Background: Patients with hematologic malignancies and stem cell transplant recipients are at increased risk for infections because of their prolonged periods of profound neutropenia. Central line–associated bloodstream infections (CLABSIs) can result in lengthy hospitalizations, increased healthcare costs, and increased morbidity and mortality.
Objectives: The aim of this comprehensive educational training program was to reduce CLABSI rates by focusing on the standardized practices associated with use, care, and maintenance of all types of central lines.
Methods: A pretest was administered to nursing staff. Based on the responses, an education program was then created. The program consisted of a comprehensive two-hour class using different modalities of teaching, including standardized practices associated with central line care.
Findings: The comprehensive education program was effective in standardizing education and improving knowledge gaps, resulting in the reduction of CLABSI rates. Overall, staff knowledge surrounding central line care and maintenance increased by 16%. In addition, no CLABSI events have been reported on the unit from the time of program initiation.
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Central venous catheters (CVCs) are a requirement in the day-to-day treatment of patients with hematologic malignancies or stem cell transplant recipients. CVCs allow for the administration of numerous antibiotics, blood products, chemotherapy and biotherapy agents, total parenteral nutrition, and stem cell infusions. CVCs also minimize the need for repetitive venipunctures for the already compromised patient with cancer. For patients with cancer, central venous access devices (CVADs) include cuffed tunneled CVCs, such as Hickman® or Broviac® catheters, peripherally inserted central catheters (PICCs), or subcutaneous ports (Zakhour et al., 2016). A central line–associated bloodstream infection (CLABSI) can independently develop within 48 hours of central line placement; it is not related to an infection from another site (Centers for Disease Control and Prevention [CDC], 2020). CLABSIs remain a significant cause of treatment-related morbidity and mortality and have been associated with increased healthcare costs in hospitalized patients (CDC, 2020; Kim et al., 2011). CLABSI infection costs in acute care hospital systems are cumulative; based on a 2017 meta-analysis, the cost from one hospital-acquired CLABSI event is $48,108 (Agency for Healthcare Research and Quality, 2017).
When it comes to CLABSIs, the population of adult patients with cancer is often compared to a high-risk or intensive care unit population of patients. However, patients with cancer may be different from other adult high-risk patient populations because of their immune-compromised status, their disease-specific comorbidities, and the frequency with which their central lines are being used (Zakhour et al., 2016). On an annual basis, more than 5 million long-term CVCs are placed in patients with cancer in the United States, giving rise to 200,000–400,000 CLABSI events. CLABSIs in patients with cancer are associated with a reported mortality rate ranging from 12% to 40% (Zakhour et al., 2016). Overall, in both non-oncology and oncology settings, CLABSIs are associated with a mortality rate ranging from 4% to 20% (Drews et al., 2017). The increased risk of mortality in the oncology population demonstrates the imperative nature of this educational initiative.
Although evidence-based prevention guidelines have reduced CLABSI rates (CDC, 2020; O’Grady et al., 2011), many healthcare systems struggle with elevated CLABSI rates for patients in hematology, oncology, and stem cell transplant settings. Patients who receive cytotoxic chemotherapy regimens and/or contract graft-versus-host disease from their treatment are at risk for translocation of oral and gut flora to the bloodstream. Patients with altered mucosal barriers are susceptible to increased CLABSI rates (Metzger et al., 2015). In January 2013, the CDC published a revised National Healthcare Safety Network (NHSN) surveillance protocol that added mucosal barrier injury laboratory-confirmed bloodstream infection (MBI-LCBI) as a new category of infection (CDC, 2013). This new surveillance definition was introduced to prevent misclassification of bloodstream infections caused by oral or intestinal microbiota in patients with cancer and to improve the comparability of CLABSI rates at cancer and non-cancer centers (Steinberg & Coffin, 2013).
In an effort to reduce infection rates at that time, all RNs in the hematologic malignancies and stem cell transplant unit at Stony Brook University Hospital were educated on these changes, as well as the importance of continued patient education regarding mouth care, in an effort to decrease infection risk. Although the unit had always followed a basic oral care program, in June 2017, the unit implemented a more comprehensive oral care program as a component of daily care for all patients with hematologic malignancies and stem cell transplant recipients.
