Estimating health care-associated infections and deaths

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RESEARCH

C entral line-associated bloodstream infections (CLABSIs) can be a devastating complication of intensive care in the hospital. Central venous cath- eters (CVCs) are venous access devices that end at or near the entry to the heart. While they are often

necessary for hemodynamic monitoring and administra- tion of fluids, medications, and total parenteral nutrition, they are not without considerable risk.

Hospital-acquired infections (HAIs) affect 1.7 million patients annually and result in 99,000 deaths each year (US Department of Health and Human Services, 2010) . There are major categories of HAIs; urinary tract infec- tions that account for 34%, surgical site infections 17%, bloodstream infections 14%, and pneumonia 13%. CLAB- SIs are a subset of bloodstream infections, and while Klevens et al (2007) estimated that the deaths caused by or associated with an HAI were 98,987 per year, one-third of these were secondary to CLABSIs resulting in a 12.3% mortality rate (U.S. Department of Health and Human Services, 2009). CLABSIs result in prolonged stays in the intensive care unit (ICU) with medical costs averaging an additional $11,971 per patient (Warren et al., 2006) . The overall effect of CLABSIs results in annual expenditures of 2.3 million dollars in U.S. hospitals (Blot et al., 2005) . However, with preventive measures, these costs could be greatly reduced and perhaps eliminated.

Hospital-acquired infections, specifically CLABSIs, were once thought to be an unavoidable risk of inten- sive care. The high use of CVCs (3 million/year in the United States) (Edgeworth, 2009). has created a risk that resulted in a CLABSI rate of 80,000 in the ICU per year and this number climbs to 250,000/year with inclusion of patients outside of the ICU (Mermel, 2000) and in 2008 alone, 37,000 CLABSIs occurred among patients receiving outpatient hemodialysis, which has resulted in a major public health problem (Centers for Disease Control and Prevention [CDC], 2011).

The initiation of the “Five Million Lives Campaign,” headed by the Institute for Healthcare Improvement (IHI), is committed to decreasing preventable deaths in the hospital. (IHI, 2012) Using a collection of evidence- based interventions, the IHI created the “Central Line Bundle” (CLB) to afford hospitals a way of achieving the

ABSTRACT In an effort to take advantage of the Highmark Quality Blue Initiative (N. D. Bastian, H. Kang, H. B. Nembhard, A. Bloschichak, P. M. Griffin, 2016 ) requiring information from hospitals detailing their central line-associated blood stream infections (CLABSIs) surveillance system, quality improvement program, and statistics regarding the CLABSI events, this institution investigated the latest evidence- based recommendations to reduce CLABSIs. Recognizing the baseline rate of 2.4 CLABSIs per 1,000 central line days and its effect on patient outcomes and medical costs, this hospital made a commitment to improve their CLABSI outcomes. As a result, the facility adopted the Society for Healthcare Epidemiology of America (SHEA) guidelines. The purpose of this article is to review the CLABSI rates and examine the prevention strategies following implementation of the SHEA guidelines. A quantitative, descriptive retrospective program evaluation examined the hospital’s pre- and post-SHEA implementation methods of decreasing CLABSIs and the subsequent CLABSI rates over 3 time periods. Any patient with a CLABSI infection admitted to this hospital July 2007 to June 2010 ( N = 78). CLABSI rates decreased from 1.9 to 1.3 over the study period. Compliance with specific SHEA guidelines was evaluated and measures were put into place to increase compliance where necessary. CLABSI rates at this facility remain below the baseline of 2.4 for calendar year 2013 (0.79), 2014 (0.07), and 2015 (0.33).

Key Words Centers for Disease Control and Prevention (CDC) , Central line-associated bloodstream infection (CLABSI) , National Healthcare and Safety Network (NHSN) , Society for Healthcare Epidemiology of America (SHEA)

Author Affiliations: Conemaugh Memorial Center (Dr Curlej) and University of Pittsburgh at Johnstown, (Dr Katrancha), Johnstown, Pennsylvania.

