Prevention of Central Line-associated Blood Stream Infections (CLABSI)

In the contemporary medical world, scholars have conducted many studies that seek to enhance understanding on the issue of Central Line-associated Blood Stream Infections (CLABSI). Given the wealth of such information, this analysis targets to look for evidence that links prevention of CLABSI with the proper use of central line bundle. Fundamental to the determination of the evidence that links the two is a scrutiny of various studies that address this issue. With such a validation of the association between the two variables, it is beyond doubt that health care personnel will have a ready solution to their woes due to CLABSI infections.

Review of Literature

Dixon, J. M., & Carver, R. L. (2010). Major article: Daily chlorhexidine gluconate bathing with impregnated cloths results in statistically significant reduction in central line-associated bloodstream infections. AJIC: American Journal Of Infection Control, 38817-821. doi:10.1016/j.ajic.2010.06.005

Summary of Article

The aim of the researchers in this study was to establish the effectiveness of the use of daily chlorhexidine gluconate bathing with impregnated cloths in reducing CLABSI, whose implications on the healthcare issues has been immense.

Research Elements: Design, Methods, Population, Strengths, Limitations

Central to the determination of the effectiveness of quality improvement tool was an observational cohort study that utilized historical controls in a 9-bed surgical intensive care unit in a Level I trauma center. All admitted and transferred patients to this unit formed the study population. The main strength of this study was its ability to use both prospective and retrospective cohort studies, which can establish the change in the study population through follow-up. A limitation of this study, however, is the likelihood of losing track of the cases and control given the inevitabilities of this life such as death.

Outcome(s): Research Results

The daily bathing of patients with cloths impregnated with chlorhexidine gluconate yielded positive results since the CLABSI rates in the study area decreased from 12.07 to 3.17 CLABSIs/1000 central-line days.

Significance to Nursing and Patient Care

The results of this study affirm that CLABSI is preventable by the use evidence-based bundles and daily bathing of patients with cloths impregnated with chlorhexidine gluconate. As such, nurses must consider this practice in their care for patients with central lines.

Furuya, E. Y., Dick, A., Perencevich, E. N., Pogorzelska, M., Goldmann, D., & Stone, P. W. (2011, January 18). Central Line Bundle Implementation in US Intensive Care Units and Impact on Bloodstream Infections. Retrieved March 09, 2017, from http://www.plosone.org/article/info:doi/10.1371/journal.pone.0015452?imageURI=info%3Adoi%2F10.1371%2Fjournal.pone.0015452.t003

Summary of Article

The motivating factor for the carrying out of this research was the increased number of bundled interventions that aim to prevent the dangers posed by CLABSI affecting patients in most USA ICUs. As such, the focus of the study was to establish the effectiveness of the bundled preventive strategies in place.

Research Elements: Design, Methods, Population, Strengths, Limitations

The researchers utilized a cross-sectional study design, in which the National Healthcare Safety Network (NHSN) provided data of reported rates of CLABSI, policies and compliance rates with central line bundle components of various hospitals. The study targeted 250 hospitals within the USA. The ability to measure all the variables at one instance shortened the time for conducting the research, which was an observed strength for this study. Regardless of the strengths, the study had limitations such as the possibility of not factoring in all factors that may confound the CLABSI rates.

Outcome(s): Research Results

The principal findings of this study included a mean CLABSI rate of 2.1 per 1000 central line days in 250 hospitals with only 49% of these hospitals reporting that they have written central line bundle policy. Central to low CLABSI rates was existence of a central line bundle policy, monitored compliance and over 95% compliance rate in ICUs.

Significance to Nursing and Patient Care

Given the evidence that bundle implementation and compliance can lead to decreased CLABSI rates, hospitals can draw optimism in effecting such strategies, which have proven effective in reducing the CLABSI.

Guerin, K., Wagner, J., Rains, K., & Bessesen, M. (2010, August). Reduction in central line-associated bloodstream infections by implementation of a post-insertion care bundle. March 10, 2017, http://dx.doi.org/10.1016/j.ajic.2010.03.007

Summary of Article

Due to the paucity of studies that independently addressed the issue of post-insertion care, the researchers of this study sought to change this phenomenon by conducting a research that solely tackled this matter.

Research Elements: Design, Methods, Population, Strengths, Limitations:

Guerin and her colleagues utilized survey methods to assess for incidence of CLABSIs after implementation of post-insertion care bundle. The strength of this approach used was yielding an opportunity to monitor for changes secondary to the implementation of the care bundle.

Outcome(s): Research Results

CLABSI rates reduced from 5.7 per 1000 catheter days to 1.1 after the implementation of the post-insertion bundle care interventions.

