Reducing Central Line–Associated Blood Stream Infections in the Neonatal Intensive Care Unit: Strategies for Change Caryn Douma, MS, RN, IBCLC
Central line–associated blood stream infections (CLABSIs) continue to be a common occurrence in the neonatal intensive care unit, often resulting in significant morbidity, mortality, and increased length of stay for survivors. Once thought to be an inevitable consequence of hospital care, device-related infection is now believed to be preventable in most circumstances. Effective change strategies to decrease the incidence of CLABSI depend on a unit culture that supports a model of prevention, with team members understanding the link between lapses in care and an increased risk of infection. Patient safety and quality initiatives have become an integral part of health care. This article will discuss strategies to reduce or eliminate CLABSI in the neonatal intensive care unit using quality improvement methods within a culture of communication and teamwork. Keywords: Central line infection; Quality improvement; Communication; Collaboration; Teamwork; Change; Culture
Background The Institute of Medicine published reports, “To Err is Human: Building a Safer Health System”1 and “Crossing the Quality Chasm: A New Health System for the 21st Century,”2 identified the overwhelming number of patients who are harmed or die due to medical error. The report estimated that up to 98 000 Americans die each year as a result of these unsafe practices. Hospital-acquired infections (HAIs), which can result from an error in carrying out a medical procedure, continue to be a common occurrence in the neonatal intensive care unit (NICU), often resulting in significant morbidity, mortality, and increased length of stay for survivors. Neonatal patients are at increased risk for developing HAI because of their immature immune system, need for central access to deliver adequate nutrition and medications, and immature skin barrier function.3-7 Multiple skin punctures for laboratory sampling and intravenous access as well as lower birth weight and gestational age result in increased opportunity for infection. The incidence of HAI varies greatly among different institutions, with reports in the literature ranging from 5% to 24%.3,4 Variation between centers indicates that patient outFrom the Newborn Center, Texas Children's Hospital, Houston, TX. Address correspondence to Caryn Douma, MS, RN, IBCLC, Newborn Center, Texas Children's Hospital, 6621 Fannin MC 1-1410, Houston, TX 77039. E-mail: [email protected]
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comes are linked to where and how care is delivered.8-11 Differences in the definition of what constitutes a central line– associated blood stream infection (CLABSI) among various organizations and associations contribute to the difficulty in quantifying, comparing, and reporting data. The Centers for Disease Control and Prevention released a report of available evidence-based research and expert opinion for the prevention of CLABSI in 2002.12 The guideline provides guidance for diagnosis, prevention, and management of central lines. The National Healthcare Safety Network was established in 2005 to provide a surveillance and reporting structure for HAI.13 Presence of a central venous catheter is one of the primary risk factors for acquiring a blood stream infection. Prevention of CLABSI is a priority for health care providers and institutions. Patient safety and quality initiatives have become an integral part of how hospital systems throughout the world have responded to the problem of CLABSI. The Institute of Medicine report states “care should be safe, effective, patient-centered, timely, efficient and equitable.”1 Once thought to be an inevitable consequence of hospital care in some unit cultures, CLABSI is now believed to be preventable. This article will discuss strategies to reduce or eliminate CLABSI in the NICU using quality improvement methods within a culture of communication and teamwork.
Culture Effective and sustained change is dependent on a unit culture that supports prevention and the belief that CLABSI is
Table 1. Two Conceptual Models for Nosocomial Sepsis in Very Low Birth Weight Infants Entitlement Causality Focus of care team Why did it happen? Responsibility Motivation for improvement
Unavoidable—inherent risk from poor immune function and necessary invasive care Early detection Chance or unavoidable Baby's vulnerability Fatalistic, inevitable
Prevention Preventable in most instances Prevention Breakdown in ideal care Care team Challenge to continually improve
Reprinted with permission from Edwards.4
preventable rather than an accepted complication of a NICU course. Each team member needs to understand the relationship between lapses in care and the increased risk of infection. Edwards describes two conceptual models for determining the cause of nosocomial infection in the very low birth weight population: entitlement and prevention (Table 1). 4 The entitlement model supports the belief that infection is an inevitable result of factors beyond the control of the care team resulting from an immature immune system and need for invasive therapy. A model of prevention views infection as a breakdown in care practices recognizing that infection is preventable, not inevitable.4 Care teams traditionally focus on early detection rather than on developing care practices designed to prevent infection from occurring. Multidisciplinary patient care rounds at the bedside with a focus on clear, wellcommunicated goals have also been demonstrated to reduce the incidence of infection and other adverse events including CLABSI.14-16
Collaboration, Communication, Teamwork The importance of collaboration, communication, and teamwork is often overlooked in planning initiatives to improve clinical outcomes. Communication failure has been linked to health care error and unintended patient harm.16 The aviation industry has demonstrated improved airline safety through standardized checklists and communication training. Health care organizations have recently been adopting these strategies to improve clinical outcomes. It has often been assumed that communication strategies and the ability to function as a team are innate. Team training and the development of a safe environment result in an improved ability to communicate and improve patient care outcomes. Physicians and nurses are trained to communicate differently and often practice in hierarchical environments that become barriers to communication. Checklists and structured communication models provide a guide for open and effective communication. A survey of organizational culture can provide valuable information to help identify potential barriers to improvement and allow teams to engage in meaningful dialogue designed to promote effective, multidisciplinary teamwork. The Safety Attitudes Questionnaire is a culture and teamwork survey used by organizations to gain insight into the organizational
