O R I G I N A L A R T I C L E
Cor joy http Cop AC
Improving Registered Nurses’ Knowledge of Evidence-Based Practice Guidelines to Decrease the Incidence of Central Line-Associated Bloodstream Infections: An Educational Intervention
Joy S. Humphrey, DNP, RN
Georgia Southwestern State University, Americus, GA
Background: The 2011 Centers for Disease Control and Prevention guidelines provide evidence-based recommendations for preventing central line-associated bloodstream infection (CLABSI). Educating and training health
care personneldincorporating bundled strategies for maximizing patient safety throughout the course of intravenous
therapydis the major area of interest. Despite a low number of reported CLABSIsdbelow national benchmarksdour
large regional medical center has the goal of 0 CLABSI.
Purpose: The purpose of our project was to develop an educational intervention guided by the Healthcare and Technology Synergy Framework to improve registered nurses’ (RNs) knowledge of evidence-based practice guidelines to
decrease the incidence of CLABSI.
Methodology: A pretest/posttest format was used to evaluate an educational session on the nursing management of central lines (CLs). Participants in the study were RNs employed at a large regional medical center who worked 50% or
more per week providing direct patient care in the hospital’s intensive care units. An educational session on nursing
management of CLs was presented. A 16-question survey (7 demographic and 9 knowledge questions) to assess RNs’
knowledge of care and maintenance of CLs was used as the pretest and posttest.
Conclusions: RNs’ knowledge of care and maintenance of CLs improved significantly after the intervention (pretest mean score ¼ 4.6 and posttest mean score ¼ 8.4; P ¼ .0001). Implications for Practice: An educational intervention can increaseRNs’ knowledgeof care ofCLs.As a result of this project, an annual evidence-based practice educational intervention was adopted for RNs at our large regional medical center.
Keywords: Healthcare and Technology Synergy Framework, evidence-based practice, Centers for Disease Control and Prevention CLABSI
ospital-associated infections (HAIs) have been considered an unavoidable result of a hospital stay and account for aH substantial portion of health care-acquired conditions.1
The Environmental and Public Health Consulting Group2
respondence concerning this article should be addressed to .firstname.lastname@example.org ://dx.doi.org/10.1016/j.java.2015.05.003 yright © 2015, ASSOCIATION FOR VASCULAR CESS. Published by Elsevier Inc. All rights reserved.
reported thatwith nearly 100million procedures performed at hos- pitals each year, legal action arising from nosocomial infections is increasing nationwide. Immunocompromised patients, the elderly, and young children are usually more susceptible than others. These infections are transmitted through direct contact from the hospital staff, inadequately sterilized instruments, aerosol droplets from other ill patients, or even the food or water provided at hospitals.2 HAIs, also referred to as nosocomial, hospital- acquired, or hospital-onset infections, are defined as infections not present and without evidence of incubation at the time of admission to a health care setting.3 HAIs affect 5% of all hospital- ized patients with 20%-30% of all HAIs occurring in intensive
j Vol 20 No 3 j JAVA j 143
Figure 1. Healthcare and Technology Synergy (HATS) framework.