Significance to Nursing and Patient Care

Of importance from this research to nursing is that institutionalizing post-insertion bundles is an effective way of reducing CLABSI in patients with central lines.

Hakko, E., Guvenc, S., Karaman, I., Cakmak, A., Erdem, T., & Cakmakci, M. (2015). Long-term sustainability of zero central-line associated bloodstream infections is possible with high compliance with care bundle elements. Eastern Mediterranean Health Journal, 21(4), 293-298.

Summary of Article

Given the growing incidence of CLABSIs in ICUs, the researchers aimed at implementing a bundle of CLABSI care measures and monitoring their effectiveness in reducing these infections.

Research Elements: Design, Methods, Population, Strengths, Limitations:

Central to this study was a cohort research design undertaken between January 2010 and June 2013 at a 13-bed medical/surgical ICU in Kocaeli, Turkey. The study population comprised all patients admitted within this unit. The strength of this research was its utilization of prospective methods to establish the effectiveness of the central line bundle of care measures. A limitation for this study design was the possibility of losing track of the cases and controls given the inevitabilities of this life such as death.

Outcome(s): Research Results:

The infections rates remained zero 38 months post implementation of the bundle care measures within the study area. A negative correlation between bundle compliance rate and CLABSI rates, however, existed.

Significance to Nursing and Patient Care:

The lesson learnt for nursing and patient care is that zero rate of CLABSI rate is attainable in areas with full implementation of the central-line bundle of care, high compliance rates and a culture of patient safety.

Ista, E., Van der Hoven, B., Kornelisse, R. F., Van der Starre, C., Vos, M. C., Boersma, E., & Helder, O. K. (2016). Effectiveness of insertion and maintenance bundles to prevent central-line-associated bloodstream infections in critically ill patients of all ages: a systematic review and meta-analysis. The Lancet Infectious Diseases, 16(6), 724-734. doi: 10.1016/s1473-3099(15)00409-0

Summary of Article

Given CLABSIs being a problem for patients in ICU worldwide, the researchers aimed at measuring the effectiveness of central line bundles in preventing the occurrence of such infections.

Research Elements: Design, Methods, Population, Strengths, Limitations

In this systematic review and meta-analysis, the researcher searched for relevant studies in Embase, MEDLINE OvidSP, Web-of-Science, and Cochrane Library. The review targeted studies that reported implementation of central-line bundles in various types of ICUs namely, adult, pediatric and neonatal.

Outcome(s): Research Results

In overall terms, the implementation of the central line bundle resulted in a decrease in the rate of CLABSIs in all types of ICUs. For instance, the meta-analysis noted a reduction of the median CLABSI rate from 6.5 to 2.5 per 1000 catheter-days after implementation.

Significance to Nursing and Patient Care

The implication for nursing from this review was that implementation of central line bundle is of the essence in reducing of CLABSIs.

Jock, L., Emery, L., Jameson, L., & Woods, P. A. (2016). Original Article: Journey to Zero Central Line-Associated Bloodstream Infections: An Intensive Care Unit’s Story of Sustained Success and Quality Improvement. Journal Of The Association For Vascular Access, 21(Infection Prevention and Control in Vascular Access), 76-80. doi:10.1016/j.java.2016.03.002

Summary of Article

The primary goal of this research was to zero CLABSI infections, which the researchers observed to have harsh implications like mortality and a high cost of treatment for most patients with central lines.

Research Elements: Design, Methods, Population, Strengths, Limitations

Jock and colleagues used a retrospective study design to determine the effect of implementation of central line bundle on patients admitted to the ICU of their organization.

Outcome(s): Research Results

The introduction of various interventions resulted in a massive decrease of CLABSI rates in the ICU. The climax of the decrease in CLABSI rates (zero) was 15 months after full implementation of the central line bundle in the ICU.

Significance to Nursing and Patient Care

The ability of the implementation of central line bundle to zero the CLABSIs within a patient care setting of any kind is worth noting. As such, implementing the same can result in similar positive results.

Lin, K., Cheng, A., Chang, Y., Hung, M., Wang, J., Sheng, W., & … Chang, S. (2015). Original article: Central line-associated bloodstream infections among critically ill patients in the era of bundle care. Journal of Microbiology, Immunology and Infection, doi:10.1016/j.jmii.2015.07.001

Summary of Article

The researchers’ drive to carry out this study was the paucity of reports linking bundle care to reduced CLABSI rates among critically ill patients residing within Asia. As such, their main aim was to determine the incidence, microbiological features, and factors that contribute to mortality in critically ill patients after bundle care implementation.

