Efforts of a Unit Practice Council to implement practice change utilizing alcohol impregnated port protectors in a burn ICU

Highlights

• Alcohol impregnated port protectors decreased CLABSI rates in our burn ICU patient population.

• Bedside nurses can initiate meaningful change and influence patient outcomes.

• A nurse-led hospital-wide collaborative effort improved patient outcomes by decreasing CLABSI rates.

Abstract

Background

Burn patients are an especially high-risk population for development of central line associated bloodstream infections (CLABSI) due to open wounds, extended length of intensive care unit stay, frequent use of central venous catheters, and generally immunocompromised state. Implementing evidence-based practices to prevent these infections is a 2014 National Patient Safety Goal per The Joint Commission.

Objectives

The purpose of this project was introduction of a commercially available alcohol impregnated central venous line port protector to reduce the incidence of CLABSI in the burn unit.

Methods

The Iowa Model for Implementing Evidenced-Based Practice was used to guide this intervention conducted by the Unit Practice Council. A pre- and post-intervention design compared rates of CLABSI before and after introduction of the port protectors.

Results

CLABSI infection rates decreased following the intervention from baseline of 7.3 per 1000 line days to an average of 3.04 per 1000 line days during calendar year 2013.

Conclusions

Introduction of an alcohol impregnated central venous line port protector can reduce the incidence of CLABSI in a burn unit.

Introduction

Efforts to decrease the number of central line associated bloodstream infections (CLABSI) and rising associated healthcare costs are not new [1]. Studies show that CLABSIs are among the most deadly types of healthcare-associated infections and more than 23,000 patients in the U.S. alone develop them annually [2]. The U.S. Centers for Disease Control (CDC) and prevention estimates the annual cost of CLABSI is more than $1 billion nationally with an estimated cost per patient up to $56,000 [3], [4]. Implementing evidence-based practices (EBP) to prevent CLABSI is a 2014 National Patient Safety Goal per The Joint Commission [5]. Our burn intensive care unit (BICU) has had historically higher CLABSI rates than the National Healthcare Safety Network CLABSI rate for burn centers of 3.7 infections per 1000 line days [6]. Average CLABSI rates in our unit per 1000 line days were: 17.7 in 2008; 16.8 in 2009; 3.6 in 2010 and 8.3 in 2011. We have assumed that BICU patients would have a higher number of blood stream infections due to the severity of their burns or open wound areas, the extended length of ICU stay, frequent use of central venous catheters (CVC) and generally immunocompromised state. Identifying that other burn centers have significantly lower rates caused our team to investigate this discrepancy more closely; our burn center achieved a lower rate in 2009, but not in the other years reported, and the reason for this was unclear.

To systematically address this clinical problem we looked to the Army Nurse Corps’ Patient CaringTouch System of Care (PCTS) (Fig. 1). The PCTS is a comprehensive system designed to reduce clinical variances by adopting best practice, in order to improve the quality of care provided to our patients [7]. Within the element of Healthy Work Environment is the concept of Shared Accountability, and an operational subset of that is the Unit Practice Council (UPC). The UPC is designed to improve practice for the bedside nurse by reviewing innovation in nursing practice. The UPC can cultivate change within a unit or to a system-wide process to improve the quality of care provided to the patient. In addition, the UPC is the voice of the bedside nurse, facilitating active participation of nurses in their practice embodying a ‘grass roots’ approach to shared accountability. The unit-based practice councils participate within an instructional and organizational framework that extends throughout the Army Nurse Corps (Fig. 2). Specific goals of the UPC include: implementation of specific nursing practice innovations; development of clinical practice guidelines; identifying and accomplishing “quick wins” in the unit; application of evidence to clinical practice; increasing nurse autonomy; providing nurses with a “voice”; and support of the PCTS at the unit level. The UPC is comprised of several staff members, elected to a one-year term, who work in conjunction with the nurse manager but are accountable to their peers (Fig. 3). The BICU clinical nurse specialist (CNS) provides guidance to the UPC in the implementation of practice change, assists with literature searches, and guides formulation of the action plan.

In 2009, staff members in the BICU began the process of using EBP bundles to improve our CLABSI rates and dispel the assumption that burn patients are inherently more susceptible to CLABSI. In 2011, the UPC actively engaged in the effort to reduce CLABSI rates beyond the use of CDC bundles with an additional intervention of utilizing an alcohol impregnated port protector. A staff member encountered these devices at a professional conference and brought samples to the UPC for evaluation. These are passive disinfection devices that securely luer-lock to the central line hub (Fig. 4); disinfection occurs within 3 min and persists for up to 7 days in situ (Curos Cap, Ivera Medical Corporation, San Diego, CA). Caps come packaged in long strips which are hung at the bedside; caps are replaced each time the catheter port is accessed (Fig. 5). The purpose of this project was introduction of a commercially available alcohol impregnated central venous line port protector to reduce the incidence of CLABSI in the burn unit. The PICOT question was: does the use of alcohol impregnated port protectors (Intervention) decrease rates of CLABSI (Outcome) for the burn intensive care unit patient population (Population) when compared to the standard isopropyl alcohol swab cleansing method (Comparison) during a six month period (Time)?