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Assessing nurses' adherence to a central line maintenance care checklist on a pediatric inpatient unit
American Journal of Infection Control 46 (2018) 221-2
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g
Brief Report
Assessing nurses’ adherence to a central line maintenance care checklist on a pediatric inpatient unit Katherine B. Sabo BSN, RN, CPHON, ATC *, Emily E. Sickbert-Bennett PhD, MS, CIC, Ashley A. Kellish DNP, RN, CCNS, Cheryl A. Smith-Miller PhD, RN-BC 5 Children’s/Intermediate Care, N.C. Children’s Hospital, Chapel Hill, NC
Key Words: Central line–associated bloodstream infection (CLABSI) Checklist Central line maintenance care bundle
Adherence to evidence-based central line maintenance practices remains a challenge, particularly in complex patient populations. Using an evidence-based observational checklist, areas of nonadherence were identified and a focused educational intervention was developed, resulting in improved adherence across all aspects of the central line maintenance care bundle. © 2018 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
BACKGROUND Central line–associated bloodstream infections (CLABSIs) continue to occur despite prevention efforts supported by the Centers for Disease Control and Prevention and hospitals and health care providers.1 The impact of these infections includes significant morbidity and mortality, increased length of hospital stay, and billions of dollars of additional health care costs.2,3 Despite the vast amount of evidence to support a decrease in central line infections, the challenge remains for health care facilities to develop sustainable processes to prevent CLABSIs and their sequelae. During 2 quarters in 2012, a pediatric inpatient unit’s CLABSI rate exceeded the National Healthcare Safety Network benchmark. To standardize and improve central line care on this unit, we proposed to assess adherence to the central line maintenance care bundle using an evidence-based checklist and to provide focused education based on findings of nonadherence. METHODS This study was a before-after design measuring adherence with a central line checklist and an educational intervention on a 24bed inpatient pediatric unit (hematology-oncology, bone marrow transplant, cardiology, and pulmonology) over a 13-month period. To address the increased CLABSI rates, an interdisciplinary team of
infection preventionists, nurses, and unit leadership developed a checklist to detail daily central line maintenance care. The checklist (available by request), based on Centers for Disease Control and Prevention guidelines and current hospital policies, was then used as the observational tool to assess adherence of nurses to all steps of the central line maintenance care bundle. Adherence was defined as the percentage of observations that were complaint with the checklist. An all or nothing scoring system was used for data analysis. Therefore, it was required that all the steps of a given skill or procedure be performed correctly for adherence to be recorded. This measurement method highlights the importance of the whole sequence of events, not only individual parts.4 Only observations with complete data were included in the all or nothing analysis. All data collectors received standardized training regarding the use of the checklist to ensure interrater reliability. The institutional review board deemed this study exempt from human studies review. Based on behaviors that were incorrectly performed, an educational intervention was developed to address specific deficits that were observed. The online learning module consisted of narrated, short video clips demonstrating correct central line care followed by a summary of key points for each skill. A short posttest was administered to assess the learner’s understanding of the material. A 94% response rate was achieved. Posteducation observations were conducted using the same checklist and protocol. RESULTS
* Address correspondence to Katherine B. Sabo, RN, BSN, CPHON, ATC, 5 Children’s/ Intermediate Care, N.C. Children’s Hospital, 101 Manning Dr, Chapel Hill, NC 27514. E-mail address: [email protected] (K.B. Sabo). Funding/support: Supported by Becton, Dickinson and Company (BD). Conflicts of interest: None to report.