Research Elements: Design, Methods, Population, Strengths, Limitations:

The study utilized a prospective surveillance on 156 patients admitted to ICUs at the National Taiwan University Hospital, Taipei between January 2012 and June 2013. The reference for eligibility of patients that developed CLABSI was primarily the National Healthcare Safety Network. The main strength of the study was the utilization of longitudinal prospective studies that enabled the researchers to get up-to-date data.

Outcome(s): Research Results

The main findings of this study were an estimated incidence of CLABSI rate of 3.93 per 1000 central-catheter days and the Gram-negative bacteria as the major cause of CLABSIs. Factors that contributed to the high proportion of CLABSI were severity of the bacteremia and long durations before catheter removal.

Significance to Nursing and Patient Care

The study findings are significant to nursing and patient care because they affirm the existing knowledge about the role played by various factors contributing to CLABSI and the need to address them in prevention of these infections.

Matocha, D. (2013). Achieving Near-Zero and Zero: Who Said Interventions and Controls Don’t Matter? Journal of the Association for Vascular Access, 18(3), 157-163. doi:10.1016/j.java.2013.03.003

Summary of Article

Matocha, (2013) in her study aimed at establishing process improvements of eliminating CLABSIs following the failure of the implemented Institute for Healthcare Improvement’s Central Line Bundle in 2005 to result in zero CLABSIs.

Research Elements: Design, Methods, Population, Strengths, Limitations

The study used prospective research design that was able to capture the multiple interventions from the beginning of the project in 2009. Methods used included staff education, surveillance and implementation of evidence-based practice into policies and protocols. The strength of this study was that the prospective study enabled the capturing the effect of multiple interventions instantly.

Outcome(s): Research Results

The CLABSIs witnessed over the five years period were 7 with the peak year being 2009 with 3 CLABSI while 2013 had no incidence of the infections. The annual CLABSI rate decreased from 1.068 to 0.000 in 2013.

Significance to Nursing and Patient Care

Of utmost importance to the success of implementation of bundle care, is collaboration and commitment to the process.

McPeake, J., Cantwell, S., Malcolm G, B., & Malcolm, D. (2012). Central line insertion bundle: experiences and challenges in an adult ICU. Nursing In Critical Care, 17(3), 123-129. doi:10.1111/j.1478-5153.2012.00491.x

Summary of Article

Given the existence of a care bundle developed by Scottish Patient Safety Programme (SPSP), the researchers aimed at identifying and describing the barriers to its implementation.

Research Elements: Design, Methods, Population, Strengths, Limitations

The study used a plan-do-study-act (PDSA) approach to implement the central line insertion bundle in cone of the adult ICU of a large inner city teaching hospital. The strength of this approach is that they are easy

Outcome(s): Research Results

Absence of clear goals and knowledge deficit among staff nurses were among the major challenges that affect implementation of the bundle care interventions.

Significance to Nursing and Patient Care

The findings of this study emphasize the need for setting clear aims and educating staff about the new bundle of care before trying to institutionalize it.

Salama, M. F., Jamal, W., Al Mousa, H., & Rotimi, V. (2016). Implementation of central venous catheter bundle in an intensive care unit in Kuwait: Effect on central line-associated bloodstream infections. Journal Of Infection And Public Health, 934-41. doi:10.1016/j.jiph.2015.05.001

Summary of Article

In this study, Salama, Jamal, Al Mousa, and Rotimi (2016) aimed at establishing the impact of insertion bundle for Central Venous Line (CVL) on the microbial agents that are common in ICU.

Research Elements: Design, Methods, Population, Strengths, Limitations:

The research design used was a longitudinal survey that involved monitoring the CLABSI rates before and after the implementation of central line care bundle in an ICU located in Kuwait. The research’s strength was its ability to establish the changes in the study population overtime through follow-up. A limitation for this study design was the possibility of losing track of the cases and control during the follow up period.

Outcome(s): Research Results

The CLABSI rates decreased from 14.9 to 11.08 CLABSI/1000 catheter days pre and post bundle implementation respectively.

Significance to Nursing and Patient Care

The study depicts the need for hospitals to implement CVL insertion care bundle for the CLABSI prevention. As such, it is significant to nursing and improvement for patient care.

Sandoval, C. P. (2015). Three practice bundles to reduce CLABSIs. American Nurse Today, 10(11), 37-38.

Summary of Article

Sandoval, (2015) focused on identifying the practice bundles that have facilitated the reduction of CLABSIs within the USA hospitals. Also, the study targeted at providing other interventions that improve the situation further.

