Eliminate CLABSIs with prevention bundles, provider feedback
Experts: ED crowding, related factors interfere with infection-prevention efforts
While there has been great progress in eliminating central line-associated bloodstream infections (CLABSIs) in intensive care units (ICUs) in this country, CLABSIs have proven to be much more difficult to vanquish in emergency settings. Most experts agree that there are multiple reasons for the problem, ranging from cultural factors to staffing limitations, to the hectic nature of most busy, urban, high-volume EDs.
Despite these issues, however, there is no denying the fact that CLABSIs simply don’t need to happen, stresses Patricia Stone, PhD, MPH, RN, FAAN, a professor of health policy in nursing at Columbia University School of Nursing in New York, NY, and a contributor to best-practice guidelines on infection prevention issued by The Joint Commission (TJC).
"We have good evidence on the processes that need to take place with central lines to prevent infections, but they need to happen all the time with each and every patient," says Stone. "This is really a matter of developing a climate of prevention and making sure it is on everybody’s radar."
Perhaps ironically, one of the reasons why more attention is being focused on CLABSIs in EDs and other hospital settings is all the progress that ICUs have made in eliminating these infections, observes Stone. "Effective processes were developed and ICUs have embraced those," she says. "That is why we are seeing infections occurring in other places. Not because more [CLABSIs] are occurring, but because less of these infections are occurring in ICUs."
What is very clear, however, is that there is much to gain from improved infection prevention. TJC estimates that 100,000 people die from health care-associated infections (HAIs) every year, and about one-third of these are attributable to CLABSIs. The accrediting agency also notes that HAIs drive up costs significantly. It estimates that hospitals are on the hook for $33 million in excess expenditures related to HAIs. (Also, see "Report: Americans face an unacceptable level of risk’ from infectious disease," p. 45)
Implement infection-prevention bundles
One strategy that has worked particularly well in reducing CLABSIs in ICUs is the implementation of infection-prevention bundles, which typically include barrier precautions, hand-washing, skin preparation with chlorhexidine, and an implementation checklist. Indeed, regulatory agencies such as TJC have called on EDs to implement such bundles. However, multiple barriers have emerged in some early efforts to adopt this strategy in the emergency setting.1
Christopher LeMaster, MD, MPH, an emergency physician with The Permanente Medical Group in Oakland, CA, and colleagues examined the approaches used by six EDs in implementing infection-prevention barriers with the goal of identifying both barriers and facilitators to central line bundle adoption in the emergency setting. To carry out this task, the researchers solicited input from 49 individuals, including both nurses and physicians from the six EDs, and they also conducted three focus groups on the issue.
Perhaps not surprisingly, what emerged from this process was the observation that key barriers to bundle adoption in the ED included high acuity, staffing and space constraints, and high ED volume. However, the researchers also noted difficulties with regard to tracking compliance and infection surveillance.
Conversely, strategies that seemed to facilitate bundle adoption included the identification of a champion, clear staff responsibilities, and a redesigned workflow that included a checklist and a central-line kit or cart with all the materials required to carry out the procedure in one place. However, LeMaster observes that sustained success requires high-level commitment and ongoing diligence.
"I think administrative buy-in for the long-term is absolutely critical. There were places with enthusiastic residents and nurse administrators, for example, but with no system in place once the champion left or once hospital financial resources were moved to other projects. Then nurses and providers stopped hearing about the bundle, compliance fell, and the project was lost," explains LeMaster. "Feedback to providers is also critical. Nothing motivates like actual data. Instances of fall-out help naysayers get on board, and successes motivate providers to continue to keep up good work."
However, as this was a qualitative study, LeMaster cautions that the results are largely explorative. "For proof, we need a different study design," he says. "Success is a complex endpoint, and depends on a host of factors falling into line."
Nonetheless, LeMaster suggests that ED leaders consider the themes in the study to determine whether to try some of the bundle-implementation strategies in their own settings.
"The ED is particularly challenging because it is dynamic, unpredictable, busy, and there is no limit to capacity, no way of shutting off the valve. Thus, physicians and nurses have conflicting goals and limited time that really make sterile line placement with the bundle difficult," explains LeMaster. "In addition, implementing bundles and other such interventions that require real effort and time must be done thoughtfully because they can create new tensions and unpredictable effects downstream, which may threaten patient safety in new, unforeseen ways."
For instance, LeMaster notes that a nurse serving as an observer for a line placement can end up neglecting a patient in another room if workflow and staffing requirements have not been carefully considered when devising a bundle implementation.
Consider crowding, related factors
There is some evidence that crowding in the ED has a detrimental impact on attempts to prevent infections. "What I am noticing is that certainly with hand hygiene, there seems to be a relationship between hand hygiene compliance and ED crowding," explains Eileen Carter, BSN, a third-year PhD student at Columbia University School of Nursing in New York, NY, who is studying this relationship as part of her doctoral dissertation. "For instance, in analyzing the data we have collected, it seems that as crowding gets worse and worse, hand hygiene compliance decreases."
Carter notes that crowding is related to a multitude of factors, ranging from patient acuity and staffing levels to space and patient volumes. Consequently, she suggests that any of those factors can potentially compromise or be related to infection prevention practices. She also stresses that it is valuable for clinical leaders to review the literature on CLABSIs.
Stone echoes these sentiments, noting that administrators need to stay abreast of the data, and to take the lead in emphasizing infection control processes. "When it starts from the top, and everybody says they are going to wash their hands and they are going to follow [infection control] processes each and every time, then people will follow," says Stone.
Given the complexities that exist in busy emergency settings, Stone suggests that quality improvement efforts need to focus even harder on making it easier to do the right thing. "That could be done by making sure that all of the central-line equipment is together on a cart that will help [clinicians] do [the procedure] the right way each time," she says. "And if people get accustomed to doing things the right way in training then evidence suggests that is the way they will think about doing them in practice."
- LeMaster C, Hoffart N, Chafe T, et al. Implementing the central venous catheter infection prevention bundle in the emergency department: Experiences among early adopters. Ann Emerg Med. 2014;63:340-350.
- Eileen Carter, BSN, Third-year PhD student,
Columbia University School of Nursing, New York, NY. E-mail: firstname.lastname@example.org.
- Christopher LeMaster, MD, MPH, Emergency Physician, The Permanente Medical Group, Oakland, CA. E-mail: Christopher.email@example.com.
- Patricia Stone, PhD, MPH, RN, FAAN, Professor of Health Policy in Nursing, Columbia University School of Nursing, New York, NY. E-mail: firstname.lastname@example.org.