Taking Central Line Infection Prevention to the Next Level

Central venous catheters (CVCs) play an integral role in healthcare, however studies have shown that they are among the most frequent cause of healthcare-associated infections (HAIs). Their use is associated with a risk of bloodstream infection caused by microorganisms colonizing the external surface of the device or the fluid pathway when the device is inserted or in the course of its use. The Joint Commission’s CLABSI Toolkit notes that “Employing relatively simple evidence-based practices to reduce, if not eliminate, CLABSIs appears to be within the reach of even resource-limited settings. Within this framework, HAIs—and CLABSIs in particular—are more and more being viewed as ‘preventable’ events.”

By Kelly M. Pyrek

Central venous catheters (CVCs) play an integral role in healthcare, however studies have shown that they are among the most frequent cause of healthcare-associated infections (HAIs). Their use is associated with a risk of bloodstream infection caused by microorganisms colonizing the external surface of the device or the fluid pathway when the device is inserted or in the course of its use. The Joint Commission’s CLABSI Toolkit notes that “Employing relatively simple evidence-based practices to reduce, if not eliminate, CLABSIs appears to be within the reach of even resource-limited settings. Within this framework, HAIs—and CLABSIs in particular—are more and more being viewed as ‘preventable’ events.”

Vascular access experts say they believe that clinicians can avoid adverse events if they are meticulous in their practices and treat central lines as they life-giving and life-saving devices that they are.

“We must pay close attention to all vascular access devices (VAD),” confirms Sophie Harnage, RN, BSN, VA-BC,  former clinical educator for infusion services, and former head of the vascular access team at Sutter Roseville Medical Center (SRMC), in Roseville, Calif. “The majority of patients admitted into hospitals today require an intravenous device to administer their ordered therapy. Without such a device in place, treatment can be delayed, and patients will suffer negative outcomes. These devices or lines must be treated and understood to be the patient’s lifeline. So the question becomes, ‘How do we insert and maintain these lifelines so our patients will be able to enter a hospital and be free from infection throughout their journey?’”

She adds, “I believe that catheter insertion overall around the country is 100 percent improved, but that’s only one small piece of the puzzle. The biggest piece is care and maintenance of these lines. What happens to these lines post insertion, say day 5, 7 or three weeks into an ordered treatment plan? We can eliminate CLABSIs, it is not difficult. In fact, it’s quite easy if facilities have the resources, the support, and understand the dire importance of educating their healthcare personnel.”

Michelle DeVries, MPH, CIC, senior infection control officer for Methodist Hospitals in Gary, Ind., echoes Harnage’s concerns about maintenance being the most challenging part of the process.”The most significant challenge I tend to hear from other clinicians is how we are tending to our dressings,” she says. “We must maintain the dressing properly, taking action when it’s not clean, dry and intact. But how, specifically, are we managing our dressings? Ideally they are staying on for a week, but just because they can last a week doesn’t mean they should last a week when they are compromised. My suspicion is that the problem is multifactorial. For example, are the dressings we are using meeting our needs? If you are placing a dressing down and it is only adhering for a day or two, is that a product failure or is it how we used it? So we grab a roll of tape and tape it back down. There is nothing in the standards I can find that actually supports how tape is to be used to reinforce dressings. If the edges are peeling, taping them back down to prevent it from flipping up and exposing the insertion site is probably okay, but once it’s actually detached and opened up, it’s not okay. So we still have the challenge of teaching personnel when it’s not okay to simply reinforce a dressing.”

Another issue DeVries has observed and heard from others around the country is faulty documentation in the electronic medical record — a behavior that can have significant ramifications for the patient. “There is a documentation disconnect between what we chart as clean, dry and intact, and what the reality is,” she says. “How many times do we go back when we do line audits and say, ‘this dressing was suboptimal’ and we’ll go ahead and get it changed, only to find that it was clearly recently documented as clean, dry and intact — yet in all likelihood it wasn’t. Check the patient, not the box.”

These missed opportunities are a byproduct of numerous competing priorities, DeVries says, something she hears from “every hospital, big and small, urban and suburban — everyone is struggling with so many competing demands on staff. I can’t say for sure that causes it, but I am a strong believer that fully staffed vascular access teams can help drive good outcomes.”

Championing the Vascular Access Team
A vascular access team (VAT) is usually composed of nurses who are specially trained in infusion therapy. These highly skilled and knowledgeable nurses are often certified by the Certified Registered Nurse Infusion (CRNI) credentialing program, or board-certified vascular access nurses (VA-BC), thus bolstering patient safety and positive outcomes. The VAT performs numerous critical functions such as placing and maintaining lines, but also trouble-shooting obstructed or otherwise problematic vascular devices; gathering and analyzing surveillance data for the facility’s quality and Infection prevention departments; providing infusion consultation services to medical and nursing staff; and teaching patients and cases managers how to care for an IV line once the patient returns home.
 