Although much research and education had gone into standardizing practices surrounding CLABSI prevention in previous years, resulting in an annual reduction in CLABSI events from the prior year, there was still room for improvement. The transplant unit had a total of 32 CLABSI events from 2013 through 2017. Based on continued CLABSI events and oral feedback from staff, unit leadership decided it would be best to develop a unit-specific education program to meet the needs of the nursing staff and ensure patient safety.
The purpose of this program was to gain insight into the baseline knowledge of the nursing staff on the unit regarding central line care and maintenance and to then create a consistent education program that provided the staff with standardized practices for CVADs and their maintenance.
The hematologic malignancies and stem cell transplant unit at Stony Brook University Hospital is a 16-bed inpatient unit comprised primarily of highly immunocompromised patients with long-term hospitalizations and prolonged periods of profound neutropenia. The patient population consists of patients with hematologic malignancies such as leukemia, lymphoma, and multiple myeloma, as well as patients who received autologous or allogeneic (including haploidentical donors) stem cell transplants. The transplant unit also consistently has one of the highest central line utilization rates in the hospital.
Nursing staff on the unit are primarily stable, with minimal staff floating into the unit. The number of years of nursing experience on this unit varies; however, on average, about 60% of the staff had more than five years of nursing experience both before and after the educational intervention.
This program was designed and taught by the unit clinical nurse specialist (CNS) and the unit educator. The institution-based central line policy and maintenance algorithms, as well as the blood culture collection policy, were reviewed and updated before the start of the education program. CLABSI criteria was defined using the CDC definitions of a LCBI that is not secondary to an infection at another body site (CDC, 2018). Although there had always been education for staff surrounding central line care and maintenance, based on oral feedback from staff members, the importance of consistent and ongoing education regarding the care and maintenance of central lines supported the necessity for a comprehensive education program to ensure standardization of practice.
Based on best evidence and practice, the unit had established and updated a maintenance bundle as a standard of care. The bundle served as the foundation for questions and discussion for the education program (see Figure 1). Prior to the development of an education program, a 38-question pretest was given to staff. The pretest evaluated knowledge gaps regarding the maintenance bundle. Sample questions from the test are shown in Figure 2. Results from the pretest provided the foundation for the two-hour education class.
From pretest data, CLABSI reduction practices were revealed. Although unit leadership assumed that staff were practicing to standards, the data proved otherwise. To ensure staff knowledge gain and skill competencies, the program incorporated different teaching modalities (visual, auditory, tactile, and kinesthetic) to relay content (Mangold et al., 2018; Nicholson et al., 2016). The program’s topics and modalities included (a) correct scrubbing of the needleless connector hub (procedure demonstrated with correct timing), (b) correct skin prep for all CVAD dressing changes (procedure demonstrated with correct timing), and (c) correct needleless connector change, all per hospital policy.
The education program was provided to staff members in small groups or individually by either the CNS or the unit educator. In all, 31 staff members attended the education program. The program was approximately two hours in duration.
The education program began with a review of pretest results, and an overview was conducted on an evidence-based practice summary sheet (based on the maintenance bundle) (see Figure 3). Following that step, the program team presented educational videos, developed or compiled by the project team members, on port-a-cath access and dressing changes, port-a-cath de-access, PICC line dressing change, CVAD administration set and needleless connector change, and CVAD blood culture collection. That was followed by performance of a hands-on return demonstration on a mannequin with appropriate feedback. To determine knowledge gain, staff completed a post-test at the end of the program with the same knowledge-based questions as the pretest.
Although central line audits had been occurring for the past seven years, and continue, the data can now be used to evaluate post-test knowledge retention and consistency in practice. Audits include the following:
• Visual inspection of central lines for all appropriate elements as educated
• Electronic health record review for correct documentation of care and maintenance
In the pretest stage of the education program, 15 of 24 staff members (60%) scored between 79% and 84%. In the post-test stage following the education program, 21 of 31 staff members (68%) scored 100%, 8 (26%) scored 95%, 1 (3%) scored 89%, and 1 (3%) scored 84%. Overall, staff knowledge associated with central line care and maintenance increased by 16% based on the test given.