The authors declare no conflicts of interest.

Correspondence: Maria H. Curlej, DNP, CRNP, FNP-BC, ACNP-BC, Conemaugh Memorial Center, 1086 Franklin St, Johnstown, PA 15905 ( mcurlej@conemaugh.org ).

One Rural Hospital’s Experience Implementing the Society for Healthcare Epidemiology of America Guidelines to Decrease Central Line Infections

Maria H. Curlej , DNP, CRNP, FNP-BC, ACNP-BC ■ Elizabeth Katrancha , DNP, CCNS, RN, CNE

DOI: 10.1097/JTN.0000000000000235

 

 

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Department of Health and Human Services (HHS) goal to decrease CLABSIs by 75% over 3 years (US Department of Health, & Human Services, 2008) . This effort has been successful as demonstrated by the 43,000 CLABSIs per year in 2001 decreasing by 58% to 18,000 CLABSIs/year in 2009 (U.S. Department of Health and Human Services, 2009).

The CLB consists of five components: hand hygiene, maximal sterile barriers (MBPs), chlorhexidine (CHG) skin asepsis, optimal catheter site selection (with subcla- vian as the preferred site for nontunneled catheters), and daily review of line necessity to ensure prompt removal of those lines that are no longer medically necessary (IHI, 2012). In the event that a department is unable to reach the HHS goal (decreasing CLABSIs by 75%) using the CLB approach, additional “Special Approaches” can be imple- mented. These consist of bathing the patients with CHG bath wipes; adding a biopatch (chlorhexidine-impregnat- ed sponge) at the dressing site; using an antibiotic, silver- sulfadine, or CHG-impregnated CVC, and/or using Swab- caps (disinfection cap for luer access valves). Through application of these interventions, along with creating a culture of change dedicated to patient safety, (Abe, Zack, Lewis, and Vanderveen (2007) have described methods not only to decrease CLABSI rates, but to potentially pre- vent them altogether.

The United Hospital Fund (UHF), in collaboration with the Greater New York Hospital Association, engaged 38 New York hospitals in a quality improvement initiative to decrease CLABSIs in the ICUs during 2007. They were able to decrease CLABSIs by 70% and maintained this reduction over 2 years (UHF, 2016). In addition, a cohort of hospitals in Michigan collaborated over 18 months to decrease CLABSIs from 2.7 at baseline to zero at 3 months postintervention (Pronovost et al., 2006).

In 2008, the Society for Healthcare Epidemiology of America (SHEA) released guidelines for decreasing CLAB- SIs that provided structure and enhancement to the CLB guidelines (SHEA, 2014) The SHEA guidelines added edu- cation for health care personnel and specific intervention at and after CVC insertion. See Figure 1 for the specific best practice guidelines.

In an effort to take advantage of the Highmark Qual- ity Blue Initiative (Bastian, Kang, Nembhard, Bloschichak, & Griffin, 2016) requiring information from hospitals de- tailing their CLABSI surveillance system, quality improve- ment program, and statistics regarding the CLABSI events, this institution investigated the latest evidence-based rec- ommendations to reduce CLABSIs. As a result, the facil- ity adopted the SHEA guidelines. The implementation of the SHEA guidelines provided a generic framework for CLABSI prevention, which led to increased nursing knowledge of hub cleansing and physician dictation of

line necessity, and a decrease in femoral line utilization. Recognizing the baseline rate of 2.4 CLABSIs per 1,000 central line days (CLDs) and its effect on patient outcome and medical costs, this hospital made a commitment to improve their CLABSI outcomes.

PURPOSE The purpose of this article was to review the CLABSI rates and examination of the prevention strategies following implementation of the SHEA guidelines.

METHODS

Design A quantitative, descriptive retrospective program evalua- tion examined the hospital’s pre- and post-SHEA imple- mentation methods of decreasing CLABSIs and the subse- quent CLABSI rates.

