Infections in hospital settings are a challenge in nursing because of the potential dangers that they pose to a wide number of patients. Bloodstream infections from central lines are particularly hazardous as they affect patients that are already vulnerable, meaning that they contribute to morbidity and mortality in the hospital setting (Rinke et al., 2012). Although the rates of central-line-associated bloodstream infections (CLABSI) can be reduced by up to 67% through the introduction of checklists (Schulman et al., 2011), the issue continues to be important in a wide number of hospital settings. It is also important to understand the different approaches that can be used to reduce the effects so that the most effective can be selected in the acute care setting. The purpose of this paper is to review the current literature on the reduction of CLABSI and to highlight the importance of this issue to hospital nursing.
PICOT Question and Relevance to Practice
CLABSI are an issue in nursing as they affect a number of vulnerable patients. Whilst the Centers for Disease Control and Prevention suggest that the incidence of central-line infections declined by 63% between 2001 and 2009 (Pronovost, Marsteller & Goeschel, 2011), there is still work to do to protect patients in the hospital setting. The following PICOT question is designed to assess the relevance of nursing education in best practice techniques for reducing the incidence of bloodstream infections in the acute care setting, with a view to understanding how these infections can be eliminated from hospitals. It is designed to give insight into the state of the issue and the best practice measures for reducing CLABSI.
Patient population – patients with a central-line catheter in the hospital setting
Intervention – nursing education about prevention bundles to prevent CLABSI
Control – standard practice
O – reduced number of CLABSI in the acute care setting
Literature Review
Literature Review Strategy
This literature review focuses on the current research into the prevention and reduction of CLABSI in the acute care, or hospital, setting. The focus is on the measures that nurses can take, which are generally grouped into preventative and maintenance “bundles” designed to incorporate various infection prevention measures (Marschall et al., 2014). The inclusion criteria for this literature review were studies published in English within the last five years, with a preference given to articles published in nursing journals. The following BOOLEAN search terms were used to identify research relevant to the aforementioned PICOT question:
Bloodstream infections AND nursing AND hospital OR acute care
Central-line-associated infections AND nursing AND hospital OR acute care
Bloodstream infections OR central-line-associated infections AND prevention AND hospital OR acute care
The databases searched included Google Scholar, EBSCOHost, and CINAHL. A total of 42 abstracts were read to identify relevant studies, with the most relevant included in the literature review.
Prevention of CLABSI
There are a number of different approaches to reducing the number of CLABSI in the acute care setting. Wheeler et al. (2011) conducted an intervention-based study on the implementation of a hospital-wide quality-improvement intervention designed to reduce the incidence of bloodstream infections. This study was conducted using retrospective data, and found that the hospital-wide rate decreased from 3.0 infections per 1000 line-days to less than 1.0 infections. Miller et al. (2011) conducted a similar study on a multi-institutional level, with a focus on the impact of chlorhexidine scrub and chlorhexidine-impregnated sponges. This study also showed a significant reduction in the number of bloodstream infections by 56% (a reduction from 5.2 to 2.3 bloodstream infections per 1000 line days). These studies both suggest that there are quality-based improvement measures that can have a reductive effect on the number of CLABSIs in the acute care setting, and that these are simple to implement.
Another interesting approach to reducing the incidence of CLABSI is the use of a line maintenance team to reduce the rate of infection. Holzmann et al. (2012) limited the central line maintenance approach to a specified team over the course of a year. It was found that CLABSI decreased by 65% by using this team, a reduction of 11.6 infections per 1000 line days to 4.0. Rinke et al. (2012) conducted a similar study that saw a reduction in the rates of CLABSI from 2.25 to 1.79 per 1000 central line days. The focus of this study was on the use of a maintenance care bundle designed to incorporate a multi-disciplinary team in the reduction of nosocomial infections. This approach appears to be particularly affective as it incorporates a number of different approaches and staff members in order to reduce the rates of bloodstream infections, which is a multi-targeted approach that covers a number of bases.
Kim, Holtom & Vigen (2011) designed a central venous line bundle that was designed to reduce the number of CRBSIs in intensive care units as well as understand the flora of CBRSIs. Ths bundle was implemented on all patients within a single ICU through 2008 and compared with the rates from 2006 and 2007. This study supports the thesis that these care bundles can reduce the rates of CRBSIs in the hospital setting, and give insight into the flora of the infections. Interestingly, there was no overall decrease in the proportion of gram-negative bacterial infections, a decrease in the proportion of gram-positive infections, and an increase in the number of fungal infections (Kim et al., 2011). This suggests that these preventative bundles may be more effective in the prevention of some infections than others. Further research is needed to assess whether this is true for all bundles, and whether any intervention decreases the rates of all forms of CBRSI.
Nursing Issues Associated with CLABSI
One major risk factor for CLABSI and other hospital-acquired infection identified by the literature review was the concurrent issues of nurse staffing and nurse burnout. Cimiotti, Aiken, Sloane & Wu (2012) found that there was a statistically significant correlation between patient-to-nurse ratio and hospital-acquired infection, including surgical site infections and CLABSI. Similarly, hospitals that put a primary focus on reducing burnout had 6,239 fewer infections (Cimiotti et al., 2012). In one literature review, Kusek (2012) suggested that putting a focus on nurse burnout reduction can reduce the incidence of CLABSI in intensive care units by 22%, and have a significant impact on the 250,000 total cases outside intensive care units in the United States. These studies both suggest that nursing issues are particularly relevant to the reduction of CLABSI as human error and nurse burnout play a role in the spread of nosocomial infection.