care units (ICUs).1 The use of intravascular catheters are a major source ofHAIs; therefore, the prevention of central line-associated bloodstream infections (CLABSIs) are of critical concern for nursing staff working in hospitals.4 CLABSIs are deadly, costly, and preventable.5More than 5million patients in theUnited States require central line (CL) placement each year. Unfortunately, infection remains themain complication of intravascular catheters in patients with chronic or critical conditions.6 Statistics show that 500,000 catheter-related infections occur in the United States, which calculates to 1,370/d, 57/h, or almost 1/min.7
Preventive measures against CLABSI have been well docu- mented in the literature. The prevention of CLABSI requires a comprehensive understanding of the major risk factors by which catheters get contaminated. Despite the possible key contribu- tions of nurses in the prevention of nosocomial infections, the main challenge is to ensure implementation of and compliance with the evidence-based recommendations in daily nursing practice.8 Risk factors for CLABSI can be intrinsic (ie, nonmo- difiable characteristics such as age or underlying diseases or conditions) or extrinsic (ie, modifiable factors such as insertion circumstances, skill of the inserter, insertion site, skin antisepsis, catheter lumens, duration of catheter use, or use of barrier pre- cautions).9 Utilizing poor technique during central venous cath- eter insertion can cause pneumothorax, catheter occlusion, thrombosis, phlebitis, endocarditis, metastatic infection, and catheter-related infection.10 The site at which a catheter is placed influences the subsequent risk for CLABSI and phle- bitis.6 Microbes from the hands of health care workers can play a role in pathogenesis by contaminating the catheter hub or a patient’s skin during medication administration, manipula- tion of the catheter, or dressing changes.11 Zingg et al12
concluded that infection control efforts to improve the quality of hand hygiene and catheter care are critical essentials for reduction of CLABSI as well as other HAIs. Labeau et al13 sug- gest that to optimize knowledge of CLABSIs educational curricula and continuing refresher education programs should include CLABSI-prevention guidelines. CLABSIs are recog- nized as a problem in ICUs.13 Due to the initiatives such as the Food and Drug Administration’s warning that positive displacement needleless connectors may increase the risk of CLABSI, the Institute for Health-care Improvement 100,000 Lives Campaign, The Pittsburg Regional Health Initiative, The Michigan Keystone Project, and the Joint Commission’s 2012 National Patient Safety Goal requiring patients or their caregivers to be educated on the use of evidence-based practices coupled with the product aspect of the Healthcare and Technol- ogy Synergy Framework model (Figure 1) has had a positive ef- fect on CLABSI rates.8,5,14 In 2005 the Centers for Disease Control and Prevention (CDC) developed the National Health- care Safety Network as an Internet-based surveillance system to collect patient safety data voluntarily reported by hospitals.6
According to O’Grady et al,6 the Agency for Healthcare Research and Quality and the CDC recommend the following quality measures for prevention of CLABSI:
1. Hand hygiene, 2. Maximal sterile barrier precautions, 3. Chlorhexidine skin antisepsis,
144 j JAVA j Vol 20 No 3 j 20
4. Appropriate insertion site selection, and 5. Prompt removal of unnecessary catheters. Since beginning these initiatives, the incidence of CLABSI
in ICU patients in the United States have been reduced from an estimated 43,000 in 2001 to 18,000 in 2009 (58% reduction).15
The CDC estimates that this reduction represents 3000-6000 lives saved and a cost saving of $414 million in 2009 alone. These results show that a coordinated, multi-institutional infec- tion-control initiative can be an effective approach to reducing CLABSIs and 0 CLABSI rates are achievable.16
Nurses have responsibilities associated with the care and maintenance of the insertion site and external catheter surfaces, such as catheter stabilization and dressing management, and the internal catheter walls, such as septum disinfection, cath- eter flushing, and applying the appropriate clamping technique with disconnection.17 Nursing knowledge of intravenous line connectors, occlusions, and proper flushing is necessary to avoid infection and decrease the risk of thrombus formation, which positively influence patient outcomes.18
Problem Statement In 2011, Hospital Compare reported 18 CLABSIs in the
ICU at a large regional medical center. This is a standardized infection ratio of 0.47 or a 54% reduction in infections. In 2012, 17 CLABSIs were reported with an standard infection ratio of 0.431 or 57% reduction. January 2013 through September 2013 the number of reported CLABSIs was 15.19
Despite clinical guidelines for appropriate care and manage- ment of central lines, ICU registered nurses (RNs) are not adhering to evidence-based practice guidelines. This is result- ing in CLABSIs, increased health care costs, morbidity/mortal- ity, and an increase in patient length of hospital stay.
Aims 1. Determine the knowledge of RNs working in critical
care areas of factors contributing to CLABSI; and
Figure 2. Nursing degree results: Participant characteristics (N ¼ 64).
Figure 4. Shift results: Participant characteristics (N ¼ 64).
2. Evaluate the influence of an educational intervention on participants’ knowledge of factors contributing to CLABSI, utilizing a pre- and posttest design.
