CLABSI

Central line-associated bloodstream infections or CLABSI are the main reason for numerous of deaths each year in the American healthcare system and result in billions of dollars annually within the healthcare system. Despite the massive losses caused by CLABSI, the issue is preventable. CLABSI is a severe infection, which happens when viruses or bacteria enter the human bloodstream via the central line (Taylor et al., 2017). The central line is a catheter, which medical personnel inserts in the large vein in the neck, groin area and chest to administer fluids, or medication or collect blood for therapeutic tests.

It is prudent that healthcare providers follow stringent measures when inserting catheters and make sure that they are sterile to ensure that CLASBI does not occur. Stringent infection control practices need to be followed by the healthcare providers, changing the dressing or checking the line. Patients who exhibit signs of CLASBI doctors need to conduct tests to check the presence of the infection. Signs may include soreness and red skin around the catheter line, and fever (Park et al., 2017). Healthcare providers need to do several things each time they handle patients to avoid the occurrence of CLASBI. Observing hand hygiene, application of the right skin antiseptic, making sure that the skin prep agent has dried entirely before deciding to insert the central line. The use of sterile gloves, mask, gown, large sterile drape and cap. Patients can help prevent cases of CLABSI by researching a hospital and learning about its CLABSI rates, speaking out about any issues they think may endanger them, which helps remind healthcare personnel to follow the recommended guidelines to help prevent infection rates.

Research study 1

Methodology

Wichmann et al. 2018 conducted a research study investigating the effectiveness of using a checklist to help reduce central venous line-associated bloodstream infections within the ICU when caring for adult patients. The study’s methodology was a prospective and observational single-center study at the department of intensive care medicine at the University Medical Center Hamburg Eppendorf, Hamburg, Germany. The study was conducted within one year, specifically between October 1st, 2011, and September 30th, 2012. The department under study contained 132 ICU beds and has 11 wards. There were 12 beds within each ward and assigned two supervising senior physicians, eight assistant physicians, and 34 specialized nursing staff. The department serves all issues that need medical care medicine. Because of unavoidable logistic reasons, some of the wards host specialized patient groups, for example, cardiac surgery patients and neurosurgery. Despite all, all teams observe to standard operating procedures, the teams also had a frequent exchange of ideas between the team. The study chose a two-step approach in line with the recommendation of central venous line placement of the Institute of Healthcare Improvement. Some of the brief measures that the institute had recommended to avoid CLABSI include full barrier nursing, hand disinfection, avoidance of femoral vein, and sterile disinfection of insertion site. The frequency of CLABSI in the patent catheter line was placed when switched the recommended checklist and at other times without was the research’s primary outcome. Data of all the patients who had been treated within the study within one of the ICU wards with a temporary dialysis catheter or CVL was analyzed. The microbiological methods of the study include in the patients who had a new sepsis episode and in other cases a CV which acted as a point of potential focus then a pair of blood cultures was extracted from the peripheral site, the tip was taken for microbiological testing after the catheter had been explanted. The catheter tips, which were explanted, were placed within a trypticase broth of 5 ml and incubated within 37⸰C; a visual inspection n of the cultures was conducted on a daily basis, an agar media was used to streak any culture that had microbial growth. The researchers decided to compute descriptive statistics like frequencies, counts, and incidence per 1000 catheter days. STATA was used to compute incidence rate ratios and confidence intervals.

