central line-associated bloodstream infections (CLABSIs).

Abstract

Aims and Objectives: The study was founded with the aim of establishing whether evidence-based nursing education is supportive in central-line associated bloodstream infection’s reduction. Towards this goal, two objectives were tested: 1) to find out if implementing evidence-based nursing education program has been done within the acute care setting, and 2) to establish whether the evidence-based nursing education program attained the objective of reducing the cases of CLABSI.

Background: Clinically, the use of central venous catheters (CVCs) is critical in aiding medication, treatment, and general management of disease. CVCs are also used in giving intravenous fluids and blood products, as well as in providing nutrition in hospitalized critically ill individuals. Despite the importance of the CVCs, they are linked to a life-threatening problem, including the development of central line-associated bloodstream infections (CLABSIs). Research evidence proving the increase in the prevalence of the infections offers the basis for the current research project.

Design: A quasi-experimental study was carried out in the ICU of a mid-level hospital.

Methods: Quantitative data was collected from nurses (n=10), who participated in a weekly training program, based on implementation of evidence-based strategies.

Results: Data was analyzed, comparing three phase: first period, second period and third period. The rate of CLABSI in the first period was 7.3, in the second period 4.2, and third period 1.8.

Conclusions: The results of the study indicated the effectiveness of evidence-based nursing education program towards achievement of reduction in CLABSI in the ICU. A conclusion was made that adequate implementation and compliance are critical for the achievement of the goal of reducing CLABSI.

Relevance: The findings have relevance in health care settings, among them, cutting the cost of treatment of CLABSI. Proper use of CVCS is also necessary in reducing the mortality rates relating to the infections.

Keywords: central line infection education, evidence-based, and nursing education

Introduction

Patients visit the health care system with the aim of getting treatment as well as manage their illnesses. However, the hope of proper care is affected by any dangers related to their care, one of the most critical being healthcare-associated infections. The critically ill patients, who have to depend on various devices to facilitate their care, including CVCs, are the most affected. As a result, infections contracted in the process of care are a major problem within the intensive care units (ICUs) (Seyman et al. 2014). The infections, including central-line associated bloodstream infection (CLABSI), are a cause of high level of morbidity and mortality. The infections have been showed to be major threats to the safety and quality of care for the patients within the ICU. Research has revealed that such infections can be prevented using effective and evidence-based strategies (Furuya et al. 2011, Seyman et al. 2014). The findings highlight the need for the implementation of evidence-based practices, including training for the nurses, an initiative aimed at preventing the infections.

Background

In the modern world of medicine, the use of CVCs cannot be underestimated. These devices are used to facilitate medication, treatment, and overall management of patients who are critically, and mostly in the ICU. They also aid in the use of intravenous fluids as well as blood products and also nutritional support for such patients (Banach & Calfee 2013). The catheters are tubes that are inserted into a vein like subclavian or peripherally inserted (PICC line). The tubes are significant in the treatment and management of patients in the ICU, but they have been associated with a life-threatening problem, CLABSI. The infections are basically bloodstream infections originating from microorganisms prevalent on the external surface of the CVCs devices or the fluid pathway when the CVCs devices are inserted (Miller et al. 2011). CLABSI is a serious problem for healthcare facilities in the United States and globally. The risk for the development of the infections is based on various factors, including the kind of ICU, quality of patient care, suitable hospital infrastructure, and effective implementation of the strategies for preventing CLABSI.

CLABSI have been associated with high mortality and morbidity rates. For instance, in the United States, over 40,000 cases of CLABSI are reported on an annual basis (Weber & Rutala 2011). The rate of mortality is estimated at between 4% and 20% based on the setting (McLaws & Burrell 2012). Silow-Carroll & Edwards (2011) provided evidence pointing out that in 2009; around 43,000 cases of CLABSI were experienced in the medical facilities across the country, leading to one death out of five infections. Many cases in hospital facilities are reported among individuals who are unable to carry out some essential activities necessary for effective treatment, thus precipitating the application of the CVCs. In spite of the pervasiveness and the gravity of this problem, research evidence is still insufficient on the most efficacious way of preventing the infections and reducing associated deaths (Furuya et al. 2011).

Most of the deaths as a result of CLABSIs are due to delayed detection, revealing insufficiency in the measures used in preventing the infections and inadequacy in the training of medical practitioners taking part in the use of the CVCs (Miller & Maragakis 2012).  Findings from various studies bring the conviction that the implementation of evidence-based education supports the overall measures for addressing cases of CLABSI (Marschall et al. 2014). Whited and Lowe (2013) indicated that while there is potential for success, this is not always evident in practice due to low observance of evidence-based practices. Inadequate use of the evidence-based measures is the cause of the increased rate of the infections in hospitals around the world.

