Lower Central Line-associated Bloodstream Infections Rates Research Articles

Compliance With Central Line Maintenance Bundle and Infection Rates.

Reliable bundle performance is the mainstay of central line-associated bloodstream infections (CLABSI) prevention despite an unclear relationship between bundle reliability and outcomes. Our primary objective was to evaluate the correlation between reported bundle compliance and CLABSI rate in the Solutions for Patient Safety network. The secondary objective was to identify which hospital and process factors impact this correlation. We examined data on bundle compliance and monthly CLABSI rates from January 11 to December 21 in 159 hospitals. The correlation (adjusting for temporal trend) between CLABSI rates and bundle compliance was done at the network level. Negative binomial regression was done to detect the impact of hospital type, central line audit rate, and adoption of a comprehensive safety culture program on the association between bundle compliance and CLABSI rates. During the study, hospitals reported 27 196 CLABSI on 20 274 565 line days (1.34 CLABSI/1000 line days). Out of 2 460 133 observed bundle opportunities, 2 085 700 (84%) were compliant. There was a negative correlation between the monthly bundle reliability and monthly CLABSI rate (-0.35, P <.001). After adjusting for the temporal trend, the partial correlation was -0.25 (P = .004). On negative binomial regression, significant positive interaction was only noted for the hospital type, with Hospital Within Hospital (but not freestanding children's hospitals) revealing a significant association between compliance ≥95% and lower CLABSI rates. Adherence to best practice guidelines is associated with a reduction in CLABSI rate. Hospital-level factors (hospitals within hospitals vs freestanding), but not process-related (central line audit rate and safety culture training), impact this association.

Advancing Nursing Science Through Site-Based Clinical Inquiry: Designing Problem Pyramids.

Advancing Nursing Science Through Site-Based Clinical Inquiry: Designing Problem Pyramids.

Implementing a Program to Standardize Central Line Maintenance

<h3>Background</h3> Central line-associated bloodstream infections (CLABSI) significantly impact patient outcomes and hospital reimbursement. CLABSI mortality can be ≥25% and cost ∼$45,814/each. In 2017, our 394-bed acute care facility identified 15 hospital-wide CLABSI, revealing opportunities for improvement with central line (CL) maintenance. The project goal was to implement standardized tools and training to decrease CLABSI. <h3>Methods</h3> A CLABSI Task Force identified a program that focused on assessing current policies, practices and dressing change kits, and implementing standardized training. In March 2018, baseline CL maintenance assessments; policy gap analyses; and dressing kit evaluations were completed. Nurse performance of four key elements were evaluated: dressing changes, blood draws, medication administration and hub maintenance. Policy and dressing change kits were revised, with ensuing education. A "train-the-trainer" model was adopted, with 30 Unit Champions (UC) instructed to the new dressing change kits and standardized checklists of the four components. Each UC agreed to train "x" number of nurses in their unit within 30 days. Following training in March 2019, post assessment was conducted. Pre- (Jan 2017-Aug 2018) and post-implementation (Sep 2018-Oct 2019) CLABSI standardized infection ratios (SIR) were compared using National Healthcare Safety Network (NHSN) analyses. The study included adult and neonatal inpatient units, except Rehab. <h3>Results</h3> CLABSI events decreased from 15 to 7, and CLABSI SIR noted non-statistically significant decreases (0.93 to 0.67; p=0.4815), subsequent to program completion. Post-assessment revealed key improvements to CL maintenance including: hand hygiene, site preparation and hub disinfection. <h3>Conclusions</h3> Gap analysis of existing practices, policies and supplies, with standardized training, can lower CLABSI rates, and decrease SIR. Policy aligned to best practice and functional CL dressing kits position nurses for success in effective CL maintenance. Standardized training eliminates practice gaps and reduces CLABSI risk.

The association between implementation of second-tier prevention practices and CLABSI incidence: A national survey.

Prevention of central-line-associated bloodstream infection (CLABSI) represents a complex challenge for the teams involved in device insertion and maintenance. First-tier practices for CLABSI prevention are well established. We describe second-tier prevention practices in Israeli medical-surgical ICUs and assess their association with CLABSI rates. In June 2017, an online survey assessing infection prevention practices in general ICUs was sent to all Israeli acute-care hospitals. The survey comprised 14 prevention measures supplementary to the established measures that are standard of care for CLABSI prevention. These measures fall into 2 domains: technology and implementation. The association between the number of prevention measures and CLABSI rate during the first 6 months of 2017 was assessed using Spearman's correlation. We used negative binomial regression to calculate the incidence rate ratio (IRR) associated with the overall number of prevention measures and with each measure individually. The CLABSI rates in 24 general ICUs varied between 0.0 and 17.0 per 1,000 central-line days. Greater use of preventive measures was associated with lower CLABSI rates (ρ, -0.70; P < .001). For each additional measure, the incidence of CLABSI decreased by 19% (IRR, 0.81; 95% CI, 0.73-0.89). Specific measures associated with lower rates were involvement of ward champions (IRR, 0.47; 95% CI, 0.31-0.71), auditing of insertions by infection control staff (IRR, 0.35; 95% CI, 0.19-0.64), and simulation-based training (IRR, 0.38; 95% CI, 0.22-0.64). Implementation of second-tier preventive practices was protective against CLABSI. Use of more practices was correlated with lower rates.