VAT members conduct a vascular access assessment of patients to determine the most appropriate type of IV line that is needed at the most optimal time. The condition of the patient’s veins, the patient’s disease and anticipated prescribed therapies are considered, coupled with other line placement factors such as how long the treatment will be needed, the type of therapy and the patient’s preferences. Studies have indicated that conducting an early vascular assessment often results in a faster start of treatment of IV drug therapies which can result in a shorter hospital stay and reduced costs. After assessing the patient, Vascular Access Team nurses consult with the patient’s other caregivers to develop appropriate treatment plans. Selecting the proper catheter early in the course of a patient’s IV therapy leads to a safer, more efficient administration of IV therapy with the best possible outcome. If the patient already has an IV line in place upon admission, the VAT will consult to ensure that the line is monitored daily.

“Our goal is to put in the most appropriate vascular access device within 24 to 48 hours of that patient’s admission,” explains Harnage. “We want to ensure the right line for the right patient, for the right diagnosis, and for the right therapy. That’s how you start on the right track from the point of admission.”

The value of a specialized team is underscored when facility leadership is made to understand how floor nurses can be overwhelmed by their workload and patient responsibilities. “Vascular access is very specialized,” Harnage says. “It requires expertise and strong clinical leadership. A nurse in a small hospital may be providing 1:1 care in the ICU but she is also supposed to go out on the floor and put in a PICC line and come back to the ICU. So, you can imagine what goes through this nurse’s mind when her ICU patient has a pulse of 35 — to her the PICC line is probably not the most important thing she is doing that day; however, to a vascular access team, that is the most important thing. So in my opinion you have to educate the C-suite about the value and importance of having a vascular access team. As an example, our chief nursing officer once said it might not be right financially but if it’s the right thing for patients, it’s the best thing for the hospital. The biggest complaint I hear is that resources are sorely lacking. I suggest that clinicians remind administration that when we do what we do best — by having a vascular access team — we have zero infections … and that we are saving them money by protecting our patients.”

The value of a specialized team is underscored when facility leadership is made to understand how floor nurses can be overwhelmed by their workload and patient responsibilities. “Vascular access is very specialized,” Harnage says. “It requires expertise and strong clinical leadership. A nurse in a small hospital may be providing 1:1 care in the ICU but she is also supposed to go out on the floor and put in a PICC line and come back to the ICU. So, you can imagine what goes through this nurse’s mind when her ICU patient has a pulse of 35 — to her the PICC line is probably not the most important thing she is doing that day; however, to a vascular access team, that is the most important thing. So in my opinion you have to educate the C-suite about the importance of having a vascular access team. As an example, our chief nursing officer once said it might not be right financially but if it’s the right thing for patients, it’s the best thing for the hospital. The biggest complaint I hear is that resources are sorely lacking. I suggest that clinicians remind administration that when we do what we do best — by having a vascular access team — we have zero infections … and that we are saving them money by protecting our patients.”

As Marschall, et al. (2014) emphasize, “Accountability is an essential principle for preventing HAIs. It provides the necessary translational link between science and implementation. Without clear accountability, scientifically based implementation strategies will be used in an inconsistent and fragmented way, decreasing their effectiveness in preventing HAIs. Accountability begins with the chief executive officer and other senior leaders who provide the imperative for HAI prevention, thereby making HAI prevention an organizational priority. Senior leadership is accountable for providing adequate resources needed for effective implementation of an HAI prevention program. These resources include necessary personnel (clinical and nonclinical), education and equipment.”

DeVries says that she has witnessed increased engagement among members of her hospital’s C-suite as a result of healthcare reform-driven initiatives. “With the advent of the Affordable Care Act and value-based purchasing, my goals as an infection preventionist and the goals of the C-suite became 100 percent aligned,” she says, “because CLABSIS, CAUTIs, MRSA and other infections now directly impact my hospital’s finances. Before, it could be dismissed as merely soft numbers, but now they are directly affecting my hospital’s viability. And so the ability to have that conversation with the C-suite is occurring on a level that I have not seen before.”

DeVries continues, “I am a frequent participant in our quality meetings, sharing infection rate data and the action plans against those numbers, so I have always been involved with our board, but over the last three years my level of involvement and the frequency of the reports and the detail of the reports being requested, have increased dramatically. They always cared and supported us, but for the programs that have not been that fortunate in the past, I think it has become a much, much easier conversation. Not everyone is in a structure where they are given that same opportunity. It’s unconscionable not to have that direct access to the C-suite to make their pleas for resources. When I started talking about the Affordable Care Act and value-based purchasing impacts, honestly I felt that’s not why I do my job, but understanding that it’s what is resonating right now in the C-suite, I knew I could learn how to use that to leverage our program goals. And more of our peers are speaking that same language in a more compelling manner.”