Findings

4416 CVL were implanted during the study; 2898 were implanted within the control group and 1518 within the checklist group. Patient characteristics within both groups differed slightly in the male-to-female ratio (2:1), length of ICU stay, patient type (medical or surgical), and disease severity. The study managed to identify CLABSI in 39 of the 1518 participants who had contributed 11 540-catheter days within the checklist group. Of the 2898 patients within the control group 127, CLABSI contributed 21,349 catheter days. Ana analysis of the colonized CVL 245 events was detected within 1518 patients within the checklists group and 776 in the 2898 control group patients. When the researcher analyzed the prescribed features of the checklist, 267 checklists were identified, which is 17.6% where incomplete compliance was visible since the paragraphs were not filled out completely. However, patients whose checklists were not complete had a similar decrease in CLABSI as those with complete checklists. Statistical evaluation of checklist adherence was not possible since most ICU patients had a length of stay which was below average, in this case, below three days. For the CLABSI, coagulase-negative were the majority within the pathogen isolates with Enterococci 5%, Staphylococci 79%, S. aureus 3%, within the checklist group. Yeast 6%, Enterococci 7%, S.aureus 6% within the control group. During the CLABS analysis, no substantial differences were detected within the catheter insertion site. Catheters, which had been placed within the jugular vein, had a 3.6 per 1000-catheter days infection rate when likened to other sites which had  2.7 for 1000 catheter days. An infection rate of 1.3 per 1000 catheter days was present within the subclavian vein catheters. The femoral vein catheter had a 2.0 per 1000-catheter days infection rate, in contrast to 7.8 per 1000 catheter days infection rate for other sites. The CVL colony’s protective effect for the catheters, which had been placed within the subclavian vein, was 5.1 per 1000 catheter days infection rates vs. 23.5 per 1000 catheter days infection rates for other sites. This represented an incidence rate ratio of 95%, 0.52, and a confidence interval of 0.34-0.76. The P value=0.0001. For both CLABSI definitions, no significant differences were noted when examining the issues of the setting in which the catheter had been positioned, routine vs. emergency.

Conclusion

Data findings showed that a checklist is a critical tool useful in preventing CLASBI within ICU patients. It may help increase patient safety and help ease costs for hospital-acquired infections. The CVL placement checklists execution needs to be supported even when highly trained ICU staffs perform it. 

Research study 2

Valencia et al. investigated the poor adherence to measures that are aimed at preventing CLABSI. A worldwide study was conducted for the research. 

Methodology

The study sample entailed nurses and medical doctors who have d world in the ICU in 2015. a definition of ICU was provided as provides which aid in invasive mechanical ventilation, function continuously without stop, pump controlled infusion administration, at all times there is an assigned doctor on standby in case of an emergency. A questionnaire was formulated and entailed five critical parts (1) clinical practices for catheter line insertion (2) ICU setting and characteristics of the respondent (3) clinical practices for catheter line maintenance (monitoring processes and outcomes (5) attitudes directed towards measure as an important toll in improvement. The study included questions about measuring outcomes and processes, including hand hygiene, prevention practice compliance, and device utilization ratio. A 5-point Likert scale was used to measure the attitudes regarding data implementation. (1 represented strongly agree while five represented strongly disagree. The questionnaire was translated into nine languages: Portuguese, German, Dutch, Mandarin, Russian, Japanese, French, Italian, and Spanish. A second native-speaking physician independently verified each translation. Anonymity was guaranteed to the participants. 

The questionnaire was disseminated to the target group through the internet. It was available online between 10th June to 31st October 2015. The questionnaire was endorsed by various groups, including the Middle East Critical Care Assembly, the European Society of Intensive Care Medicine, and other organizations. There was no sample size for the questionnaires was conducted. To analyze the data, descriptive analysis was used to summarize the population characteristics. Standard error calculations were also calculated. Nations were categorized as either low-income countries, middle-income nations, or high income nations. Total nation population was used to compute weighted estimates for the high and middle-income nations. 

Findings

3,407 complete individual responses were received out from ninety-five nations. Standard errors and weighted estimates for 27 high-income and 14 middle-income nations are based on 3250 responses received from forty-one nations, out of which ten complete replies were available. Low-income nations did not provide 10 or more responses. One hundred fifty-seven participants came from 55 nations, which had provided less than ten responses. 2214 were from high-income nations, which had at least ten replies, while 836 were from 14 middle-income nations with at least ten responses. 

Conclusions

The research demonstrates awareness and clear interests in the ICU for CLABSI prevention within middle-income and high-income nations but the adherence and implementation of prevailing guidelines if insertion and upkeep of catheter line need to be strengthened within the ICU level. Some of the areas of improvement of CLABSI prevention in ICU include reducing device exposure through daily assessment of catheter line, full barrier precaution, data utilization for monitoring progress in preventive actions. The primacies of improvement tend to differ nation by nation. The study discovered that it would be advantageous to continue addressing factors and encouraging collaboration aimed at accountability within ICU through close monitoring of infection rates, the establishment of a reliable data collection system, and providing feedback to staff. 

Research study 3

Park et al., 2017 studied the implementation of CLABSI bundles within surgical intensive care units through peer tutoring. 

