Running head: IMPLEMENTATION OF PRACTICE CHANGES

Implementation of Practice Changes to Reduce CLABSI Payton Beavers University of South Florida, College of Nursing

IMPLEMENTATION OF PRACTICE CHANGES Implementation of Practice Changes to Reduce CLABSI Patients receiving care via a central catheter are already susceptible to difficulties, adding an infection of the bloodstream only increases their risk of severe complications. Not only are infections of the blood stream critical in the patients survival outcome, but they increase the length of stay and resources used to treat the patients infection. Central line associated blood stream infections (CLABSI) and its accompanying complications are a severe and lethal hospital acquired infection (HAI) that can be avoided with the proper medical practices. PICOT Question The following information can be obtained by asking the PICOT question: In patients receiving care through a central line, how do nurse driven interventions compared to those not receiving the interventions affect the number of patients with hospital acquired infections of the blood stream over the duration of central line access in the patients? Infrastructure to Support a Change These practice changes will initially begin at Morton Plants Intensive Care Unit and will be financially supported by the unit manager and director of the hospital.

Summary of Synthesized Literature Review Literature Search In order to find adequate information, PubMed, CINAHL EBSCOhost and Science Direct were used. Upon searching, three clinical research studies and one guideline were found providing information with interventions to prevent CLABSIs. The keywords used to find these articles were: CLABSI, prevention, intervention, and central catheter. Synthesis

IMPLEMENTATION OF PRACTICE CHANGES Considering the fact that nurses are the primary caregivers post insertion of a central line, it is vital for them to be educated in the current evidence-based practice. Research proves that personalized teaching methods that are continuously given to nurses result in increased adherence to protocol and ultimately resulting in a decreased rate of CLABSI in compromised patients (Sannoh, Clones, Munoz, Montecalvo, & Parvez, 2012). Within their study, Lobo and colleagues (2010) also discovered that after 9 months, ICU A had a constant decrease from 12 CLABSI/1000 CVC-days at baseline to 0. In ICU B, the rate decreased from 16.2 to 0 CLABSI/1000 CVC-days, but then increased to 13.7 CLABSI/1000 CVC-days. Sannoh et al.,(2012) also studied the correlation of nursing education and the incidence of CLABSI in NICU patients. Nurses were given continuous audiovisual education as well as checklists for appropriate catheter care. The CLASBI rate in patients with an umbilical catheter decreased from 15/1000 catheter-days to 10/1000 catheter-days. The infection rate in patients with a PICC line decreased from 23/1000 catheter-days to 10/1000 catheter-days. Both studies support that not only does continual education decrease the prevalence of CLABSIs in a short period of time, but it prevents infections for a longer period of time. Marschall and associates (2008) developed a set of guidelines to assess and prevent CLABSIs. These particular guidelines were approved by professionals to be used in healthcare facilities to aid in decreasing the incidence of CLABSIs in patients. The results pertain directly to the PICOT in the fact that it lays out pertinent recommendations for nurses to follow in order to reduce the number of bloodstream infections in critical patients. Included are recommendations for CLABSI prophylaxis including before, during, and after insertion of the central catheter. Researchers also incorporated the responsibilities of all healthcare personnel that should come in contact with a patient receiving care through a central line catheter. Also included in the

IMPLEMENTATION OF PRACTICE CHANGES guideline, is a list of intervention recommendations for nurses to perform in order to reduce the risk of contracting a CLABSI. This set of guidelines acknowledges certain methods used in the previous three articles selected and states that they are beneficial in the reduction of CLABSI in the intensive care settings. Therefore, the research studies analyzed were accurate in their hypotheses and all of which can be used with some preferred modifications in the intensive care settings to both prevent and reduce the incidence of blood stream infections caused by central catheters. Research also supports the nursing intervention of using chlorhexidine solutions at the insertion site and all access points on the tubing. Researchers discovered that by using a chlorhexidine dressing at the insertion point of a central catheter, the CLABSI rate decreased by 60% (Timsit et al., 2009). Sannoh and researchers (2012) utilized chlorhexidine and alcohol based swabs before access to any central line and discovered a decrease in gram-negative septicemia (P <.05). The guidelines also include the use of chlorhexidine both pre and post insertion. The only part not completely supported universally is the amount of chlorhexidine in the solution. Proposed Practice Change Based on evidence, it is concluded that there are evident practices that need to be enforced in order to reduce the incidence of blood infections caused by central line catheters. The main focus of this new practice change is the use of chlorhexidine at all points of access on the central line catheters. The consensus appears to be that nurses can intervene by receiving current evidence-based knowledge on the care of a central line. It is thought to be imperative for all intensive care units to provide frequent meetings for all nursing personnel to be educated on proper steps to sterile dressing changes and hub care. Nurse educators would be wise to apply