An understanding of the outcomes associated with hospital-acquired CLABSI can advance that dialogue. According to Marschall, et al. (2014), CLABSIs trigger an increased length of hospital stay as well as increased cost (the non-inflation-adjusted attributable cost of CLABSIs has been found to vary from $3,700 to $39,000 per episode). And as the Joint Commission’s CLABSI Toolkit explains, “CLABSI costs include those related to diagnosis and treatment, prolonged hospital stays, and, more recently in some countries, lack of reimbursement by third-party payers for expenses incurred. Lack of consistency in the methods used by various researchers to estimate CLABSI costs and differences in financial systems in various parts of the world add to the complexity of quantifying these costs.” The toolkit also notes that “An essential component in understanding the costs attributable to CLABSI is having reliable and valid surveillance data on the incidence of infection. Three types of economic analyses are frequently used in healthcare decision making: cost-effectiveness analysis, cost–utility analysis, and cost–benefit analysis. A business case analysis is most closely related to a cost–benefit analysis. Conducting a business case analysis is helpful in determining whether the financial benefits of a new or increased investment in activities to prevent HAIs will outweigh their additional cost. In preparing the business case, it is important not to under-estimate staff time and costs or to overstate benefits. A well thought-out business case can help show that infection prevention is an investment rather than an expense.”

Best Practices
The literature is rife with recommendations for CLABSI prevention strategies, techniques and technologies, and a number of organizations have provided recommendations. The Joint Commission’s CLABSI Toolkit address some important concepts: 

- Hand hygiene is a key component of any effective patient safety and infection prevention program.

- Aseptic technique, a method used to prevent contamination with microorganisms, is recommended by the evidence-based guidelines for all instances of insertion and care of central venous catheters (CVCs).

- When preparing to insert CVCs, healthcare personnel should be attentive to maximal sterile barrier precautions, skin preparation, catheter selection, and use of catheter kits or carts.

- Using an insertion checklist can improve adherence to best practices and reduce error. The insertion process includes catheter site selection, insertion under ultrasound guidance, catheter site dressing regimens, securement devices, and use of a CVC insertion bundle.

- Proper maintenance of CVCs includes disinfection of catheter hubs, connectors, and injection ports and changing dressings over the site every two days for gauze dressings or every seven days for semipermeable dressings. A dressing should also be changed if it becomes damp, loose, or visibly soiled.

- Healthcare personnel must ensure that a patient’s CVC is removed or replaced at the appropriate time and in a safe manner. Such considerations include daily review of line necessity, changing administration system components, and CVC exchanges over a guidewire.

For additional real-world implementation strategies, there is the Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals: 2014 Updates, a series of articles sharing evidence-based strategies to help healthcare professionals effectively control and prevent the spread of HAIs. Last June, infection prevention and control experts released new practical recommendations to assist acute-care hospitals in implementing and prioritizing prevention efforts, including CLABSI prevention. The guidance was published in the July 2014 issue of Infection Control and Hospital Epidemiology and produced in a collaborative effort led by the Society for Healthcare Epidemiology of America, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology and the Joint Commission.

“There is no shortage of guidelines and recommendations to prevent CLABSI, including those from government, public health and professional organizations. But translating this evidence into practice, while challenging, is critically important,” says Leonard Mermel, DO, ScM, co-lead author of the guidelines with Jonas Marschall, MD. “We’ve included examples of successful implementation approaches and references to published examples that can be adapted and adopted by hospitals.”

The updated guidance includes a special section on implementation, emphasizing engagement with healthcare personnel through the supportive, vocal healthcare leaders and sharing of data with employees on the frontlines to track prevention progress. Implementation recommendations are highlighted below.

- Engage both hospital frontline staff and senior leadership in the process of an outcome improvement plan. Focus on a culture of safety including teamwork, technical process and promotion of accountability. Work to make the problem real to all those involved by identifying a patient in the unit who has suffered harm as a result of developing a CLABSI and sharing that story with the team.

- Educate healthcare personnel involved in the insertion and care of central lines. Educational programs should employ multiple teaching strategies to best engage diverse learners.

- Execute best practices by standardizing the care process to help increase staff compliance. Consider using quality improvement methodologies to structure prevention efforts.

- Evaluate the impact of strategies. Multidisciplinary strategies, using quality improvement collaboratives, should be used to set goals and identify the key factors to be measured. Feedback should be given to all personnel with the goals for improvement clearly and frequently articulated.

