Posted: March 22nd, 2023

Central Line-Associated Bloodstream Infections (CLABSIs) Reduction Through Evidence-Based Nursing Education

 Abstract

Central Venous Catheters (CVCs) are commonly used to treat hospitalized and critically sick patients. Despite their important use, CVCs are associated with developing central line-associated bloodstream infections (CLABSIs). The high incidence of CLABSIs is the rationale for this study project, which seeks to reduce these infections by implementing evidence-based nursing education. The program will be implemented in acute care settings to determine whether effective evidence-based nursing education will achieve positive results in reducing CLABSIs. Results from the study will significantly save on costs at the individual and organizational levels.

Chapter I

The current study is on Central line infection reduction through evidence-based nursing education. The introduction to the study includes a detailed description of the research problem that will be solved using the evidence gathered in the research process. The chapter will also include a description of the importance or significance of the study. The research is carried out with the purpose of closing a gap in research and should be applicable in real-life situations for policy formulation and practice. The purpose or goal of the study is included in the chapter as indicating why the study is being carried out and what it seeks to achieve. Finally, the chapter includes the criteria for evaluating the outcome of the research project.

Statement of the Problem

Central venous catheters (CVCs) are useful tools for treating various life-threatening diseases. These are the tube placed into a large vein such as a subclavian or can be peripherally inserted (PICC line). CVCs are important in treating and managing critically ill patients, especially patients needing long-term antibiotic therapy. Nonetheless, despite these devices’ important role, they have been associated with another life-threatening problem. According to Banach & Calfee (2013), CVCs have been linked to serious healthcare-associated bloodstream infections (BSIs). Among these infections is “central-line associated bloodstream infection” (CLABSI), which results from improper insertion or maintenance of the CVCs.

On the other hand, CVCs have been associated with a high mortality rate from infections; the rates are estimated at between 4 and 20 percent, depending on the setting (McLaws & Burrell, 2012). Silow-Carroll & Edwards (2011) claim that, in 2009, approximately 43,000 CLABSIs happened in hospitals, and as a result, one out of five infected persons succumbed to the infection. Regardless of the prevalence of the problem, there are still inadequate findings on the most effective means of preventing these infections and saving the lives of the many affected persons (Furuya et al., 2011).

The Importance of the Project

The project’s importance is finding evidence-based nursing education to help reduce the rate of CLABSI in the ICU units. The results will be useful in policymaking, where the best practice needs to be implemented at the institutional level to reduce the cases of CLABSIs. Therefore, this will include the development of policies relating to implementing evidence-based nursing education during training and in practice (Weber & Rutala, 2011). Nurses will be taught about the importance of hand hygiene, proper and timely central line dressing changes, changing soiled dressings instead of reinforcing them,  the usage of alcohol-impregnated caps (green caps), changing the green cab each time after the line is accessed, evaluating the need of the CVCs daily, and daily chlorhexidine baths. The results will be used to implement evidence-based practice (EBP) in ICU nursing. Resistance to change will be addressed by making the project’s results known to all stakeholders, including nurse leaders, nurses, and other healthcare providers (Miller & Maragakis, 2012).

The results of this study will be critical in assisting the care providers in the ICU settings to understand best practices in caring for and maintaining CVCs to reduce the number of CLABSIs. Some of the lessons that the health care providers will obtain are the significance of preventing CLABSIs (Marsteller, et al. 2012). They will understand the proper care and maintenance for CVCs. Adequate implementation of evidence-based nursing education will lower the chances of CLABSIs, which will benefit the patients. In this case, the patients will be relieved from the additional burden of pain and suffering. It will also reduce the chances of the additional cost of treatment due to the infections that are acquired in the process of getting treatment for a different disease (Marschall, et al., 2014).

Purpose or Goal of the Study

The primary objective of this study is to establish the effectiveness of evidence-based nursing education in reducing “central-line associated bloodstream infection.” This will show whether implementing evidence-based nursing education will play a role in reducing the prevalence of CLABSI in acute care settings. This will be fundamental in assisting more patients in experiencing better hospital stays and patient outcomes without worrying about extra pain and suffering (Miller, et al. 2011). The findings from the project will be used after the implementation of evidence-based nursing education to determine whether the reduction in the cases of infections has been achieved.

