Rising Rates Prompt Action
Seeing a dramatic increase in CLABSIs in the first quarter of FY2021, the line team looked back over data and realized that rate had begun to climb in in 2020, when many hospitals started seeing healthcare-associated infections (HAIs) surge as the pandemic set in. ECU Health had fewer than 10 CLABSIs in the first quarter of FY2020, but by the first quarter of FY2021, 30 patients were infected.
Looking at it another way, the CLABSI peak was two per 1,000 patient days, after being below one by the same measure a year earlier.
The Love of the Line project began with gathering more data, identifying the problems, meeting with leadership, and then establishing teams, Hall said.
“Simultaneously, we built a project team for each unit, as well as a hospital-wide [effort] to implement the projects,” she said.
“There were so many different projects occurring at the same time that having a strong, purposeful, engaged team was imperative to success,” she added. “We chose a realistic, obtainable goal of a 5% CLABSI reduction.”
They obliterated that goal, but in the early days of the project, it probably seemed appropriate because of the many factors contributing to the CLABSI increase.
There was a revision in the way lab specimens were submitted and results returned. A new definition for CLABSIs had to be addressed in reporting to the Centers for Disease Control and Prevention’s National Healthcare Safety Network.
“And, of course, we all know about COVID and how it greatly impacted the world and healthcare,” Pearson said. “COVID was rampant at the medical center. There were changes to staff-patient ratios, as well as isolation protocols during the height of COVID. [Staff] were relocated to help care for patients, and morale was negatively affected.”
New employees had to be onboarded to replenish staff, and vendor on-site education for new equipment was restricted because of the pandemic.
“Our patients were really sick, and they were mostly in isolation,” Pearson said. “When we looked at all these factors, we quickly realized that it wasn’t just one thing that caused our [CLABSI increase], it was multiple, different things.”
PDSA Model, Overcoming Barriers
Most of the individual projects were based on the Plan-Do-Study-Act (PDSA) model.3
In going through each phase, it is important to identify barriers, compare data back to the pre-project baseline, and repeat the process to see if it can be improved, Hall said. “Improve the recipe and then test again, start the PDSA cycle over again,” she said.
Given the aforementioned barriers and others that arose, Hall stressed the importance of open communication among all staff.
“All projects encounter barriers — feedback helps improve the team,” Hall said. “Not every solution will work. Frontline staff is critical in saying, ‘Hey, this is not working here.’ But they can also offer outside-the-box thinking — a solution that can help tackle an issue. Being defensive just discourages and stifles others’ ideas, and they may have a solution that works better.”
The hospital-wide effort included a thorough literature review and an “all-lines assessment.”
“We went out with a multi-disciplinary approach and looked at every single central line from the NICU (neonatal intensive care unit) babies to our geriatric population,” Pearson said. “We quickly discovered that best practice was not being consistently done, so we did a hospital-wide back-to-basics approach with education and rounding. We had weekly [back-to-basics] huddle sheets and friendly competitions throughout the hospital.”
The huddle sheets essentially reinforced the practices in the hospital’s central venous line (CVL) bundle, including chlorhexidine bathing, dialysis line care, blood cultures, disinfectant caps, dressings, and central line insertion.
“All of our patients with central lines receive a chlorhexidine bath daily,” Pearson said. “Many of our lines are in dialysis patients and so are some of our CLABSIs, so we wanted to make sure that we were focused on dialysis lines, and that everyone throughout the medical center knew the right way to take care of those patients.”
Again, clinical teaching and corrections had to be done in a positive manner or risk buy-in from staff. “We understood that morale was low,” Pearson said.
This positive, celebratory approach included pizza and donuts to encourage and recognize staff. Some of the work done on individual units focused on dressing changes and blood cultures.
“Again, we noticed that there were gaps with our best practice care and work being done in silos, so we got leadership and staff buy-in,” she said. “We were able to partner with our physicians on every unit that we worked in, and we were able to reduce our CLABSIs.”
Concerning gaps in best practice, the decision was made to share “learning opportunities” with other units but not single out any one unit.
“It builds trust and makes it a more positive experience,” Hall said. “Also, it ensures everyone is being told the same thing. Trust and respect are very significant motivators.”
Nothing in the project was designated as mandatory, which could “cause resentment in an already stressed and disengaged staff environment,” Hall added. “Make it about improving knowledge and improving patient outcomes.”
Another key was bringing in unit leaders, showing them the data, but letting them lead the work.
“We realized very quickly that our unit leaders knew what their [staff] could handle,” Pearson said. “They knew what else they could take on or couldn’t take on. We would tweak the solutions, and then we implemented them. By doing that, we were able to get buy-in from the [unit].”
Pushing ahead in a novel manner, the line team hosted an “Infection Olympics” on an intermediate unit that went so well it now has gone hospital-wide and includes other HAIs. The CLABSI Olympics had various stations set up to demonstrate critical aspects of the process, including proper line care, hand hygiene, and sterile gloving, Hall explained.
“Staff demonstrated sterile gloving, and this helped with pointing out to team members they needed to be mindful in [donning and doffing] sterile gloves to avoid contamination,” she said.
For hand hygiene, the Olympics used florescent powder or gel to simulate microbes, then had staff wash their hands and put them under an ultraviolet light. “It would show the areas they missed,” she said. “This emphasized the importance of hand hygiene in CVL care.”
The hospital-wide Olympics included a poster contest that included all departments, not just patient care. Posters had to be on hand hygiene or CLABSIs, and the displays were complemented by interactive games, such as a “Wheel of Fortune” that rewarded correct answers on the CVL bundle. There was widespread department participation, and it was a fun and a positive way to educate.
Appropriate to the line team message, Hall closed with a note of encouragement.
“Sometimes when you do project work you can easily become discouraged,” she said. “Persevering through challenges and obstacles is essential. And when you see the collaboration and project work that has been done and is successful, it reinvigorates the team.”
- Toor H, Farr S, Savla P, et al. Prevalence of central line-associated bloodstream infections (CLABSI) in intensive care and medical-surgical units. Cureus 2022;14:e22809.
- Chovanec K, Arsene C, Gomez C, et al. Association of CLABSI with hospital length of stay, readmission rates, and mortality: A retrospective review. Worldviews Evid Based Nurs 2021;18:332-338.
- Agency for Healthcare Research and Quality. Health Literacy Universal Precautions Toolkit, 2nd Edition. Plan-Do-Study-Act (PDSA) directions and examples. Last reviewed September 2020. https://www.ahrq.gov/health-literacy/improve/precautions/tool2b.html