Central line-associated bloodstream infections (CLABSIs) are costly for both patients and providers. An estimated 250,000 CLABSIs occur in hospitals each year, and as many as 62,000 patients die as a result, according to the On the CUSP: Stop BSI initiative.
CLABSIs result in longer hospital stays and increased risk of mortality among patients with already compromised immune systems.
"CLABSIs come at a very high expense, for patients and hospitals," said Kimberley Kelly, MBA, BSN, RN, ICU nursing director, Suburban Hospital, a member of Johns Hopkins Medicine, in Bethesda, Md. "Every extra day a patient stays in the hospital puts them at risk for other complications and adds tremendously to hospital costs."
Suburban's CLABSI rates consistently fell below national standards, but that wasn't good enough for the facility or its nurses.
In an effort to eliminate CLABSIs altogether, Suburban joined the Maryland Hospital Association's On the CUSP: Stop BSI initiative in November 2010.
"We participated because we felt it was a worthwhile initiative," said Kelly. "Even though our rates were quite low, given the risks these infections pose, we owed it to our patients to participate."
The initiative, which is funded by the Agency for Healthcare Research and Quality, aims to reduce the national CLABSI rate and boost the overall culture of safety by using the comprehensive unit-based safety program (CUSP) model.
Facilities participating in this two-year initiative have shown marked improvement in CLABSI rates. The percentage of units with zero CLABSIs per quarter increased from 27.3% at baseline to 69.5% among these units, according to the program's website. Suburban was one such facility.
The recent recipient of the Maryland Hospital Association's CLABSI award for reducing the rate of CLABSIs, Suburban was one of 23 Maryland hospitals to achieve zero line-associated bloodstream infections since joining the initiative in 2010.
Additionally, the facility's ICU was ranked No. 1 of the top 10 hospital units recognized.
With national support and a hospitalwide commitment, Suburban's ICU and its nurses set the foundation for success.
"This program taught us we can always improve our vigilance," stressed Kelly. "As a team, we have implemented policies to ensure that everything is done to protect our patients."
A group of intensivists and a critical care nurse practitioner are responsible for all central line insertions in the ICU. Kelly and her team took a close look at facility practices and determined that issues arise when a line stays in for more than 5-7 days or a line in a femoral site remains intact for more than four.
Today, all central lines are removed as soon as possible and before transfers.
"We did a chart review of the patients who had had central line infections in the two years prior to our joining the initiative," said Kelly. "That led us to focus, initially, on line maintenance, which is the job of the nurse."
"We have grown so much as a unit and we couldn't have done it without our nurses and patient care technicians," added Kelly. "They are at the center of our success."
Patient Care Techs in the ICU are responsible for keeping the Line Carts stocked and ready with the necessary supplies for lines insertions. Nurses are responsible for line care and upkeep following insertion, making them key components of CLABSI reductions. And so Suburban's CUSP team, comprised of nurses, a physician, a nurse practitioner, infection control specialists and the CNO, set out to educate staff and improve central line care.
"Our team began conducting central line surveillance rounds," noted Kelly. "This afforded us the opportunity to not only improve central line maintenance, but also educate staff."
"The intent of the rounds was not to penalize, but rather foster improvement," she added. "Together we made central lines a priority on daily morning rounds; all tubes, lines, dressings and drains are reviewed."
A section of the daily rounds order sheets at Suburban are devoted to central lines and the documentation of their care. These surveillance rounds were also used to reinforce the importance of masks and caps.
"We made sure that all staff entering the room and all staff already present for a procedure wore a mask with the shield and a cap," stated Kelly. "Since, our focused rounds compliance has become second nature. Masks and caps are an accepted part of the process."
In addition to rounds and staff education, the team at Suburban worked together to develop a custom designed central line kit.
The team met with practitioners in other areas where central lines are placed, including the emergency department. "The ED is another key area when it comes to central lines," noted Kelly. "In the critical care unit we have line carts that are well-stocked by our patient care techs every shift, but that was not the case in the ED.
"In light of this review, we set out to create a customized, all-inclusive central line kit for our facility," she added. "Development of the kits was a lengthy process, but well worth the effort."
Over the course of nine months, the team built bundled central line kits that were simple yet effective, adhering to best practices. Suburban does not use special coated catheters or specialized impregnated dressings or IV caps.
"Since the release in October 2011, the benefits of an all-inclusive kit have been made clear," said Kelly. "Everything you need is available in the order you need it. Central line care has been streamlined throughout the facility as a result."
Kelly attributes Suburban's success to extensive collaboration between the nursing and medical staff. The CUSP team fostered teamwork through research, communication and a willingness to learn.
"We are holding one another responsible," she said. "Staff at every level are taking personal ownership of CLABSI reduction and helping their peers to do the same."
To find success, facilities must recognize the value of patience. "This is not just a program," emphasized Kelly. "It is a culture shift. And culture shifts take time.
"You cannot expect overnight success," she added. "You must gain support at every level and be prepared to devote yourself entirely to the changes."
Suburban achieved and maintained success through a network of support. "We recognized that the team has to be dynamic," Kelly said. "It can't be a project of few; the team has to be representative of the entire unit."
CLABSIs remain a central focus of the facility; nurses and the entire Suburban healthcare team recognize that there is always room for improvement.
The lessons and successes they have had through the On the CUSP initiative have led Kelly and her staff to implement a CUSP team of their own dedicated to the reduction of catheter-associated UTIs. While only a few months in, the team has made strides in reaching their goal: zero.
"We are dedicated to providing optimal patient care, which includes the safest environment possible," said Kelly. "Settling for a low rate of infections is unacceptable. Exceptional care requires constant improvement and nurses are in the perfect position to lead these initiatives."
Catlin Nalley is on staff at ADVANCE. Contact: CNalley@advanceweb.com