Methodology

A 767-bed hospital was used as the environment for conducting the study. The surgical intensive care unit (SICU) had fifteen beds where most of them had been full by patients for the thoracic surgery and neurosurgery departments. A ratio of 3:1 was present for the nurse-patient ratio. All patients who had been admitted to the SICU were considered in the research. The hospital had an infection control office comprised of one infectious disease physician who also served as the director. There was one full-time nurse and a part-time nurse. The main aim of the intervention n was to reduce CLABSIs in the SICU and maintain reduced rates. The auxiliary objectives were improving the discernment of base understanding linked to CLABSI prevention and retaining compliance with using o maintenance bundles and insertion. The study was divided into three regions first nine months was the pre-intervention period: the six-month period, which was the intervention period, and a final intervention period of nine months. The insertion bundle consisted of maximal barrier precautions, hand hygiene, optimal catheter site selection, with the preferred insertion site being the subclavian vein, chlorhexidine skin antisepsis. The maintenance bundle consisted of hub care, catheter site dressing, hand hygiene, daily review of the necessity of central line. 2% chlorhexidine tincture was used to disinfect the site. 70% alcohol was used to cleanse to decrease contamination. The performance of hand hygiene was monitored in the SICU every week by a nurse in charge of infection control using the WHO hand hygiene guide.

Physicians or residents who were overseeing inserted the catheter. The checklist of insertion bundle was explained to the patient before the insertion procedure by the nurse charge. The nurse also checked for adherence. The resolve of default was documented in the checklists, and the nurse pointed out the default of the bundle. The nurse was reasonable for pointing out the default in the middle of the procedure, and the checklists were used to record the default. The nurse was not authorized to stop the procedure. CLABSI was defined as a laboratory-confirmed bloodstream infection where a central line was put in place for Moe, then two days where the catheter line was set up on the day of the occasion. If the positive blood culture and clinical symptoms of infection of CLABSI happened at least 48 hours following admission, then the CLABSI was considered valid hence the data was captured. The CLABSI was monitored by the infection control office as well as compliance with central line bundles use. The amount of blood-paired cultures per 1000 patient days was computed in the course of the study period to observe suitable practices of blood culture. Systematically fixed programs continued after the intervention period. Hand hygiene monitoring was done weekly. The infection office checked the performance checklist in the maintenance and insertion bundles of CLABSI prevention, which the users and EMR were checking used to monitor. Active informative meetings were not being held anymore. Educational materials were provided monthly through email for new residents or physicians. Poisson regression was used to equate the CLABSI incidence rates during and after the baseline intervention period: a 95% confidence interval and two-tailed statistical tests. P less than n 0.05 were deemed significant. 

Findings

There was a decrease in the pre-intervention period from 6.9 infections to 2.4, then dropping to 1.8 in the intervention period, which is the rate of CLABSIs per 1000 catheter days. A decreasing trend was seen in the regression model on the rates of infection from the period of pre-intervention. (P<0.001). In the fifth month, observance to each factor reached a 100% rate. There was an increase for line used, but the central lien utilization ratio when patient days are factored in has recorded a decrease from 0.58 to 0.48. CLBSI prevention practices awareness increased within six months. The predominant causative organisms in the pre-interventional period were the Acinetobacter baumannii (20%), Enterococcus species (20%), and Staphylococcus aureus (5%). 

Conclusions 

For the execution of CLABSI prevention, peer tutoring was useful in an SICU where it helped reduce infection rates for a while, in this case, one year. It applied to hospitals with inadequate resources, which are trying to commence prevention bundles. A multifaceted cooperative approach and resource support are essential to help reduce the rates of CLABSI.

National initiatives

Within the national level, a Department of Health and Human Services component launched a national plan in 2009 dubbed the national Action Plan to Eliminate Healthcare-Associated Infections (Taylor et al., 2017). The CDC, the office of the Assistant Secretary of Health and Human Services, and the Centers for Medicare and Medicaid Services all aligned their service with the national plan. Several organizations, which include The Joint Commission and American Hospital Association, were also brought on board. The diverse group where it was synergized with other efforts to reduce CLABSI, which includes economic incentives for the hospitals with the aim of encouraging them to reduce infection rates and improved social pressure through public reporting of CLABSI rates brought increased awareness and increased support to the initiative. Each state was assigned the initiative, and a project coordinator was assigned from RHET; MHA provided a data expert while a faculty quality improvement researcher was provided to coach and support state leads and teams (Taylor et al., 2017). 