After evidence-based education, adherence to all aspects of the central line maintenance care bundle improved (Table 1). When comparing pre- and posteducation adherence, statistical significance was identified in 2 categories, observations and dressing change or port
0196-6553/© 2018 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.ajic.2017.07.023
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K.B. Sabo et al. / American Journal of Infection Control 46 (2018) 221-2
Table 1 Adherence to the central line maintenance care bundle Category of activity (specific steps) Observations (IV tubing labelled; dressing clean, dry, or intact; CHG-impregnated sponge applied correctly) Medication administration (hand hygiene, gloves donned, needleless access device cleaned, bag and tubing connection swabbed) Dressing change or port access (hand hygiene; mask [RN and patient]; gloves applied for dressing removal; hand hygiene repeated; sterile supplies; sterile gloves donned; skin cleaned with CHG and allowed to dry; CHGimpregnated sponge applied correctly; transparent and occlusive dressing applied; gloves removed; hand hygiene; time, date, and initials on new dressing) Laboratory draw (hand hygiene, gloves donned, needleless access device cleaned, line flushed, waste withdrawn, sample withdrawn and transferred to laboratory tube, line flushed, fluids restarted or line heparinized) Needleless access device change (hand hygiene, gloves donned, new needleless access device primed with NS, capcatheter junction cleaned, line clamped, old needleless access device removed, new needleless access device connected, line flushed, fluids restarted or line heparinized)
Pre-education
Posteducation
P value
3/18 (16.7) 8/14 (57.1)
21/23 (91.3) 7/11 (63.6)
<.0001 >.99
9/14 (64.3)
.0071
0/7 (0)
4/7 (57.1)
3/3 (100)
.50
1/1 (100)
2/2 (100)
>.99
NOTE. Values are n/N (%) or as otherwise indicated. CHG, chlorhexidine; IV, intravenous; NS, normal saline; RN, Registered Nurse.
access (P < .0001 and P = .0071, respectively). Highlights of improvement include the following: dressings found to be clean, dry, and intact; correct application of the chlorhexidine-impregnated sponge; repeated hand hygiene prior to applying sterile gloves; and increased cleansing time of the needleless access device to at least 15 seconds prior to entry. DISCUSSION An improvement in central line care was observed in all categories after the creation of a checklist and a focused educational module based on pre-education observations. The use of checklists in several industries, most notably aviation and health care, has proven to reduce human error and enhance safety.5 Organizations such as the World Health Organization and the Agency for Healthcare Research and Quality endorse and encourage checklists as one way to standardize care and increase patient safety.6,7 A review of the literature indicates that the implementation of a central line maintenance care bundle (ie, a checklist) is effective in reducing central line infections.8-10 Insertion of a central venous access device and continued daily maintenance are the 2 primary opportunities for central line infections. For some time, this hospital has had a checklist for central line insertion. This quality improvement project was unique in that it created a checklist to outline daily central line maintenance care bundle items and developed a focused educational intervention based on the findings. Because of long-term treatment plans and the need for hazardous medication infusions, most of the unit’s pediatric patients have ≥1 central lines and are immunocompromised. Therefore, these patients have 2 CLABSI risk factors.8,10 This particular challenge necessitates meticulous daily care and maintenance. Our checklist and observations were instrumental in identifying the actual care that nurses were providing related to central lines and highlighting deficits of daily practice. Failure to follow any component of the central line maintenance care bundle could increase the CLABSI risk.10 Noncompliance to the bundle was likely multifactorial related to increased acuity of patients, new staffing, and complacency over time. This study was carried out on a single pediatric acute care unit where a new patient population was introduced and corresponding nursing staff changes occurred. Generalizability to other populations may be limited; however, nonadherence to evidencebased practices has been reported in many diverse settings. The posteducation observation period occurred up to 4 months after the online learning module was completed. Results may be altered if a longer time frame was chosen.
