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Nursing Research & Evidence-Based Practice NUR 561

Overview

In researching the topic of central line associated bloodstream infections (CLABSIs), writer completed an online search for relevant articles to the topic. Articles selected were a quantitative and a qualitative article on CLABSI and prevention of CLABSI. This paper is based on the five-peer reviewed article on CLABSIs and CLABSIs prevention. CLABSI is considered a blood stream infection which is confirmed primarily by laboratory work (Sacks et al., 2014). CLABSI is a bloodstream infection that happens to the patient who has central line within 48 hours of insertion and is not related to an infection from another site (CDC, 2016). In general, CLABSI happens when there is a possibility of not correctly inserting the central venous line (CVL) or not monitoring or supervising the site after the insertion and not adhering to CLABSI protocol. It is one of the major blood stream infection with the increased morbidity and mortality rates of 10 to 20 % (Morrison, 2012). It cost a lot of money to the U.S. healthcare system and thousands of deaths in America, yet it is preventable healthcare associated infections just by implementing CLABSI bundle (CDC, 2016).

PICOT Question

The Evidence Based Practice research PICOT Question to be addressed: Does having a CLABSI prevention/elimination team who are dedicated to supervise entire central line insertion in Intensive Care Unit (ICU) and CLABSI bundle protocol as opposed to bedside ICU nurse be responsible to implement the CLABSI-related preventive measures for the purpose of reducing the risk of CLABSI?

P- Patients admitted in ICU

I- Having a CLABSI team to supervise the central line insertion

C- Bedside ICU nurses responsible to maintain and prevent CLABSI

O- Decreased rate of CLABSIs

T- During ICU stay

Keywords: Compliance, CLABSI bundles, Guidelines, CLABSI prevention, CLABSI

Literature Review

According to the article by Furuya et al., (2016), CLABSI is a condition that can be prevented. The intention of this study was to assess the compliance with the central line insertion bundle overall in US. The research method involved cross-sectional design involving National sample of adult ICUs participating in National Healthcare Safety Network (NHSN) surveillance (Furuya et al., 2016). The overall study involved 984 adult ICUs in 632 hospital (Furuya et al., 2016). The results of the study showed that only 69 percent of the US hospitals reported compliance with the set regulations to prevent CLABSI. It is therefore evident that compliance to the stipulated guidelines is not strictly followed. According to Furuya et al., compliance is the most effective method of preventing CLABSI. Most of the healthcare organization and healthcare centers are aware regarding the guidelines recognized by the World Health Organization (WHO) and Center of disease Control to presents the central line associated blood steam infections in ICU’s settings. This article by Furuya et al. (2016), is based on a qualitative study which is focused on the mutli-center research on the prevention and elimination of the CLABSI. This articles also focuses on why some of the hospital are more diligent on preventing the CLABSI than other despite the guidelines provided by national mandates. Research was conducted in 250 hospitals with the mean CLABSI rate of 2.1 per 1000 CVL (Furuya et al., 2016). Among them only 49 % reported to have a written CLABSI bundle policy (Furuya et al., 2016). Even on those who monitored compliance, only 38 % were highly compliant with the CLABSI bundle (Furuya et al., 2016). In this research, first the hospital’s infection preventionist was questioned by phone and then in person interviewed was conducted. On this research there was a use of snowball sampling to conduct the phone interview, in person interviews. The phone interview and in person interview was conducted on the epidemiologists, Physicians, unit managers, nurses in the ICU’s unit. After the interview it was identified that most of the organization had the common challenges to implement the CLABSI protocol in their organizations. There were basically four common challenges which were discussed by all the healthcare organization. The four challenges were the politics, culture, structure, and emotions. Politics meaning the relationship among the employee on the unit, culture as a values and beliefs which were shared by the employee, structure meaning some factors which are affecting the quality improvements projects, and lastly emotions as the level of commitment and passion shared on the unit (Furuya et al., 2016). After analyzing the article, it has been noted that those hospital who had a higher score on the culture and emotion were also the ones who were more committed and passionate about fostering change, improving implementation,  and collaborating more quality improvement projects. On the other hand, those hospital who did not score high on the four challenges were also found to be not having favorable environment for change.  The proposed study will close a gap in knowledge as it identifies that for effective implementation and collaboration of CLABSIs’ prevention plan, plan dissemination was deciphered as a prodigious step. From this article it has been found that the effect of implementing the CLABSI bundle protocol and educating nurses has a significant impact on reducing the CLABSI and associated infection as the p value was 0.015 (P = 0.015), incidence rate ratio [IRR] 0.77, 95% confidence interval and  (β = -1.029, p = 0.015).As we know that the p value less then .05 is significant and that we reject the null hypothesis of stating that there is no difference. The result indicated that there was a significant difference in reduction of CLABSI infection when the CLABSI bundles protocol were implemented and education were provided to the ICU employees on CLABSI. As a plan disseminating for the quality improvement was to meet the guidelines evidence-based practice research and implementing a Vascular Care Team (VCT) to monitor the CLABSI bundle protocol. Normally time frame for these kinds of projects will be three months. On a timely basis meeting were conducted between nurses and CLABSI team to monitor the progress towards prevention of the CLABSI.

