Post on 14-Aug-2015
Abstract
Linda Stein MPH, RN, CIC, Maureen Rosenbarger MS, BSN, RN-BC, Jean Alberts, MSN, MBA, RN, CNN
Advocate Lutheran General Hospital
INTRODUCTION: According to the Centers for Disease Control and
Prevention (CDC), many Central Lines are found outside of the Intensive
Care Unit (ICU) environment. Prevention strategies have traditionally been
focused on the care and maintenance of Central Lines in the ICU location,
with little attention towards the Non-ICU setting. In one study cited by the
CDC, 55% of ICU patients had Central Lines; while 24% of non-ICU
patients also had Central Lines. The CDC specifies “personnel responsible
for insertion and maintenance of catheters should be trained and
demonstrate competence”. As the acuity of the Non-ICU patient population
increases, the probability of caring for Central Lines outside of the ICU will
increase.
Our project aim was to provide safe care to patients by reducing the
incidence of Central Line Associated Bloodstream Infections (CLABSI) in
the non-ICU setting.
METHOD: Advocate Lutheran General and Advocate Children’s Hospital is
a 637 bed teaching hospital and Level I Trauma center. Using the Plan-Do-
Study-Act method, an analysis of CLABSI data collected from January
through December, 2012 was completed. An oversight team, including the
site’s executive leadership, was initiated in December 2012. A literature
review was conducted. As a result, an educational plan was created by a
team of Advanced Practice Nurses, Nurse Educators and members of the
Vascular Access Team (VAT). The education was considered a mandatory
requirement for all nurses caring for patients in the ICU and Non-ICU
Medical-Surgical settings and was delivered over a three month time period.
Content of the education included appropriate care and maintenance
techniques via a blended learning approach which included video
instruction, small group activities and return demonstration. Additional care
measures included, implementation of a Chlorhexidine (CHG) bathing
program and an integrated daily rounding audit process for all Central
Lines. Nurse Care Technicians (NCTs) were engaged in the project as well,
with a major focus on the implementation of CHG bathing.
RESULTS: Using the National Healthcare Safety Network (NHSN)
surveillance definition, from January through July 2012, it was found that 15
Non-ICU CLABSI events took place. Using the same surveillance criteria
from January through July 2013, a 67% reduction in Non-ICU CLABSI was
identified.
CONCLUSION: Lack of consistent opportunities to care for and maintain
Central Lines results in nursing knowledge deficits and inconsistent
application of best practice. Maintaining a high comfort level and
appropriate knowledge of the practice of Central Line care requires ongoing
educational support.
Methods In 2012 the Infection Prevention Team, along with the Non-ICU units,
focused on improvements identified through causal analysis of CLABSI
events. The investigation identified the need to develop a more
standardized approach to CLABSI care and maintenance. An educational
plan was created by a team of Advanced Practice Nurses, Nurse Educators
and members of the Vascular Access Team (VAT). The education was
considered a mandatory requirement for all nurses caring for patients in the
ICU and Non-ICU Medical-Surgical settings and was delivered over a three
month time period. Content of the education included:
• Appropriate care and maintenance techniques via a blended learning
approach which included video instruction, small group activities and
return demonstration.
• Implementation of a Chlorhexidine (CHG) bathing program.
• An integrated daily rounding audit process for all patients with Central
Lines.
• Nurse Care Technician (NCT) project engagement, with a major focus
on the implementation of CHG bathing.
Next Steps
Lack of consistent opportunities to care for and maintain Central Lines
results in nursing knowledge deficits and inconsistent application of best
practice. Maintaining a high comfort level and appropriate knowledge of the
practice of Central Line care requires ongoing educational support.
Results
• Expansion of the role of Vascular Access Team to perform routine
scheduled dressing changes.
• Point prevalence study to determine current practice.
• Central Venous Catheter policy review to identify gaps between policy
and bedside practice.
• Assessment of Registered Nurse knowledge related to care and
maintenance of Central Lines.
• Development of video presentations to address various aspects of
Central Line care, including: obtaining blood cultures, acquiring blood
specimens from PICC lines, cap and tubing changes, declotting of lines,
dressing changes, PICC line removal, documentation of Central
Line care and patient/family education in the electronic medical record.
• Small group Central Line instruction sessions, which included a return
demonstration, were a mandatory requirement for ICU and Non-ICU
nurses. Didactic instruction was incorporated and role play activities were
performed.
• Competency Checklist: Upon successful completion of the small group
session, a Competency Checklist, signed by the session educator, was
issued.
• Development of a laminated “Quick Reference Guide” to serve as an easy-
access Central Line process tool for nurses caring for patients with Central
Lines.
• Advanced Practice Nurses role as Central Line experts. Daily rounding on
patients with Central Lines is performed, partnering with the bedside nurse
to assess the Central Line site, function, continued need and potential
conversion to an alternative method of medication administration.
Process
Diagram 2: Standardized Competency Checklist used to verify and document associate education.
Diagram 1: CVC care and maintenance reference guide for nurses.
Decision Support Algorithms
Educational Videos
• January through December 2012: 18 Non-ICU CLABSI events were
identified using the National Healthcare Safety Network (NHSN)
surveillance definition.
• January through June 2013: Using the same NHSN surveillance
criteria, a significant reduction in the number of CLABSI events was
revealed.
Conclusions
Implementing strategies to reduce CLABSI in a Non-ICU setting
in a academic medical center
Diagram 3: Non-ICU CLABSI January 2012-July 2013
• Implementation of Unit-Based Central Line “Champions” with practice
oversight by Advanced Practice Nurses.
• Central Line “Tip of the Month”: A flyer electronically delivered on a
monthly basis to highlight a key component of Central Line care. The
flyer is to be shared at daily Unit Huddles and monthly Unit Practice
Council meetings. It serves as ongoing reinforcement of key practices
related to the care and maintenance of Central Lines.
• Repeat the point prevalence study to measure Central Line care and
maintenance compliance.
• Incorporate Central Line care and maintenance into Unit-Based Skill Day.
Resource Tools
Acknowledgements:
Melissa Acuna, Eric Amar, Linda Bartjen, Darlene Dagle, MaryAnn
Dizon, Erin Duellman, Diane Eckhouse, Valsamma Eettickal, Mary-
Jennelle Guevara, Marie Hagman, Angela John, Deborah Kantoris,
Susan Norberte, Mallika Patel, Royce Peppa, Darcy Reum, Elena
Skourletos, Malgorzata Sokolowski, Leelamma Thomas, Jill Vana.