Rollout Plan to Decrease the Incidence of CLABSI Outside of the ICU

Abstract

Clinical problem: Central venous catheters (CVC) are used in patients who require a steady supply of medicines, nutrients, or direct blood supply to the heart, and can be left in place for much longer than intravenous catheters. Central Line-Associated Bloodstream Infections (CLABSI) occur over the course of a CVC placement due to a host of reasons. CLABSI represents a significant threat to the health and well-being of patients who require long-term supplies of medicines, nutrients, or direct blood supply to the heart.

Objective: To distinguish the most effective evidence-based practices for implementation within non-ICU, general population patients who require CVC. A specific objective is to distinguish the most effective method of decreasing CLABSI within non-ICU patients through the regular utilization of chlorohexidine impregnated dressings.

Data sources: Published results of three randomized control trials were obtained using PubMed. In order to focus the search parameters, the key words used included: chlorohexidine, CLABSI, non-ICU, central catheter, and patient cleansing. A clinical guideline for the reduction of CLABSI was obtained from the Centers for Disease Control and Prevention.

Results: Chlorohexidine impregnated catheters showed a significant decrease in the incidence of CLABSI for all patient populations. Interventions such as evidence-based practices and training programs for healthcare professionals implicated in CVC placement showed a significant decrease in the prevalence of CLABSI.

Conclusion: Chlorohexidine is an important factor in reducing CLABSI across all patient populations, and while the guidelines are challenging for ICU conditions they can be implemented in general patient populations when necessary.

Introduction

As the advances in medical technology move forward, the primary limiting step will continue to be the application of new technologies to patients. The use of central venous catheterization, a technique that allows for immediate supply of medicines or nutrients to the heart, has increased and is no longer confined to intensive care units (ICU). Central venous catheters (CVC) are commonly used for patients who require a steady supply of medicines, nutrients, or direct blood supply to the heart, and they can remain in place for much longer than intravenous catheters. Outpatient hemodialysis treatment centers are a common situational example in which the utilization of a CVC is both convenient and effective. There are risks, however. Central Line-Associated Bloodstream Infections (CLABSI) can occur when the application or management of a CVC does not follow certain standards of care.

CLABSI represents a significant threat to the health and well-being of patients who require long-term supplies of medicines, nutrients, or direct blood supply to the heart. In order to determine evidence-based practices that can assist in the prevention of CLABSI in non-ICU patients the following research question was proposed: In general medical patients (non-ICU) with central lines, would daily bathing with chlorohexidine-impregnated wipes compared with non-antimicrobial cloths decrease the incidence of CLABSI within three months? The infrastructure needed to implement such an evidence-based practice includes a willing and able team of nursing staff, a non-ICU ward or clinic in which the use of CVC is common and the occurrence of CLABSI is in line with national statistics, nursing management willing to manage the implementation of the new practice, administrative assistance support, and the acceptance of the proposed change in practice from an advisory council of hospital/clinic leadership. With proper coordination of such infrastructure an evidenced-based practice of using chlorohexidine-impregnated wipes in the daily bathing process for non-ICU patients could decrease the incidence of CLABSI within three months.

Summary of Synthesized Literature

A computerized search of the PUBMED databases was conducted using the following key words: chlorohexidine, CLABSI, non-ICU, central catheter, and patient cleansing. The listed references from each case study were reviewed for additional studies, and other related review articles were also summarized to gain insights into the randomized-controlled clinical trials selected.

Three randomized, controlled trials were evaluated for evidence-based practices that could answer the PICOT question. The first study by Maki, Stolz, Wheele, and Mermel (1997) was used as a baseline to determine the efficacy of chlorohexidine in CVC placement and maintenance. As the study took place in the early stages of chlorohexidine use for CVC utilization, it was determined to be relevant to the utilization of a novel chlorohexidine therapy. The study by Maki et al. (1997) focused on determining the level of effectiveness of a novel antiseptic catheter, to distinguish between certain sources of CLABSI, and to determine how well patients would respond to a new antiseptic catheter. The study concluded that chlorohexidine catheters were well tolerated, reduced the incidence of CVC-related infection, increased the amount of time CVC’s could be left in place, and could even allow for significant cost savings in long term health care incidences (Maki et al., 1997).