The research study by Park et al. (2017) was conducted in a community hospital which was based on the qualitative analysis of midline catheter and central line care that were provided by medical-surgical nurses. Most of the community hospitals are not equipped with the required tools or had experience with preventative measure which are needed to fight central line associated bloodstream infections (CLABSIs). In this research, the researcher has utilized the phenomenological framework and the methods of exploration was the interview process (Park et al., 2017). The study was approved by the Centers for Disease Control and Prevention institutional review board (IRB) and the New Jersey Department of Health’s IRB use in this analysis (Park et al., 2017). Consents were obtained from qualified participants. No human harm was noted on this study as it is an education study and was conducted by interviewing process. The researcher on this research study conducted 45-minute interview with the medical-surgical nurses on the medical-surgical units that has the highest rate of CLABSI. This research studies were basically focused on the nurse’s perspective at central line care. Fifteen medical surgical nurses were interviewed from the medical surgical units who had highest’s incidence of CLABSI who were working as fulltime. After the interview process various challenges emerges out. The biggest challenge was to follow the correct procedure along with CLABSI prevention. Also, nurses did not have high exposure with CLABSI and patient with CLABSI. 15 nurses identified that there is a need for education concentrating on the central line care and CLABIs prevention training. As, a teaching strategy, nurses who were seasoned and experienced related to CLABSI were brought to the community hospital to guide the nurses. As a result, plan was created which was based on the experiences nurses experience and when implemented decreased the CLABSI rate. This article focuses on the prevention of infection from the nurses prospective who were working nurse in a community hospital.  This article explores the interventions that can be implemented to prevent CLABSI. The article highlights that the condition can be prevented if healthcare organizations take the necessary preventive measures. This data collection methods involved exploring the impacts of overall intervention implemented by peer tutoring which involved 1000 days of continuous tutoring. The results of the research showed that CLABSI decreased from 6.9 infections in the pre-intervention period to 2.4 and 1.8 in the intervention (Park et al., 2017). This article focused on the CLABSI rate for 9 months pre-intervention, 6 months during the intervention and 9 months post-intervention. SPSS 22.0 was utilized to conduct the statistical analysis for this article. It has been found from this research that CLABSI rate decreased from 6.9 infections in the pre-intervention phase to 2.4 and 1.8 in the intervention period of 6 months with P value being 0.102 (p= 0.102) per 1000 catheters per 9-month period (Park et al., 2017). The researcher used the regression model to show the significant difference between the pre intervention and post intervention drop rate in CLABSI where the P value was  less than 0.001 (P < 0.001). As mentioned above P value less than 0.05 is considered to be statistically significant and shows the difference preintervention and postintervention of applying the CLABSI bundles and education provided to the nurses and we reject the null hypothesis stating there will be no difference in pre intervention of applying CLABSI bundle and post intervention of CLABSI bundles. Hence, this research showed significant increase in CLABSI when there was no peer tutoring. To close the gap in knowledge, the article highlights that without peer tutoring interventions, the rate of CLABSI infections can increased again. From this article it has been noted that in order to prevent the CLABSI, healthcare organization need to concentrate on clinical reasoning and preventative actions. This article can be used in healthcare organizations to explain the importance of peer tutoring towards the prevention of CLABSI.