Research Elements: Design, Methods, Population, Strengths, Limitations

A review of studies that addressed the implementation of care bundle was essential in coming up with the study findings. A strength noted in the approach undertaken was the reliance on evidence-based studies to make conclusions on the bundles commonly used and recommended interventions.

Outcome(s): Research Results

The three commonly used bundles to reduce CLABSI rates were insertion, maintenance and patency bundles. Other interventions that hospitals can explore centered on nurses taking up the patient advocacy role throughout the implementation of the care bundle. The advocacy entailed but not limited to stopping insertion when the practice is incongruent to guidelines and removal of lines when they are unnecessary.

Significance to Nursing and Patient Care

Implementation of research-based practice has the potential to reduce the CLABSI rates significantly. Thus, it is of the best interest if the practice becomes one of the hospitals’ policies.

Scheithauer, S., Lewalter, K., Schröder, J., Koch, A., Häfner, H., Krizanovic, V., & … Lemmen, S. (2014). Reduction of central venous line-associated bloodstream infection rates by using a chlorhexidine-containing dressing. Infection, 42(1), 155-159. doi:10.1007/s15010-013-0519-7

Summary of Article

The purpose of the researchers in this study was to determine the effectiveness of a chlorhexidine-containing dressing to reduce CLABSIs given the high infection rate despite the existence of such interventions.

Research Elements: Design, Methods, Population, Strengths, Limitations

A cohort study design enabled the researchers to establish the CLABSI rates between November 2010 and 2012 in two ICUs, which they used to compare with historical controls. The population studied within this timeframe was 1298 patients. The strength of this study was its ability to use both prospective and retrospective studies in the determination of the overtime effect of the intervention. A weakness of this research was its reliance on historical controls whose factors might have differed significantly with the exposed group in this investigation.

Outcome(s): Research Results

CLABSI rates in patients that utilized chlorhexidine-containing dressing were low (1.51/1000 catheter days) as compared to 5.87 and 6.2 per 1,000 catheter days in patients with standard dressing and historical controls respectively. Lastly, main factor not utilizing the chlorhexidine-containing dressing was bleeding at the insertion site.

Significance to Nursing and Patient Care

The implication drawn from this study is that chlorhexidine-containing dressing is an effective approach to reducing CLABSI rates that can facilitate the optimization of patients’ outcomes.

Sung, Y. W., Huang, M. J., Chou, C. Y., Hung, C. T., Tsai, J. R., & Chen, S. H. (2014). The effect of bundle care on the central line-associated bloodstream infection in a medical intensive care unit. Hu Li Za Zhi, 61(3), 87.

Summary of Article

The purpose of this project was to reduce the CLABSI rate to below 0.3% given the high average rates of CLABSI in the ICU (0.47%).

Research Elements: Design, Methods, Population, Strengths, Limitations

The researchers conducted the study project between June 2011 and May 2012 and observed for the overall effect after full implementation of the bundle care in the ICU.

Outcome(s): Research Results

The findings showed that CLABSI rates reduced significantly from 0.47% to 0.24%, which was way below the initial target of 0.3%.

Significance to Nursing and Patient Care

The implication drawn is that central line bundle care can improve the health outcomes of critical care patients by minimizing the CLABSI rate to zero.

Tang, H., Lin, H., Lin, Y., Leung, P., Chuang, Y., & Lai, C. (2014). The impact of central line insertion bundle on central line-associated bloodstream infection. BMC Infectious Diseases, 14(1), 356. doi:10.1186/1471-2334-14-356

Summary of Article

Tang and colleagues (2014) conducted this study with the aim of increasing knowledge about the impact of each central line insertion bundle on CLABSI given the paucity of studies addressing this matter.

Research Elements: Design, Methods, Population, Strengths, Limitations

Longitudinal studies were central in the identification of information on CLABSI rates and catheter utilization rates. The study took place in five adult ICUs with 63 ICU beds. The strength of this study was its ability to use both prospective and retrospective studies in the determination of the overtime effect of the intervention. A limitation of the research was its reliance on historical controls whose confounding factors might have differed significantly with the exposed group in this research.

Outcome(s): Research Results

The rate of CLABSI reduced significantly from 1.65 per 1000 catheter day to 0.65 per catheter day after implementation of the bundle care program.

Significance to Nursing and Patient Care

The implication drawn is that a multidisciplinary approach to the control of CLABSI is of utmost significance to the zeroing of CLABSIs.

Tomlinson, S. (2015). Impact on CLABSIs with Bundle Implementation and Staff Education. Journal of the Association for Vascular Access, 20248. doi:10.1016/j.java.2015.10.037

Summary of Article

In this article, Tomlinson, targeted at establishing the impact of bundle implementation and staff education on CLABSIs.