Sample Any patient with a CLABSI infection admitted to this hos- pital July 2007 to June 2010 ( N = 78). Inclusion criterion was a diagnosed CLABSI per the three levels of criterion set forth by the CDC (2010) as detailed in Table 1 .

The sample consisted of an N = 76 patients meeting inclusion criteria between July 2007 and June 2010. The sample was divided over three time periods (period 1: n = 27; period 2: n = 27; and period 4: n = 24). The CLABSI rate per 1,000 days was 1.9 in period 1, 1.7 in period 2, and 1.3 in period 3. The sample ranged in age from 26 weeks to 91 years with 61% of the total being male. The CVC line types included triple lumen catheters, hemodialysis catheters, implanted ports, umbilical cath- eters, and pulmonary artery catheters. The insertion sites included subclavian, internal jugular, femoral, brachial, upper chest, and umbilical. See Table 2 for details.

Setting The project was conducted at a 486-bed rural, Level 1 trauma, teaching hospital in Pennsylvania. The hospital has 20 patient care departments, including maternity, pediatric, psychiatric, medical/surgical, step-down, and ICUs.

Data Collection The CLABSI rates were obtained from CDC National Healthcare and Safety Network (CDC, 2010) database. CLABSI rate is calculated by multiplication of CLABSI epi- sodes with 1,000 and then dividing by the total number of CLDs. (CDC, 2010)

The intravenous (IV) therapy management team was the frontline staff responsible for surveillance and cen- tral line maintenance using the Lean Six Sigma (LSS)

 

 

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performance methodology (George, Rowlands, Price, & Maxey, 2005) . The IV therapy management team consists of 16 registered nurses who cover all IV therapy in the hospital. The team staffs the hospital 24 hours a day, 7 days per week. The team’s responsibility was to educate health care personnel, survey central lines, evaluate inter- vention strategies, and analyze rates of CLABSI interven- tion compliance.

Data collection was made over three periods, that is, Period 1 (July 2007–June 2008), Period 2 (July 2008–June 2009), and Period 3 (July 2009–June 2010). CLABSI (de- fined as laboratory-confirmed bloodstream infection in Table 2 ) event reporting was obtained from NHSN da- tabase (CDC, 2011) The outcome of decreasing CLABSI rates was examined and evaluated for compliance to quality improvement strategies.

The IV therapy team performed daily inspections on central line management and line insertion compliance. The team located central line insertion departments (in- terventional radiology, emergency department, and ICU/ critical care unit [CCU]) and identified the certified inser- tion performers. The LSS team gathered data using the “Get Off Your Armchair” (GOYA) method. The GOYA is a method of observation found in the LSS Pocket Toolbook

(2005) that calls for visiting the site, questioning staff, observing technique, and then documenting quality improvement strategies. Variations were corrected on the spot by providing education on an immediate basis (George et al., 2005).

Data Analysis Descriptive statistics, including demographic data (age, sex) and comparison of outcomes (femoral line utilization rates [FLURs], dictation of maximal barrier use, nursing care of the line, and necessity dictations), were calculated across the time periods using standard analysis of vari- ance (ANOVA) and correlation techniques.

RESULTS The monthly CLABSI rates over the period of 3 years (July 2007–September 2010) divided into three time peri- ods were evaluated. In addition to a decrease in infection rates, an in-depth review of each prevention strategy and compliance to the strategy was analyzed.

CLABSI rates showed a downward trend across the three time periods (1.9, 1.7, and 1.3, respectively). Inter- ventions were introduced at each time period to correct deficiencies. Currently CLABSI rates at this facility remain

Before insertion

• Educate health care personnel

At insertion

• Use a catheter checklist to ensure adherence to infection prevention practices

• Perform hand hygiene before catheter insertion or manipulation

• Avoid using the femoral vein

• Use an all-inclusive catheter cart or kit

• Use maximal sterile barrier precautions

• Use a chlorhexidine-based antiseptic for skin preparation

After insertion

• Disinfect catheter hubs, needleless connectors, and injection ports

• Remove nonessential catheters

• For nontunneled CVCs change transparent dressings and perform site

care with a chlorhexidinebased antiseptic every 5–7 days or more

frequently as needed

• Replace administration sets at intervals not longer than 96 hr

• Perform surveillance for CLABSIs

• Use antimicrobial ointments for hemodialysis catheter insertion sites

Figure 1. Basic practices for prevention and monitoring of CLABSIs: Recommended for all acute care hospitals. CLABSIs = central line-associated blood stream infections; CVCs = central venous catheters.