Criteria for Evaluation

Evaluation will be done after the implementation of the evidence-based nursing education program. Data will be collected following implementation to determine whether the program’s objective has been achieved. The main objective is to use the evidence-based nursing education program to reduce the cases of CLABSIs in ICU settings. The data collected will be aimed at establishing the reduction rate, for instance, by 50 percent, as this is the goal. The starting point is to establish the causes of infection before the implementation of the program and the cases after implementation.

Chapter II

Why this Project is Important

This project is very important because Central Venous Catheters (CVCs) are being used more frequently now, and Central-line associated bloodstream infections (CLABSI) are rising. It is essential for the healthcare provider who cares for patients with CVCs to have knowledge of the importance of proper care and maintenance for CVCs. Healthcare providers know the reason behind proper hand hygiene, daily chlorhexidine bath, use of alcohol-impregnated cabs, and timely and proper central line dressing changes.

Still, most are not aware of how many death are due to CLABSI each year because of improper care of CVCs. The project’s importance is finding evidence-based nursing education to help reduce the rate of CLABSIs in the ICU. The results will be useful in policymaking, where the best practice needs to be implemented at the institutional level to reduce the cases of CLABSIs. Therefore, this will include the development of policies relating to implementing evidence-based nursing education during training and in practice (Weber & Rutala, 2011).

Nurses will be taught about the importance of hand hygiene, proper and timely central line dressing changes, changing soiled dressings instead of reinforcing them,  the usage of alcohol-impregnated caps (green caps), changing the green cab each time after the line is accessed, evaluating the need of the CVCs daily, and daily chlorhexidine baths. The results will be used to implement evidence-based practice (EBP) in ICU nursing. Resistance to change will be addressed by making the project’s results known to all stakeholders, including nurse leaders, nurses, and other healthcare providers (Miller & Maragakis, 2012).

The results of this study will be critical in assisting the care providers in the ICU settings to understand best practices in caring for and maintaining CVCs to reduce the number of CLABSIs. Some of the lessons that the health care providers will obtain are the significance of preventing CLABSIs (Marsteller, et al. 2012). They will understand the proper care and maintenance for CVCs. Adequate implementation of evidence-based nursing education will lower the chances of CLABSIs, which will benefit the patients. In this case, the patients will be relieved from the additional burden of pain and suffering. It will also reduce the chances of the additional cost of treatment due to the infections that are acquired in the process of getting treatment for a different disease (Marschall, et al., 2014).

Literature Review

The chapter reviews past research evidence on using best practice training on proper care and maintenance of CVCs, including central line dressing changes in central line care to prevent central line-associated bloodstream infections. Nine sources will be used in writing the literature review, which will be obtained from online databases.

Body of Evidence

The reviewed research indicates the importance of effective training for the nurses involved in central line dressing changes and strategies that nurses can use to prevent CLABSI in hospital settings and reduce the prevalence of CLABSI. Pérez et al. (2015) provide evidence of the effectiveness of training programs for nurses on venous line care in reducing CLABSI in intensive care Units. The focus of the study is the proper care of venous lines, which involves proper central line dressing changes. Cicolini, et al. (2014), in a multicenter survey, highlight the importance of knowledge in nurses as training provides the necessary evidence-based practice in preventing CLABSI.

 Other researchers support the importance of evidence-based training on proper central line care procedures during catheter use in critically ill patients (Longmate et al., 2011). Stevens, et al. (2012) further suggest the importance of context and the unit’s culture in implementing central line care practices in preventing CLABSI. The research suggests the importance of providing continuous training to the nurses within their practice settings and following the unit’s culture to reduce CLABSI. Burden, et al. (2012) acknowledge that the prevention bundle is not enough. Instead, the policymakers should include simulation training for the nurses on properly taking care of the patients using the catheter during their treatment.