CONCLUSIONS Adherence with the central line maintenance care bundle improved after the careful implementation of a standardized checklist and a focused evidence-based educational intervention on this pediatric inpatient unit. Use of a checklist prior to implementing an intervention can help to identify specific education needs. As with many quality improvement projects, long-term education and sustainability will be imperative to maintain the improvements made. Specifically, future education efforts should focus on areas of the checklist with which nurses continue to have difficulty. Ongoing education pertaining to central line care is important in the reduction of CLABSIs.8 Consideration should also be given to include educational interventions as part of a new nurse orientation process. Acknowledgments We thank the following individuals for contributions to the design, implementation, and analysis of this project: Christopher Wiesen, MSEd, MA, PhD; Heather Curran, RN, BSN, CPN, CPHON; the UNC BD Fellowship workgroup; and the unit leadership team. References 1. Centers for Disease Control and Prevention. Central line-associated bloodstream infections: resources for patients and healthcare providers. 2010. Available from: http://www.cdc.gov/HAI/bsi/CLABSI-resources.html. Accessed January 26, 2017. 2. Medina A, Serratt T, Pelter M, Brancamp T. Decreasing central line-associated bloodstream infections in the non-ICU population. J Nurs Care Qual 2014;29:13340. 3. O’Neil C, Ball K, Wood H, McMullen K, Kremer P, Jafarzadeh R, et al. A central line care maintenance bundle for the prevention of catheter-associated bloodstream infection in non-ICU settings. Infect Control Hosp Epidemiol 2016;37:692-8. 4. Nolan T, Berwick D. All-or-none measurement raises the bar on performance. JAMA 2006;295:1168-70. 5. Hales B, Pronovost P. The checklist-a tool for error management and performance improvement. J Crit Care 2006;21:231-5. 6. Williams R, Colligan L. Back to basics: checklists in aviation and healthcare. BMJ Qual Saf 2015;24:428-31. 7. Agency for Healthcare Research and Quality. Checklists. 2014. Available from: https://psnet.ahrq.gov/primers/primer/14/checklists. Accessed March 14, 2017. 8. Secola R, Lewis M, Pike N, Needleman J, Doering L. “Targeting to Zero” in pediatric oncology: a review of central venous catheter-related bloodstream infection. J Pediatr Oncol Nurs 2012;29:14-27. 9. Jones C, Stewart C, Roszell S. Beyond best practice: implementing a unit-based CLABSI project. J Nurs Care Qual 2015;30:24-30. 10. Duffy E, Rodgers C, Shever L, Hockenberry M. Implementing a daily maintenance care bundle to prevent central line-associated bloodstream infections in pediatric oncology patients. J Pediatr Oncol Nurs 2015;32:394-400.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g
Brief Report
Assessing nurses’ adherence to a central line maintenance care checklist on a pediatric inpatient unit Katherine B. Sabo BSN, RN, CPHON, ATC *, Emily E. Sickbert-Bennett PhD, MS, CIC, Ashley A. Kellish DNP, RN, CCNS, Cheryl A. Smith-Miller PhD, RN-BC 5 Children’s/Intermediate Care, N.C. Children’s Hospital, Chapel Hill, NC
Key Words: Central line–associated bloodstream infection (CLABSI) Checklist Central line maintenance care bundle
Adherence to evidence-based central line maintenance practices remains a challenge, particularly in complex patient populations. Using an evidence-based observational checklist, areas of nonadherence were identified and a focused educational intervention was developed, resulting in improved adherence across all aspects of the central line maintenance care bundle. © 2018 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
BACKGROUND Central line–associated bloodstream infections (CLABSIs) continue to occur despite prevention efforts supported by the Centers for Disease Control and Prevention and hospitals and health care providers.1 The impact of these infections includes significant morbidity and mortality, increased length of hospital stay, and billions of dollars of additional health care costs.2,3 Despite the vast amount of evidence to support a decrease in central line infections, the challenge remains for health care facilities to develop sustainable processes to prevent CLABSIs and their sequelae. During 2 quarters in 2012, a pediatric inpatient unit’s CLABSI rate exceeded the National Healthcare Safety Network benchmark. To standardize and improve central line care on this unit, we proposed to assess adherence to the central line maintenance care bundle using an evidence-based checklist and to provide focused education based on findings of nonadherence. METHODS This study was a before-after design measuring adherence with a central line checklist and an educational intervention on a 24bed inpatient pediatric unit (hematology-oncology, bone marrow transplant, cardiology, and pulmonology) over a 13-month period. To address the increased CLABSI rates, an interdisciplinary team of