The second study by Tennenberg et al. (1997) focused on the efficacy of antibiotic-CVC versus antiseptic-CVC in order to determine new measures for CVC-related infections. As the study took place in the early stages of chlorohexidine use for CVC utilization, it was determined to be relevant to the utilization of a novel chlorohexidine therapy despite the study being conducted in 1997. Patients were prospectively randomized to receive either the standard CVC or the antiseptic silver sulfadiazine and chlorohexidine coated CVC. While the antiseptic CVC showed a significant decrease in catheter site colonization and in local catheter-related infection rates, there was not a significant reduction in the incidence of CVC septicemia. Tennenberg et al. (1997) concluded that this was likely due to an increased pathogenic dependence on contamination of the catheter hub, instead of catheter site colonization at time of CVC introduction.

The third prospective, randomized, controlled trial by Freixas et al. (2013) focused on introducing multimodal interventions within non-ICU wards to address the prevalence of CLABSI in hospitals in Spain. Freixas et al. (2013) used four different measures to run their study including evidence-based bundles of practices relating to catheter insertion, training programs for those involved, tracking forms to follow the status of catheters with a four-point prevalence survey, and feedback reports from healthcare workers. Their study showed that the incidence of CLABSI from CVC decreased from 0.14 to 0.10 after randomized multimodal interventions, and a statistically significant improvement in the adequate maintenance of CVC in non-ICU wards (Freixas et al., 2013).

Proposed Practice Change

Good patient care techniques like regular bathing and the tracking of medication regimens are necessary steps for proper treatment of patients by nursing staff, but there must also be a focus on maintaining standards of care when new medical treatments and strategies are implemented in new patient populations. With the rising utilization of CVC in non-ICU wards, the incidence of CLABSI in non-ICU patients is also on the rise. An important evidence-based clinical practice that nursing staff can utilize in order to decrease the amount of CLABSI cases in non-ICU wards includes the use of chlorohexidine-impregnated dressings and washcloths when completing regularly schedule cleansing of patients who have, or are set to have, a CVC placed. Nursing staff involved in the bathing of patients with chlorohexidine-impregnated dressings should make use of a 2% chlorohexidine solution, use two extra dressings than previously used, and clean the body of the patient up to the jaw line. This chlorohexidine-based intervention should also be coupled to four minimal nursing practices: bundling of CVC insertion supplies, use of a checklist to identify the best insertion practices, ensuring that nursing staff have proper channels through which they can stop a CVC insertion in cases where proper steps are not followed, and regular cleaning of the hub or access port of the CVC with 2% chlorohexidine solution.

Change Strategy

As indicated in the Rollout Plan below, the implementation of this new evidence-based practice of using 2% chlorohexidine-impregnated dressings coupled to augmented CVC management nursing practices will follow the Evidence-Based Practice (EBP) model: plan, implement, evaluate, define, and assess. Changes to nursing practices do not come easily, however, as nurses are educated in a vacuum contemporary to the most recent level of medical knowledge, and on-the-job educational sessions are generally given a backseat to the primary tasks of patient care. In their discussion of the EBP model Sparger et al. (2012) noted that the strategies to promote staff and team engagement fall on the nursing management or other leaders implicated in the process of change. “Change leaders need to listen to concerns, alleviate misperceptions, and realize that not all resistance is negative” they state (Sparger et al., 2012, p.16). Indeed, the implementation of changes to a nursing practice will largely be focused on motivating nursing staff to accept the change. Bulletin-board notifications must be made clear and present in the period of time leading up to the scheduled implementation of the new change. This will allow nursing staff to prepare for the change in a timely manner. In-services, when possible, aid the process of linking all nursing staff members together in their understanding of the new change, and such meetings also allow for an open forum for questions. The communication of such changes through in-service meetings and bulletin-board notifications can also be augmented through the use of work emails, more creative public notification advertisements, and the use of feedback notes

Rollout Plan

The implementation of this new evidence-based practice of using 2% chlorohexidine-impregnated dressings coupled to augmented CVC management nursing practices will follow the Clinical Excellence through Evidence-Based Practice (CETEP) model: plan, implement, evaluate, define, and assess. These steps are based primarily on the nursing process, as they are fluid, dichotomous, and applicable within a dynamic environment.

1. The first step in the rollout plan includes getting the approval of the protocol that details the use of 2% chlorohexidine-impregnated dressings in a non-ICU ward or clinic by the board or council in charge of evidence-based clinical practices. In order to accomplish this, an electronic rollout form will be created that details the time frame, administrative requirements, and infrastructural requirements for the implementation of such a practice. An educational plan will be made for the administrative assistants involved in the process that will detail the specific changes to forms, electronic notification systems, and pertinent databases. Finally, meetings will be scheduled with the heads of the other clinic or hospital units in conjunction with the board or council in charge of evidence-based clinical practices.