Targeted implementation of the Comprehensive Unit-Based Safety Program through an assessment of safety culture to minimize central line-associated bloodstream infections.

Approximately 250,000 central line-associated bloodstream infections (CLABSIs) occur annually in the United States, with 30,000 related deaths. CLABSIs are largely preventable, and the Comprehensive Unit-Based Safety Program (CUSP) is a proven sustainable model that can be used to reduce CLABSIs. CUSP is a resource intensive program that, although widely used, has not been universally adopted. The purpose of this study is to identify the significant factors of safety culture prior to CUSP implementation associated with a reduction or elimination of CLABSIs. By identifying these factors, hospitals can target CUSP to those units expected to have the greatest odds of reducing CLABSIs. Using logistic and negative binomial regressions, we analyzed 649 hospital units that completed the national On the CUSP: Stop BSI study between May 2009 and June 2012. Hospital units provided CLABSI rates and staff survey responses on perceptions of factors of safety culture prior to CUSP implementation and CLABSI rates for six quarters thereafter. We found that hospital units reduced infection rates in the six quarters following CUSP implementation from 1.95 to 1.04 CLABSIs per 1,000 central line days. Most of the improvement occurred within the first two quarters following implementation. Hospitals with a stronger preimplementation safety culture had lower CLABSI rates at conclusion of the study. We found communication openness, staffing, organizational learning, and teamwork to be significantly associated with zero or reduced CLABSI rates. CUSP appears to have a greater impact on CLABSI rates when implemented by units with a strong existing safety culture. Targeted implementation allows hospitals to optimize success, maximize scarce resources, and alleviate some of the CUSP program's cost concerns if CUSP cannot be implemented in all units. To enhance the impact of CUSP, hospitals should improve safety culture prior to implementation in units that poorly exhibit it.

Central Line-Associated Bloodstream Infection Reduction and Bundle Compliance in Intensive Care Units: A National Study.

OBJECTIVES To describe compliance with the central line (CL) insertion bundle overall and with individual bundle elements in US adult intensive care units (ICUs) and to determine the relationship between bundle compliance and central line-associated bloodstream infection (CLABSI) rates. DESIGN Cross-sectional study. PARTICIPANTS National sample of adult ICUs participating in National Healthcare Safety Network (NHSN) surveillance. METHODS Hospitals were surveyed to determine compliance with CL insertion bundle elements in ICUs. Corresponding NHSN ICU CLABSI rates were obtained. Multivariate Poisson regression models were used to assess associations between CL bundle compliance and CLABSI rates, controlling for hospital and ICU characteristics. RESULTS A total of 984 adult ICUs in 632 hospitals were included. Most ICUs had CL bundle policies, but only 69% reported excellent compliance (≥95%) with at least 1 element. Lower CLABSI rates were associated with compliance with just 1 element (incidence rate ratio [IRR] 0.77; 95% confidence interval [CI], 0.64-0.92); however, ≥95% compliance with all 5 elements was associated with the greatest reduction (IRR, 0.67; 95% CI, 0.59-0.77). There was no association between CLABSI rates and simply having a written CL bundle policy nor with bundle compliance <75%. Additionally, better-resourced infection prevention departments were associated with lower CLABSI rates. CONCLUSIONS Our findings demonstrate the impact of transferring infection prevention interventions to the real-world setting. Compliance with the entire bundle was most effective, although excellent compliance with even 1 bundle element was associated with lower CLABSI rates. The variability in compliance across ICUs suggests that, at the national level, there is still room for improvement in CLABSI reduction. Infect Control Hosp Epidemiol 2016;37:805-810.

Impact of self-reported guideline compliance: Bloodstream infection prevention in a national collaborative

We sought to examine self-reported compliance with 5 evidence-based central line-associated bloodstream infection (CLABSI) prevention practices and link compliance to CLABSI rates in a national patient safety collaborative. We analyzed data from a national CLABSI prevention program. Adult ICUs participating in the program submitted their CLABSI rates and a Team Checkup Tool (TCT) on a monthly basis. The TCT responses provided self-reported perceptions about how reliably the unit team performed the evidence-based practices in the previous month. Monthly data were aggregated into quarters for the analysis. We analyzed a total of 2775 ICU quarters during the program. Chlorhexidine skin preparation and hand hygiene had the highest adherence. Avoidance of the femoral site and removal of unnecessary lines had the lowest compliance. Regression results showed that consistent performance of all practices was significantly associated with lower CLABSI rates. In terms of each practice's independent effect, femoral site avoidance for line placement and removal of unnecessary lines were independently associated with lower CLABSI rates after controlling for other factors. Our findings suggest that uptake of the 2 low-compliance practices, avoidance of the femoral site and removal of unnecessary lines, is important for reducing CLABSI rates in conjunction with other practices.