Marschall, et al. (2014) recommend the following basic practices for preventing and monitoring CLABSI:

Before insertion
- Provide easy access to an evidence-based list of indications for CVC use to minimize unnecessary CVC placement.
- Require education of healthcare personnel involved in insertion, care, and maintenance of CVCs about CLABSI prevention. Include the indications for catheter use, appropriate insertion and maintenance, the risk of CLABSI, and general infection prevention strategies. Ensure that all healthcare personnel involved in catheter insertion and maintenance complete an educational program regarding basic practices to prevent CLABSI before performing these duties. Periodic retraining with a competency assessment may be of benefit. Ensure that any healthcare professional who inserts a CVC undergoes a credentialing process (as established by the individual healthcare institution) to ensure their competency before independently inserting a CVC. Reeducate when an institution changes components of the infusion system that requires a change in practice (e.g., when an institution’s change of the needleless connector requires a change in nursing practice). Consider using simulation training for proper catheter insertion technique.
- Bathe ICU patients over 2 months of age with a chlorhexidine preparation on a daily basis.

At insertion
- Have a process in place to ensure adherence to infection prevention practices at the time of CVC insertion in ICU and non-ICU settings, such as a checklist. - Ensure and document adherence to aseptic technique.
- Checklists have been suggested to ensure optimal insertion practices. If used, the documentation should be done by someone other than the inserter.
- Observation of CVC insertion by a nurse, physician, or other healthcare personnel who has received appropriate education to ensure that aseptic technique is maintained. Such healthcare personnel should be empowered to stop the procedure if breaches in aseptic technique are observed.
- Perform hand hygiene prior to catheter insertion or manipulation. Use an alcohol-based waterless product or antiseptic soap and water; use of gloves does not obviate hand hygiene.
- Avoid using the femoral vein for central venous access in obese adult patients when the catheter is placed under planned and controlled conditions. Controversy exists regarding infectious and noninfectious complications associated with different short-term CVC access sites. The risk and benefit of different insertion sites must be considered on an individual basis with regard to infectious and noninfectious complications. Do not use peripherally inserted CVCs (PICCs) as a strategy to reduce the risk of CLABSI. The risk of infection with PICCs in ICU patients approaches that of CVCs placed in the subclavian or internal jugular veins.
- Use an all-inclusive catheter cart or kit. A catheter cart or kit that contains all necessary components for aseptic catheter insertion has to be available and easily accessible in all units where CVCs are inserted.
- Use ultrasound guidance for internal jugular catheter insertion
- Use maximum sterile barrier precautions during CVC insertion. A mask, cap, sterile gown, and sterile gloves are to be worn by all healthcare personnel involved in the catheter insertion procedure.
- Use an alcoholic chlorhexidine antiseptic for skin preparation. Before catheter insertion, apply an alcoholic chlorhexidine solution containing more than 0.5 percent CHG to the insertion site. The antiseptic solution must be allowed to dry before making the skin puncture.

After insertion
- Ensure appropriate nurse-to-patient ratio and limit the use of float nurses in ICUs
- Disinfect catheter hubs, needleless connectors, and injection ports before accessing the catheter. Before accessing catheter hubs, needleless connectors, or injection ports, vigorously apply mechanical friction with an alcoholic chlorhexidine preparation, 70 percent alcohol, or povidone-iodine. Alcoholic chlorhexidine may have additional residual activity compared with alcohol for this purpose. Apply mechanical friction for no less than 5 seconds to reduce contamination. It is unclear whether this duration of disinfection can be generalized to needleless connectors not tested in these studies. Monitor compliance with hub/connector/port disinfection since approximately half of such catheter components are colonized under conditions of standard practice.
- Remove nonessential catheters. Assess the need for continued intravascular access on a daily basis during multidisciplinary rounds. Remove catheters not required for patient care. Audits to determine whether CVCs are routinely removed after their intended use may be helpful. Both simple and multifaceted interventions are effective at reducing unnecessary CVC use.
- For non-tunneled CVCs in adults and children, change transparent dressings and perform site care with a chlorhexidine-based antiseptic every five to seven days or immediately if the dressing is soiled, loose or damp
- Replace administration sets not used for blood, blood products, or lipids at intervals not longer than 96 hours
- Perform surveillance for CLABSI in ICU and non-ICU settings. Measure the unit-specific incidence of CLABSI (CLABSIs per 1,000 catheter-days) and report the data on a regular basis to the units, physician and nursing leadership, and hospital administrators overseeing the units. Compare CLABSI incidence with historical data for individual units and with national rates. Audit surveillance as necessary to minimize variation in interobserver reliability.

Some experts believe the guidelines are a good place to start, but that they sometimes fall short in providing the specifics that are required to provide the “how” component of the recommended best practices.