Nurses, being central to providing central line care, have been shown in research to be at the forefront of preventing CLABSI through evidence-based strategies. Marsteller et al. (2012) implemented training for nurses in the intensive care unit to establish the role of training in dressing change to reduce the cases of CLABSI. The training was effective towards this end. According to the research, implementation involves proper training of the nurses on how to change central line dressing properly. The study involved the input of the health care providers in implementing good practices in reducing the cases of CLABSI in the ICU.

The research proposes some strategies nurses can use to prevent CLABSI (Marschall et al., 2014). First, there is the aspect of educating the staff on the proper insertion, care, and management of CVCs. Secondly, there is the aspect of bathing patients using chlorhexidine daily. Thirdly, ensure that there are an adequate number of nurses (1 to 2 nurse to patient ratio) to care for the needs of the patients after insertion. Fourthly, it was evident that the nurses should disinfect catheter hubs, injection ports, and needleless connectors, applying mechanical friction to lower the chances of contamination (Marschall et al., 2014). Finally, there is the need for continuous monitoring of CVCs, proper care of dressing, antimicrobial ointments for insertion sites, and surveillance for CLABSI. Research provides evidence of best practices and effective central line management by trained nurses in preventing CLABSI (Weingart et al., 2014; Gupta et al., 2015).

The State of Science

From the reviewed studies on best practices in reducing CLABSI, there is consistency in the argument that best practice by well-trained nurses has a role in reducing CLABSI. Thus, the studies advocate promoting best practices in preventing CLABSI, which involves proper training of the nurses in central line cases, including central line dressing changes. In fact, safe procedures during central venous catheter use, including how to change the dressing without causing infections, are a consistent topic in the reviewed studies. In essence, The majority of the reviewed studies and projects reveal the importance of training the nurses to prevent cases of CLABSIs and, more importantly, training the nurses on how to change central line dressing.

The studies indicate that nurses are important in preventing infections in the patients under their care, especially within the intensive care unit. The research is also consistent in support of prevention using the best practice as opposed to treatment, which is associated with high mortality rates. The researchers seem to focus on the value of effective training approaches for the nursing staff. Finally, other studies that focused on implementing best practices in care settings realized considerable decreases in the rates of CLABSI where they were properly implemented using well-trained nurses. 

However, there are some inconsistencies in the reviewed studies. For instance, in the study by Burden et al. (2012), there is an indication that training is ineffective unless simulation is used. In the study, the researchers propose adding the simulation to the usual training of nurses to improve practice. The inconsistencies will likely arise based on various factors, including the study’s design. It is worth noting that some of the research were primary studies, including Longmate et al. 2011, Marsteller et al. (2012),  Cicolini et al. (2014), and Gupta et al. (2015). On the contrary, other studies, such as Burden et al. (2012), Marschall et al. (2014), and Bramesfeld et al. (2015), were reviews of the literature. Therefore, it is evident that their findings would be expected to differ. Another reason behind the inconsistencies is the settings that were used in carrying out the study. Different hospital units were used in the different studies, indicating that different findings could be expected. However, most of the studies were carried out in the ICU.

It is worth noting that more research is necessary to close some of the gaps evident in the studies. Most reviewed studies focused on using evidence-based training for nurses in proper central line care. Others focused on the general reduction of CLABSI. Thus, there is limited research that focuses on training nurses in best practices concerning proper central line dressing changes to reduce CLABSI. Therefore, more research is required to close this gap and promote best practices in preventing CLABSI using training on proper central line dressing changes.

The use of catheters in the treatment of hospitalized patients is necessary but limited by central line-associated bloodstream infections. Therefore, the research provides evidence of effectiveness in preventing infections, will benefit hospitals and nurses as they can use the catheters without being concerned about the possibility of infections. It will also be possible to save more lives that would otherwise be lost due to the infections. Under those premises, the cost-saving benefits will be achieved at the individual and organizational levels. 

