduce the overall CLABSI rate. We implemented many interventions along the way, including the central line bundle, dressing change kits, proper line assessment and documentation, and the swabable, positive displacement, clear cap. We are still working to reduce our rate further and have continuing challenges.
One of the most important things you can do is to continually remind staff about the importance of line care and let them know the CLABSI rate their unit is experiencing. You can’t just perform education and walk away and think it’s going to stick. It’s not going to. People do drift over time. We continue to strive for zero infections and now see that it is possible.