“I think the current guidelines are important but there are many, they aren’t too specific, and while there are numerous guidelines stated by various organizations, I am not seeing the ‘how-to’ supporting tools to perform the actual best practice,” Harnage affirms, adding, “But I want zero, I don’t want anything else — so if I want zero, I need more than what’s in the guidelines. Sometimes opinions in the guidelines don’t necessarily align with the comprehensive bundle I developed and implemented. It’s difficult to address an entire country with guidelines because we are all so different. At my facility, I have a whiteboard that we are responsible to write down every patient that has every central line, date, type of line, and the vascular access team rounds every day on those — that’s how you get to zero. That’s the level of detail you must to add to the basics that the guideline provides. That’s called complete ownership of lines.That’s what it takes to get to and to stay at zero. It’s pretty easy to get to zero — we have all the tools — but let me talk to you a year later and then tell me how you are doing. That’s why I look to consistency and standardization and the repetitiveness that ensures consistency.”

DeVries concurs. “The CDC guidelines and the INS standards tell us what to do but they really don’t operationalize it, and that’s where I have struggled on some aspects,” she says. “I know I am supposed to do it, but how do I do it — although I think I would resist someone coming in as even more prescriptive and spoon-feeding me, maybe it’s what we need?”

DeVries says that there is distinct value in information-sharing among practitioners. “I think about what I have learned over the last several years of talking to other people who have this same passion — critical-care nurses, infection preventionists and vascular access nurses, and I have become a better person in my practice from learning everyone else’s struggles and victories. I think the no-barriers, peer-to-peer sharing that takes place makes a difference. We’re all working from the same guidelines, standards and recommendations, but how we found a way to implement them within our own hospital structures, provides a wealth of information. So between the SHEA Compendium and CDC, INS and the evidence-based literature, where do you even start in terms of cross-walking? That’s what I think the SHEA Compendium tried to do for us, but there are dozens of other recommendations that are still important but didn’t make their way in.”

Evidence-Based Practice Compliance
As we have seen there is no dearth of information about proper practice, but getting clinicians to follow evidence-based practices can be challenging. Common barriers to implementation of best practices to reduce or eliminate CLABSIs include lack of leadership support, lack of a safety culture, unavailability of resources, and issues with staffing, such as suboptimal nurse-to-patient ratios and inadequate education, training, and competence of healthcare personnel., according to the Joint Commission’s CLABSI Toolkit. 

Researchers have tried to characterize compliance with known best practices. Stone and Pogorzelska-Maziarz, et al. (2014), in their Prevention of Nosocomial Infections and Cost Effectiveness Refined (P-NICER) study, provided a national cross-sectional snapshot of infection prevention and control programs and clinician compliance with the implementation of processes to prevent healthcare-associated infections (HAIs) in intensive care units (ICUs). The P-NICER survey inquired about the implementation of evidence-based infection prevention policies — and clinician adherence to these policies — for the prevention of device-associated HAIs in adult ICUs.

For CLABSI prevention, these policies included the use of an insertion checklist and five evidence-based processes (monitoring hand hygiene at insertion, using maximal barrier precautions for insertion, applying chlorhexidine at the insertion site, selecting an optimal catheter site, and checking the line daily for necessity). Based on previous research showing that clinician adherence to these policies needs to be consistently high to impact HAI rates, the researchers dichotomized these variables into those that achieved more than 95 percent adherence the last time the policy was monitored versus other lower compliance or no monitoring. Of the 3,374 eligible hospitals, 975 provided data on 1,653 ICUs, and there were complete data on the presence of policies in 1,534 ICUs. The hospitals are located in all settings across the country. Overall, CLABSI prevention policies were widespread (ranging from 87 percent for checking lines daily to 97 percent for applying chlorhexidine at catheter insertion sites).

The researchers note, “The United States has seen vast improvements in CLABSI rates, with impressive progress toward the five-year targets as set out in the HAI Action Plan. In the present descriptive study, infection prevention and control program characteristics, presence of policies, and clinician adherance were not linked to actual HAI rates. Multivariate analyses are needed, and we will present these associations in future reports. Nonetheless, our present results suggest that the reduction in CLABSI rates may be a result of advances in the ability of infection prevention and control programs to fully implement evidence-based care, such as bundled care policies, to drive down CLABSI and VAP rates.” And according to the HAI Action Plan (2013), “Hospitals adopting [a bundle] approach in their intensive care units (ICUs) have achieved significant reductions in CLABSI. The more than 1,000 adult ICUs that participated in AHRQ’s nationwide CUSP for CLABSI project reduced the rate of CLABSI by 41 percent, prevented more than 2,100 of these infections, saved more than 500 lives, and avoided more than $36 million in excess costs.”

There are a number of strategies to ensure compliance. Best-practice interventions are frequently bundled, as Marschall, et al. (2014) explain, “Numerous studies have documented that use of such bundles is effective, sustainable, and cost-effective in both adults and children. Bundles are most likely to be successful if implemented in a previously established patient safety culture, and their success depends on adherence to individual measures. However, recent data suggest that not all components of bundles may be necessary to achieve an effect on CLABSI rates. After catheter insertion, maintenance bundles have been proposed to ensure optimal catheter care. More data are needed to determine which components of the maintenance bundle are essential in reducing risk.”