Chapter III

Implementation

The primary objective of this project is to establish the effectiveness of evidence-based nursing education in reducing “central-line associated bloodstream infection.” The chapter includes implementing evidence-based nursing education to achieve the project’s objective. Procedures/Methods, results, and artifacts are the sections that make up the content of this chapter.

Procedures/Methods

The setting for the project will be the Intensive Care Unit caring for critically ill people. The purpose is to establish evidence-based strategies, as nurses implement, that will reduce CLABSI within the settings. The results of this project will be critical in assisting the nurses within the acute care settings to understand best practices in caring for and maintaining CVCs to reduce the number of CLABSI (Marsteller et al., 2012).

Nurses will be involved in a monthly training program, primarily based on the different strategies which can be implemented in practice to reduce the cases of CLABSI. Some strategies that will be used in the training program are using alcohol-impregnated caps (green caps), proper and timely central line dressing changes, bathing patients using chlorhexidine preparation every day, and evaluating the need for the CVCs changes daily. To implement these strategies, important changes will be made in practice. The changes will include stocking the alcohol-impregnated caps at the end and beginning of each shift at the bedside for patients with CVCs, stocking units with adequate supplies of chlorhexidine bath soap and CVC dressing change kit, and educating nurses about proper care and maintenance (which include timely and proper dressing change) of CVCs (Marschall et al., 2014).

The number of cases of CLABSI before the program’s implementation will be taken and recorded. Once the program has been implemented and the necessary changes made for one month, the number will be taken again and recorded. The difference between the two will indicate the effectiveness or lack thereof of the evidence-based training program for the nurses.

Results

Research provides evidence of best practices and effective central line management by trained nurses in preventing CLABSI (Weingart et al., 2014; Gupta et al., 2015). Thus, the training of the nurses is expected to be the basis for better practice in relation to the use of CVCs within acute care settings. The project will allow the nurses to understand better the proper care and maintenance for CVCs within acute care settings. The trained nurses will be better placed to increase the use of alcohol-impregnated caps (green caps), change the green cap each time after the line is accessed, implement effective central line dressing changes, and evaluate the daily need of the CVCs. These strategies will be increasingly used in acute care settings by trained nurses.

Proper implementation of the proposed strategies is expected to decrease the chances of CLABSIs and decrease the hospital’s infections (Marschall et al., 2014). The proposed strategies will help ensure fewer patients contract infections, as the nurses will know how to prevent them. The expected results will be a decline in the cases of CLABSI from the number before the implementation of the number after the implementation of the program.

The project is expected to result in a culture change within the acute care setting. Training the nurses on effective strategies to prevent hospital-related infections will go a long way in preventing them in the future (Longmate et al., 2011). In essence, effective training is the basis for long-term changes as they are better equipped to implement best practices in their work.

The Artifacts

The project will lead to the development of new procedures relating to the use and maintenance of CVCs. The nurses are expected to abandon the old practice and adopt the new strategies, stocking the alcohol-impregnated caps at the end and beginning of each shift at the bedside for patients with CVCs, frequently stocking the CVC dressing change kit, and performing regular audits on the proper CVC dressing change (McLaws & Burrell, 2012). The procedures will also be documented in a new policy relating reduction of CLABSI within the hospital where the project will be implemented. If the hospital has an existing policy addressing CLABSIs, the project will lead to major changes, including the proposed strategies (Miller et al., 2011). But if the hospital does not have such a policy, the project will create one. Therefore, the policy will influence care within the entire hospital in an effort to reduce cases of CLABSI.

Chapter IV: Evaluation

Following the implementation of the project to reduce Central line infection using evidence-based nursing education, an evaluation of the project was carried out. Therefore, this section of the project includes the evaluation, the discussion of the project’s results, and recommendations for future projects. 

Discussion of the Results

During the project’s implementation phase, nurses used various strategies to reduce central-line-associated bloodstream infections. A weekly training program based on the different strategies was implemented. Two evaluation objectives were considered, including whether an evidence-based nursing education program was implemented and whether the evidence-based nursing education program attained a reduction in the cases of CLABSIs in the acute care settings where it was implemented.