Methods Evidence-based practice supports the use of various educa-
tional techniques used in hospital settings designed to mini- mize the incidence of CLABSI.20 To determine factors contributing to CLABSI at this large regional medical center information was gathered from monthly infection disease com- mittee meetings, meetings with product vendors, interviews with RNs, observations of RNs, and reviews of the literature. From these resources 3 themes evolved:
1. Evidence-based practices reduce CLABSI; 2. Policy and evidence-based practices and use of central
line bundles, coupled with education for patient/nurse/ CL management, reduce CLABSIs; and
3. Product influences CLABSI rates. The Melnyk and Fineout-Overholt21 tool was used to rate
the quality of the 13 studies selected for the literature review.21
The Grading of Recommendations Assessment, Development, and Evaluation was used to rate the quality of the study: 12 out
Figure 3. Years of experience results: Participant characteristics (N ¼ 64).
of 13 were rated critical for decision making and 1 was rated important, but not critical.22
The conceptual framework utilized in this project was the Healthcare and Technology Synergy (HATS) Model (Figure 1). According to Chernecky and Macklin,14 clinical research has primarily focused on the variables patient and practice and not on another very important variable product. This changing phenomenon in nursing must include technol- ogy and associated products in research methods and in pro- grams of research. The HATS framework includes the synergy of 3 variables: patient, product, and practice. All 3 variables are of equal importance in clinical outcomes. The synergy among these 3 variables is a major key to their effectiveness.14
For the purpose of this research the patient variable con- sisted of patients cared for by nurses who worked in ICUs and the product variable consisted of the products used with the insertion, infusion, and maintenance of CLs. The CL sup- plemental prevention strategies recommended by the CDC included chlorhexidine bathing, antimicrobial-impregnated catheters, and chlorhexidine-impregnated dressings.9 To decrease the incidence of CLABSIs the facility incorporated these products. They also included chlorhexidine biopatches, neutral IV connectors, and swab-caps. The practice variable consisted of implementation of the CDC evidence-based prac- tice guidelines. These products, as well as guidelines, were highlighted during the educational offering. Clinical data were collected by the researcher in a Magnet
status 650-bed general medical/surgical facility’s ICU. Magnet
Figure 5. Time commitment results: Participant characteristics (N ¼ 64).
j Vol 20 No 3 j JAVA j 145
Figure 6. Care and maintenance results: Partici- pant characteristics (N ¼ 64).
status is an award given by the American Nurses’ Credential- ing Center (ANCC), an affiliate of the American Nurses Asso- ciation, to hospitals that satisfy a set of criteria designed to measure the strength and quality of their nursing. The Magnet� pretest and posttest questionnaires included 7 demo- graphic questions and 9 CLABSI knowledge questions based on a literature review. Face validity of the pretest and posttest were measured by having the questionnaires reviewed by CLABSI experts. Reliability of the research is unknown. The pretest, educational intervention, and posttest design were pro- vided to all ICU RNs who attended biannual skills competency sessions to determine the knowledge base of the RNs in rela- tion to the care and maintenance of CLs.
The hospital reported approximately 210 RNs were working in the facility ICUs. Skills competency is scheduled 2 times a year with half of the RNs attending the spring session and half
Figure 7. Inservice training during the past 12 months results: Participant characteristics (N ¼ 64).
146 j JAVA j Vol 20 No 3 j 20
of the RNs attending the fall session. For the purposes of this research, the educational intervention was targeted to those ICU RNs who attended the fall skills competency. Approxi- mately 70 RNs attended the fall skills competency with 64 ICU RNs participating in the educational program. Multiple sessions were offered every day over a 3-day period. Each of the 64 RNs attended 1 of the sessions. Criteria for participation in the study included being an ICU
RN employed at the regional medical center and having a work schedule that included at least 50% or more per week as direct patient caregivers in the medical center ICUs. For example, a nurse who worked 24 h/wk would be included if she or he pro- vided direct patient care at least 12 or more hours during the week. RNs who were full-time and part-time workers from all ethnic origins, genders, and between the ages of 18 and 99 years were considered eligible. The study required that the nurses who participated must be able to read, write, and un- derstand English. Finally, all RNs with a diploma (ADN or ASN, BSN, MSN, and DNP/PhD) were included. Over a course of 3 days a hands-on 30-minute interactive
educational intervention was provided to the ICU RNs. The intervention was developed as 3-part training:
Part 1: Pretest to evaluate ICU RNs’ knowledge on care of CLs. Part 2: Delivery of educational material to ICU RNs. Part 3: Posttest to evaluate ICU RNs’ knowledge after the educational intervention. Participants were given a paper survey consent letter to read.