Checklists also can be a helpful tool. “I am a huge believe in bundles and checklists if staff are trained on them and given the time to use them,” says DeVries. “I go back to the concept of ‘check the patient, not the box.’ We can have all the tools in the world, and awesome documentation of doing everything perfectly, but if it’s merely a bunch of checked boxes — that won’t drive better care. We know through various studies that checklists and bundles matter for CLABSI prevention, but there’s a different between having the tools and actually using them.”

Another critical component of CLABSI prevention is standardizing care processes. As Marschall, et al. (2014) note, “This can be done through implementation of guidelines, bundles and protocols that address both insertion and maintenance of central lines. Consider conducting structured daily multidisciplinary rounds. During rounds, discuss whether the patient still requires the central line, patient goals for the day, and potential barriers or safety issues. Empower staff to report process defects or barriers to implementation encountered to appropriate leadership. This can facilitate rapid intervention and process improvement. Assign accountability for adherence to specific departments or functions.”

Creating redundancy is equally important. As Marschall, et al. (2014) advise, “Build redundancy or independent checks into the care delivery process to increase staff compliance. This can be done by incorporating visual cues as reminders for proper procedures. Implement a line insertion and line maintenance checklist both inside and outside ICUs. Consider the use of screen-saver messages, posters, banners, fact sheets, preprinted order sets, pocket cards, and the like to educate and serve as reminders for staff.”

Harnage emphasizes, “I believe in consistency and repetitive treatment administered by a specialized team because that’s what they do day after day. So what I find is the nurses on the floor, I don’t want to say it’s not their passion, but they are so busy that they will put Band-aids on it until they can get it to work. Sutter Roseville has a culture of safety and I have had strong support from leadership who recognize how important a specialized team is. The biggest gap for hospitals is that they don’t have a specialized team to insert and take care of these lines. Sutter is definitely a leader with a PICC team, a 24/7 team — key is ownership. To this day my vascular access team has inserted more than 18,000 PICC lines and they have not had one central line infection. That shows you the control, the consistency and the repetitive expertise. They take strong ownership of every line throughout the hospital, they are working on central insertion of central catheters (CICC) owning the insertion piece and not just PICC lines, as our vision and best practice is we  own every line from assessment, to insertion, to maintenance, to discontinuing.”

According to the AHRQ, “An important component of staff education is process standardization. A potential barrier to compliance with evidence-based practices is that clinicians have to go to several different places to collect the equipment they need to comply with guidelines. Establishing well-stocked line insertion carts that contain all the equipment and supplies needed to insert central lines reduces workflow complexity and makes it easy for clinicians to adhere to evidence-based practice. Gain consensus on what supplies should be included and how the central line cart should be organized for your unit. Johns Hopkins care teams use four-drawer carts, but use what will work best on your unit.”

If a facility does not have a VAT, there are other ways to champion improvement related to CLABSI prevention, including implementing clinical practice guidelines (CPGs) into actual practice. As the Joint Commission’s CLABSI Toolkit notes, “As a first step, consider using a systematic and multidisciplinary approach to identify and prioritize CPGs and remove the local barriers that can diminish CPG adherence. Among the most important internal and external factors that can affect the success of any improvement initiative designed to reduce or eliminate healthcare-associated infections, including CLABSIs, are leadership, culture of safety, multidisciplinary teams and teamwork, accountability of healthcare personnel, empowerment, resource availability, data collection and feedback of CLABSI rates, policies and procedures, and involvement of patients and families.”

As a component of the quality equation for CLABI prevention, the Association for Healthcare Research and Quality (AHRQ) has made available a number of tools that, when used with the Comprehensive Unit-based Safety Program (CUSP) Toolkit, have dramatically reduced CLABSI rates in more than 1,000 hospitals across the country. The tools align with the E’s found in the CUSP toolkit:
Engage: How will this make the world a better place?
Educate: How will we accomplish this?
Execute: What do I need to do?
Evaluate: How will we know we made a difference?

