efforts of a unit practice council to implement practice ......efforts of a unit practice council to...
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Volume 43 , Issue 5 , Pages 956 – 964, August 2017 ISSN 0305-4179
Efforts of a Unit Practice Council to implement practice change utilizing alcohol impregnated port protectors in a burn ICUAmy Martino, Leanna Thompson, Colleen Mitchell, Rachel Trichel, William Chappell, Justin Miller, David Allen, Elizabeth Mann-Salinas
Efforts of a Unit Practice Council to implementpractice change utilizing alcohol impregnated portprotectors in a burn ICU
Amy Martino a, Leanna Thompson a, Colleen Mitchell a, Rachel Trichel a,William Chappell a, Justin Miller a, David Allen b,Elizabeth Mann-Salinas a,*aUS Army Institute of Surgical Research, Army Burn Center, JBSA Fort Sam Houston, TX,United Statesb Brooke Army Medical Center, JBSA Fort Sam Houston, TX, United States
a b s t r a c t
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.
Published by Elsevier Ltd.
1. Introduction
Efforts to decrease the number of central line associatedbloodstream infections (CLABSI) and rising associated health-care costs are not new [1]. Studies show that CLABSIs areamong the most deadly types of healthcare-associatedinfections and more than 23,000 patients in the U.S. alonedevelop them annually [2]. The U.S. Centers for DiseaseControl (CDC) and prevention estimates the annual cost ofCLABSI is more than $1 billion nationally with an estimatedcost 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 burnintensive care unit (BICU) has had historically higher CLABSIrates than the National Healthcare Safety Network CLABSI ratefor burn centers of 3.7 infections per 1000 line days [6]. AverageCLABSI 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 thatBICU patients would have a higher number of blood streaminfections due to the severity of their burns or open woundareas, the extended length of ICU stay, frequent use of centralvenous catheters (CVC) and generally immunocompromisedstate. Identifying that other burn centers have significantlylower rates caused our team to investigate this discrepancymore closely; our burn center achieved a lower rate in 2009, but
* Corresponding author at: US Army Institute of Surgical Research, Nurse Scientist, 3698 Chambers Pass, Fort Sam Houston, TX 78234,United States.
E-mail addresses: [email protected], [email protected] (E. Mann-Salinas).http://dx.doi.org/10.1016/j.burns.2017.01.0100305-4179/Published by Elsevier Ltd.
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not in the other years reported, and the reason for this wasunclear.
To systematically address this clinical problem we lookedto the Army Nurse Corps’ Patient CaringTouch System of Care(PCTS) (Fig. 1). The PCTS is a comprehensive system designedto reduce clinical variances by adopting best practice, in orderto improve the quality of care provided to our patients [7].Within the element of Healthy Work Environment is the conceptof Shared Accountability, and an operational subset of that is theUnit Practice Council (UPC). The UPC is designed to improvepractice for the bedside nurse by reviewing innovation innursing practice. The UPC can cultivate change within a unit orto a system-wide process to improve the quality of careprovided to the patient. In addition, the UPC is the voice of thebedside nurse, facilitating active participation of nurses intheir practice embodying a ‘grass roots’ approach to sharedaccountability. The unit-based practice councils participatewithin an instructional and organizational framework thatextends throughout the Army Nurse Corps (Fig. 2). Specificgoals of the UPC include: implementation of specific nursingpractice innovations; development of clinical practice guide-lines; identifying and accomplishing “quick wins” in the unit;application of evidence to clinical practice; increasing nurseautonomy; providing nurses with a “voice”; and support of thePCTS at the unit level. The UPC is comprised of several staffmembers, elected to a one-year term, who work in conjunctionwith the nurse manager but are accountable to their peers
(Fig. 3). The BICU clinical nurse specialist (CNS) providesguidance to the UPC in the implementation of practice change,assists with literature searches, and guides formulation of theaction plan.