The first objective was achieved as the program was implemented. The strategies used in the training program implementation included using alcohol-impregnated caps (green caps), proper and timely central line dressing changes, bathing patients using chlorhexidine preparation every day, and evaluating the need for the CVCs changes daily. After three weeks of weekly education, it was evident that the nurses had become used to stocking the alcohol-impregnated caps at the end and the beginning of each shift at the bedside for patients with CVCs, using chlorhexidine bath soap regularly to bath patients, and CVC dressing change kit. The nurses had also become used to proper care and maintenance (which include timely and proper dressing changes) of CVCs (Marschall et al., 2014).

Before the program’s implementation, the number of cases of CLABSI was found to be at least five cases per month. In the third week after the training program implementation, the project’s second objective was evaluated. It was expected that following the weekly teaching, the cases of CLABSI would be reduced by 50%. While the results from the program implementation did not achieve a 50% reduction during the first three weeks after implementation, the training achieved positive results. On taking the record of the number of patients with infections during the third week, there was a decrease from the first cases a month to three. Marsteller et al. (2012) suggest that implementing training for nurses in the intensive care unit is effective in preventing cases of CLABSI. As such, the project proved effective towards this end as it achieved a 40% reduction in the cases of CLABSI in the setting (McLaws & Burrell, 2012). Thus, the project can be argued to have realized the objective of reducing CLABSIs.

Recommendations

The project offers a foundation for using the best practice in preventing CLABSI in intensive care units. Such projects are expected to initiate and support a change in the culture of the nurses within hospital settings. Hospitals should implement the results of the findings by including weekly in-services for the nurses. It is important for the administrators and leaders of the hospitals to ensure that the resources necessary for the implementation should include adequate alcohol-impregnated caps, dressing change kits, chlorhexidine baths, and alcohol-based hand washing (Marschall et al., 2014). Such changes will effectively address the problem of infections in the future.

Future research is also critical to ensure continued performance measurement and improvement in implementing strategies to prevent CLABSI. Research should focus on the potential for hospital-wide training for the nurses to ensure a change in the hospital’s culture toward preventing CLABSIs (Miller & Maragakis, 2012). Thus, the research should not only focus on the intensive care of a hospital but also on all units. Indeed, to change the culture of the hospital, it is necessary to look beyond a single unit and focus on the entire hospital. It is also necessary to look beyond the nurses to include other hospital staff in implementing some of the strategies, such as hand hygiene (Longmate et al., 2011). Essentially, effective training for the entire workforce is the basis for long-term changes in the hospital. Past research has provided evidence of the efficacy of evidence-based training for nurses in preventing CLABSIs (Weingart et al., 2014; Gupta et al., 2015). Therefore, the results of the project are supported by similar projects carried out in the past. In essence, future studies can borrow from this project to provide the basis for their study and identify gaps in research that should be addressed.

Conclusion

The first chapter of the project has provided the background of the research project to reduce the incidence of CLABSIs in ICU settings using evidence-based nursing education. The background is the basis for the remaining part of the project, including a review of the literature, methodology, results, and discussion. Meanwhile, the second chapter discussed how research provides evidence of major steps to take in preventing central line-associated bloodstream infections following the use of the catheter to treat hospitalized patients. The review of the research identifies some gaps that need to be filled in the current research project. Future research will also address some of the limitations evident in past studies. The third chapter provides the implementation of a project proposing the use of evidence-based training for nurses to reduce CLABSI within acute care settings. The project will involve training of nurses on strategies to use to ensure a reduction in the cases of CLABSI in patients under their care. The chapter also provides the expected results of the study, increased compliance with strategies, reduced cases of CLABSIs, and change in culture. In essence, the results will lead to changes in procedures and the policy on CLABSI reduction. Nurses, being the important stakeholders in the provision of care in hospitals, should be in the front position in preventing CLABSI through evidence-based strategies. Implementing the program to offer monthly evidence-based training to the nurses has proven successful in achieving a 40% reduction in the cases of CLABSI. The project provides the basis for future focus on preventing CLABSIs, not only within the ICU but also in other units in the hospital. Effective implementation of the project results is the basis for a change in culture to adopt continued prevention of CLABSIs. Implementing the proposed strategies will help ensure that the burden to the hospital and patients resulting from the infections will be reduced

 

References

Banach, D. B., & Calfee, D. P. (2013). Central Line-Associated Bloodstream Infection. Healthcare-Associated Infections: A Case-based Approach to Diagnosis and Management.