Essentially, the results from previous studies draw attention to the necessity for additional research on the use of evidence-based education implemented by nurses, to reduce the incidence of CLABSI in ICU and other medical settings. Thus, the primary aim of the study project is to establish whether implementation of evidence-based nursing education in the ICU has the potential for reducing CLABSI. Two main objectives were measured in the study: 1) to find out if implementing evidence-based nursing education program has been done within the acute care setting, and 2) to establish whether the evidence-based nursing education program attained the objective of reducing the cases of CLABSI in the ICU.

Methodology

Procedures/Methods

A quasi-experimental study was performed within the ICU of a mid-level hospital in the US. The primary purpose of the study was implementation of evidence-based strategies by nurses towards the end of reducing CLABSIs within the settings. The sample of nurses involved in the study was 10. The nurses providing services within the setting were used in implementing the training program carried out monthly. As such, the nurses were trained on the use of diverse evidence-based strategies, such as application of alcohol-impregnated caps, change of central line dressing in a timely and proper manner, use of chlorhexidine preparation for the daily baths of the patients, and assessment of the daily need changing CVCs (Marschall et al. 2014). Basically, extensive changes were done to achieve success in the implementation of the strategies, such as making accessible the alcohol-impregnated caps at the patients’ bedside, using CVCs at the end and the beginning of shifts, ensuring that the ICUs have sufficient chlorhexidine bath soap supply, as well as change kits for CVC dressing, and providing evidence-based training for nurses on proper use of CVCs, such as correct and well-timed dressing changes (Marschall et al. 2014).

Data Collection and Analysis

Critical data was collected and analyzed to establish the effectiveness of the evidence-based training for nurses in reducing the cases of CLABSI. Hospital records on the cases of CLABSI were used in collecting the quantitative data. The data was collected in three phases, for the first period, it was done before the implementation of the training program. The data indicated the rate of CLABSI before the program commenced. For the second period, data was collected one month following implementation of the program and again after the second month for the third period. The interviews for nurses were used in collecting the data before and after implementing the program to indicate the level of compliance with the strategies. In addition, the interview would provide important information on the changes that will have taken place within the setting after implementing the program.

Ethical Approval

Given that the study was carried out in a hospital setting, ethical approval was obtained from the hospital board before collection of data. Nurses involved in the study also gave their approval by signing informed consent. The patients did not have to give consent because the study did not threaten their safety. In addition, the research did not involve manipulation of their conditions.

Data Analysis

The data to be analyzed was obtained from the rates of CLABSI of three ICUs in the hospital. The preliminary data that was used suggested 8.08% rate of CLABSI. For the purpose of achieving a reduction in CLABSI with statistical significance with 80% power, it was presumed that there would be a decrease in the infection rates of at least 25% from one period to the next. Indeed, to assess the changes over time in the rates of infection, Poisson regression was applied. Overall CVC days and patient days were used in calculating the total infection counts. The researchers used adjusted incidence rate ratios in reporting the results, accompanying confidence intervals of 95%. The analysis of the data was carried out with the use of SAS, version 9.2 (SAS Institute, USA). The analysis of the qualitative data was carried out using discourse analysis, indicating changes in the setting after implementing the evidence-based program.

Results

Table 1 shows the data on the characteristics of the study units, the types of ICU, the quantity of beds in the ICUs, the patient days and the figures of admissions in the ICUs.

Table I: study units’ characteristics

ICU: intensive care unit

The rates of CLABSI are shown in Table II. From the analysis of the data, it was revealed that in first period, the rate was 7.3, in second period the figure was 4.2 and 1.8 in the third period. The results indicate a reduction in the rates of CLABSI of 43.8% from the first to the second period of the study. From the second to the third periods of study, a reduction in the rate of CLABSI of 57.6% was achieved. The results revealed an interesting finding, which indicated that the reduction in the rate of CLABSI was highest from the first to the second period, marking the first month following implementation of the training program.