Implementation

Step 1: Identify improvement opportunities where there is a need to reflect on long-term care to help reduce the CLABSI rate. A staff safety assessment will help in the identification process. Questions such as whether the outcome improves and how the residents experience improvement need to be asked in the identification phase (Pronovost et al., 2018). 

Step 2: engaging the team to improve safety whereby the users will be aiming at improving the culture of safety. despite all this is a team effort, leaders, nurses, other frontline staff, and residents all need to be included in the process to sustain the improvement made. This call for leadership buy is a critical component of implementing interventions, which are aimed at improving the safety of the residents (Pronovost et al., 2018). There needs to be a commitment to improving safety culture from the medical personnel. Core team members will include the facility team leader, who is the director of nursing, or the nurse manager. At other times the individual may be the staff educator or the infection preventionist. They ensure that all team completes their needed activities. A data coordinator will also form part of the group who will help collect and analyze the data.

Step 3; utilizing data

Data is critical to ensuring that the rate of CLABSI occurrence is tracked. The data collected will be used to determine the necessary intervention measure, which will be taken to reduce occurrence rates. 

The major stakeholder is the prices will include the patients; they are the ones who are affected by CLABSI. Nurses are responsible for taking care of the patients; they are in charge of catheter insertions and catheter line maintenance. They need to ensure that they adhere to the recommendations to reduce CLABSI since they deal with patients more than other medical groups. The government, both federal and state, is responsible for studying the rates of CLABSI and coming up with guidelines to deal with the issue. 

One of the most important data to have before implementation is bloodstream infections. This laboratory data is crucial to help act as a control group for the data that will later be collected. CLABSI incidence rates before the data is collected are important before implementation. All other information collected will be based on this data that has already been analyzed. The researcher can state their infection incidence rates and compare them to the CLABSI pre-intervention data. 

Summary of planned change

To reduce the incidence of CLABSI, there are several things that the hospital will need to do to avoid the occurrence of CLASBI. Performing hand hygiene, applying the right skin antiseptic, ensuring that the skin prep agent has dried completely before deciding to insert the central line. The use of sterile gloves, gown, cap, mask, and large sterile drape. Patients can help prevent cases of CLABSI by researching a hospital and learning about its CLABSI rates, speaking out about any issues they think may endanger them, which helps remind healthcare personnel to follow the recommended guidelines to help prevent infection rates (Pronovost et al., 2018). The patient will also need to avoid wetting the central line insertion as it may become a bacteria-breeding site. Visitors should not be allowed to touch the tubing or catheter (Taylor et al., 2017).. Every individual, including visitors and the nurses, and other medical personnel, will need to wash their hands before and after the visit. 

Reference

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), 1-7.

Pronovost, P. J., Marsteller, J. A., Weeks, K., Watson, S. R., Berenholtz, S. M., Goeschel, C. A., … & Combes, J. R. (2018). A national initiative to reduce central line-associated bloodstream infections: a model for reducing preventable harm. Health Aff Blog, available at: http://healthaffairs. org/blog/2013/09/23/a-nationalinitiative-to-reduce-central-line-associated-bloodstream-infections-a-model-for-reducingpreventable-harm/(accessed November 21, 2013).

Taylor, J. E., McDonald, S. J., Earnest, A., Buttery, J., Fusinato, B., Hovenden, S., … & Tan, K. (2017). A quality improvement initiative to reduce central line infection in neonates using checklists. European journal of pediatrics, 176(5), 639-646.

Valencia, C., Hammami, N., Agodi, A., Lepape, A., Herrejon, E. P., Blot, S., … & Lambert, M. L. (2016). Poor adherence to guidelines for preventing central line-associated bloodstream infections (CLABSI): results of a worldwide survey. Antimicrobial Resistance & Infection Control, 5(1), 1-8.

Wichmann, D., Campos, C. E. B., Ehrhardt, S., Kock, T., Weber, C., Rohde, H., & Kluge, S. (2018). Efficacy of introducing a checklist to reduce central venous line associated bloodstream infections in the ICU caring for adult patients. BMC infectious diseases, 18(1), 1-6.