The research by Blot et al. (2014) is based on systematic review and meta-analysis of the interventions taken to prevent CLABSI. The article sought to determine whether central line–associated bloodstream infections. The research method involves analysis of the previously done studies from 1995–June 2012 (Blot et al., 2014). CLABSI per 1,000 catheter-days, CLABSI per 1,000 inpatient-days, and catheter utilization rates were identified in this article. Maryland Health Care Commission (MHCC) measured the objectives and difficulties of reporting data publicly and has approved this study (Blot et al., 2014). The research was conducted in a five adult ICUs at a regional teaching hospital, that has 63 ICU beds. The CLABSI bundle was introduced to ICU which has four components: hand hygiene, sterile technique upon insertion, use of chlorohexidine wipes for skin preparations, and avoidance of the femoral vein as the access site (Blot et al., 2014). The research was conducted for 10-month period over 18,656 inpatient-days and 9,388 catheter-days (Blot et al., 2014). In this research 687 CVL insertions on 481 patients were performed (Blot et al., 2014). Consents were obtained from qualified participants and no human harm was noted on this study as it is an education study and was conducted by interviewing process. The results of the study show that CLABSI have decreased significantly over the years due the use of CLABSI bundles and education regarding CLABSI. A ratio of 95% confidence intervals proved that CLABSI can be prevented (Blot et al., 2014). Hence, from the article, quality improvement interventions are crucial in preventing CLABSI. Continuous quality improvement can be used to close the gap in knowledge on how to implement continuous quality improvement in ICU. This article by studied a visual design of information from widely-reported central line-associated blood stream infection (CLABSI) ending data for generating decisions by different target individuals, health care customers and professionals. In deciding on the best way to openly document CLABSI data results Maryland Health Care Commission (MHCC) measured the objectives and difficulties of reporting data publicly and has approved this study (Blot et al., 2014). The visual view of quantitative knowledge explains data for customers and health care professionals for creating decisions. The purpose of visual design, to systematize the information for relaying a message successfully, can be achieved by prioritizing, combining, and arranging the information appropriately. The study used formative methods with several groups to verify the choices that the researchers did to obtain the members, and they employed an extensive cross section of the intended user populations. The researchers confirmed visualizations that were accepted and publicly organized for customers and health care professionals in Maryland. This article recognizes that in order to expedite the CLABSI prevention program, a peer-reviewed research framework which assimilates evidence into practices is really crucial. This article focused on systematic review and meta-analysis examines to find out the impact of quality improvement interventions on central line-associated bloodstream infections in ICU patient. Also, the researcher used the Meta-regression which assessed the impact of CLABSI bundle interventions and high baseline rate on intervention effect. From this article it has been found that the effect of implementing the CLABSI bundle protocol and educating nurses has a significant impact on reducing the CLABSI and associated infection as the p value was .03 (P = .03). As we know that the p value less then .05 is significant and that we reject the null hypothesis of stating that there is no difference. The result indicated that there was a significant difference in reduction of CLABSI infection when the CLABSI bundles protocol were implemented and education were provided to the ICU employees on CLABSI.