In 2009, staff members in the BICU began the process ofusing EBP bundles to improve our CLABSI rates and dispel theassumption that burn patients are inherently more suscepti-ble to CLABSI. In 2011, the UPC actively engaged in the effort toreduce CLABSI rates beyond the use of CDC bundles with anadditional intervention of utilizing an alcohol impregnatedport protector. A staff member encountered these devices at aprofessional conference and brought samples to the UPC forevaluation. These are passive disinfection devices thatsecurely luer-lock to the central line hub (Fig. 4); disinfectionoccurs within 3min and persists for up to 7days in situ (CurosCap, Ivera Medical Corporation, San Diego, CA). Caps comepackaged in long strips which are hung at the bedside; caps arereplaced each time the catheter port is accessed (Fig. 5). Thepurpose of this project was introduction of a commerciallyavailable alcohol impregnated central venous line portprotector to reduce the incidence of CLABSI in the burn unit.The PICOT question was: does the use of alcohol impregnatedport protectors (Intervention) decrease rates of CLABSI(Outcome) for the burn intensive care unit patient population(Population) when compared to the standard isopropyl alcoholswab cleansing method (Comparison) during a six monthperiod (Time)?
Fig. 1 – US Army Nurse Corps patient CaringTouch System of Care. Unit Practice Councils are an essential element of the SharedAccountability concept within the Healthy Work Environment.
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Fig. 2 – Army Nurse Corps Unit Practice Council (UPC) structure. OR/PACU, Operating Room/Post Anesthesia Care Unit; NPC,Nurse Practice Council.
Fig. 3 – Unit Practice Council (UPC) structure. OIC, officer in charge.
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2. Methods
The Regulatory Compliance Office of our institution approvedthe implementation of this project.
2.1. Setting and participants
The BICU is a 16-bed ICU in a regional burn center co-locatedwith a Level 1 Trauma Center. Patients admitted to the unit arethermal burns greater than 10% total body surface area,
Fig. 4 – Cross section of an alcohol impregnated central line port protector on a central line port.
Fig. 5 – Strip of alcohol impregnated port protectors hanging from pole adjacent to patient bed.
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inhalation injuries, electrical injuries, skin injuries undergoinggrafting, and other dermatologic conditions necessitatingcomplex wound care. Patients arrive with multiple diseaseprocesses, often coupled with poly-trauma in addition to theinjury for which they were primarily admitted. The interdisci-plinary staff consists of physicians, physician’s assistants,CNSs, wound care specialists, registered nurses, licensedvocational nurses, and nursing assistants; additionally thereare dedicated rehabilitation and respiratory therapists, be-havioral health specialists, social workers and dieticians whobelong to our burn center. The staffing ratio is one to twonurses per patient to meet the extensive wound care needs ofthis population.
2.2. Measures and interventions
As previously discussed, CLABSI rates in our BICU from 2009 to2011 fluctuated from extremely high (17.7/1000 line days) to3.6/1000 line days, just within the NHSN standard of3.7/1000 line days despite efforts to implement the CDCcentral line bundle (Fig. 6) [8,9]. The CDC recommended bundleconsists of: optimal site selection, hand hygiene, cleaning theinsertion site with chlorhexidine (CHG), maximum sterilebarriers, and prompt discontinuation of the central line whenno longer necessary [8]. Our ICU developed an insertion sitechecklist for nurses to improve bundle compliance andattempt to lower CLABSI rates. Other implemented interven-tions included: increased frequency of central line changes todecrease dwell time from seven to five days; a mobile cart wasstocked with CVC supplies that were easily accessible toclinicians during insertion; and daily CHG dressing changes forcentral lines. The nurses on our unit received education onCDC CLABSI bundles and preventive measures, and receivedupdates on our CLABSI rates during quarterly staff meetings.BICU nurses were expected to vigorously cleanse all CVC ports
with 70% isopropyl alcohol swabs for 15s prior to access (“scrubthe hub”), per CDC bundle recommendations [8].