In the year leading up to the pretest, the transplant unit reported seven CLABSI events, six MBI-LCBI events, and one LCBI-1 event. The overall CLABSI rate per 1,000 central line days from March 2017 to March 2018 was 1.37. However, of note, zero CLABSI events were reported on the transplant unit from the time of the pretest through the post-test (see Table 1). The authors believe that this is partly attributed to the overall heightened awareness surrounding central line care and maintenance.
In an effort to reduce the rate of CLABSI events on the hematologic malignancies and stem cell transplant unit, a comprehensive education program featuring different modalities in teaching served as a successful method of educating the nursing staff. Dedicated time to adequately educate staff on practices involving central line use, care, and maintenance is imperative to the success of CLABSI reduction in a hematology, oncology, and transplant setting. Additional ongoing evaluation will need to take place to confirm the long-term effect of this intervention.
CLABSI prevention has been one of the key focus points of many quality improvement initiatives aimed at reducing harm from hospital-acquired infections (Drews et al., 2017; Kim et al., 2011). Studies have demonstrated that the use of central venous care bundles is associated with lower infections rates. This responsibility greatly lies on the staff nurses’ knowledge and compliance surrounding the use, care, and maintenance of central lines (Pronovost et al., 2006). The areas for improvement noted on the pretest included when to change a needleless connector, the practice associated with prepping of the skin around a central line site with dressing changes, and the practice associated with the scrubbing of the needleless connectors.
Implications for Practice
It is well recognized that any performance improvement effort involves a culture change by staff and patients in an effort to sustain any achieved goals. In other words, any efforts put forth, if not maintained, can easily be lost. The importance of continuing to engage leadership, frontline staff, and patients is ongoing. Every staff member who comes in contact with the care and maintenance of a CVAD plays an important role in CLABSI prevention and is ultimately responsible for the overall well-being of the patient. Despite the challenges that arise when implementing evidence-based practice in nursing, it can be a rewarding and inspirational experience that can promote collaborative efforts of team members to improve quality care (Irwin et al., 2013). Reporting of any barriers that the staff may encounter to adequately carry out the education program is encouraged. Patients and their families and caregivers are also encouraged to report any concerns or questions they may have regarding their central line care and maintenance. This education program is included in the orientation of all new hires to the transplant unit and will be an annual mandate for all unit RN staff going forward.
The implementation of a comprehensive education program focused on teaching nurses standardized elements surrounding the maintenance and care of central lines, using different modalities in teaching, is an effective way to reduce CLABSI rates in the hematologic malignancy and stem cell transplant recipient population.
About the Author(s)
Josephine Beaudry, MS, RN, ANP-C, CNS-A, CNS-N, is a clinical nurse specialist and Kathleen ScottoDiMaso, BSN, RN, BMTCN®, is a unit educator, both in the inpatient hematologic malignancies and stem cell transplant unit at Stony Brook University Hospital in New York. The authors take full responsibility for this content and did not receive honoraria or disclose any relevant financial relationships. The article has been reviewed by independent peer reviewers to ensure that it is objective and free from bias. Beaudry can be reached at firstname.lastname@example.org, with copy to CJONEditor@ons.org. (Submitted June 2019. Accepted September 27, 2019.)
Agency for Healthcare Research and Quality. (2017). Estimating the additional hospital inpatient cost and mortality associated with selected hospital-acquired conditions. https://www.ahrq.gov/hai/pfp/haccost2017.results.html
Centers for Disease Control and Prevention. (2013). Central line associated bloodstream infection event. http://www.socinorte.com/wp-content/uploads/2013/03/Criterios-de-IN-2013...
