Literature exists for specialty areas of practice related to the management of central line-associated bloodstream infections (CLABSIs) in children.1–4 The referenced standards of practice are based on activities done in 2011. When multiple specialty areas oversee CLABSI prevention efforts, it is imperative to consider the professional guidance documents used by each specialty when developing process improvement plans. The authors' process was developed and implemented to demonstrate how collaboration between specialty areas of practice can have a positive effect on outcomes for pediatric patients and increase staff satisfaction with improvement efforts when working to reduce and/or prevent CLABSIs.
In 2011, a cardiovascular intensive care unit (CVICU) in a moderate-sized pediatric facility experienced a marked increase in its CLABSI rate. At the time, the rate was 2.3 CLABSIs/1000 central line days, compared with the national average of 1.6 CLABSIs/1000 central line days.5 In response, 3 areas of specialty practice of the pediatric hospital system—infection prevention and control (IP), vascular access (VA), and skin integrity (SI)—began work on CLABSI prevention activities independent of one another. Each specialty practitioner implemented improvements based on clinical findings and recommendations from professional guidance documents, with all 3 practitioners having the goal of lowering CLABSI rates on their individual units. Working independent of one another resulted in confusion among bedside staff, overall dissatisfaction with improvement activities, and no progress on lowering the CLABSI rate.
At the time of the CLABSI rate increase in the CVICU, a significant turnover in bedside nursing staff was noted. It seemed that the less experienced nurses did not have the same understanding of CLABSI prevention as more experienced nurses, who had been involved in creating evidence-based science in the past. The 3 specialties—IP, VA, and SI—were housed in a single department in the organization. As each specialty practitioner met with the department director to discuss progress on reducing CLABSIs, the CVICU clinical leadership noted that each specialty was implementing processes that were confusing to staff and, at times, contradictory to recommendations made by the other 2 specialties. The following examples illustrate these challenges. The IP practitioner noted that impairment in skin integrity was a problem, but wasn't sure what measures to implement to sustain healthy skin. The SI practitioner noted that a different type of dressing should be used, but was unsure what type of dressing would meet IP standards and promote maintenance of skin integrity. The VA nurse focused on the frequency of unscheduled dressing changes and correct device selection, based on administration of vesicant medications and vasopressors. As a result of the lack of care continuity, the director met with the 3 specialty practitioners and suggested that they work collaboratively to develop an improvement plan. The skin integrity, infection prevention, and vascular access (SIPVA) team was created, and joint interventions were implemented according to evidence-based guidelines. The development and outcomes of the SIPVA team interventions among the patients in the pediatric CVICU are detailed in this article.
The SIPVA team intervention began with initial meetings between the 3 practitioners to review current guidance documents from each professional group and to establish ground rules for the team's work going forward. The primary guidance documents that were reviewed included the Infusion Nursing Society's Infusion Nursing Standards of Practice,1 “Acute and Chronic Wounds: Current Management Concepts,”2 and the 2011 Centers for Disease Control and Prevention's “Guidelines for the Prevention of Intravascular Catheter-Related Infections.”3 In addition to reviewing the guidelines and standards, the team developed a Plan, Do, Study, Act (PDSA) document to guide its performance (Figure 1). The team began the first PDSA cycle in October 2011. This initial cycle identified how skin assessments were performed in relation to the maintenance of central lines, evaluating the central line maintenance practices that were performed, and determining whether VA procedures were completed and documented in the patient's electronic health record on a consistent basis. Subsequent PDSA cycles built on the issues identified in previous cycles.
The SIPVA team started daily team rounding on the unit next. Each patient with a central line of any type was assessed. The bedside nurse and physician were included in the assessment when they were available. The assessment focused on the functionality of the central line; the condition of the skin surrounding the central line insertion site; and the care and maintenance of the central line, including the frequency of dressing changes and the type of dressings used. During patient assessments, many different scenarios were encountered that required a more in-depth review, using staff interviews to determine the cause of noncompliant occurrences and/or how to prevent the occurrences from happening. For example, it was noted by the SIPVA team that central line dressings were being changed more frequently than recommended. This resulted in increased exposure of the insertion site and dermal stripping that was exhibited by red, sensitive skin with and without breakdown around the insertion site. Staff interviews revealed that patients with any amount of drainage under the dressing, from scant to moderate, would result in the dressing being changed. The SIPVA team developed a comprehensive improvement plan based on specific, measurable, achievable, relevant, and time-based (SMART) principles related to maintenance of the central line. The plan included staff education related to maintaining skin integrity while consistently implementing the hospital's central line bundle elements. These elements included hand hygiene prior to donning personal protective equipment, donning a mask and clean gloves to remove the old dressing, performing hand hygiene after doffing clean gloves and before donning sterile gloves, using chlorhexidine to clean the skin and insertion site, applying a no-sting skin barrier around the insertion site, applying a chlorhexidine patch with a transparent dressing, and labeling the dressing with the date and time of the dressing change.
The SIPVA team first identified multiple issues related to care and maintenance of central lines. Some of the issues identified included inconsistent dressing times, inconsistent use of dressing types, and an overall lack of understanding about the importance of the hospital's central line bundle elements. Once issues were identified, the team worked with bedside and medical staff to determine why the issue occurred or to discuss their perception as to why the issue occurred. Based on the identified issues, the team developed a comprehensive assessment tool (Table 1) to document issues, the potential cause of each issue, and the plan to resolve each one. The resolution plan included assigning responsibility for each task to a SIPVA team member and providing a timeline for completing the tasks.
