Evidence-Based Practices, No CLABSIs Achieved Through Quality Improvement
The unit's leadership team was formed with the goal of reducing the CLABSI rate.
Not surprisingly, central venous access devices (CVADs) are an important aspect of administering chemotherapy and supportive treatments to oncology patients. But with this, comes many risks including central line-associated bloodstream infections (CLABSIs), and use of these devices is the most common cause of these infections.1 Although there is a large variance in the literature about their cost, some estimate it to be up to $46,000 per infection.2 But the greater impact is mortality. The Centers for Disease Control and Prevention (CDC) estimates the mortality rate to be 12% to 25%.3 Prevention of these infections is paramount. This article will discuss an inpatient oncology unit's struggles with CLABSI and how significant strides to improve line care reduced the number of infections from 8 CLABSIs in 1 year to 0 in a 367-day period.
Located in the Northwest, this 26-bed inpatient medical/surgical oncology unit cares for patients at all phases of cancer treatment. Similar to most oncology units, most of the neutropenic population consists of posttransplant patients and those with hematologic malignancies. Central venous catheters range from implanted ports, tunneled catheters (Groshong®), and peripherally inserted central (PICC) lines. In this hospital, a variety of clinicians place central lines for patients undergoing chemotherapy for cancer including surgeons, interventional radiologists, and nurses on the venous access device (VAD) team. Most patients go home with central lines in place to continue treatment and supportive care in the hospital's outpatient infusion center or in a tertiary setting due to the rural nature of the state. Eight CLABSIs were identified on the inpatient oncology unit in a 9-month period, a significant increase for the unit as well as the hospital. The unit's leadership team was charged with reducing the CLABSI rate.
Through the direction of the unit nurse educator, a team was formed to develop an assessment plan and team approach to resolve this significant issue. The team consisted of staff nurses, oncology educator, leadership team, infection control nurses, members of the VAD team, and a member of the Yellow Belt/Operational Excellence Team to lead the meetings. In addition, all staff were invited to attend the meetings including unit clerks and certified nursing assistants (CNAs).
A survey was developed regarding current management of central venous catheters to identify gaps between current unit practices and evidence-based practices. Frequent meetings were held during the development process to keep the team on track. Multiple issues were identified, and an action plan was created.
One of the first issues identified was bathing practices of patients on the unit, specifically the covering over central lines for showering. A literature review supported the use of a water impermeable covering. However, the current practice on the unit was to cover the CVAD with Glad® Press'n Seal® and secure it with tape, or to use Tegaderm dressing, neither were evidence-based practices. In addition, central line dressings got wet after bathing and were not re-dressed immediately.