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.