 

 

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lower than the baseline of 2.4 for calendar year 2013 (0.79), 2014 (0.07), and 2015 (0.33).

An ANOVA was calculated and no significant decrease in the FLUR was observed ( F = 3.315; p = .078). The utili- zation rates (0.09–0.06) and the femoral line days (44–36), however, decreased.

An ANOVA was applied to compare compliance to dictation of MBP between the three time periods. Results showed no change over time ( F = 1.833; p = .168) for MBP as well as for skin asepsis ( F = 0.690; p = .506).

Despite a nursing education in-service, baseline re- call was only 30% for nurses on the “Scrubbing the Hub” program. There was an increase in knowledge from this baseline in July 2009 to 86% in November 2009 following the educational intervention, but no significant increase in technique knowledge between November 2009 and May 2010. Chi-square test revealed no changes with 95% CI ( − 0.21, 0.08), χ 2 = 2.899, and p = .093.

There was a statistically significant increase in line necessity dictations from 55% to 82% (chi-square,

TABLE 1 Criteria for Classification of a CLABSIs Criterion 1 Patient has a recognized pathogen cultured from one or more blood cultures and organism cultured from

blood is not related to an infection at another site.

Criterion 2 Patient has at least one of the following signs or symptoms: fever (>38ºC), chills, or hypotension and signs and symptoms and positive laboratory results are not related to an infection at another site and common skin is cultured from two or more blood cultures drawn on separate occasions.

Criterion 3 Patient < 1 year of age has at least one of the following signs or symptoms: fever (>38ºC core) hypothermia (<36ºC core), apnea, or bradycardia and signs and symptoms and positive laboratory results are not related to an infection at another site and common skin contaminant is cultured from two or more blood cultures drawn on separate occasions.

TABLE 2 Characteristics

Period 1

(July 2007–June 2008) Period 2

(July 2008–June 2009) Period 3

(July 2009–June 2010) Number of CLABSIs 27 27 24

CLABSI rate per 1,000 CVC days 1.9 1.7 1.3

Mean patient age (years) 57.2 67 67

Gender (male: female) 18 : 9 18: 9 12: 12

Line type

Peripherally inserted central catheter 2 (7%) 4 (15%) 4 (17%)

Triple lumen catheter 11 (41%) 8 (30%) 9 (38%)

Hemodialysis catheter 5 (19%) 6 (22%) 4 (17%)

Implanted port (Mediport) 0 (0%) 3 (11%) 2 (8%)

Umbilical catheter 1 (4%) 0 (0%) 0 (0%)

Pulmonary artery catheter 0 (0%) 1 (4%) 1 (4%)

Line location

Subclavian 2 (7%) 4 (15%) 4 (17%)

Internal jugular 8 (30%) 10 (37%) 9 (38%)

Femoral 6 (22%) 1 (4%) 1 (4%)

Brachial 12 (44%) 9 (33%) 8 (33%)

Upper chest 0 (0%) 3 (11%) 2 (8%)

Umbilical 1 (4%) 0 (0%) 0 (0%)

Note . CLABSIs = central line-associated blood stream infections; CVC = central venous catheter.