Let’s review these further:

Engage: How does this make the world a better place?
According to the AHRQ, “To engage your colleagues, first make the CLABSI problem real by identifying a patient on your unit who suffered needless harm from a CLABSI and share that patient’s story with your colleagues. Once you share the story with your colleagues and leaders, ask them if this is the kind of care they would want for their family, if this is care they are proud of, and if this is the best your unit can do. Second, post the number, by month, of patients who developed a CLABSI and the total number of CLABSI cases for the previous year on your unit. Post a trend line so nurses and physicians can see at a glance the unit’s CLABSI rate and how it changes over time. Post the number of days (or weeks or months) since the unit’s last CLABSI. Use formal and informal opportunities to talk about the intervention and about unit-specific infection rates. Third, raise awareness among unit staff members of evidence-based practices to eliminate CLABSI. The biggest barrier to compliance with evidence-based practice is that providers do not know the evidence exists or do not know what they should be doing. To inform providers, outline evidence-based practices to eliminate CLABSI and gives supporting evidence for each practice. Once a week for two consecutive weeks, determine the number of staff members who received the fact sheet. If fewer than 90 percent of staff members received it, hold a meeting to increase knowledge of evidence-based practices among providers. Fourth, using baseline data on CLABSI rates on your unit, calculate the potential opportunity to improve the number of preventable CLABSIs, preventable deaths, excess hospital days, and cost savings per year.”

Educate: How will we accomplish this?
According to the AHRQ, “Make sure your staff members understand how they can reduce CLABSI. Numerous interventions have reduced the incidence of CLABSI and the ensuing morbidity, mortality, and costs. In addition, the Centers for Disease Control and Prevention (CDC), the Society of Critical Care Medicine, the Society of Healthcare Epidemiologists of America (SHEA), the Infectious Disease Society of America (IDSA), and several other organizations have developed evidence-graded guidelines to prevent catheter-related infections. Improving compliance with these evidence-based practices will result in dramatic reductions in CLABSI rates on your unit. Additionally, partnering with the hospital epidemiologist or an infection control practitioner can help your CUSP team ensure you are using National Healthcare Safety Network definitions for CLABSI; educate staff members about how to reduce CLABSI; ensure you have chlorhexidine in your central line kits; and post publicly the number of people infected per month and your quarterly infection rates.

Execute: What do I need to do?
The AHRQ makes several recommendations:
Implement a checklist: The field of aviation uses checklists extensively to create independent redundancies for key steps in a process. Creating independent redundancies through the use of a checklist is an effective technique to monitor whether or not providers adhere to care processes. Some organizations require a nurse to be present bedside during all central line insertions and to complete a checklist during every central line insertion. Using a checklist allows nurses to serve as an independent, redundant check to encourage physician adherence to evidence-based practices. Establish baseline compliance with evidence-based practices. Consider implementing a two-week observation-only phase during which nursing staff observe physicians during central line placements and complete the checklist for each procedure. Physicians would not be aware that they were being observed during the observation-only phase. You could then calculate the percent of central line insertions for which providers were compliant with evidence-based practices and share the results with your staff. Ask providers daily whether catheters can be removed: One of the most effective strategies for preventing CLABSI is to eliminate, or at least reduce, exposure to central lines. The decision for whether or not a patient needs a central line is complex and difficult to standardize into a practice guideline. Nonetheless, to reduce patient exposure to central lines, units should have a systematic approach to ask providers daily if any can be removed. Develop a strategy to ensure unit staff members ask providers daily if any catheters or tubes can be removed. To ensure that staff ask the question, add it to a rounding form. The Daily Goals Checklist is used to develop daily care plans for patients. Alternatively, if you have existing reporting mechanisms on your unit (nurse-to-nurse report forms, charge nurse report forms, for example) add the question of whether or not any catheters or tubes can be removed. To decrease the risk for infection, you should also develop a strategy to place tunneled catheters if central access will be required for a long period. Develop or refine vascular access device policies: As you focus your efforts to eliminate CLABSI, refine existing policies or establish clearly defined policies for caring for patients with central lines. Empower nurses to stop procedures: Although efforts to improve interpersonal communication improved aviation safety, the same is not yet true in healthcare’s hierarchical culture. Successful checklist implementation requires effective interpersonal communication skills and provides a means to learn teamwork skills experientially. Units should require nurses to complete the checklist at bedside during central line placement. Tell the physician staff that the checklist is being implemented after the observation-only phase ends. Empower nurses to stop the procedure, absent an emergency, if they observe a violation of evidence-based practices. Have the nurses indicate on the checklist if the procedure was stopped. Develop a unit strategy and support system for nurses to minimize the risk of an undesirable encounter.

Evaluate: How will we know that we made a difference?
The first step in evaluating the success of your CLABSI prevention efforts is to collect unit baseline CLABSI rates for the past 12 months. The second step is to track unit CLABSI rates over time. Enter your data into a State-level database or to CDC’s National Healthcare Safety Network. Although all units are urged to adopt the CDC’s standardized definitions for CLABSI, definitions may still vary among hospitals. As long as your definition of a CLABSI remains constant, you can evaluate trends over time in infection rates. The team leader should discuss these issues with the director of hospital epidemiology or infection control. Communicate your results widely with caregivers and patients and their families. Put the incidence of CLABSI in clear, real terms and present the actual number of infections over a period of time, not just a rate or ratio.