infection preventionists, nurses, and unit leadership developed a checklist to detail daily central line maintenance care. The checklist (available by request), based on Centers for Disease Control and Prevention guidelines and current hospital policies, was then used as the observational tool to assess adherence of nurses to all steps of the central line maintenance care bundle. Adherence was defined as the percentage of observations that were complaint with the checklist. An all or nothing scoring system was used for data analysis. Therefore, it was required that all the steps of a given skill or procedure be performed correctly for adherence to be recorded. This measurement method highlights the importance of the whole sequence of events, not only individual parts.4 Only observations with complete data were included in the all or nothing analysis. All data collectors received standardized training regarding the use of the checklist to ensure interrater reliability. The institutional review board deemed this study exempt from human studies review. Based on behaviors that were incorrectly performed, an educational intervention was developed to address specific deficits that were observed. The online learning module consisted of narrated, short video clips demonstrating correct central line care followed by a summary of key points for each skill. A short posttest was administered to assess the learner’s understanding of the material. A 94% response rate was achieved. Posteducation observations were conducted using the same checklist and protocol. RESULTS
* Address correspondence to Katherine B. Sabo, RN, BSN, CPHON, ATC, 5 Children’s/ Intermediate Care, N.C. Children’s Hospital, 101 Manning Dr, Chapel Hill, NC 27514. E-mail address: [email protected] (K.B. Sabo). Funding/support: Supported by Becton, Dickinson and Company (BD). Conflicts of interest: None to report.
After evidence-based education, adherence to all aspects of the central line maintenance care bundle improved (Table 1). When comparing pre- and posteducation adherence, statistical significance was identified in 2 categories, observations and dressing change or port
0196-6553/© 2018 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.ajic.2017.07.023
222
K.B. Sabo et al. / American Journal of Infection Control 46 (2018) 221-2
Table 1 Adherence to the central line maintenance care bundle Category of activity (specific steps) Observations (IV tubing labelled; dressing clean, dry, or intact; CHG-impregnated sponge applied correctly) Medication administration (hand hygiene, gloves donned, needleless access device cleaned, bag and tubing connection swabbed) Dressing change or port access (hand hygiene; mask [RN and patient]; gloves applied for dressing removal; hand hygiene repeated; sterile supplies; sterile gloves donned; skin cleaned with CHG and allowed to dry; CHGimpregnated sponge applied correctly; transparent and occlusive dressing applied; gloves removed; hand hygiene; time, date, and initials on new dressing) Laboratory draw (hand hygiene, gloves donned, needleless access device cleaned, line flushed, waste withdrawn, sample withdrawn and transferred to laboratory tube, line flushed, fluids restarted or line heparinized) Needleless access device change (hand hygiene, gloves donned, new needleless access device primed with NS, capcatheter junction cleaned, line clamped, old needleless access device removed, new needleless access device connected, line flushed, fluids restarted or line heparinized)
Pre-education
Posteducation
P value
3/18 (16.7) 8/14 (57.1)
21/23 (91.3) 7/11 (63.6)
<.0001 >.99
9/14 (64.3)
.0071
0/7 (0)
4/7 (57.1)
3/3 (100)
.50
1/1 (100)
2/2 (100)
>.99
NOTE. Values are n/N (%) or as otherwise indicated. CHG, chlorhexidine; IV, intravenous; NS, normal saline; RN, Registered Nurse.