Implementing unit-based quality nurses can also have a positive effect on the number of CLABSI infections in the acute care setting. Thom et al. (2014) found that introducing a specialized nursing staff member whose role was to consistently perform patient safety and infection control activities for 30% of the time on the ward reduced the incidence of infections by 5.1%. Unruh & Zhang (2012) conducted an observational study based on nursing staff levels and qualifications and also saw a reduction in the number of CLABSI in the hospital setting. These results suggest that the presence of nurses on the ward can have a significant effect on the levels of hospital infections, which suggests that more moves should be made to incorporate nursing specializations into the hospital setting, as well as ensuring that staffing levels are adequate for patient needs. More research needs to be done to assess whether specific types of nursing approaches and staffing levels have this positive effect on the number of CLABSI in the hospital setting, and what can be done to improve this situation in the acute care setting.
Conclusions and Summary
Nurses have a vital role to play in the reduction of CLABSI in the acute care, hospital setting. These infections can be reduced with a focus on prevention and maintenance bundles designed to protect patients with central-lines. Using a variety of different methods as part of these bundles appears to be the most effective way of reducing the rates of nosocomial CLABSI, particularly when there are a combination of cleaning routines, maintenance checklists, and a focus on the correct insertion of these central-lines and catheters. The effect on reducing the number of bloodstream infections has the potential to significantly reduce costs in the hospital setting, as well as having a positive impact on morbidity and mortality in the acute care setting. A focus also needs to be placed on reducing nurse staffing issues and burnout, as these are positively correlated with a higher rate of CLABSI across a wide range of health care settings.
References
Cimiotti, J. P., Aiken, L. H., Sloane, D. M., & Wu, E. S. (2012). Nurse staffing, burnout, and health care–associated infection. American Journal of Infection Control, 40(6), 486–490. http://doi.org/10.1016/j.ajic.2012.02.029
Holzmann-Pazgal, G., Kubanda, A., Davis, K., Khan, A. M., Brumley, K., & Denson, S. E. (2012). Utilizing a line maintenance team to reduce central-line-associated bloodstream infections in a neonatal intensive care unit. Journal of Perinatology, 32(4), 281–286. http://doi.org/10.1038/jp.2011.91
Kim, J. S., Holtom, P., & Vigen, C. (2011). Reduction of catheter-related bloodstream infections through the use of a central venous line bundle: Epidemiologic and economic consequences. American Journal of Infection Control, 39(8), 640–646. http://doi.org/10.1016/j.ajic.2010.11.005
Kusek, L. (2012). Preventing Central Line-Associated Bloodstream Infections: Journal of Nursing Care Quality, 27(4), 283–287. http://doi.org/10.1097/NCQ.0b013e31825733d1
Marschall, J., Mermel, L. A., Fakih, M., Hadaway, L., Kallen, A., O’Grady, N. P., Yokoe, D. S. (2014). Strategies to Prevent Central Line–Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update. Infection Control and Hospital Epidemiology, 35(7), 753–771. http://doi.org/10.1086/676533
Miller, M. R., Niedner, M. F., Huskins, W. C., Colantuoni, E., Yenokyan, G., Moss, M., Teams, the N. A. of C. H. and R. I. P. I. C. U. C. L.-A. B. I. Q. T. (2011). Reducing PICU Central Line–Associated Bloodstream Infections: 3-Year Results. Pediatrics, 128(5), e1077–e1083. http://doi.org/10.1542/peds.2010-3675
Pronovost, P. J., Marsteller, J. A., & Goeschel, C. A. (2011). Preventing Bloodstream Infections: A Measurable National Success Story In Quality Improvement. Health Affairs, 30(4), 628–634. http://doi.org/10.1377/hlthaff.2011.0047
Rinke, M. L., Chen, A. R., Bundy, D. G., Colantuoni, E., Fratino, L., Drucis, K. M., Miller, M. R. (2012). Implementation of a Central Line Maintenance Care Bundle in Hospitalized Pediatric Oncology Patients. Pediatrics, 130(4), e996–e1004. http://doi.org/10.1542/peds.2012-0295
Schulman, J., Stricof, R., Stevens, T. P., Horgan, M., Gase, K., Holzman, I. R., others. (2011). Statewide NICU central-line-associated bloodstream infection rates decline after bundles and checklists. Pediatrics, 127(3), 436–444.
Thom, K. A., Li, S., Custer, M., Preas, M. A., Rew, C. D., Cafeo, C., Lissauer, M. E. (2014). Successful implementation of a unit-based quality nurse to reduce central line-associated bloodstream infections. American Journal of Infection Control, 42(2), 139–143. http://doi.org/10.1016/j.ajic.2013.08.006
Unruh, L. Y., & Zhang, N. J. (2012). Nurse Staffing and Patient Safety in Hospitals: New Variable and Longitudinal Approaches. Nursing Research, 61(1), 3–12. http://doi.org/10.1097/NNR.0b013e3182358968
Wheeler, D. S., Giaccone, M. J., Hutchinson, N., Haygood, M., Bondurant, P., Demmel, K., Brilli, R. J. (2011). A Hospital-wide Quality-Improvement Collaborative to Reduce Catheter-Associated Bloodstream Infections. Pediatrics, 128(4), e995–e1007. http://doi.org/10.1542/peds.2010-2601