According to the article by Chopra et al. the main objective was to research on effective evidence-based care to prevent CLABSI infections among ICU patients. The article notes that Central Venous Catheters (CVC) play a central role in preventing the infections. The method of data collection involved 34 evidence-based studies done previously to identify causes and prevention of CLABSI (Chopra et al., 2013). Moreover, review was conducted in accordance with the protocol proposed by the Federal University of São Paulo. 1,485 studies were initially selected but only 34 studies were considered necessary for this study (Chopra et al., 2013). The results from the study showed that interventions such as hand hygiene and maximal barrier precautions are effective in preventing CLABSI among ICU patients. Therefore, the article concludes that that commitment of stuff plays a crucial role in preventing CLABSI. This article is can be used to seal the gap by teaching members of the staff how to commit themselves in preventing CLABSI. This article by Chopra et al. (2013) is a crossover randomized prospective pilot study of central venous catheter (CVC) team intervention in comparison to standard care. Consents were obtained from qualified participants and no human harm was noted on this study as it is an education study and was conducted by interviewing process. In most cases, treatment for children suffering from cancer includes chemotherapy that is delivered via CVC. Although the CVC is a reliable source for delivering chemotherapy, it increases the risk of bloodstream infections (BSIs). The study takes place in a children’s hospital with the focus on two inpatient oncology units with 41 patients in the experiential unit and 41 in the control unit. The study compares patients who receive CVC blood draw bundle by nurses on the CVC team experimental interventions versus standard care from a bedside nurse. In the six-month study, a significant difference was seen in the CVC team and standard care by the bedside nurse related to risk of BSIs. In determining the effectiveness of the CVC team, a larger cohort group is needed.  While the use of CVC is pervasive, most studies related to CLABSIs are done in the adult population. This article provides data related to CLABSIs in the pediatric population. A vascular team needs to be created to monitor the CLABSI protocol and to calculate the data of CLABSI. The vascular team will be conducting he seminar, meetings, and creation of the EBP bundles for the elimination of CLABSI. A vascular team should be created to monitor the CLABSI protocol and to calculate the data of CLABSI. The vascular team will be conducting he seminar, meetings, and creation of the EBP bundles for the elimination of CLABSI. Vascular team was providing PowerPoint presentation, webinar, websites and handouts regarding the prevention of CLABSI to educate nurses and empower them on CLABSI bundle protocol. In this research the pre intervention and post intervention of education and CLABSI bundles drastically decreased the rate of CLABSI from 3.9 per 1,000 catheter days to 1.0 per 1,000 catheter days. Also, in this research study the P value was 0.000 which is less than 0.5 and is considered to be statistically significant as the (P< 0.001).

According to the article by Sacks et al. (2014), a central line-associated bloodstream infection (CLABSI) develops within 48 hours of the line placement. This article is based on the research done to investigate pathogens associated with CLABSI. The research method involved analysis done from October 2011 to September 2012, with the intention of identifying the infectious causing agents associated with CLABSI. This article investigated the effect of the effect of implementing a checklist for the placement of central venous lines (CVL). Participants were  assigned to the checklist group either control or experimental in a 1:2 ratio (Sacks et al., 2014). In this research the frequency of CLABSI was compared in control and experimental groups. In this study total of 4416 CVL were inserted; 1518 were from checklist group and 2898 participants were in the control group (Sacks et al., 2014).This article explains that the use of checklist during CVL placement has caused lowered incidence of CLABSI frequency. Consents were obtained from qualified participants. There was no human harm noted as the education conducted was online and screenings were performed during routine exams. The results of the study showed that majority of infections were caused by staphylococci 34.1 percent, enterococci16 percent, and Staphylococcus aureus, 9.9 percent (Sacks et al., 2014). The article concludes that the action taken by healthcare organizations to prevent CLABSI like use of antibiotics, echinocandins and parenteral vancomycin which is an antibiotic intervention. The knowledge from the article is useful to medical practitioners working in ICU. The recommendations provided can prevent CLABSI. The study by  (Sacks et al., 2014). was based on a two-year case matched controlled retrospective study of central line associated bloodstream infection (CLABSI) in an urban trauma service. The population consisted of 6014 admissions to the trauma service. The case reviewed 105 case-matched controlled groups who did not suffer from CLABSI. There were 35 CLABSI catheters that were identified, 25 out of 35 documented breaks in sterile technique, and 16 catheters were placed in intensive care unit (ICU). CLABSIs were associated with documented break in sterile technique placed in the ICU setting. Practitioners were encouraged to increase awareness and education to adhere to strict sterile precautions. An emphasis was put on the use of CLABSI bundle and education on CLBASI prevention. Research was approved by the Department of Intensive Care Medicine at the University Medical Center Hamburg–Eppendorf, Hamburg, Germany. Independent variable: Catheterize patients, dependent variables: CLABSI infections (Sacks et al., 2014). The researcher in this article have utilized the SPSS 22.0 has a data analysis method which is mostly used for quantitative data. The researcher noted that the rate of CLABSI per catheter days reduced 19/3,784 to 3/1,870 after implementation and collaboration of the CLABSI protocol Bundle. It was also noted that the p value was 0.02, which is statistically significant value. P value in this research study was less then .05, (p=0.02), p <0.05). With the CLABSI bundle and education intervention, CLABSI rate decreased from 3.9 per 1,000 catheter days to 1.0 per 1,000 catheter days. Also, in this research study the P value was 0.000 which is less than 0.5 and is considered to be statistically significant as the (P= 0.02),and (b = −0.505, χ2 (1) = 4.20) (Sacks et al., 2014). We can conclude that we can reject the null hypothesis and state that there was significant difference noted when CLABSI bundle was applies towards the prevention of the CLABSI. In conclusion, most of the CLABSI identified in the trauma service were related to break in the sterile technique. It is most frequent in the ICU setting. The adherence to proper sterile technique guidelines while placing catheter can help to reduce CLABSI and patient mortality. Also, the CLABSI bundles has been found very effective by various health organizations. As identified in this article, appropriate implementation of the bundle reduces the rate of infections by 38%.