 

 

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χ 2 = 96.33, p < .05). An ANOVA also revealed significant improvement to adherence in dictating line necessity for physicians ( F = 7.052, p = .00). Tukey’s HSD depicted significance between periods 1–3 (95% CI: − 0.18, 1.49; p = .010) and between periods 2–3 (95% CI: − 0.21, 1.31; p = .004). Central line days increased ( χ 2 = 1,576; p < .05) over the three periods but no correlation was observed with the decreased infection rate ( r = .096). An investiga- tion ensued into the increased CLDs and a significance trend was found for length of stay (LOS) of patients with CLABSIs during Periods 1–3 (95% CI: − 43.53, 2.11; p = .07). The LOS averaged 28.93, 25.00, and 47.00 for each of the three periods but the Atlas MQ Pro statistical soft- ware averaged the expected values as 20.6, 15, and 20.5, respectively. There was an inverse relationship between LOS and CLABSI rate ( r = .20).

DISCUSSION The collaborative aspects of this program managed to de- crease CLABSIs by compliance to the quality improvement strategies. Steady decline was observed in the periods with 1.3/1,000 CLDs at the end of fiscal year 2010. Each indi- vidual strategy was scrutinized for compliance and any ad- ditional shortcomings were identified and addressed.

Before Insertion The before insertion period was evaluated by a critical review of the existing education protocol that was ob- tained from the Resident Orientation Handbook ( ROH ). This educational process involved the credentialing of the health care professionals to ensure CVC insertion profi- ciency, maintenance, and CLABSI prevention.

In Period 2, during a Performance Improvement/Infec- tion Control meeting, it was discovered that internal med- icine residents did not receive formal education on CVC insertion. As a result, residents from all services received CLI education when they attended the Medical Skills Lab Competencies and Human Simulator Lab session begin- ning in June 2010.

At Insertion Catheter Checklist SHEA guidelines defined the use of a central line insertion checklist to ensure compliance with aseptic technique. Educated health care personnel, nurses, and physicians were checklist operators. Investigation of catheter check- list compliance was derived from the chart review, as it is a permanent part of the patient’s record (Friedman & Peterson, 2014).

An audit uncovered that only three out of 10 patients’ charts contained this completed form. Through GOYA, additional findings were the lack of timeouts prior to

insertion, as well as documentation of timeouts on the back of the patient consent form.

An educational mandate and reminder forms for the checklist completion and timeout documentation were carried out. As a result of missing checklist forms, physi- cian dictations were reviewed for inclusion of compliance to those items on the checklist (aseptic technique, maxi- mal barrier precautions, etc.).

Hand hygiene As per SHEA guidelines, hand hygiene consisted of us- ing an alcohol-based waterless product or antiseptic soap and water. Compliance measurements were obtained by actual observation and documented on the central line checklist (Boyce & Pittet, 2002). In lieu of the missing checklist, measurements to compliance of hand hygiene by operators inserting the line had been gained from page 4 of the NHSN database, which details whether the operator included maximal barrier precautions in his or her transcribed dictation. Compliance to these guidelines was evaluated by review of dictation of the provider who had inserted the CVC. An incomplete dictation rate of 50% was discovered upon review. A memo requesting compliance to proper dictation was sent to physicians and a dictation template was created.

Avoid the Femoral Vein According to SHEA guidelines, the use of femoral access sites increases infection risk and deep venous thrombosis in adults (Lorente, Henry, Martín, Jiménez, & Mora, 2005). Physician dictations were reviewed for dictating adher- ence to NHSN database measurements. Femoral vein use data were obtained through the nursing electronic chart- ing system of femoral line delays (FLDs) in Period 3. The femoral line device utilization ratio was calculated by di- viding the number of femoral lines days by the number of CLDs.

Considering that there was no significant decrease in the FLURs, a decision was made to restrict patients with femoral lines from leaving the ICU until removed, unless specifically ordered by a physician, and was implemented in Period 2, May 2010.

Catheter Cart The all-inclusive catheter kit for aseptic catheter inser- tions should be accessible in all CVCs units, as defined by SHEA. LSS member performing GOYA analyzed the all-inclusive catheter kit/cart via walk around analysis for the supplies in all sections of the hospitals in which the CVCs were situated.

The team discovered that the staff members were con- tinuously moved in and out of the interventional radi- ology and emergency departments to collect additional

 

 

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supplies and the kit was not always readily available in the ICU/CCU.