The researcher reviewed the paper survey consent letter with the volunteer participants and answered their questions. Participants did not have to consent and participate in the pre- or posttest to participate in the educational intervention. Participants could withdraw from the study at any time during the session. Partic- ipants were given a copy of the paper survey consent letter. The participants were given the 16 question pretest. After
completion of the pretest the participant placed the pretest into a locked box appropriately labeled with the researcher’s information on the front. The interactive hands-on educational session was completed utilizing an upper body mannequin with a peripherally inserted central catheter, port-a-cath, sub- clavian central line, and a perma-cath. Questions were answered by the researcher. The participants then completed the posttest and placed it into a locked box appropriately labeled with the researcher’s information on the front.
Results All questionnaires were collected and the data were entered
basedondevelopment of a researchcodebook and anExcel spread sheet (Microsoft Corp, Redmond,WA). This information was run through SPSS statistical software (IBM-SPSS Inc, Armonk, NY). The sample consisted of 64 RNs: 56% of the responding
RNs have a bachelor’s degree, 36% an associate’s degree, 5% a master’s degree, and 3% have earned a doctorate (Figure 2). Eleven percent of RNs had <1 year of experience, 39% had 1-5 years of experience, 16% had 5-10 years of expe- rience, and 34% had >10 years of experience in critical care. Overall, 50% of RNs studied in this research had 5 years or
Table 1. Pretest and Posttest Knowledge Frequencies (N ¼ 64)
Question n % n % P valuea
8: What is a CLABSI? 28 43.75 59 92.19 <.0001a
9: Which of the following is the most common site for CLABSI?
48 75 59 92.19 .0045a
10: What is the most effective intervention you can do to decrease the chance of CLABSI?
43 67.19 64 100 .0001a
11: When is it appropriate to use chlorhexidine bathing for your patient?
62 96.88 63 98.44 .317
12: Which type of connector (not the name brand) do you use in your facility?
3 4.69 63 98.44 <.0001a
13: Which statement best describes proper flushing of the connector used in your facility?
6 9.38 47 73.44 <.0001a
14: According to your institution’s policy, which of the following best describes the procedures for flushing catheters?
28 43.75 52 81.25 <.0001a
15: Please list 2 complications related to improper maintenance of intravenous line connectors used by your facility?
15a: RNs could list 1 complication 39 60.94 59 92.19 <.0008a
15b: RNs could list 2 complications 21 32.81 58 90.63 <.0001a
CLABSI ¼ Central line-associated bloodstream infection; RN ¼ Registered nurse. aMcNemar’s c2 test, significant at the .05 significant level.
greater experience (Figure 3). According to Benner et al,23
these would be identified as expert critical care nurses. Most nurses (47%) worked the day/evening shift (7 AM-7 PM). Other shifts included evening night shift (3-11 PM) (30%), day shift (7 AM-3 PM) (22%), and night shift (11 PM-7 AM) (2%) (Figure 4). Seventy-seven percent of RNs worked full time, 16% worked part time, and 8% worked a flexible or contract-based schedule (Figure 5).
Thirty percent of nurses stated that they were involved in > 6 hours of intravenously administered therapy and mainte- nance per 12-hour shift; 14% were involved in 5-6 hours of this work per shift, 27% were involved in 3-4 hours of this work per shift, 26% in 1-2 hours of this work per shift, and 3% stated that they were not involved in intravenous line care or maintenance of CLs (Figure 6).
Seventy-eight percent had been educated during the past year on the institutions’ policy in regard to maintenance of CLs (Figure 7).
Of all health care personnel, nurses have the most direct, ongoing role in the care of patients and the interventions or procedures that put patients at risk of CLABSI. Question 8 (failure to recognize CLABSIs as a primary infection) indi- cates a lack of understanding the value that RN care has in pre- venting CLABSIs (Table 1).