Table II: Rates of CLABSI during the three periods

CLABSI: central line-associated bloodstream infections

Discussion

In the quasi-experimental study, which measured the rate of infection before and after the intervention, the research revealed that adequate implementation of evidence-based practices had the potential for reducing the prevalence of CLABSI in ICU settings. The emphasis was use of evidence-based strategies in providing patient safety through evidence-based training (Freixas et al. 2013). The two objectives of the study were achieved. There was an adequate implementation of the evidence-based strategies in the setting, and by the end of the first month, the nurses were already used to the adopted changes. The second objective, achieving a reduction of the infections following the implementation of the strategies was also achieved. Before implementation of the program, the cases were found to average at 7.3%, after one month of training, the rate went down to 4.2% and further down to 1.8 during the second month.

It was anticipated that following implementation, the cases of CLABSI from one period to the next would decrease by 25%. Taylor, McDonald & Tan (2015) made a suitable proposal that by using evidence-based strategies, Centers for Disease Control and Prevention (CDC) and its guidelines shape the trajectory of addressing the cases of CLABSI. On the same breadth, Whited and Lowe (2013) captured the view that while there are successes on the compliance with the evidence-based guidelines, it emerges that the basis of poor infection outcomes is pegged on the ineffective compliance with the strategies.

After implementing the program, and after one month of effective training of the nurses, it was realized that the second objective was achieved. However, the reduction in the cases of CLABSI was not by 25% as anticipated. In fact, the reduction was greater than anticipated. Even one month of implementing the program, it was realized that the cases of infections were going down. After taking the cases of those who had acquired infections by the fourth week of the program, it was realized that a reduction to a rate of more than 40% was achieved. Marsteller et al. (2012) revealed that execution of training for nurses in ICU works in reducing the case of all forms of infections in health care settings.

Research on the reduction of CLABSI focuses on the ICU patients as well as the generalized non-ICU patients. Fundamentally, some of these studies pointed out the necessity to reduce the pervasiveness of the infections by using different strategic inputs and measures. The nursing practitioners must appreciate that the rate of CLABSI must be dealt with within the paradigm of evidence-based practice (Freixas et al. 2013, Taylor, McDonald & Tan 2015, Weingart et al. 2014, Pérez et al. 2015). However, they should also recognize that success in the reduction depends on their level of compliance with the implemented strategies; otherwise, the process will be counterproductive.

Conclusion

From the study, it becomes evident that the two objectives were achieved. The nurses revealed a change in the ICUs to include use of evidence-based strategies in preventing the infections. Even one month into the program, the nurses had become accustomed to using the strategies, to such an extent that a greater level of reduction was achieved even compared to the second month. All the approaches were implemented in the first month of the program. The second objective was also achieved by surpassing the projected level of reduction. Clearly, the results revealed that use of evidence-based education and strategies is effective in preventing the prevalence of CLABSI in intensive care settings.

As it is palpable from the analysis, the study has indicated the need to decrease the incidence of CLABSI applying different strategies through evidence-based training program. It is apparent from research that the rate of CLABSI decreases on adequate and appropriate adoption of evidence-based strategies in the use of CVCs. On the other hand, the effect is dependent on the effective implementation of the interventions and observance of the evidence-based approaches. In essence, such evidence will play a role in helping the nurses to contribute to the reduction of the infections in hospitals.

Relevance to Clinical Practice

The findings have relevance in health care settings, among them, cutting the cost of treatment of CLABSI as is borne by individuals and the health care settings. The achievement is evident in reducing the complication of illnesses, and longer hospital stays due to the infections. Proper use of CVCS is also necessary in reducing the mortality rates relating to the infections. The health care system will also achieve safety and quality of care to the patients following the implementation of the strategies. Therefore, a change in the culture of the nurses to include the evidence-based strategies in their practice will achieve this goal. However, the study does not cover all the aspects of the reduction in CLABSI, highlighting implications for future studies. The factors that relate to the implementation have not been studied regardless the fact that they also determine success of lack thereof. Hence, future studies should focus on those factors and the role they play in the implementation process.

References

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Freixas N, Bella F, Limón E, Pujol M, Almirante B &Gudiol F (2013) Impact of a multimodal intervention to reduce bloodstream infections related to vascular catheters in non-ICU wards: a multicentre study. Clinical Microbiology & Infection 19, 838-844.

Furuya EY, Dick A, Perencevich EN, Pogorzelska M, Goldmann D & Stone PW (2011) Central line bundle implementation in US intensive care units and impact on bloodstream infections. PloS one 6, e15452.

Marsteller JA, Sexton JB, Hsu YJ, Hsiao CJ, Holzmueller CG, Pronovost PJ & Thompson DA (2012) A multicenter, phased, cluster-randomized controlled trial to reduce central line-associated bloodstream infections in intensive care units. Critical care medicine 40, 2933-2939.

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