2.3. Planning the intervention
In 2011 the 6-member UPC, consisting of bedside nurses andancillary staff, identified the need for further interventionbeyond the CDC bundle to reduce CLABSI rates. The Chairper-son of the UPC researched a commercially available alcoholimpregnated port protector, and felt the product may be usefulin our unit with our patient population. In order to start theproject, our CNS needed evidence that we were consistentlymaintaining greater than 90% compliance to our current BICUCLABSI prevention bundle. The addition of the port protectorwould be used in conjunction with the bundle; an addedstrategy in the fight to decrease line infections. The UPCChairperson verified greater than 90% CLABSI interventioncompliance and selected the Iowa Model for ImplementingEvidence-Based Practice to promote this change [10]. Thismodel provides a systematic framework for changing nursingpractice, facilitates critical thinking, encourages use of bestevidence, fosters interdisciplinary collaboration, and enablescontinued review of the change. Based on the Iowa approach,the PICOT question was formulated. An interdisciplinary teamwas formed to include UPC members who implemented theadoption of the port protectors; the CNS who facilitated theliterature review, evaluated CDC bundle compliance, andlogistical support; and the unit’s infection control nurse whoprovided the team data on CLABSI rates. In collaboration withthe infection control nurse and the CNS, the UPC developed apractice innovation proposal in accordance with the PCTSCprocess and submitted this proposal to the nurse manager inMay, 2011. Included in the proposal was a plan to monitor theeffectiveness of the port protectors on CLABSI rates andevaluate the success of staff education on practice change
Fig. 6 – Trend of central line associated blood stream infections compared to NHSN benchmark for burn centers (3.7 infectionsper 1000 line days). NHSN, National Healthcare Safety Network.
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compliance. The project was approved by the CNS and NurseManager in June 2011. The UPC then coordinated a meetingwith the manufacturer representative of the alcohol impreg-nated caps, resulting in free samples to test ease of use anddurability in the BICU. The UPC collaborated with institutionalstakeholders to initiate the formal requisition process,consultation with the Resource Manager, Logistics Depart-ment, and purchasing officials.
The alcohol-impregnated port protector (Curos Cap, IveraMedical Corporation, San Diego, CA) was selected for thisproject. In-service lectures were provided to the UPC membersby the vendor and the UPC members trained the remainingstaff nurses. To promote staff acceptance, training conductedin December 2011 included evidence supporting the effective-ness of the alcohol impregnated caps to reduce CLABSI rates,the probable benefit to the burn population, and the relativeease of use of the product for the bedside nurse. Port protectorswere made accessible through the institutional LogisticDepartment and adopted as standard of care in January of2012. To promote use, the port protectors were hung on allintravenous poles in patient rooms and included on theadmission room readiness checklist. Thus, the primaryintervention was to maintain CDC Bundle compliance withthe addition of the protection cap (no scrubbing of the port wasrequired).
2.4. Data collection procedures
Weekly observational audits were conducted by the UPCmembers to verify usage of the alcohol impregnated caps.Simultaneous, on-going observational central line bundlesurveillance was conducted by members of the infection
control committee. Identification and reporting of CLABSIrates was done by the unit Infection Control Nurse.Re-education of individual staff nurses was provided by UPCmembers as needed at the time deviations were observed.Rates of CLABSI were compared for the 6 month period of Julyto December 2011 (pre-intervention) with January–June 2012(post-intervention). CLABSI was defined through the sourcesof the project using the CDC definition: a laboratory confirma-tion of blood stream infection in a patient with a central line atthe time of or within 48h prior to the onset of symptoms andthe infection is not related to an infection from another site.Patient demographics for each period were compared: age;number of ICU, ventilator, and hospital days; mechanism ofinjury; presence of inhalation injury; use of continuous renalreplacement therapy during hospital stay; and mortality rate.Total number of central venous line days, number of CLABSIoccurrences, CLABSI rate per 1000 line days, and compliancewith the central line bundle were compared.
2.5. Data analysis
Descriptive, Linear Regression, Analysis of Variance (ANOVA)and and non-parametric statistics were used to evaluate thefindings. Significance was accepted at the p<0.05 level.