Compliance with prevention practices and their association with central line–associated bloodstream infections in neonatal intensive care units

Bundles and checklists have been shown to decrease the rates of central line-associated bloodstream infections (CLABSIs), but implementation of these practices and association with CLABSI rates have not been described nationally. We describe implementation and levels of compliance with preventive practices in a sample of US neonatal intensive care units (NICUs) and assess their association with CLABSI rates. An online survey assessing infection prevention practices was sent to hospitals participating in National Healthcare Safety Network CLABSI surveillance in October 2011. Participating hospitals permitted access to their NICU CLABSI rates. Multivariable regressions were used to test the association between compliance with NICU-specific CLABSI prevention practices and corresponding CLABSI rates. Overall, 190 level II/III and level III NICUs participated. The majority of NICUs had written policies (84%-93%) and monitored compliance with bundles and checklists (88%-91%). Reporting ≥95% compliance for any of the practices ranged from 50%-63%. Reporting of ≥95% compliance with insertion checklist and assessment of daily line necessity were significantly associated with lower CLABSI rates (P < .05). Most of the NICUs in this national sample have instituted CLABSI prevention policies and monitor compliance, although reporting compliance ≥95% was suboptimal. Reporting ≥95% compliance with select CLABSI prevention practices was associated with lower CLABSI rates. Future studies should focus on identifying and improving compliance with effective CLABSI prevention practices in neonates.

Impact of Nursing Staffing on Patient Outcomes in Intensive Care Unit

Background: The impact of nursing care on patient outcomes is not well understood. The objective of this study is to assess the effects of nursing care hours per patient day, nursing skill mix, and nurse turnover on central line-associated bloodstream infection (CLABSI) rates, length of stay (LOS), and mortality in the context of intensive care units (ICUs) using interventions to reduce bloodstream infections and improve patient safety, teamwork and interdisciplinary communication. Methods: This study uses longitudinal data from 45 ICUs from 35 hospitals in two faith-based health systems across12 states. The 45 ICUs were divided into two groups. We analyzed 19 months of experience for the first group and a year of experience for the second group. We collected hours worked by all bedside nurses to calculate National Quality Forum (NQF) nursing measures. We used a two-level random-intercept model to account for the correlations among repeated measures for the same ICU. Regressions accounted for the influences of number of Intensivists, type of ICUs, ICU bed size, which health system the unit belonged to, nursing practice environment (PES-NWI) and project phase. Models also adjusted for average patient charges, to partially account for ICU casemix. Results: Nursing care hours per patient day greater than 20 hours was associated with lower CLABSI rates. Increasing nursing hours per patient day was also associated with shorter LOS, with the strongest relationship where nursing hours per patient day was lower (< 20 hours compared to ≥ 20 hours). A Higher skill mix was associated with shorter LOS but higher CLABSI rates. We found no significant relationships of nursing turnover with any outcome, or between any nursing variables and mortality. Conclusions: Our findings suggest that nursing care hours per patient day and nursing skill mix significantly contribute to CLABSI prevention and LOS in the ICU setting.

Hospital costs of central line-associated bloodstream infections and cost-effectiveness of closed vs. open infusion containers. The case of Intensive Care Units in Italy

ObjectivesThe aim was to evaluate direct health care costs of central line-associated bloodstream infections (CLABSI) and to calculate the cost-effectiveness ratio of closed fully collapsible plastic intravenous infusion containers vs. open (glass) infusion containers.MethodsA two-year, prospective case-control study was undertaken in four intensive care units in an Italian teaching hospital. Patients with CLABSI (cases) and patients without CLABSI (controls) were matched for admission departments, gender, age, and average severity of illness score. Costs were estimated according to micro-costing approach. In the cost effectiveness analysis, the cost component was assessed as the difference between production costs while effectiveness was measured by CLABSI rate (number of CLABSI per 1000 central line days) associated with the two infusion containers.ResultsA total of 43 cases of CLABSI were compared with 97 matched controls. The mean age of cases and controls was 62.1 and 66.6 years, respectively (p = 0.143); 56% of the cases and 57% of the controls were females (p = 0.922). The mean length of stay of cases and controls was 17.41 and 8.55 days, respectively (p < 0.001). Overall, the mean total costs of patients with and without CLABSI were € 18,241 and € 9,087, respectively (p < 0.001). On average, the extra cost for drugs was € 843 (p < 0.001), for supplies € 133 (p = 0.116), for lab tests € 171 (p < 0.001), and for specialist visits € 15 (p = 0.019). The mean extra cost for hospital stay (overhead) was € 7,180 (p < 0.001). The closed infusion container was a dominant strategy. It resulted in lower CLABSI rates (3.5 vs. 8.2 CLABSIs per 1000 central line days for closed vs. open infusion container) without any significant difference in total production costs. The higher acquisition cost of the closed infusion container was offset by savings incurred in other phases of production, especially waste management.ConclusionsCLABSI results in considerable and significant increase in utilization of hospital resources. Use of innovative technologies such as closed infusion containers can significantly reduce the incidence of healthcare acquired infection without posing additional burden on hospital budgets.