Bloodstream infections reduced through better central line care at three hospitals

June 5th, 2014
Whether through the use of alcohol-containing caps or basic cleaning of the injection port of the central line, infection preventionists at three hospitals are finding successful ways to stop germs from entering central line catheters and causing bloodstream infections in patients.

A trio of abstracts, to be presented on June 7 at the 41st Annual Conference of the Association for Professionals in Infection Control and Epidemiology (APIC), addresses the challenge of keeping bacteria from entering the bloodstream through a central line, a catheter placed in a large vein to deliver medicine and fluids during hospitalization.

Patients in intensive care units (ICUs) may need to have their lines accessed 20 or more times per day, increasing the risk for infection and contamination. Many facilities follow a bundle of best practices to reduce risk factors during the insertion of a central line, but continuous and safe maintenance of the line is difficult.

"Sharing successful process improvement strategies for catheter maintenance is essential to continuing efforts to prevent these serious bloodstream infections," said APIC 2014 President Jennie Mayfield, BSN, MPH, CIC. "For patients with long lengths of stay, maintenance-related issues become very important. As these examples demonstrate, each health system needs to review its own data and work as a team with front-line caregivers to tailor interventions that will be successful at their institution."

Texas Health Presbyterian Hospital of Dallas: Disinfecting caps cut CLABSI rates by 68 percent; simple device can supplement other measures to prevent bloodstream infections

When infection preventionists at Texas Health Dallas, an 800-bed facility, noticed an increase in hospital-wide central line-associated bloodstream infections (CLABSI) in 2011, they assembled a task force to assess infection data and recommend improvement strategies. A gap analysis, utilizing observational audits, identified inadequate catheter maintenance; specifically, employees were not consistently scrubbing the hub with alcohol for the required 15 seconds before accessing the line. Keeping catheter connector hubs and injection ports disinfected reduces the risk of bloodstream infections.

The task force, including members of the infection prevention department, as well as hospital employees, tried a range of evidence-based strategies to improve line maintenance, but did not see improvement in CLABSI rates until alcohol-impregnated port protectors, which had already been used successfully in the hospital's neonatal intensive care unit (NICU), were introduced.

In November 2012, infection preventionists received approval from hospital administration to use the disinfecting caps on every patient, for every port, on every unit. In 10 months, CLABSI rates decreased by 68 percent. By adding a simple device to other evidence-based measures, Texas Health Dallas prevented 17 CLABSIs during the first 10 months for a total cost savings of $410,000. Additionally, by eliminating the need to scrub the hub, they calculated an annual time savings of 144 nurse hours.

"We did this in a very systematic fashion," said Barbara Danielson, RN, BSN, CIC, study author and infection prevention manager at Texas Health Dallas. "We involved a team and went through the necessary steps to show that this was the intervention that we needed."

To maintain compliance with use of the alcohol-impregnated port protectors, the infection prevention team educated nurse managers and front-line providers, conducted weekly audits, and made sure the port protectors were readily available at every point-of-use. It took five months to reach their goal of 85 percent of patients having 100 percent of their connector hubs and ports covered.

"The alcohol-impregnated port protectors represent one way to protect the line and keep it in a constant state of disinfection, but there's a lot more involved than just adding a cap," said Danielson. "You have to stay on top of the process."

Loyola University Medical Center, Maywood, IL: Significant improvement in CLABSI rates following routine use of disinfection caps on all connector hubs and access ports

With 140 ICU beds, the infection prevention team at Loyola knew it was necessary to identify the best ways to decrease colonization beyond scrubbing the hub. They did a three-arm study comparing disinfection caps to an intense scrub-the-hub intervention to standard care. At the end of the study, both the scrub-the-hub and the disinfection caps interventions reduced CLABSI significantly.

During the last three months of the study, the team discovered that 80 percent of the infections that occurred in the scrub-the-hub arm were related to a significant drop-off in adherence to scrubbing the hub for the required 15 seconds.

"It became clear that relying solely on the scrub-the-hub method may not be sustainable for many staff," said Marcelina M. Wawrzyniak, MSN, RN, study author and infection preventionist at Loyola University Medical Center. "The alcohol-impregnated caps, by comparison, were very well received due to their ease of use. Our study shows that long-term, they have a sustained, positive impact on CLABSI reduction."

During a follow-up two-year study being presented at the APIC conference, the Loyola researchers found a 68 percent decrease in the overall number of CLABSIs. A total of 59 CLABSIs occurred during the 12-month standard care period, compared to 23 CLABSIs during the 12-month intervention period during which alcohol-impregnated disinfection caps were used on all central line access ports.

Using a recent analysis published in JAMA Internal Medicine which estimates the cost of CLABSI at $45,814 per infection, preventing these additional 36 CLABSIs reduced CLABSI-related costs by more than $1 million over the intervention year.

"It was vital to get C-suite support for this intervention," said Dr. Jorge Parada, MD, MPH, FACP, FIDSA, professor of medicine at Loyola University Chicago Stritch School of Medicine. "By demonstrating that implementing this method to reduce CLABSI would not only yield improved patient outcomes, but also an improved bottom-line, it was a no-brainer for our leadership."

UPMC St. Margaret, Pittsburgh: It's possible to get to zero CLABSIs with basic central line maintenance

After a decision in August 2012 to halt use of the alcohol-impregnated caps previously used on central lines at University of Pittsburgh Medical Center St. Margaret, the 250-bed community hospital saw an increase in the number of CLABSIs occurring. This led the infection prevention team to institute a "back to the basics" approach to the maintenance of central lines.

The team rolled out a variety of educational tools, including videos, talking points, printed pocket cards and postcards, as well as an extensive online manual accessible on the facility's intranet. These tools covered topics such as scrubbing the hub, proper labeling, dressing, and tubing change requirements and techniques.

The toolkit was rolled out in May 2013 and the facility saw zero CLABSIs through November 2013.

"Sometimes people can become a bit too reliant on products, like we were with the alcohol caps," said Jenny Bender, MPH, BSN, RN, CPH, study author and infection preventionist, UPMC St. Margaret, Pittsburgh. "Our staff got so used to having them and letting them do the work for us that we became too relaxed with our good nursing care, when it comes to maintaining a line. As a team, we were able to retrain and re-introduce good practices back into our everyday routine to improve our patient outcomes."

The basic steps of maintaining a safe central line include the following: conduct hand hygiene before accessing the line; determine if the line is still needed and if not, obtain an order to have it removed; assess and document the condition of the line; scrub the hub for 15 seconds; conduct line flushing; and finally, change the dressing and tubing according to protocol.

"Basic line care should always be the first defense against bloodstream infections," said Bender. "This demonstrational study shows that going back to the basics can in fact make a difference in infection prevention."

Provided by Association for Professionals in Infection Control

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