3. Results
Patient demographics for the baseline, implementation andpost-implementation periods are described in Table 1; therewas no difference found in the patient populations among thevarious project periods indicating a homogenous cohort of
Table 1 – Patient demographics. (CRRT=continuous renal replacement therapy; ICU=intensive care unit; SD=standarddeviation).
Baseline Implementation Post-implementation p
July–December 2011 January–June 2012 July–December 2012 January–December 2013
n 107 153 136 287Age years mean�SD (range) 42�16 (17–87) 44�18 (17–97) 46�19 (16–87) 45�19 (15–93) 0.36ICU days mean�SD (range) 10�25 (1–182) 11�22 (1–147) 10�18 (1–117) 12�23 (1–143) 0.78Ventilator days mean�SD (range) 4.2�12 (0–89) 6�17 (0–147) 3�10 (0–83) 6�17 (0–133) 0.21Hospital days mean�SD (range) 17�28 (1–185) 19�26 (1–160) 15�22 (1–128) 19�27 (1–154) 0.46Thermal injury % (n) 96% (103) 99% (152) 99% (135) 97% (278) 0.14Inhalation injury % (n) 17% (17/103) 26% (39/153) 16% (22/135) 15% (43/279) 0.07CRRT % (n) 11% (12) 10% (16) 7% (9) 8% (22) 0.44Mortality % (n) 12% (13) 13% (20) 10% (13) 10% (30) 0.75
Table 2 – Central line associated blood stream infection (CLABSI) rates. CVL, central venous line.
Time period Total CVLdays
# ofCLABSI
CLABSI rate per 1000 linedays
CVL bundlecompliance
Notes
January–June 2011 950 9 9.47 91.7%July–December 2011 673 5 7.43 92.5% BaselineJanuary–June2012 intervention period
1272 3 2.36 86.5% May 2012: relocated burn unit
July–November 2012 1109 10 9.0 74.3% July 2012: 60% nursing staffturnover
December 2012–December2013
2624 8 3.04 Data unavailable Bundle assessment changed
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patients (p>0.05 for all comparisons). Table 2 represents thenumber of central venous lines inserted and rate of CLABSIduring each period. The trend of CLABSI rates over time fromJanuary 2009 to December 2013 is represented in Fig. 6;potentially confounding events are noted and the NHSNbaseline CLABSI rate for US Burn Centers is provided forcomparison. Rates for 2014 were noted to be 5.4/1000 line days,with a total of 2042 central line days; this rate was not differentfrom the averages in 2012 or 2013, p=0.81 and 0.37 respectively.The overall trend of CLABSI rates decreased from 2009 through2014 (p=0.0045).
4. Discussion
Our results suggest that the use of an alcohol-impregnated capis associated with a decrease in CLABSI rates when comparedto scrubbing the hub with an alcohol pad for 15s. Followingimplementation of the caps, the rates of CLABSI within theburn ICU were significantly reduced despite having almostdouble the number of central line days during the interventionperiod.
Utilizing alcohol impregnated port protectors in the BICUsetting has proven to be clinically effective. The success of ourproject can be attributed to multiple factors. First, staffacceptance of the practice change was high because the ideaoriginated from a unit staff member and was spearheaded bythe UPC. Studies have demonstrated that evidence-basedpractice, driven by peers within a supportive culture, deliversthe highest quality of care and best patient outcomes [13].Comments from the members of the UPC corroborated thiseffect, in that their peers perceived the change as coming fromstaff member who recognize a potential to improve clinicalpractice. Secondly, the ease of use with the caps simplifieddaily tasks, leading to higher compliance. Central lines in ourunit are oftentimes placed in sub-optimal locations due topatient instability and burn severity, such as: insertionthrough burned skin; placement near the groin; or areaswhere pseudoeschar, wound exudate or burn creams mayform a residue on the line (Fig. 7). Although we have notformally studied this, we believe that there may be times whenthe hub is more vulnerable to contamination in the BICUenvironment. The nature of complex burn care benefits fromtimely intravenous analgesic medication administration insub-optimal settings that are contaminated, such as duringdaily hydrotherapy showers or extensive dressing changes.We believe that in these common situations nurses may not beable to completely scrub the hub free of contaminants becauseof the time pressure to administer the analgesic medications.Furthermore, the design of the hub includes crevices thatconceal debris requiring an extraordinary amount of attentionto effectively clean. Use of the alcohol-impregnated cap servesas a barrier from contamination, simplifying line access andensuring sterility. Additionally, compliance with the “scrubthe hub” technique was very hard to monitor; visualizingnurses performing the task was time consuming and unreal-istic. The bright green caps hang at the bedside and are easilyidentified when in place; the caps are a great visual cue forinfection control team members to accurately monitor ourcentral line bundle compliance.