culture and plan improvement strategies. Implementation failure in organizations is often linked to resistance to change, system issues, and organizational culture.17,18 The Vermont Oxford National Evidence-Based Quality Improvement Collaborative for Neonatology (VON) Care Group developed and implemented a survey for the Neonatal Intensive Care Quality Improvement Collaborative Year 2000 (NIC/2000). The key practices that were identified included the importance of a clear, shared vision; the presence of effective team and individual communication; engaged leaders who were able to lead by example; and competent and committed teams willing to commit to effective and positive conflict management.18
Benchmarking-Collaborating With Other Institutions The first step in developing a strategy to decrease CLABSI is to identify the scope of the problem and review pertinent data. Consultation with an infection control practitioner is useful to verify the accuracy of the data collection and clarify the definition for CLABSI selected by your organization. Obtaining blood cultures for accurate diagnosis is often challenging in the NICU population because of the difficulty obtaining sufficient volume for blood sampling. Comparing outcomes and practices between centers through the formation of collaboratives and informal benchmarking enables organizations to target and prioritize opportunities for improvement. There is evidence to show that organizations that participate in collaboratives with other institutions have greater success with initiatives to improve outcomes.10,11 The VON organization provides benchmark data for NICU quality improvement. Review of VON data and comparing to other centers demonstrate the practice variation that exists between participating centers. This is a useful tool to see how individual NICUs compare with the larger group in all categories. In 1998, a group of six NICU members joined together to develop strategies to decrease infection. Following a literature review, internal analysis, and external benchmarking, recommendations for practice change were developed and implemented. Using rapid cycle improvement methods, the team focused on three main initiatives: hand hygiene, line management, and accuracy of diagnosis.10,11
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A summary of best practices from other institutions offers improvement teams a variety of practice changes to test and modify to their own institutional culture. Sharing successes and failures provides support and knowledge to improvement teams. The Institute for Healthcare Improvement (IHI), using the Model for Improvement and care bundles, has been a leader in developing successful campaigns to prevent CLABSI throughout the world. The IHI website provides toolkits and guides to facilitate planning and implementation. The toolkits can be modified to meet the needs of each improvement team.19
Strategies and Interventions Strategies to reduce or eliminate infection include establishing a culture of continuous learning and developing strong improvement teams that involve frontline staff. Aligning with the vision and mission of the institution and obtaining executive support is an important step toward achieving successful and sustained improvement. Strategies designed to reduce CLABSI in the NICU can be implemented using quality improvement tools for successful achievement and maintenance of goals (Table 2).
Choose an Improvement Model or Method The Model for Improvement (Fig 1) is a widely used method to develop, test, and implement change. The Plan, Do, Study, Act Cycle (PDSA; Fig 2) represents the mechanism used for planning and tracking rapid cycle changes when using this model. Developing simple worksheets or adapting readily available templates provides a guide that can be easily shared with team members.19,20 Start the process by asking the three questions19,20 as quoted from the model:
Fig 1. The Model for Improvement. Reprinted with permission from Associates in Process Improvement (API). 20 enhances the likelihood of success during the implementation phase. For example, a team for CLABSI project might include a doctor of medicine; neonatal nurse practitioner; registered nurse staff; and leadership, infection control representative and others.
• What are we trying to accomplish? • How will you know it is an improvement? • What changes need to be made to result in improvement?
Form a Team Forming a multidisciplinary team and including frontline staff is essential to a successful improvement initiative.21 Each discipline brings a unique body of knowledge to the team, and the inclusion of key personnel early in the process
Table 2. Strategies for Improvement • Establish daily goals with multidisciplinary care team. • Daily review of line, laboratory, and medication necessity • Establish reliable processes to eliminate or decrease variation in practice. • Ongoing staff education • Family participation in care • Create climate of collaboration and teamwork.
Fig 2. PDSA cycle. Reprinted with permission. 20
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Fig 3. Multiple PDSA cycles. Adapted with permission. 20 Potential Improvement Strategies and Interventions to Decrease CRBSI:
Brainstorm and Prioritize Initiatives A brainstorming session with the team provides insight into the problem and reveals defects in the system being studied. The data collected from the session should be displayed using appropriate quality improvement tools to assist with prioritization and planning multiple rapid cycles of improvement (Fig 3). Process mapping, cause and effect (fishbone) diagrams, gap analysis (Fig 4) diagrams, and interrelationship diagraphs are a few examples. Using tools to interpret data allows the team to develop an objective plan (Table 3). The data assist the team members in planning how they are going to initiate interventions and the sequence of the multiple cycles to reach the target or aim of the project. Evidence supports multiple interventions for decreasing CLABSI that include developing a central line bundle for insertion and maintenance. Nurses are critical to the success of this process given that much of the maintenance of central lines is a part of daily NICU nursing practice.