access (P < .0001 and P = .0071, respectively). Highlights of improvement include the following: dressings found to be clean, dry, and intact; correct application of the chlorhexidine-impregnated sponge; repeated hand hygiene prior to applying sterile gloves; and increased cleansing time of the needleless access device to at least 15 seconds prior to entry. DISCUSSION An improvement in central line care was observed in all categories after the creation of a checklist and a focused educational module based on pre-education observations. The use of checklists in several industries, most notably aviation and health care, has proven to reduce human error and enhance safety.5 Organizations such as the World Health Organization and the Agency for Healthcare Research and Quality endorse and encourage checklists as one way to standardize care and increase patient safety.6,7 A review of the literature indicates that the implementation of a central line maintenance care bundle (ie, a checklist) is effective in reducing central line infections.8-10 Insertion of a central venous access device and continued daily maintenance are the 2 primary opportunities for central line infections. For some time, this hospital has had a checklist for central line insertion. This quality improvement project was unique in that it created a checklist to outline daily central line maintenance care bundle items and developed a focused educational intervention based on the findings. Because of long-term treatment plans and the need for hazardous medication infusions, most of the unit’s pediatric patients have ≥1 central lines and are immunocompromised. Therefore, these patients have 2 CLABSI risk factors.8,10 This particular challenge necessitates meticulous daily care and maintenance. Our checklist and observations were instrumental in identifying the actual care that nurses were providing related to central lines and highlighting deficits of daily practice. Failure to follow any component of the central line maintenance care bundle could increase the CLABSI risk.10 Noncompliance to the bundle was likely multifactorial related to increased acuity of patients, new staffing, and complacency over time. This study was carried out on a single pediatric acute care unit where a new patient population was introduced and corresponding nursing staff changes occurred. Generalizability to other populations may be limited; however, nonadherence to evidencebased practices has been reported in many diverse settings. The posteducation observation period occurred up to 4 months after the online learning module was completed. Results may be altered if a longer time frame was chosen.
CONCLUSIONS Adherence with the central line maintenance care bundle improved after the careful implementation of a standardized checklist and a focused evidence-based educational intervention on this pediatric inpatient unit. Use of a checklist prior to implementing an intervention can help to identify specific education needs. As with many quality improvement projects, long-term education and sustainability will be imperative to maintain the improvements made. Specifically, future education efforts should focus on areas of the checklist with which nurses continue to have difficulty. Ongoing education pertaining to central line care is important in the reduction of CLABSIs.8 Consideration should also be given to include educational interventions as part of a new nurse orientation process. Acknowledgments We thank the following individuals for contributions to the design, implementation, and analysis of this project: Christopher Wiesen, MSEd, MA, PhD; Heather Curran, RN, BSN, CPN, CPHON; the UNC BD Fellowship workgroup; and the unit leadership team. References 1. Centers for Disease Control and Prevention. Central line-associated bloodstream infections: resources for patients and healthcare providers. 2010. Available from: http://www.cdc.gov/HAI/bsi/CLABSI-resources.html. Accessed January 26, 2017. 2. Medina A, Serratt T, Pelter M, Brancamp T. Decreasing central line-associated bloodstream infections in the non-ICU population. J Nurs Care Qual 2014;29:13340. 3. O’Neil C, Ball K, Wood H, McMullen K, Kremer P, Jafarzadeh R, et al. A central line care maintenance bundle for the prevention of catheter-associated bloodstream infection in non-ICU settings. Infect Control Hosp Epidemiol 2016;37:692-8. 4. Nolan T, Berwick D. All-or-none measurement raises the bar on performance. JAMA 2006;295:1168-70. 5. Hales B, Pronovost P. The checklist-a tool for error management and performance improvement. J Crit Care 2006;21:231-5. 6. Williams R, Colligan L. Back to basics: checklists in aviation and healthcare. BMJ Qual Saf 2015;24:428-31. 7. Agency for Healthcare Research and Quality. Checklists. 2014. Available from: https://psnet.ahrq.gov/primers/primer/14/checklists. Accessed March 14, 2017. 8. Secola R, Lewis M, Pike N, Needleman J, Doering L. “Targeting to Zero” in pediatric oncology: a review of central venous catheter-related bloodstream infection. J Pediatr Oncol Nurs 2012;29:14-27. 9. Jones C, Stewart C, Roszell S. Beyond best practice: implementing a unit-based CLABSI project. J Nurs Care Qual 2015;30:24-30. 10. Duffy E, Rodgers C, Shever L, Hockenberry M. Implementing a daily maintenance care bundle to prevent central line-associated bloodstream infections in pediatric oncology patients. J Pediatr Oncol Nurs 2015;32:394-400.