Findings from this project were congruent with severalother studies that not only showed a decrease in infectionrates but also a cost savings of up to $500,000 annually [11]. Onesuch study demonstrated that continuous passive disinfectionof catheter hubs reduces contamination and blood streaminfection rates. The aim of that three-phase study was toassess the in vivo performance of a luer access valvedisinfection cap impregnated with a sponge saturated in70% alcohol affixed to catheter hubs [12]. During phase 1,CLABSI rates were assessed in the setting of standard of care.This is similar to our project in that we ensured 90%compliance with the CDC CLABSI bundle, which was thestandard of care in the BICU. During phase 2, disinfection capswere used on all central venous catheters, and phase 3 requiredthe removal of the disinfection caps and the return to baselinestandard of care. Overall, fewer patients had bacterialorganisms recovered from their lines following implementa-tion of the disinfection cap (phase 2) compared with baseline(phase 1), and this reduction was consistent when measured asa percentage of the lumens sampled. An estimated$390,617 would be saved annually in the participating centersaccording to this multi-hospital study. The authors alsoestimated that there would be 21 fewer infections, 4 fewerdeaths, and free 13 beds per year using this intervention.
McFarlan and Hensley [14] found that using an antisepticbarrier cap was highly effective in sterilizing the septum of aneedle-free valve connector and preventing entry of anymicroorganisms, even with heavy contamination of theseptum. After testing multiple disinfecting caps, researchersfound that if the septum of the needleless valve connector isheavily contaminated, conventional disinfection with 70%alcohol does not reliably prevent entry of microorganisms,which can multiply in the connector’s intraluminal fluid
Fig. 7 – Central line placed in femoral vein through burnedskin (without alcohol-impregnated luer lock hub).
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column or colonize the internal surface of the valved device. Incontrast, the use of the antiseptic barrier cap was highlyeffective in sterilizing the valve. The researchers recommendfurther clinical trials using catheter related BSIs as the primaryoutcome measure.
In a prospective clinical trial on prevention of cathetercontamination using a hub protection cap for needlelessinjection devices, demonstrated the effectiveness of a barriercap compared to a three-way stopcock to decrease CLABSI rates[15]. The protection cap was a simple clip-on polypropylenedevice that completely covered all areas of the membranesurface of the injection port. This protection cap was removed,and both the cap and stopcock entryways were scrubbed withalcohol swabs prior to access. Additionally, nursing staff wereprovided with disinfection education every three months. Theauthors concluded that the use of a protection cap was moreeffective than a 3-way stopcock at preventing intraluminalbacterial contamination. The use of a protection cap alonereduced contamination, but did not provide disinfection. Thecombinationof a protective barrier cap and disinfectant was notthe focus of the study by Oto et al. [15] however the authorssuggest that the newly designed antiseptic barrier caps thathave become available may be a better option for disinfectionproviding both a barrier to prevent contamination in the firstplace and disinfection after the fact.