Preintervention, responses to question 10 revealed that 67% of RNs knew that hand hygiene is the single most important measure in preventing the spread of CLABSI.9 Although 67% is better than many of the other variable findings, hand hygiene is such a basic infection control principle that a more robust finding for this variable was expected (Table 1). Knowing whether a negative, neutral, or positive-pressure
system connector is being used is essential to patient care out- comes. According to Chernecky et al,18 several issues can develop based on connectors, including total or partial occlusion and bloodstream infections. This is vital because proper flushing technique can only be accomplished if the type of connector is known.18 Ninety-five percent of RNs did not know the type of connector that was used. The educational intervention resulted in a 93% improvement in their knowledge in this area (addressed in question 13). Only 9% knew the proper flushing technique for the connector used in their facility. However the postintervention results showed a 64% improvement in this area. Responses to question 14 revealed that 56% did not know the flushing policy, which indicates the value of having a written policy; however, reliance on policy but not understand- ing the science behind flushing technique or connector identifi- cation is of concern. There was almost a 40% improvement in the results after the intervention (Table 1).
j Vol 20 No 3 j JAVA j 147
Table 2. Mean Values of Subscale Variables Before and After the Interevention (N ¼ 64)a
Variable Mean � standard deviation Range Mean � standard deviation Range P value Knowledge 4.6 � 1.1 2-7 8.41 � 0.89 6-9 .0001b aCronbach alpha at pretest: �0.37; at posttest: 46. bPaired, 2-tailed t test significant at the .05 level.
Responses to question 15 revealed that the majority (61%) could list 1 complication; however, only 33% were able to list 2 complications (Table 1). Failure to identify 2 common complications could delay early recognition and interventions thereby increasing morbidity and length of stay. Responses to both variables increased to >90% on the postintervention findings (Table 1).
Nurses’ knowledge of care and maintenance of CLs were statistically significant after the educational intervention (P ¼ .0001) (pretest mean score ¼ 4.6, posttest mean score ¼ 8.4) (Table 2). This validates the CDC’s position that education is a cornerstone of CLABSI prevention.
Limitations For this research a small sample size was used, it was
completed in a short time frame, and included only ICUs located at 1 facility. Due to these limitations the findings are not generalizable. There were levels of education ranging from associate’s degrees to doctorates; also, the experience of the nurses varied from 11% of nurses working <1 year to 34% of nurses having >10 years of experience. Another important limitation was nurses had either worked a 12-hour shift or 3 12-hour shifts before attending the session.
The Cronbach’s alpha value for the findings is low: the pre- test is �0.37 and posttest is 46 (Table 2). The nursing knowl- edge questionnaire only included 9 knowledge questions, which negatively influences the Cronbach’s alpha values. In addition, particularly on the pretest, the Cronbach’s alpha value was influenced by a higher percentage of fill-in-the- blank questions not answered.
Recommendations for Practice Based on the results of this work, we have the following rec-
ommendations for practice. d Educational programs can increase nurses’ knowledge of care of CLs,
d A commitment to continuing education programs that promote evidence-based practice guidelines can reduce the incidence of CLABSIs,
d Knowledge of evidence-based practice of CL care requires ongoing educational support, and
d Use of the HATS framework can reduce CLABSI rates.
Conclusions Future studies should include all areas of inpatient care,
ensuring a larger sample size. Also, following RNs for a longer period of timedretesting them in 6 and 12 monthsdwould
148 j JAVA j Vol 20 No 3 j 20
help determine if the educational intervention was effective over an extended period of time. A need was identified for further nursing education
regarding identification, assessment, care, and maintenance of connectors. Comments such as, “I did not know that our fa- cility used a neutral connector,” “I am ashamed that I could not correctly answer any of the questions,” and “Hand hygiene? Well I knew it was important” were revealing. The most pro- found revelation came when an ICU nurse with >10 years of experience in the same unit stated, “I use a 3-mL syringe to declot central lines.” The fact that nurses lack knowledge in the area of line care is a crisis, especially because this work encompasses approximately 50% of their patient care respon- sibilities per shift. This research confirms that an educational intervention can increase nurses’ knowledge of care of CLs.
Disclosure The author has no conflict of interests to disclose.
References 1. Centers for Disease Control and Prevention. Vital signs:
central line-associated blood stream infections-United States, 2001, 2008, and 2009. MMWR Morb Mortal Wkly Rep. 2011;60(8):243-248 [Medline]. http:// emedicine.medscape.com/article/967022-overview.
2. EHA Consulting. Nosocomial infections & hospital-acquired illnesses-overview. http://www.ehagroup.com/epidemiology/ nosocomial-infections/. Accessed July 3, 2015.
