Central Line Associated Bloodstream Infections
QSEN Case Study
Gebrelua Mengistu
University of Maryland School of Nursing
Central line associated bloodstream infection
Central line catheters are highly used as an essential part of care for critically ill patients as well as for those that need long time therapy. However, these central line catheters have become the leading source of catheter associated bloodstream infection (Stevens et al. 2013). Healthcare associated bloodstream infection has significant morbidity and mortality rate. Every year there are approximately 90,000 new catheter associated bloodstream infection (CLABSI) cases reported in Intensive Care units (ICUs) (Stevens et al. 2013). According to Marschall et al. (2014), patients in ICUs are at a higher risk of CLABSI due to frequent insertion of catheters, the use of specific types of catheters, repeated access of ports, and the need for access over extended periods of time. These risks along with some other complications cost the United States approximately 600 million to 2.7 billion dollars annually, as well as leading to prolonged hospitalization and in some cases ending in mortality (Stevens et al., 2013). About 25% of patients with CLABSI in the ICU die annually in the United States (Weeks, Hsu, Yang, Sawyer, & Marsteller, 2014). Approximately 50% of CLABSI cases could be prevented with thorough patient safety measures and strict adherence to recommended guidelines (McPeake, Cantwell, Booth, & Daniel, 2012). The United States Centers for Medicare and Medicaid Services has stopped reimbursing hospitals and other healthcare institutions for CLABSI complications, to encourage them to implement and use effective CLABSI prevention strategies (Ziegler, Pellegrini, & Safdar, 2015).
In this paper, the case of GM, a patient admitted for thrombotic thrombocytopenic purpura (TTP) will be discussed. The patient had a central line catheter inserted, which placed him at a higher risk for developing CLABSI. QSEN competencies of safety, quality improvement, evidence based practice, patient centered care, teamwork and collaboration, were not identified and addressed in GM’s care (QSEN Institute, 2014). The primary QSEN priority is safety, which includes knowledge, skills and attitudes for preventing CLABSI.
Case Study
Patient GM is a 30-year-old male who was brought to the emergency room after experiencing shortness of breath, fever, and noticing purple dots on the skin. In the emergency room, the patient was assessed and labs were drawn. Following this, the patient was sent to the ICU for further evaluation, diagnosis, treatment, and management of acute respiratory distress. When the patient arrived to the ICU, he was confused, pale, and had signs of jaundice on his hands. The patient had tachycardia, with a rate of 115, and his oxygen saturation level was in the higher 80s on 2L nasal cannula. The doctor diagnosed the patient with a rare form of blood disorder called TTP, and ordered high flow oxygen to manage the patient’s oxygen saturation. The doctor further placed a nothing by mouth (NPO) order for patient until further evaluation was made to confirm the diagnosis and a central line catheter to be inserted for plasmapheresis treatment.
The hospital has introduced a central line insertion bundle strategy and infection control protocol in an effort to reduce its high CLABSI rate. In the bundle, highly skilled and trained nurses that are part of the hospital’s IV therapy team place central lines in patients. The doctor followed strict infection control protocol and central line insertion bundle strategy when inserting the central line in the patient’s chest. However, after 7 days it was time to do a central line dressing change and the nurse did not follow the proper infection control protocol. Even though the nurse began performing the dressing change procedure with the proper sterile technique she was unable to maintain it to the end. While cleaning the catheter site with a chlorohexidine swab the nurse accidentally dropped the swab. However, instead of stopping at this point and starting with a new kit, she picked the swab up and continued the dressing change with the now contaminated swab and sterile glove to finish the dressing change. She did not ask any of her team members for assistance. Though she realized that she had made several errors during the procedure she failed to do anything about it.
Safety: The QSEN Institute has defined safety as minimizing risk of harm to patients and providers by system effectiveness and individual performance (QSEN Institute, 2014).