2. The second step in the rollout plan includes the review process of the protocol by the board or council. This step will include the answering of questions for an interdisciplinary group or unit and department heads and will include a full expression of the evidence behind the stratagem. The protocol will first have to be placed on the necessary agenda for the council members and distributed through the proper administrative channels. The council meeting will be scheduled according to their calendar.

3. The third step in the process will include assigning a “go-live” date. The administrative issues brought up through the protocol meeting will be double checked at this stage to assure all complexities are straightened out in a timely manner. When these timing issues are hammered out a roll-out/go-live calendar will be published electronically and physically to be posted throughout the work environment.

4. The fourth step in the process will include the coordination of educational issues necessary for the implementation of 2% chlorohexidine-impregnated dressings for patient bathing. An educational teaching module will be created and placed in line with other online teaching modules in each nursing staff’s workplace folder. Certain requirements for the completion of such a module will be implemented, but only at the discretion of direct nursing management and in conjunction with other on-the-job educational training requirements.

5. The fifth and final step of the rollout plan will include the ongoing evaluation of the rollout, and the overall effectiveness of the change. In order to do this, it is necessary to create a convenient forum by which nursing staff implicated in the change can share their thoughts. Positive or negative, email surveys and notifications will serve as that forum. It should be a focus at this stage to involve all members of the nursing staff and evidence-based practice educators, and it should also be a focus to notate the specifics of personal feedback.

Project Evaluation

A great deal of effort will be made to coordinate with nursing staff to implement the necessary changes, but it will be a focus of ongoing projects to meet specific standards in data collection. Weinstein and Deyo (2000) found that in order to meet such standards in data collection, “careful thought must be given to the exact questions they are to address” (p. 3104). Certainly, the outcomes that define the success or failure of an evidence-based practice change will come from the source of the question. The data elements include:

Demographic data: age, sex, CVC used, daily vital signs, antibiotic receipt, and a regular Acute Physiology and Chronic Health Evaluation (APACHE) II.

Infection record: noninfectious events, infectious events prior to clinic/non-ICU ward stay, and novel CLABSI.

Clinical and laboratory records checked against nursing staff checklists and new administrative forms.

The statistical considerations that will be used to assess the degree of success following the three-month period of evidence-based practice change implementation includes calculations of the incidence of difference between the different wings of the study for CLABSI per 1000 central line days. The incidence difference per 1000 patient days will also be calculated between the different wings of the study and a 95% confidence interval will be correlated. Graphic comparisons will include Kaplan-Meier plots, a t-test for continuous variables, and chi-square tests for categorical variables.

Dissemination of EBP

The implementation of this evidence-based change will take place in two different outpatient hemodialysis treatment centers within the same area. Since hemodialysis outpatients are a common receiver of non-ICU CVC, this patient population will allow for all of the parameters and standards of care to be met in an isolated environment. Furthermore, this will take place in a hemodialysis treatment center that is part of a national corporation which will create the grounds for external application of this new practice if the response to the change is favorable to patients. Based on the standards of care in such treatment centers the trial hypothesis will not be affected if it is later applied to a hospital setting, and multiple wings of a randomized-controlled trial study can be applied to multiple centers as their own internal standards and practices are shared across each center.

References

Freixas, N., Bella, F., Limon, E., Pujols, M., Almirante, B., & Gudiol, F. (2013). Impact of a multimodal intervention to reduce bloodstream infections related to vascular catheters in non-ICU wards: A multicentre study. Clinical Microbiology and Infection, 19(9), 838-844.

Maki, D. G., Stolz, S. M., Wheele, S., & Mermel, L. A. (1997). Prevention of central venous catheter-related bloodstream infection by use of an antiseptic-impregnated catheter. Annals of Internal Medicine, 127(4), 257.

Sparger, K., Selgas, M., Collins, P. M., Lindgren, C. L., Massieu, M., & Castillo, A. S. (2012). The EBP rollout process. Nursing Management, 43(5), 14-20.

Tennenberg, S., Lieser, M., Mccurdy, B., Boomer, G., Howington, E., Newman, C., et al. (1997). A prospective randomized trial of an antibiotic-and antiseptic-coated central venous catheter in the prevention of catheter-related infections. Archives of Surgery, 132(12), 1348-1351.

Weinstein, J. N., & Deyo, R. A. (2000). Clinical research: Issues in data collection. Spine, 25(24), 3104-3109.