As a result, an educational mandate was developed with a directive to ensure that the kits were adequately stocked in each ICU/CCU room and the two central line carts were placed in the emergency and interventional radiology areas to limit contamination by staff to collect supplies.

Maximal Sterile Barrier Precautions The SHEA outlined that MBP needs to be worn by health care personnel and involves in insertion or procedure. The question of MBP utilization was answered over 3 years through evaluation of physician dictations. The question asked was: “Were MBP utilized during insertion of the central line, including hand hygiene, wearing a cap, mask, and sterile gown?” The answer was recorded as “yes,” “no,” or “unknown.” The “unknown” dictations were incomplete in that they did not specify each com- ponent of insertion.

There was a dictation rate of “unknown” at 50%, despite notification sent to physicians in January 2010. Through GOYA, additional findings included insufficient masking and improper covering of sterile supplies during insertion.

A memo for compliance to proper dictation, as well as a template for dictation, was sent to physicians. An additional mask and hat were included in each CLI kit as well as an educational mandate for adherence to aseptic policies so that all personnel in the room had masks and maintained distance from sterile areas (Marschall et al., 2014).

Chlorhexidine Gluconate Use for Skin Prep According to SHEA guidelines, the application of an al- coholic chlorhexidine solution containing a concentration of chlorhexidine gluconate greater than 0.5% must be ap- plied to the insertion site before catheter insertion and should be allowed to dry before making skin puncture. Record of physician dictation (detailing the individual el- ements of maximal barrier precautions and skin asepsis) was utilized here. A memo and physician dictation tem- plate were developed and distributed as a form of cor- rective action.

After Insertion Disinfect Hubs/Flushing Lines The SHEA guidelines outline the catheter hub or injection port cleaning with an alcoholic chlorhexidine (70%) to reduce contamination. Disinfection of hubs was evalu- ated pre- and two posteducation inquiries, that is, ( n = 29; n = 40) of Scrub the Hub. This was administered ran- domly to registered nurses on various units that admitted

patients with CVCs. A form was used that indicated the question “How do you Scrub the Hub?” Data included the date, nursing unit, and RN designation to be filled as a part of questionnaire response. GOYA was used to ob- serve the proper findings through which correct answers were obtained. These included an alcohol prep utilization to cleanse CVC hub by twisting it 10 times around the hub. The cleansing was coded as yes/no or pass/fail on the form with dichotomous data points.

Despite a nursing education in-service, baseline re- call was only 30% for nurses on the “Scrubbing the Hub” program. There was an increase in knowledge from this baseline in July 2009 to 86% in November 2009 following the educational intervention, but no significant increase in technique knowledge between November 2009 and May 2010.

Through GOYA, flushing the line was also observed. It was found that flushing of the lines was not standard- ized and multidose vials of saline and heparin were being used for flushing, increasing the risk for contamination.

Flushing lines was standardized after the webinar of “Keeping the Lines Open” in August 2008 (period 2) and a policy was developed. A reminder was placed on the patient’s Medication Administration Record documenta- tion form (Voluntary Hospitals of America, 2008). Prefilled single-use syringes with saline and heparin were intro- duced. During the month after this initiative, a unit that had a high CLABSI infection rate was able to decrease the rate to “0.”

Nonessential Catheters The assessment need for continued CVC access is critical as outlined by the SHEA guidelines. Initially, informa- tion of a CVC line was communicated to the IV thera- py team through nurse-to-nurse phone call notification, which carried the risk of missing information. With the development of the computerized charting system, the nurse’s entered data were used to evaluate the awareness of nonessential catheters and provide data for total CLDs within the institution. Nurses were required to chart on patients’ CVCs at least once in every 8-hr period. A line report was then printed out for the IV therapy team to be used for daily rounds. Data charted (spanned mid Pe- riod 2 to early Period 3) included date of insertion, type of line, location of line, necessity of the line, and if the line was placed in “less than ideal” conditions. Physician dictations and the calculation of CLDs were other meth- ods to analyze line necessity, collected monthly from July 2007 to June 2010.