Table 3. Project Planning • • • • • • • • • • • • • •
Identify improvement initiative. Form a multidisciplinary team. Evaluate the evidence. Brainstorm. Identify and prioritize the key processes that need improvement and will result in improved outcomes. Define the problem. Determine the aim. Develop outcome measures and data collection strategy. Plan PDSA improvement cycles. Provide education. Implement changes. Evaluate and plan multiple change cycles. Continue cycles until the aim is reached. Ongoing evaluation to sustain and spread change
• Evaluate unit and organizational culture. • Implement a central line bundle. • Identify best practices (research, benchmarking, standards, collaboratives, etc) for central line insertion, access, and maintenance. • Develop and implement care strategies based on identified best practices. • Design and implement a dedicated procedure cart for line insertion and maintenance. • Develop a line access process that includes implementation of a closed medication system and closed blood sampling system. • Develop feeding practices that emphasize early enteral feeding and increased use of human milk to decrease the need for central line access. • Clarify CLABSI definitions to improve accuracy of diagnosis. • Develop process for obtaining blood cultures—volume and sampling technique. • Decrease number of skin punctures through development of an algorithm to assess need and type of vascular access. • Incorporate central line necessity as an aspect of daily rounds. • Implement specialized teams for peripherally inserted central catheter insertion and maintenance.
What Are You Trying to Accomplish? Develop an Aim Statement An aim statement needs to clearly state the goal or aim of the project. It should have measurable outcomes with a defined numerical target and include the population, scope, location, and completion time.19 A sample aim statement: To decrease CLABSI in the NICU by 25% over the next 12 months.
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How Will You Know an Improvement Has Occurred? Determine Outcomes. Establishing measures before testing allows the team to learn whether the change resulted in improvement. Measures are categorized as outcome, process, or balancing measures and should link back to the aim.
What Changes Need to Be Made to Result in Improvement? Plan PDSA Cycles for Improvement. Improvement in line care practice and maintenance has been described in the literature as a key to decreasing infection. Careful review and revision of central line–related policies and insertion guidelines assist the improvement team to determine a starting point for choosing priority interventions and developing a staff education plan in preparation for implementation. Grouping interventions into care bundles allows for multiple changes through the PDSA rapid improvement process. A central line bundle is defined as a group of interventions that when implemented together result in
improved outcomes. The components of a bundle used to decrease CLABSI are typically divided into an insertion and a maintenance component. Most improvement teams start their first cycle of improvement by implementing an insertion bundle. An insertion bundle typically includes hand hygiene, full-barrier protection for line insertion, proper gestational age-appropriate antiseptic, optimal site selection, and daily review of line necessity. Each team can create a bundle that meets their individual needs and improvement goals. Hand hygiene education and sustained compliance have been shown to result in decreased nosocomial infection rates.22 Successful teams have used a variety of approaches but most include engaging frontline staff, system changes, increasing availability of products, and feedback to all staff. Proper procedure for line insertion is facilitated by the use of a line insertion checklist that reflects elements of the bundle. The checklist reviews all components of the process and empowers staff to stop the procedure any time a single component is not performed. Implementation of a bundle is enhanced by the use of a daily goal sheet during multidisciplinary rounds to improve communication and collaboration between all team members participating in the care of the
Fig 4. Gap analysis to determine priority sequence. Reprinted with permission. 20 NEWBORN
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patients and families.14,19 Daily review of line and laboratory necessity and early removal of unnecessary lines are an important strategy that has proven to be successful in decreasing line-related infections.
Staff Education Before testing changes, staff education needs to be developed. Frontline staff should understand the rationale behind the need for change and be engaged in the change process. Transparency and sharing of all available data and frequent progress reports provide a connection between the infection rates and the interventions. Use adult learning principles, role play, and video to demonstrate best practice and allow for active discussion. Online resources and manuals provide access to educational content.
Test Changes Using rapid cycle improvement tools, plan and implement multiple PDSA cycles (Fig 3) until the goals have been reached. Decreasing line-related infection is a complex process often requiring multiple cycles for several years to achieve sustained results
Sustain and Spread Sustaining and spreading improvements in an organization are a challenge. The success of quality improvement initiatives like reducing line infection is dependent on the development of a culture of teamwork and collaboration. The staff members must understand the value of the intervention and incorporate it into their culture. It is often easy to roll out a new initiative, but it will not be maintained unless the practices become standard and the education is continued at intermittent intervals. Building effective, empowered teams with the ability to work together is an essential component of creating an environment with sustained change and a focus on quality and patient safety.
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ihi.org/IHI/Topics/Improvement/ImprovementMethods/ HowToImprove. 20. Langley GL, Moen RD, Nolan KM, Nolan TW, Norman CL, Provost LP. The improvement guide: a practical approach to enhancing organizational performance. 2nd ed. San Francisco: Jossey-Bass; 2009.
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