3. Custodio HT. Hospital-acquired infection. 4. Schwaiger K, Christ M, Battegay CM, Heppner HJ. Pre-
vention of catheter-related infections: minimizing second- ary complications in geriatric patients [article in German]. Z Gerontol Geriatr. 2013;46(4):361-371.
5. DeLa Cruz CR, Caillouet B, Guerrero SS. Strategic patient education program to prevent catheter-related blood stream infection. Clin J Oncol Nurs. 2012;16(1):e9-e14.
6. O’Grady NP, Alexander M, Burns LA. Guidelines for the prevention of intravascular catheter-related infections. www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011 .pdf; Accessed July 3, 2015.
7. Macklin D. The impact of IV connectors on clinical prac- tice and patient outcomes. Journal of the Association for Vascular Access. 2010;15:126-139.
8. Vandijck DM, Labeau SO, Vogelaers DP, et al. Preven- tion of nosocomial infections in intensive care patients. British association of critical care nurses. 2010;15(5): 251-256.
9. Kallen A, Patel P. Central line-associated bloodstream in- fections (CLABSI) in non-intensive care unit (NON-ICU) settings toolkit. www.cdc.gov/hai/pdfs/toolkits/clabsi toolkit_white020910_final.pdf. Accessed July 3, 2014.
10. Ugas MA, Cho H, Trilling GM, et al. Central and periph- eral venous lines-associated bloodstream infections in the critical ill surgical patients. Ann Surg Innov Res. 2012;6:8.
11. Napolitano J. Prevention of complications in hospitalized patients. http://www.med.ucla.edu/modules/xfsection/ article.php?articleid=325#top.
12. Zingg W, Imhof A, Maggiorini M, Stocker R, Keller E, RuefC. Impactof a prevention strategy targetinghandhygiene and catheter care on the incidence of catheter-related blood- stream infections. Crit Care Med. 2009;37(7):2167-2173.
13. Labeau SO, Vandijck DM, Rello J, et al. Centers for Dis- ease control and Prevention guidelines for preventing cen- tral venous catheter-related infection: results of a knowledge test among 3405 European intensive care nurses. Crit Care Med. 2009;37(1):320-323.
14. Chernecky C, et al. The Healthcare and Technology Syn- ergy (HATS) framework for comparative effectiveness research as part of evidence-based practice in vascular ac- cess. Journal of the Association for Vascular Access. 2013;18(3):169-174.
15. Dumont C, Nesslerodt D. Preventing CLABSI central line- associated bloodstream infections. Nursing. 2012;42(6): 41-46.
16. Centers for Disease Control and Prevention. Reduction in central line-associated blood stream infections among pa- tients in intensive care units-Pennsylvania, April 2001- March 2005. http://www.cdc.gov/mmwr/preview/mmwr html/mm5440a2.htm. Accessed July 3, 2015.
17. Lynch D. Achieving zero central line-associated blood stream infections: connector design combined with prac- tice in the long-term acute care setting. J Assoc Vasc Access. 2012;17(2):74-77.
18. Chernecky C, Macklin D, Casella L, Jarvis E. Caring for patients with cancer through nursing knowledge of IV con- nectors. Clin J Oncol Nurs. 2009;13(6):630-633.
19. Medicare.gov. Hospital compare. www.medicare.gov/ hospitalcompare. Accessed July 3, 2015.
20. Raup GH, Putnam J, Cantu K. Can an education pro- gram reduce CLABSIs? www.nursingmanagement.com; 2013.
21. Melnyk BM, Fineout-Overholt E. Evidence-Based Prac- tice in Nursing and Healthcare. Philadelphia, PA, Lippin- cott, Williams, & Wilkins, 2011.
22. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Schunmann HJ. GRADE: what is “quality of evidence: and why is it important to clinicians?” BMJ. 2008;336: 995-998.
23. Benner P, Sutphen M, Leonard V, Day L. Educating Nurses: A Call for Radical Transformation. San Francisco, CA: Jossey-Bass, 2010.
j Vol 20 No 3 j JAVA j 149
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
- Improving Registered Nurses’ Knowledge of Evidence-Based Practice Guidelines to Decrease the Incidence of Central Line-Asso …
- Problem Statement
- Recommendations for Practice