The CVC line need assessment was charted daily with clear instructions on prompt femoral line removal due to its susceptibility toward CLABSIs (Lorente et al., 2005) . To enhance awareness to physicians of their patients with

 

 

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CVCs, an interface was created between the nurses chart- ing program and the Physician’s Patient List in which this rounding list was populated with patient CVC data in- cluding line type, site, date of insertion, and femoral lines or less than ideal lines need removed in 48–72 hr. Pa- tient discharge and placement issues were addressed by the case management meetings anytime the LOS became greater than 10 days.

Dressing Changes Nontunneled CVCs transparent dressings needed to be changed and site care performed using chlorhexidine- based antiseptic (every 5–7 days) as outlined in SHEA guidelines. GOYA was used to assess dressing changes in November 2009 with a random question put forward to the nurse, that is, “What do you do when a dressing is damp, soiled, or lose?” Dressing changes for pre- (n = 20)/post-(n = 27) educational analysis were assessed via interviews/questionnaires from nurses, LSS team, and performance improvement personnel.

Only 80% knew how to change the dressing. Central line catheter-dressing kits were not readily available in various departments.

The IV therapy team revealed the importance of these kits and thus additional stock was provided. Enhancing the knowledge of dressing changes increased the knowl- edge to 96% through participation in the annual Nursing Education Program.

Limitations and Future Directions The single-site retrospective design of this study lim- its it generalizability. The study also employed various methods of data collection that may have impacted va- lidity and analysis. Future studies with a larger more diverse sample size would be of benefit. In addition, randomized prospective studies looking closely at in- dividual interventions may be of benefit. Difference in data interpretation due to various sources/methods of observations is also a concern. There are two special ap- proaches in the SHEA guidelines, CHG bathing of ICU patients and CHG sponge dressings for CVCs. These were executed at the end of Period 3 but not evaluated for this study. Future evaluation of CLABSI rates at this facility should include these 2 items and their impact on the CLABSI rates.

CONCLUSION This retrospective study demonstrated a facilities ability to reduce CLABSI rates over time using the SHEA meth- od. It reinforced the importance of ongoing education and evaluation of the consistent use of the SHEA meth- odology. Current CLABSI rates continue to stay below

the baseline.

REFERENCES Abe , C. , Zack , J. , Lewis , R. S. , & Vanderveen , T. ( 2007 ). Zero

tolerance: Curbing catheter-related bloodstream infections . Patient Safety and Quality Healthcare , 4 ( 6 ), 14 – 18 .

Bastian , N. D. , Kang , H. , Nembhard , H. B. , Bloschichak , A. , & Griffin , P. M. ( 2016 ). The impact of a pay-for-performance program on central line-associated blood stream infections in Pennsylvania . Hospital Topics , 94 ( 1 ). Retrieved from http://www.tandfonline. com/doi/full/10.1080/00185868.2015.1130542

Blot , S. I. , Depuydt , P. , Annemans , L. , Benoit , D. , Hoste , E. , De Waele , J. J. , … Vandewoude K. H. ( 2005 ). Clinical and economic outcomes of critically ill patients with nosocomial catheter-related bloodstream infections . Clinical and Infectious Diseases , 41 ( 11 ), 1591 – 1598 .

Boyce , M. J. , & Pittet , D. ( 2002 ). Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force . Morbidity and Mortality Weekly Report , 51 ( RR-16 ), 1 – 48 .

Centers for Disease Control and Prevention (CDC) . ( 2010 ). Healthcare-associated infections (HAI) . Retrieved from http:// www.cdc.gov/ncidod/dhqp/hai.html

Centers for Disease Control and Prevention (CDC) . ( 2011 ). Vital signs: Central line–associated blood stream infections—United States, 2001, 2008, and 2009 . Morbidity and Mortality Weekly Report , 60 ( 8 ), 243 – 248 .

Edgeworth , J. ( 2009 ). Intravascular catheter infections . Journal of Hospital Infection Control , 73 ( 4 ), 323 – 330 .