When it comes to the VAT process, DeVries shares the key concern about challenging vendors on what their product is indicated for and what it has been proven to do. “This is one more facet of making evidence-based decisions for our patient,” she says. “Sometimes there is a big disconnect between what is implied and what has actually been cleared by the FDA as an indication, and our patients deserve interventions that have proven themselves effective.”

Reporting the Data
Once resources are secured, practitioners are following best practices, and efforts are being made to introduce and maintain a culture of safety, it’s time to report the data. As Marschall, et al. (2014) explain the various state and federal requirements, “Hospitals in states that have mandatory reporting requirements for CLABSI must collect and report the data required by the state … Hospitals that participate in external quality initiatives or state programs must collect and report the data required by the initiative or program … There are many challenges in providing useful information to consumers and other stakeholders while preventing unintended consequences of public reporting of HAIs.”

“What scares me — as public reporting has become a reality and hospital money being tied to these outcomes — is that many of our programs are under tremendous pressure to report zero,” DeVries says. “Reporting zero and being at zero are two different things. So when you look at the validation studies that have been conducted by various states on CLABSI reporting, the amount of under-reporting that is occurring should be very, very troubling. Is it that the IPs aren’t trained on how to do it? The CDC is very clear there is no adjudication, but when the IP calls the CLABSI but then it goes through the food chain to the ICU director and the chief nursing officer, they explain it away — it’s not a CLABSI because of X, Y or Z. And so those don’t get reported even though they meet the definition. That’s probably one of the biggest conversations that I think we need to have as a community. Where I caution people is when you are under that pressure to report zero, if this met the CDC definition, you have to report it. We may do a root cause analysis afterward and we may say it really wasn’t a central line infection, but at the end of the day if you met the definition, you have to report it.”

DeVries continues, “Every time we get pushed into reporting zero, we are making our ability to stay focused on prevention efforts even harder, because if you’ve told your administration for weeks, months or even years that you are at zero, why would they invest more into prevention efforts? Because sooner or later they will begin to start believing that number. I hear at least every month from folks who are saying they are pushed into using PICC lines and short peripheral catheters because they don’t have to report a CLABSI. I am heavily involved in the peripheral world, as that is my real passion, but it’s the right device in the right patient for the right reason, and avoiding a CLABSI is a great thing, but not when you put the patient at risk for other complications because the medication is being run through a catheter that is inappropriate. So how do we make people understand that we’re all under the same pressure but every time we give in to that pressure, we hurt our patients.”

“I hear comments about medical staff going to peripheral lines as their line of choice and that’s more than concerning,” Harnage says. “That may not be the right line for the right patient — you have to assess the patient to provide the most appropriate line. And when you do that, hopefully you will eliminate complications for that patient. I think sometimes people may inadvertently undermine the expertise of a vascular access team – they envision a vascular access team as a PICC, stick, and run team — but you need to tell me everything about that patient and then together we will agree which device is an appropriate one, and how we will maintain that device together for that patient length of stay.  It’s all of us working together to ensure a safe journey for our patients.”

“I think another missing piece are the lab-identified MRSA bacteremias,” DeVries adds. “Are people looking into where those are coming from? Because it doesn’t have to be caused by a central line — it could be a peripheral line, or it could be something else going on we don’t even know about because all we need to see is MRSA in the blood and report it, without any investigation as to the ‘why’. We have found some pretty strong trends by looking into the ‘why’ on those, and I hope other people will look into their ‘why’s.’ My persuasion is that every vascular device deserves our attention for the risk it poses to our patients. So look beyond the ‘must do’s’ and move on to the ‘should-do’s’, and consider the role that your other devices can play, such as PICCs and peripherals. If you look, you will find. And if you ignore them, bugs don’t care.” 

References:

Association for Healthcare Research and Quality (AHRQ). Tools for Reducing Central Line-Associated Blood Stream Infections. Accessible at: http://www.ahrq.gov/professionals/education/curriculum-tools/clabsitools/index.html

Joint Commission. CLABSI Toolkit – Preventing Central-Line Associated Bloodstream Infections: Useful Tools, An International Perspective. Accessible at: http://www.jointcommission.org/Topics/Clabsi_toolkit.aspx

Marschall J, Mermel L, Fakih M, Hadaway L, Kallen A, O’Grady N, Pettis AM, Rupp M, Sandora T, Maragaki LS and Yokoe D. Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update. Infect Control Hosp Epidemiol. 35:7. July 2014.

Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. New England Journal of Medicine 2006;355(26):2725-32. http://www.nejm.org/doi/pdf/10.1056/NEJMoa061115

Stone PW, Pogorzelska-Maziarz M, Herzig CTA, Weiner LM, Furuya EY, Dick A and Larson E. State of infection prevention in US hospitals enrolled in the National Health and Safety Network. Am J Infect Control. February 2014. Vol. 42, No. 2, Pages 94-99.



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