Conclusion

As we all know, there are several comprehensive studies and research done on CLABSI and prevention of CLABSI. The main purpose of this research study is to establish the effect of working as a team on the quest to improve the patient’s safety and prevention of infection in ICU patient. It has been found from different article review that the best way to prevent CLABSI is by developing models, educating bedside nurses, attending seminar, attending continue education based on CLABSI and CLABSI protocol guidelines. The models have to be based on the Evidence Based Research (CDC, 2016).  Knowledge is defined as power (Morrison, 2012). Attending PowerPoint presentation, attending seminar based on the CLABSI and prevention, and keeping communication open on significance of CLABSI prevention was the best way of prevention of CLABSI.  As to test knowledge a competency test should also be conducted on the bedside nurses for competency and knowledge.

References

Blot, K., Bergs, J., Vogelaers, D., Blot, S., & Vandijck, D. (2014). Prevention of central line–      associated bloodstream infections through quality improvement interventions: a                                  systematic review and meta-analysis. Clinical Infectious Diseases, 59(1), 96-105.

CDC National and State Healthcare-Associated Infections Progress Report, (March 2014), retrieved from www.cdc.gov/HAI/pdfs/progress-report/hai-progress-report.pdf

Chopra, V., Olmsted, R.N., Krein, S.L., Safdar, N., & Saint, S. (2013). Prevention of central line-            associated bloodstream infections: Brief update review in making health care safer II: An             updated critical analysis of the evidence for patient safety practices. Rockville (MD):

 Agency for Healthcare Research and Quality (US), No. 211(10).  doi: 10.1007/s11606-    011-1935-y.

Furuya, E. Y., Dick, A. W., Herzig, C. T., Pogorzelska-Maziarz, M., Larson, E. L., & Stone, P.                W. (2016). Central line–associated bloodstream infection reduction and bundle                                   compliance in intensive care units: a national study. infection control & hospital                                   epidemiology, 37(7), 805-810.

Morrison, T. (2012). Qualitative analysis of central and midline care in the medical/surgical

setting. Clinical Nurse Specialist, 26(6), 323-328.

Park, S. W., Ko, S., An, H. S., Bang, J. H., & Chung, W. Y. (2017). Implementation of central                 line-associated bloodstream infection prevention bundles in a surgical intensive care unit                     using peer tutoring. Antimicrobial Resistance & Infection Control, 6(1), 103.

Sacks, G. D., Diggs, B. S., Hadjizacharia, P., Green, D., Salim, A., & Malinoski, D. J. (2014).

Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit using the Institute for Healthcare Improvement Central Line Bundle. The American Journal of Surgery, 207(6), 817-823.