Knowledge Skills Attitude
The nurse was able to demonstrate her knowledge about maintaining aseptic technique throughout central line dressing change. She went through the steps of proper central line dressing change with me to confirm her knowledge about the procedure. However, instead of getting a new set of sterile kit to complete the task, she failed to comply with hospital protocol to reduce the risk of infection and harm to the patient. The nurse was able to inform the patient what she was doing and why she was doing it. She also stressed the importance of maintaining aseptic technique during dressing changes, keeping the dressing clean and intact. However, she did not maintain a sterile field and use aseptic technique properly. Instead of communicating the error she made to the patient and trying to correct it, she went on with the procedure placing the patient at an increased risk for infection. She also did not communicate the error to her other teammates. Through the nurse’s action during this procedure, I learned that the nurse is not committed to what she is doing and is just doing her job for the sake of doing it. She wanted to do her job fast and move on to the next patient. The nurse should have put the patient’s safety need first and change her attitude. She should understand the important role she plays in preventing the risk of infection in patients.
Literature review
Marsteller et al. (2012) conducted a multicenter cluster randomized controlled trial in two Adventist healthcare systems. The research was conducted in forty- five ICUs from 35 hospitals; study participants were recruited from March 2007 to September 2008. The trial included all participants except those that were admitted to the ICU with CLABSI. The researchers wanted to find out if implementing a multifaceted intervention involving evidence based practice in ICUs could help reduce the incidence of CLABSI.
The baseline data for comparing CLABSI between both the intervention and control group was collected in phase 1. In the second phase, both groups were exposed to the intervention and data was collected to assess the impact of the intervention. The researchers stressed several components of the intervention by implementing a dressing change checklist for nurses, utilizing a preplanned curriculum on previous educational work, recognizing nurses as the likely drivers of the intervention, and making use of qualitative and quantitative data collection tools.
Stata 10.0 was used to make all statistical analyses. In the intervention group, when the mean CLABSI rate at baseline was compared with post implementation period, it resulted in a decrease from 4.5/1000 line days to 1.3/1000 line days. In the control group, the mean decreased from 2.7/1000 line days to 2.2/1000 line days. Analysis of both phase 1 and phase 2 showed a decrease in central line days in both groups. There was an 81% reduction of CLABSI in the intervention group, and a 69% reduction in the control group. By the end of the study, both groups reduced CLABSI to about 0.8/1000 line days. Marstellar et al. (2012) found the use of evidence-based infection control practices, teamwork, and communication helped to decrease the rate of CLABSI in the ICU. The combined use of bloodstream infection prevention bundle and the Comprehensive Unit Based Safety Program led to practice improvement and success.
Ziegler, Pellegrini & Safdar (2015) did a systematic review and meta-analysis of 18 studies with CLABSI cases using a random effects model. The review and analysis was done to assess and compare mortality rates in ICU patients with and without CLABSI. The study included case control and cohort study that were both retrospective and prospective. Studies that utilized Centers for Disease Control and Prevention (CDC) and Infectious Diseases Society of America (IDSA) definitions and guidelines were included.
The researchers aimed to identify the adverse effects associated with CLABSI, so it can be used for assessment, prevention, and treatment. The study used ICU mortality or hospital mortality to collect mortality data. All included studies were assessed based on illness severity index. A priori subgroup analysis was performed for the primary outcome, and a secondary ex post facto analysis was conducted to assess if certain types of organisms that cause CLABSI were associated with lower rates of mortality. Standardized forms were used to extract data from different studies; the studies were evaluated for methodological quality using the Cochrane Handbook of Systematic reviews.
The researchers used the Newcastle-Ottawa Scale to assess the risk of bias in the included studies. RevMan version 5.2 and Cochrane Collaboration were used for statistical analysis and I2 statistic was used to assess the included studies for heterogeneity. An odds ratio of mortality was also conducted in the meta-analysis of all included studies.
