CLABSI Prevention Case Study: Overcoming Organizational Barriers to Enhance Patient Safety

By: Olivia Lounsbury, Clinical Research Coordinator, Patient Safety Movement Foundation

A Central Line-Associated Bloodstream Infection (CLABSI) in just one patient can result in as much as $56,000 for payers, due to a mortality rate of 14-40% and an average prolonged length of stay of between 7.5 and 25 days (Ranji et al., 2007). CLABSI prevention remains a challenge for hospitals worldwide. It is estimated that through process change in organizations to enhance CLABSI prevention efforts, hospitals can save up to $2.7 billion per year while significantly improving quality and safety (Scott, 2009). Implementation of a CLABSI bundle, which would provide standardization, reliability, and consistency, has been shown to reduce cases by up to 74% (IHI, 2012).

Most clinicians are aware of the basic nursing care components involved in CLABSI prevention, including:

Insertion

  • Perform hand hygiene frequently. 
  • Use chlorhexidine for skin preparation.
  • Use full barrier precautions during insertion.
  • Select the optimal site for insertion.
  • Immediately remove unnecessary catheters.

Maintenance

  •  Comply with hand hygiene requirements. 
  •  Bath ICU patients over two months of age with a chlorhexidine preparation on a daily basis. 
  • Use disinfection caps on all access ports.
  •  Scrub the access port or hub with friction immediately prior to each use with an appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70% alcohol). 
  •  Use only sterile devices to access catheters. 
  •  Immediately replace dressings that are wet, soiled, or dislodged. 
  •  Perform routine dressing changes using aseptic technique with clean or sterile gloves. 
  • Change gauze dressings at least every two days or semi permeable dressings at least every seven days. 
  • For patients 18 years of age or older, use a chlorhexidine impregnated dressing with an FDA cleared label that specifies a clinical indication for reducing CLABSI for short-term non-tunneled catheters unless the facility is demonstrating success at preventing CLABSI with baseline prevention practices. 
  • Change administrations sets for continuous infusions no more frequently than every four days, but at least every seven days.
  • If blood or blood products or fat emulsions are administered change tubing every 24 hours.   If propofol is administered, change tubing every 6-12 hours or when the vial is changed. 

Removal

  • Perform daily audits to assess whether each central line is still needed. 
  • Promptly remove as soon as unnecessary. 

These prevention measures are relatively inexpensive and are already available in healthcare organizations. However, these measures require prioritization, standardization, and support. 

So why is CLABSI such a significant cause of harm and death in hospitals?

Despite international focus and an extensive body of literature outlining best practice guidelines, hospitals are still underperforming in their prevention of CLABSI. According to one study, policies regarding insertion, care, and removal of catheters varied vastly: only 28% of cases used a maximal sterile barrier on the device and only 36% mandated hand hygiene before every catheter insertion (Ranji et al., 2007). 

Although it is easy to place blame on the individual clinician, a step back will highlight the gaping systemic and organizational barriers that are so ingrained in the hospital’s culture that they permeate into every aspect of clinical practice. A person-centered culture of safety, holistic, continuous improvement plan, and a model for sustainment must be established and reinforced as fundamental components of the organization before any population-specific performance improvement project, such as CLABSI prevention projects, can be successful. Without these fundamental components of safe care, all subsequent attempts to improve patient safety will fall short. 

Implementation of CLABSI prevention processes can significantly benefit from shared learning and peer collaboration. We were joined by Pat Posa, MSA, BSN, RN, CCRN-K, FAAN, currently the Quality and Patient Safety Program Manager at University Hospital & Frankel Cardiovascular Center. The below CLABSI case study is in reference to Pat’s work at St. Joseph Mercy Hospital.

Since their launch of the CLABSI ICU collaborative in 2004, Pat has been instrumental in its development, implementation, and sustainment. 