A limitation of this evidence based project is that it wasimplemented at a single burn center and may not adequatelyrepresent other hospital experiences. Comparing our use of analcohol impregnated cap with its implementation on otherunits or burn centers may reveal dissimilar findings andresulting CLABSI rates. Future multicenter work is needed toassess the use of the caps in other environments. Secondly, theresults of our study were monitored over a period of nearlythree years, with many changes occurring within the unit toinclude: moving our entire unit to a new tower within thehospital; a visit from The Joint Commission; a large turnover ofstaff; and hiring a new infection control nurse specialist. Thesignificant turnover of organic burn center staff seems to havecontributed to the large increases in overall CLABSI rates notedin late 2012 and early 2013 (Fig. 6). Likewise, we must considerthat increased monitoring of the CLABSI bundle improved staffcompliance, which helped decrease our infection rates. Theinfection control nurses might have used different tools toevaluate and determine the definition of a central lineinfection thereby skewing CLABSI rates during the projectperiod. Regardless, the sustained trend toward CLABSI ratesclose to or below the National average after introduction of theimpregnated caps has persisted throughout 2013 and 2014.Finally, burn size was not collected as a data element for thisproject and should be included in future efforts.
Having the UPC embark on the journey of formulating anidea of reducing CLABSI rates, systematically reviewing theliterature, and implementing a new product on our unit provedto be both highly rewarding and quite demanding. The greatestchallenge we faced was having enough time away from patientcare to gather information and get the selected port protectorsordered from hospital supply. Our Nurse Manager wassupportive of the project, however additional time away fromthe bedside was not offered due to our increased patient load.The UPC had ‘protected time’ which was allotted each month
and was ultimately sufficient overall to accomplish key tasks.Our CNS wanted to ensure that the CLABSI bundle, which ourICU had been utilizing, had a high compliance rate before wewere able to move forward with our project. It was important toensure the bedside nurses were at least 90% compliant withthe bundle to minimize variance in the project. This proved aninvaluable piece of information, and assisted us in distinguish-ing between our current bundle and the newer bundle thatincluded the port protectors. The UPC was actively engaged onthe unit when the port protectors were introduced to answerquestions or explain the product to staff. Since UPC memberswere peer-selected and trusted individuals, fellow nurses wereopen to spot corrections and accepted UPC members as guidesin adopting the product.
Our results demonstrate that grass-root level evidence-based interventions implemented by nursing staff haveimpacted patient outcomes. The process implemented re-sulted in a successful process and will serve as a future meansof making change in our burn center. Furthermore, The ArmyNurse Corps PCTS model highlights the role of the staff nurseto identify and effect change within the clinical environment[7]. The UPC provides the operational mechanism for suchpractice innovation. Even in our extremely vulnerable burnpopulation our staff members were able to decrease CLABSIrates. Not only was the financial burden of avoided infectionsdecreased, but, most importantly, we improved patient out-comes. Future studies are recommended to validate theeffectiveness of the PCTS model and implementation of UPCsto implement significant clinical change.
5. Conclusion
Use of alcohol impregnated port protectors was shown todecrease CLABSI rates in our burn patient population. Thisproject demonstrates that nurses at the bedside can initiatemeaningful change and influence patient outcomes, spear-headed by a UPC. The ultimate goal of this endeavor was toimprove patient outcomes by decreasing CLABSI rates; througha hospital-wide collaborative effort, this goal was met. Sharingour successful grass-roots EBP project will hopefully motivatenurses in other settings to impact their own change to improveCLABSI rates in vulnerable patient populations.
Conflicts of interest
No conflict of interest has been declared by the authors.
Funding sources
This research did not receive any specific grant from fundingagencies in the public, commercial, or not-for-profit sectors.
Disclaimer
The opinions or assertions contained herein are the privateviews of the authors and are not to be construed as official or as
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reflecting the views of the Department of the Army or theDepartment of Defense.
Acknowledgements
The authors acknowledge and want to thank entire Depart-ment of Nursing in the USAISR, and Infection Control NursesMayra Castillo and Kristine Chafin for their support andencouragement for this EBP project. Sincere appreciation tothe Unit Practice Council Members who were also activeparticipants in this project: Daniel Rubalcalba, Darik Forrest,Gerald Laxson, and Mickey Sweet. Special thanks to SaraMurray for thoughtful review and editing of the manuscript.
R E F E R E N C E S
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