IMPLEMENTATION OF PRACTICE CHANGES recurrent audiovisual methods to demonstrate proper techniques to caring for these particular patients (Sannoh et al., 2012). Change Strategy Promote Team Engagement If perhaps, a patient acquires CLABSI while in the hospital, they will require more resources from the hospital team. For those healthcare providers that come in contact with intensive care patients with a central line are aware that the patients are in poor condition and should receive care geared towards minimizing their length of stay in the hospital. It is wise for all personnel who invest time and supplies in these patients to adapt to new evidence based practices that will ultimately be resourceful. The nurses who succeed will receive a certificate and pin for their badge showcasing their ability to maintain a healthy, infection-free environment for ICU patients. The Model for Evidence-Based Practice Change The Model for Evidence-Based Practice Change was chosen because it best suits the changes being made in the hospital. The healthcare team at Morton Plant should initially be informed of the clinical problem at hand with supporting data and evidence. The next step is to notify the personnel of the proposed change with a suitable description of the implementation and evaluation of the new practice being enforced. The process and outcomes of the change will be monitored during the implementation. If any complications or concerns occur throughout the execution process, they will be acknowledged, revised and corrected. Roll Out Plan Steps Step 1: Assess the need for change in practice Key Actions Collect data about current practices to reduce CLABSI in ICU patients Time Frame September, 2013

IMPLEMENTATION OF PRACTICE CHANGES Step 5: Implement and evaluate change in practice Step 6: Integrate and maintain change in practice Compare my data to Morton Plants data Identify problem Identify types and sources of the evidence in Morton Plant Review research sources Plan and conduct the research Synthesize the best evidence from research Assess benefits and risks of implementing chlorhexidine and regular nursing education Identify resources needed to implement chlorhexidine at all points of access Design the evaluation Design the implementation of chlorhexidine and nursing education Implement the study Evaluate nurse adherence, number of CLABSI, and cost of implementation Develop conclusions and recommendations for further change Communicate recommended change to nursing educators, managers and nurses themselves Integrate into standards of practice Continually monitor the number of CLABSI

Step 2: Locate the best evidence

October, 2013

Step 3: Critically analyze the evidence

November, 2013

Step 4: Design practice change

December, 2013

January, 2014

March, 2014

Project Evaluation The desired outcomes with this practice change are ultimately to reduce the duration of the central catheter and to decrease the incidence of CLABSI in the intensive care hospital setting. Statistics of the infection rate will be collected both pre and post intervention period using catheter-days as a unit of measurement. The specific data will be collected and measured by the Infection Control Team at Morton Plant Hospital. The ideal parameter to determine success is to note a decrease in the infection rate of the ICU by 10%. It would be ideal to have

IMPLEMENTATION OF PRACTICE CHANGES the specific colonization rates pre and post intervention; however the rate of infection serves the purpose for this particular practice intervention. Dissemination of EBP Methods of dissemination will vary between other intensive care units, local hospitals, and other regions. For the Morton Plant ICU, the material will be addressed in a mandatory QI meeting via audiovisual presentation. The audiovisual presentation technique is allegedly the most effective form of teaching due to the fact that it presents the material in multiple ways, which intrigues all types of learners. The manner thought best for reaching the maximum number of nurses and hospital employees in local and regional hospitals, is the composition of a journal article and proceeding to publish it in a research database, magazine, or journal.

IMPLEMENTATION OF PRACTICE CHANGES References Lobo R., Levin A., Oliveira M., Gomes L., Gobara S., Park M., . . . Costa S. (2010). Evaluation of interventions to reduce catheter-associated bloodstream infection: Continuous tailored education versus one basic lecture. American Journal of Infection Control, 38 (6), 440448. http://dx.doi.org/10.1016/j.ajic.2009.09.013 Sannoh S., Clones B., Munoz J., Montecalvo M., & Parvez B. (2012). A multimodal approach to central venous catheter hub care can decrease catheter-related bloodstream infection. American Journal of Infection Control, 38(6), 424-429. http://dx.doi.org/10.1016/j.ajic.2009.07.014 Timsit J., Schwebel C., Bouadma L., Geffroy A., Garrouste-Orgeas M., Pease S., . . . Lucet J. (2009). Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: A randomized controlled trial. JAMA, 301(12), 1231-41. doi: 10.1001/jama.2009.376