Burden, A. R., Torjman, M. C., Dy, G. E., Jaffe, J. D., Littman, J. J., Nawar, F., … & Reboli, A. C. (2012). Prevention of central venous catheter-related bloodstream infections: is it time to add simulation training to the prevention bundle? Journal of clinical anesthesia, 24(7), 555-560.

Cicolini, G., Simonetti, V., Comparcini, D., Labeau, S., Blot, S., Pelusi, G., & Di Giovanni, P.      (2014). Nurses’ knowledge of evidence-based guidelines on the prevention of peripheral venous catheter-related infections: a multicentre survey. Journal of Clinical Nursing, 23(17/18), 2578-2588

Furuya, E. Y., Dick, A., Perencevich, E. N., Pogorzelska, M., Goldmann, D., & Stone, P. W. (2011). Central line bundle implementation in US intensive care units and impact on bloodstream infections. PloS one, 6(1), e15452.

Gupta, A., Samra, T., Banerjee, N., & Sood, R. (2015). Management of central venous catheters   in intensive care units: Comparative study of guidelines versus practice. Indian Journal of Critical Care Medicine, 19(1), 54-56

Longmate, A. G., Ellis, K. S., Boyle, L., Maher, S., Cairns, C. J., Lloyd, S. M., & Lang, C. (2011). Elimination of central-venous-catheter-related bloodstream infections from the intensive care unit. BMJ quality & safety, 20(2), 174-180.

Marsteller, J. A., Sexton, J. B., Hsu, Y. J., Hsiao, C. J., Holzmueller, C. G., Pronovost, P. J., & Thompson, D. A. (2012). A multicenter, phased, cluster-randomized controlled trial to reduce central line-associated bloodstream infections in intensive care units. Critical care medicine, 40(11), 2933-2939.

Marschall, J., Mermel, L. A., Fakih, M., Hadaway, L., Kallen, A., O’Grady, N. P., … & Yokoe, D. S. (2014). Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infection Control & Hospital Epidemiology, 35(S2), S89-S107.

McLaws, M. L., & Burrell, A. R. (2012). Zero risk for central line-associated bloodstream infection: are we there yet? Critical care medicine, 40(2), 388-393.

Miller, M. R., Niedner, M. F., Huskins, W. C., Colantuoni, E., Yenokyan, G., Moss, M. & Brilli, R. J. (2011). Reducing PICU central line–associated bloodstream infections: 3-year results. Pediatrics, 128(5), e1077-e1083.

Miller, S. E., & Maragakis, L. L. (2012). Central line-associated bloodstream infection prevention. Current opinion in infectious diseases, 25(4), 412-422.

Pérez-Granda, M. J., Guembe, M., Rincón, C., Muñoz, P., & Bouza, E. (2015). Effectiveness of   a training program in compliance with recommendations for venous lines care. BMC  Infectious Diseases, 15(1), 1-5.

Silow-Carroll, S., & Edwards, J. N. (2011). Eliminating central line infections and spreading success at high-performing hospitals. The Commonwealth Fund, December, 2, 15.

Stevens, T. P., & Schulman, J. (2012). Evidence-based approach to preventing central line-associated bloodstream infection in the NICU. Acta Paediatrica, 11-16

Weber, D. J., & Rutala, W. A. (2011). Central line–associated bloodstream infections: prevention and management. Infectious disease clinics of North America, 25(1), 77-102.

Weingart, S. N., Hsieh, C., Lane, S., & Cleary, A. M. (2014). Standardizing Central Venous         Catheter Care by Using Observations from Patients with Cancer. Clinical Journal of Oncology Nursing, 18(3), 321-326.