 The Initiative

“At St. Joseph Mercy Hospital, we began working on CLABSI prevention in 2004 as an improvement project with the Michigan Hospital Association’s Keystone ICU Collaborative.  Our initial focus was on the CLABSI Prevention Insertion Bundle.  Along with implementing the insertion bundle, we also began to examine our safety culture and implemented the Comprehensive Unit Based Safety Program (CUSP) to create a positive safety culture.  We put a multidisciplinary team together with members from all three of the ICUs in our hospital to tackle both the insertion of the CLABSI Prevention Insertion Bundle and CUSP.

Our focus was two-fold: improve safety culture on the units and decrease the CLABSI rate.  We wanted to prevent unnecessary harm to our patients.”

Specific Barriers

“One of the first barriers to overcome was the belief that CLABSI could not be prevented in the very critically ill population.  It was a belief of most providers that this was just one of the complications that happened to ICU patients.  There was emerging literature that demonstrated a significant impact on infection rates by standardizing insertion practices.  This was one of the first times that we had attempted to do standardization across all types of ICU, which brought its challenges, because each ICU believed they were different.  The #1 barrier was having all the supplies readily available so the frontline staff so it would be easy for the frontline staff to follow the evidence-based prevention practices.”

The Team

The multidisciplinary team consisted of the medical director from each of the ICUs, unit nursing leadership team (nurse manager, educator and nurse coordinator), staff nurses from each shift, respiratory therapists, pharmacists, and nutritionists.

Getting Started

“We started by looking at the evidence related to CLABSI prevention, defining our current state and what our new practices would be.  We looked also at our baseline infection rates and would track those monthly.   For the work on safety culture, Johns Hopkins’ CUSP program was outlined by the Keystone ICU Collaborative and we began to implement it by first educating the multidisciplinary team on the ‘Science of Safety’ and administering a safety culture survey to all of the ICUs so we could get a baseline and identify our opportunities.

One of the strategies to assist the staff in following the defined best practices for central line insertion was to have all the supplies readily available.  To do this, a central line insertion cart (that was the same for each of the ICUs) was developed, where all the needed supplies were together in one place.  Part of the process change was to also have a checklist that a nurse or respiratory therapist would complete while assisting with the line insertion, to ensure all of the evidence-based practices were followed.  We got key stakeholder buy in through the multidisciplinary team as well as meeting with medical leadership to get their support for the new practices.  To ensure that an error was not made and that the practice was being followed, the staff assisting with the line insertion was empowered to ‘stop the line’ insertion if the practices on the checklist were not done.  This was one of the first significant changes we made to our safety culture—ensuring that staff felt comfortable speaking up to prevent potential errors.  This speaking up was supported by both medical and nursing leadership and our journey to a positive safety culture had begun.”

Evolution

“This project continued to evolve to focus on all types of harm prevention for the ICU patients.  For CLABSI prevention, after the insertion bundle was implemented, we audited practices and gave feedback to teams when we missed the mark.  We learned from and reflected on each CLABSI that occurred. After implementation of the insertion bundle, we then focused on standardizing the care and maintenance of central lines through implementation of a maintenance bundle.  As new evidence emerged related to CLABSI prevention, the team would review and integrate into the existing workflow.”

Advice

“Key components to implementing new evidence-based practices to prevent harm include forming a multidisciplinary team of key stakeholders that follow a standardized implementation and process improvement methodology like IHI PDSA or Johns Hopkins’ Translating Evidence into Practice. These frameworks include reviewing the evidence, identifying gaps between current practices and future state, and walking the current process to identify challenges and barriers.  Also key to sustainable change is to work on improving the safety culture to create an environment where all staff feel empowered to speak up with a safety concern and errors are not blamed on individuals but rather warrant examination into the system and process issues.”

References

Ranji, S. R. (2007). Closing the quality gap. a critical analysis of quality improvement strategies. Place of publication not identified: Agency for Healthcare Research and Quality.

Scott, R. (2009). The Direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention. Retrieved September 05, 2020, from http://stacks.cdc.gov/view/cdc/11550/