The results indicated that CLABSI has increased odds of mortality with an odds ratio of 2.75 (CI 1.86 – 4.07). In the five studies that included ICU mortality, an odds ratio of 2.15 (CI 0.83 – 5.56) was found. The secondary analyses found that 30% and greater of CLABSI cases were attributed to a certain organism, an odds ratio of 1.64 (CI 1.02 – 2.65). An analysis of 30% and less had an odds ratio of 4.71 (CI 1.54 – 14.39). Only two of the 18 studies included showed a decrease in mortality and seven of the studies showed no significant difference in mortality. The researchers found decreased mortality rates in matched studies suggesting that illness severity plays a significant role in unmatched studies. The researchers also found that certain organisms that cause CLABSI were associated with reduced mortality. In general the researchers found that CLABSI has a considerable affect on mortality rate.
Stevens et al. (2013), did a retrospective cohort and cost of illness study in a tertiary care hospital for 2 years. The researchers aimed at identifying high mortality rates and costs associated with CLABSI in ICU and non-ICU patients. The study participants included 398 patients at a tertiary care hospital. The patients were selected through a database that tracks all CLABSI cases in the hospital.
The researchers used fixed and variable costs to identify costs related to CLABSI, and identified causes of 30-day admission and mortality rates in patients with CLABSI. The length of stay for all patients was calculated as the sum of days from the time of admission to discharge. Radiological data was used to identify patients that had a new central line inserted during current hospital stay. Patients were excluded if a new central line was inserted to replace an infected central line.
A Stata 12 analysis was used for multivariable cost models and SAS V9.3 was used for all other analyses. Chi- square tests were used to compare patients with and without CLABSI. Multivariable generalized linear models were used for fixed and variable costs, and multivariable logistic regression was used for thirty-day readmission and mortality rates.
CLABSI is associated with high hospital costs and an increased risk of mortality. CLABSI patients had greater than 80% variable costs than patients without CLABSI. The results showed that the median length of stay in patients before CLABSI was 24 days (30 days) and after CLABSI was 18 days (27 days). The study found that CLABSI was associated with $ 49,600 in fixed costs and $32, 400 in variable costs, regardless of patients being in the ICU or not. Between the beginning of the study and the end, 74 patients died, causing a mortality rate of 18.6 %. The researchers found that CLABSI patients had an increased risk of mortality by 2.27 fold (CI 1.15 – 4.46) than patients without CLABSI. The study concluded that CLABSI patients are more likely to die than patients without CLABSI.
Synthesis of Nursing Implications
Practice
Nurses play an important role in the prevention of central line associated blood stream infections, and in reducing associated mortality rates. They can follow evidence based guidelines and bundles to prevent and minimize complications and mortality from CLABSI. After studying the discussed research in this paper, the best practice to reduce the risk of CLABSI in ICU patients is to implement evidence based interventions. Improper use of procedural guidelines and ineffective maintenance of sterile technique were an issue in GM’s case.
The procedural guideline is to use clean gloves to remove dirty dressing and use sterile one to place the new dressing (CDC, 2011). The CDC (2011) recommends that dressing changes should not be done more than once a week, unless the dressing is visibly soiled or loose. Nurses should follow these recommendations along with other evidence based practice guidelines to help prevent and reduce the incidence of CLABSI in patients.
Central line dressing change requires the use of strict sterile technique and adherence to proper procedural guidelines. Marsteller et al. (2012) found that using evidence-based practice and using strict aseptic technique significantly reduced CLABSI rates and costs associated with increased length of stay.
Education
The CDC (2011) has recommended guidelines to use when performing central line dressing changes. Nurses can follow these guidelines or other hospital specific guidelines to help fight increasing CLABSI rates in patients. Nurses in the hospital that I was in should receive ongoing continuing education classes on central line dressing changes and the importance of strict infection control procedures. After completing the class the nurses should be able to implement what they have learned when caring for patients.
Research
There has been numerous research done to link the incidence of CLABSI and the rate of mortality in patients with CLABSI. Research has also been done to find interventions to reduce and prevent the incidence of CLABSI. According to Stevens et al. (2013), even though there have been several guidelines and interventions to prevent CLABSI, the mortality rate for patients with CLABSI increased over the 2-year period. The researchers find indicates that there is still a need for further research to reduce CLABSI rates.