Changing practice behaviors reduces central line-associated bloodstream infections

The effects of cancer treatment place patients at high risk for central line-associated blood stream infections (CLABSIs), which directly reflect the care provided at the time of insertion and through the lifetime of the central line. These infections are a significant cause of morbidity, mortality, and increased health care costs. These are the findings of a study presented at the Oncology Nursing Society 36th Annual Congress.

When the Smilow Cancer Hospital at Yale-New Haven, in New Haven, Connecticut, experienced a high incidence of CLABSIs in its inpatient oncology units, intervention was warranted to reduce the incidence, said Lisa Barbarotta, MSN, AOCNS, and colleagues.

They determined the effect of a multifactorial approach to reduce central line-associated bloodstream infections, including creative educational strategies and performance feedback. The oncology clinical nurse specialist and a master's nurse practitioner student then designed and implemented a project on the inpatient oncology units to evaluate nursing practice based on national guidelines for central line care. Fifty nurses were given a 19-item written test to evaluate their knowledge of central line care. Then, more than 50 observations were conducted using a central line maintenance checklist to determine nurses' adherence to best practices.

Although the staff performed well on the test, deficiencies in observed nursing practice were found, leading the authors to conclude that “nurses know the right thing to do, but they don't always do the right thing.” These results posed a challenge, noted Barbarotta in her presentation. Because the deficits were not cognitive, general education about central line-associated bloodstream infections would not change practice.

She said the first approach was to share the data with all of the inpatient nursing staff to reinforce how poor technique directly contributes to central line-associated bloodstream infections. Observed practice deficiencies then drove targeted educational interventions.

Additionally, to ensure standardization of practice, the entire oncology nursing staff was revalidated on port technique; port kits were revised to facilitate sterile procedure; and education was provided to other areas where ports are commonly manipulated, including the interventional radiology, diagnostic imaging, and emergency departments.

The success of the project will be evaluated by comparing preintervention and postintervention CLABSI incidence data, measured as cases per week. Barbarotta concluded that changing behavior is more complex than simply providing education; to prevent central line-associated bloodstream infections, the culture of the unit must be transformed with a commitment to adhering to evidence-based standards of care.

To continue their research on central-line procedures, the team plans to examine subpopulations with high incidence of CLABSIs; implement ongoing processes that can determine RNs' adherence to practice standards through a peer observation program; and asses for trends in CLABSIs based on RN characteristics and staffing patterns.
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