Friedman , C. , & Peterson , K. H. ( 2014 ). Infection Control in Ambulatory Care. Burlington, VT : Jones and Bartlett Publishers .

George , M. L. , Rowlands , D. , Price , M. , & Maxey , J. ( 2005 ). The Lean Six Sigma Pocket Toolbook . New York : McGraw Hill .

Institute for Healthcare Improvement (IHI) . ( 2012 ). How-to guide: Prevent central line associated bloodstream infections . Retrieved from http://www.ihi.org/Engage/Initiatives/ Completed/5MillionLivesCampaign/Pages/default.aspxError! Hyperlink reference not valid.

Klevens , R. M. , Edwards , J. R , Richards , C. L. , Jr. , Horan , T. C. , Gaynes , R. P. , Pollock , D. A. , & Cardo , D. M. ( 2007 ). Estimating health care-associated infections and deaths in U.S. hospitals, 2002 . Public Health Reports , 122 ( 2 ), 160 – 166 .

Lorente , L. , Henry , C. , Martín , M. M. , Jiménez , A. , & Mora , M. L. ( 2005 ). Central venous catheter-related infection in a prospective and observational study of 2,595 catheters . Critical Care , 9 ( 6 ), R631 – R635 .

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

KEY POINTS • The central line-associated bloodstream infections

(CLABSIs) are a source of signifi cant health risk in hospitals. • The article describes quality improvement strategies to

decrease CLABSI rates. • The implementation of the SHEA guidelines provided a

generic framework for CLABSI prevention. • Documentation of Line Necessity showed a signifi cant

increase from 55% baseline. • LOS increased during Periods (1–3) for CLABSI-positive

patients due to its inverse relationship with the CLABSI rate. • Femoral Site utilization rates (0.09–0.06) and FLD (44–36)

decreased with the estimation of FLURs as it relies on CLDs.

 

 

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hospitals: SHEA/IDSA practice recommendations . Infection Control Hospital Epidemiology , 29 ( S1 ), S22 – S30 .

Mermel, L.A. ( 2000 ). Prevention of intravascular catheter-related infections . Annals of Internal Medicine , 132 ( 5 ), 391 – 402 .

Pronovost, P. , Needham, D. , Berenholtz, S. , Sinopoli, D. , Chu, H. , Cosgrove, S. , & Goeschel C. ( 2006 ). An intervention to decrease catheter-related bloodstream infections in the ICU . New England Journal of Medicine , 355 ( 26 ), 2725 – 2732 .

Society for Healthcare and Epidemiology in America (SHEA) . ( 2014 ). Compendium of strategies to prevent healthcare-associated infections in acute care sospitals . Retrieved from http://www. shea-online.org/priority-topics/compendium-of-strategies-to- prevent-hais

United Hospital Fund (UHF) . ( 2016 ). NYS partnership for patients . Retrieved from https:// www.uhfnyc.org/initiatives/quality_ improvement/NYSPFP/

U.S. Department of Health and Human Services ( 2010 ). Adverse Events in Hospitals: National incidence among Medicare beneficiaries . Retrieved from http://oig.hhs.gov/oei/reports/ oei-06-09-00090.pdf .

U.S. Department of Health and Human Services . ( 2009 ). HHS action plan to prevent healthcare-associated infections: Introduction . Retrieved from http://www.hhs.gov/ash/initiatives/hai/ introduction.html

U.S. Department of Health, & Human Services ( 2008 ). Secretary Sebelius releases inaugural health care “success story” report . Retrieved from http://www.hhs.gov/news/ press/2009pres/07/20090713a.html

Warren, D. K. , Quadir, W. W. , Hollenbeak, C. S , Elward, A. M. , Cox, M. J. , & Fraser, V. J. ( 2006 ). Attributable cost of catheter-associated bloodstream infections among intensive care patients in a nonteaching hospital . Critical Care Medicine , 38 ( 8 ), 2084 – 2089 .

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