Research Elements: Design, Methods, Population, Strengths, Limitations

The researcher utilized introduced an educational program in a local acute-care facility and determined the outcome after 28 days of classes. The strength of the approach is that there was a follow-up of the studied group to establish the change in the outcomes.

Outcome(s): Research Results

The research findings determined that CLABSI rates reduced to zero after the 28 days of classes.

Significance to Nursing and Patient Care

The findings of this study affirmed that staff education and bundle implementation are important strategies that nurses that aim to minimize the CLABSI rates to zero.

Conclusion

Concisely, this analysis aimed to review studies that address the use of central line bundle care in the prevention of CLABSIs. In overall terms, the implementation of central line bundle care alongside other factors like high compliance rates and monitoring of the compliance results in decreased rates of CLABSIs in clinical practice. As such, going into the future, institutionalization of such practices is of the essence to the attainment of zero CLABSI.

References

Dixon, J. M., & Carver, R. L. (2010). Major article: Daily chlorohexidine gluconate bathing with impregnated cloths results in statistically significant reduction in central line-associated bloodstream infections. AJIC: American Journal Of Infection Control, 38817-821. doi:10.1016/j.ajic.2010.06.005

Hakko, E., Guvenc, S., Karaman, I., Cakmak, A., Erdem, T., & Cakmakci, M. (2015). Long-term sustainability of zero central-line associated bloodstream infections is possible with high compliance with care bundle elements. Eastern Mediterranean Health Journal, 21(4), 293-298.

Ista, E., Van der Hoven, B., Kornelisse, R. F., Van der Starre, C., Vos, M. C., Boersma, E., & Helder, O. K. (2016). Effectiveness of insertion and maintenance bundles to prevent central-line-associated bloodstream infections in critically ill patients of all ages: a systematic review and meta-analysis. The Lancet Infectious Diseases, 16(6), 724-734. doi: 10.1016/s1473-3099(15)00409-0

Jock, L., Emery, L., Jameson, L., & Woods, P. A. (2016). Original Article: Journey to Zero Central Line-Associated Bloodstream Infections: An Intensive Care Unit’s Story of Sustained Success and Quality Improvement. Journal Of The Association For Vascular Access, 21(Infection Prevention and Control in Vascular Access), 76-80. doi:10.1016/j.java.2016.03.002

Lin, K., Cheng, A., Chang, Y., Hung, M., Wang, J., Sheng, W., & … Chang, S. (2015). Original article: Central line-associated bloodstream infections among critically-ill patients in the era of bundle care. Journal of Microbiology, Immunology and Infection, doi:10.1016/j.jmii.2015.07.001

Matocha, D. (2013). Achieving Near-Zero and Zero: Who Said Interventions and Controls Don’t Matter? Journal of the Association for Vascular Access, 18(3), 157-163. doi:10.1016/j.java.2013.03.003

McPeake, J., Cantwell, S., Malcolm G, B., & Malcolm, D. (2012). Central line insertion bundle: experiences and challenges in an adult ICU. Nursing In Critical Care, 17(3), 123-129. doi:10.1111/j.1478-5153.2012.00491.x

Salama, M. F., Jamal, W., Al Mousa, H., & Rotimi, V. (2016). Implementation of central venous catheter bundle in an intensive care unit in Kuwait: Effect on central line-associated bloodstream infections. Journal Of Infection And Public Health, 934-41. doi:10.1016/j.jiph.2015.05.001

Sandoval, C. P. (2015). Three practice bundles to reduce CLABSIs. American Nurse Today, 10(11), 37-38.

Scheithauer, S., Lewalter, K., Schröder, J., Koch, A., Häfner, H., Krizanovic, V., & … Lemmen, S. (2014). Reduction of central venous line-associated bloodstream infection rates by using a chlorhexidine-containing dressing. Infection, 42(1), 155-159. doi:10.1007/s15010-013-0519-7

Sung, Y. W., Huang, M. J., Chou, C. Y., Hung, C. T., Tsai, J. R., & Chen, S. H. (2014). The effect of bundle care on central line associated bloodstream infection in a medical intensive care unit. Hu Li Za Zhi, 61(3), 87.

Tang, H., Lin, H., Lin, Y., Leung, P., Chuang, Y., & Lai, C. (2014). The impact of central line insertion bundle on central line-associated bloodstream infection. BMC Infectious Diseases, 14(1), 356. doi:10.1186/1471-2334-14-356

Tomlinson, S. (2015). Impact on CLABSIs with Bundle Implementation and Staff Education. Journal of the Association for Vascular Access, 20248. doi:10.1016/j.java.2015.10.037

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