To address the inconsistent timing of dressing changes, 1 day of the week was designated for all central line dressing changes to be completed. This ensured that all dressings were changed at least every 7 days, although some dressings required an increased frequency to enable staff to manage the changes on the designated day. The SIPVA team, in collaboration with the clinical nurse leaders on the unit, developed and implemented a staff education program. In a group setting during the unit's education days, staff members were educated on the hospital's central line bundle elements and the importance of consistent implementation. In addition, central line management competencies were completed with each nurse on the unit. Staff demonstrated competency by completing a dressing change on a mannequin and verbally identifying each step in the dressing change process. The competencies were complemented by just-in-time education related to central line dressing changes, with rationales given for each step. At predetermined intervals, signs related to CLABSI prevention efforts were posted at the nurse's desk of each patient room (Figures 2 and 3). The signs identified issues that required repeated reinforcement of concepts, such as the multiple elements of the central line bundle. Each sign was posted for 1 month, and the impact on practice was evaluated by reviewing central line bundle compliance rates and interviews with staff to confirm information synthesis. Staff satisfaction with implemented processes was measured by in-person interviews conducted by the SIPVA team during daily rounding and through reports from the clinical leadership of the unit.
There was a notable decrease from 2.3 CLABSIs/1000 central line days to 0.9 CLABSIs/1000 central line days by the fourth quarter of 2011, which was sustained throughout the second quarter of 2012 (Figure 4). The team was able to identify multiple factors related to the increased CLABSI rate that required short-term and long-term interventions. The interventions for care and management of central lines included staff education (formal and just-in-time), process changes and improvements, as well as updates and changes to products used.
In the beginning assessment phase, staff verbalized confusion with guidance through real-time informal interviews. Before the collaboration of the 3 specialty areas, changes to practice were implemented at varying intervals by each specialty practitioner, and staff were unsure which practice to follow and how to implement some of the practices. This resulted in inconsistent implementation of practices. The SIPVA team responded by engaging staff in the process improvement planning. It was helpful to compare recommended practice with actual practice. The informal interviews allowed staff to express concerns and frustrations without fear of retribution. The result of the collaboration was improvement in staff satisfaction as noted by continued informal interviews.
Staff expressed satisfaction with the new process of SIPVA rounding on all patients with central lines and became more engaged in the process of managing and maintaining functional central lines and healthy skin for their patients. Physicians expressed satisfaction with the team approach and frequently consulted the team when issues with central lines, or with the skin around central lines, were identified.
This project was not without its challenges. Daily rounding was hard to sustain because each specialty practitioner had competing priorities, and rounding required a large time commitment from each practitioner. Some of the issues experienced were an increase in skin team consults (which were not anticipated) and the occurrence of an IP-related emergency: a water leak in a unit that required immediate attention. These situations made it difficult—sometimes impossible—for the team to round as a group. All of the practitioners managed multiple patient care units on 2 campuses of the organization. At times, responsibilities on the opposite campus precluded completing rounds on the CVICU. The education provided to staff increased confidence in their bedside practice but also resulted in the unintended consequence of bedside nurses implementing changes to standard processes without consulting anyone from the SIPVA team. Current staff were noted to implement changes made in the past by the SIPVA team with current patients without consulting anyone from the SIPVA team. Because of staff turnover, the demographics of the SI team and VA team changed during the project, making it difficult to continue with established processes. As a result, each specialty team returned to managing central lines independently without consulting the other 2 specialties, which led to staff confusion and the unit experiencing an increase in its CLABSI rate in quarter 3 of 2013 (Figure 4).
To successfully manage CLABSIs, specialties involved in care and maintenance of central lines can benefit from establishing a collaborative approach. Collaboration resulted in improved learning and understanding by bedside staff, increased engagement from clinical teams on the unit, and helped establish a process for ongoing recognition of problems with multiple foci as the cause, such as SI, IP, and VA.
The decreased CLABSI rate was sustained with small increases in the CLABSI rate in 2014 and 2016. In 2018, the CVICU experienced an increase in the CLABSI rate to 1.83 per 1000 central line days. The unit experienced an unexpected increase in the unit census as a result of the inability of a competing organization to sustain a cardiac program. Patient acuity increased with the added census. Additionally, with the growth of the population of the unit, the number of new graduates and newly employed and traveling staff increased. At the time of this writing, the Center for Professional Development and Practice (CPDP) had implemented simulation-based mastery (SBM) education on the CVICU to support continued learning for staff on the unit. SBM allows all learners to meet a standard outcome or minimum passing standard, with an individualized amount of time and support for each learner.7,8 In 2019, the CPDP will implement the next phase of SBM to determine the retention of learning from the 2018 sessions.
Organizations that desire to build a collaborative team for central line management should start with identifying the practitioners in each specialty area with responsibility for the devices. Once the practitioners are identified, a shared goal should be developed to guide work practices and provide the foundation for implementing process improvements. Bedside staff and clinical leaders on the unit must be engaged in the assessment, planning, and implementation of new processes. Feedback from the clinical team is imperative to determine whether process improvement measures are successful. Successfully sustaining improvements requires constant vigilance and a commitment to the maintenance of the collaborative working relationships.
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Keywords:© Copyright 2019 by Infusion Nurses Society
CLABSI; collaboration; competency; infection; outcomes; reduction; skin integrity; vascular access