Centers for Disease Control and Prevention. (2018). Central line associated bloodstream infection event. https://www.cdc.gov/nhsn/pdfs/validation/2018/pcsmanual_2018-508.pdf
Centers for Disease Control and Prevention. (2020). Bloodstream infection event (central line-associated bloodstream infection and non-central line associated bloodstream infection). https://www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf
Drews, F.A., Bakdash, J.Z., & Gleed, J.R. (2017). Improving central line maintenance to reduce central line-associated bloodstream infections. American Journal of Infection Control, 45(11), 1224–1230. https://doi.org/10.1016/j.ajic.2017.05.017
Irwin, M.M., Bergman, R.M., & Richards, R. (2013). The experience of implementing evidence-based practice change: A qualitative analysis. Clinical Journal of Oncology Nursing, 17(5), 544–549. https://doi.org/10.1188/13.CJON.544-549
Kim, J.S., Holtom, P., & Vigen, C. (2011). Reduction of catheter-related bloodstream infections through the use of a central venous line bundle: Epidemiologic and economic consequences. American Journal of Infection Control, 39(8), 640–646.
Mangold, K.L., Kunze, K.L., Quinonez, M.M., Taylor, L.M., & Tenison, A.J. (2018). Learning style preferences of practicing nurses. Journal for Nurses in Professional Development, 34(4), 212–218. https://doi.org/10.1097/nnd.0000000000000462
Marschall, J., Mermel, L.A., Mohamad, F., Hadaway, L., Kallen, A., O’Grady, N.P. . . . Yokoe, D.S. (2014). Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infection Control and Hospital Epidemiology, 35(7), 753–771. https://doi.org/10.1086/676533
Metzger, K.E., Rucker, Y., Callaghan, M., Churchill, M., Jovanovic, B.D., Zembower, T.R., & Bolon, M.K. (2015). The burden of mucosal barrier injury laboratory-confirmed bloodstream infection among hematology, oncology, and stem cell transplant patients. Infection Control and Hospital Epidemiology, 36(2), 119–124. https://doi.org/10.1017/ice.2014.38
Nicholson, L.L., Reed, D., & Chan, C. (2016). An interactive, multi-modal anatomy workshop improves academic performance in the health sciences: A cohort study. BMC Medical Education, 16, 7. https://doi.org/10.1186/s12909-016-0541-4
O’Grady, N.P., Alexander, M., Burns, L.A., Dellinger, E.P., Garland, J., Heard, S.O., . . . Saint, S. (2011). Summary of recommendations: Guidelines for the prevention of intravascular catheter-related infections. Clinical Infectious Diseases, 52(9), 1087–1099. https://doi.org/10.1093/cid/cir138
Pronovost, P., Needham, D., Berenholtz, S., Sinopli, D., Chu, H., Cosgrove, S., . . . Goeschel, C. (2006). An intervention to decrease catheter-related bloodstream infections in the ICU. New England Journal of Medicine, 355(26), 2725–2732. https://doi.org/10.1056/nejmoa061115
Schiffer, C.A., Mangu P.B., Wade, J.C., Camp-Sorrell, D., Cope, D.G., El-Rayes, B.F., . . . Levine, M. (2013). Central venous catheter care for the patient with cancer: American Society of Clinical Oncology clinical practice guideline. Journal of Clinical Oncology, 31(10), 1357–1370. https://doi.org/10.1200/jco.2012.45.5733
Steinberg, J.P., & Coffin, S.E. (2013). Improving the central line-associated bloodstream infection surveillance definition: A work in progress. Infection Control and Hospital Epidemiology, 34(8), 777–779. https://doi.org/0.1200/jco.2012.45.5733
Zakhour, R., Chaftari, A.M., & Raad, I.I. (2016). Catheter-related infections in patients with haematological malignancies: Novel preventive and therapeutic strategies. Lancet Infectious Diseases, 16(11), e241–250. https://doi.org/10.1016/s1473-3099(16)30213-4
Zimlichman, E., Henderson, D., Tamir, O., Franz, C., Song, P., Yamin, C.K., . . . Bates, D.W. (2013). Health care-associated infections: A meta-analysis of costs and financial impact on the US health care system. JAMA Internal Medicine, 173(22), 2039–2046.