Running head: SAFETY PERFORMANCE IMPROVEMENT - CLABSI 1

Safety Performance Improvement - Central Line Associated Bloodstream Infection

Amanda Elliott, Jordan Fredrickson,Cassandra Gallagher,

Teresia Isiaho, Erin Keim, Sarah Larkin, Raena Mayfield

Old Dominion University School of Nursing

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Safety Performance Improvement

The Central line-associated bloodstream infections (CLABSIs) occurs when germs enter the

patients central line and then enter the bloodstream during the insertion and removal of central

venous catheters (CVCs). The Joint Commission has set safety strategies to stop, prevent, and

improve the outcomes of central line-associated bloodstream infections (CLABSIs). According

to the Centers for Disease Control and Prevention (CDC), an estimated 41,000 primary

bloodstream infections caused by contaminated central lines occur in American hospitals each

year. CLABSIs infections are life-threatening and increase the patient rate of mortality by 12%

and 25% (Rutkoff, 2014).

CLABSIs is one of the universal health acquired infections (HAIs) in hospitals. Per CDC,

an estimated 30,000 to 62,000 patients die every year from central line infections they acquired

while hospitalized (Rutkoff, 2014, p.173). CLABSIs are costly to the facility and patient; such

infection also prolongs a patient hospital stay. The Medicare, Medicaid services, and many

private insurers are not reimbursing hospitals for health acquired infections (Rutkoff, 2014).

The root-cause analyses of CLABSIs occurrences are the lack of adequate education

about the right protocols to follow when inserting or removing catheters as well as failing to

support the use evidence-based practices (EBPs) and nursing research to stop CLABSIs. Most of

the research has shown that if nurses and doctors follow EBPs, then they can achieve a zero

CLABSI environment. It is important to support and implement a central line bundle, nurses

ongoing training services, policies and procedures adherence, care packages, and use of

antimicrobial for PICC patient to improve care and decrease the rate of mortality in the hospitals.

Intervention to Address the Problem

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CLABSI prevention strategies have expanded as innovative studies are published.

Additionally, experience with implementing these strategies is increasing. One of the most

successful interventions implemented is the central line bundle. The central line bundle (CLB)

has five key components: hand hygiene, maximal barrier precautions, chlorhexidine skin

antisepsis, optimal catheter site selection with avoidance of femoral vein in adult patients, and

daily review of line necessity with prompt removal of unnecessary lines (Marschall, Mermel,

Fakih, Hadaway, Kallen, etc., 2014).

The first step of reduction of CLABSIs is engaging professional healthcare members.

Multidisciplinary teams should be used to form quality improvement collaboratives to set goals

and identify the key factors to be measured. Next, the problem should be made to feel real to all

of those involved to increase awareness and compliance. Another major step is to educate.

Educational programs for all healthcare personnel involved with the insertion and care of all

types of CVCs should be established and strictly adhered to. This includes, but is not limited to,

education and training regarding the five key components of the CLB. Lastly, successful

implementation of this intervention includes evaluation.

Evaluation involves both process and outcome measurement. Process measurement

includes but is not limited to compliance with insertion bundles. Outcome measurement is the

incidence rate of CLABSI and other infections associated with all types of vascular access

devices such as exit-site infection or thrombophlebitis (Marschall, Mermel, Fakih, Hadaway,

Kallen, etc., 2014).

Lastly, Feedback to all healthcare staff is critical for the success of any evaluation

program. Unit-based recognition of achievement of low CLABSI rates encourages staff

involvement. Audit compliance with completion of insertion checklists and give feedback to
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staff along with clearly articulated goals for improvement. These forms of feedback could be

periodic, monthly or quarterly, communication such as e-mail messages or written reports of

process measurement data: posters, reports, or other forms of communication with graphs

showing cumulative compliance with process measures (Marschall, Mermel, Fakih, Hadaway,

Kallen, etc., 2014).

Nurse Leaders Role in Safety Performance Improvement

The Nurse Leader's role for the performance improvement process of CLABSI is a four

part process. First, the Nurse Leader should engage staff by making the problem real. The

leader should provide situations where a patient had developed a preventable CLABSI and the

adverse effects that occurred as a result. This should also be made real by providing the number

of CLABSIs, if any, that were acquired by patients on their particular unit. Second, the leader

should educate staff by providing evidence based practice on the importance of preventing

CLABSI. The staff should be educated on hand hygiene, cleansing the patients with

chlorhexidine skin wipes, maintaining sterile field while inserting or changing central line

dressing, as well as removing the central line as soon as it is no longer needed. Third, the Nurse

Leader is responsible for ensuring the process is accomplished by using a checklist as a guide to

confirm whether or not the process is being implemented. The leader should complete tasks such

as checking daily to see if the central lines are still needed. Lastly, the leader should evaluate

whether or not the efforts helped in the reduction of CLABSIs. This can be accomplished by

tracking the infection rates over a period of time and evaluate the trend. These results should be

relayed back to the staff for feedback to allow staff to know whether or not their efforts were

successful or need additional work. (Tools for Reducing Central Line-Associated Blood Stream

Infections, 2013)
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Potential supporters of the process would include upper management because they would

benefit from the decrease in hospital expense from CLABSI. In addition, other potential

supporters would include nurses that are passionate about providing the best care to their

patients, as well as the infection control team that ensures infection control is being followed by

those involved in direct patient care. Likewise, potential opposers could potentially be bedside

nurses that feel this process would be an additional task added to their already busy day or nurses

that dont understand the impact that a CLABSI has on patients.

Some strategies to build a coalition of supporters would include obtaining feedback from

the staff on the CLABSI reduction process to discover any negatives of the process. Once the

negatives are discovered staff could be reeducated on how the infection affects patients

adversely. Another strategy to utilize would be to provide positive reinforcement to the staff

adhering to the policy.

Change Model or Theory

To implement a successful practice change within the healthcare environment, we must

consider the best way to approach the change in the context of human behavior and the forces

that will impact the desired change. An important tool to facilitate change is a change model or

theory, which helps explain the change process from a social-psychological viewpoint and can

be used to prepare for, initiate and evaluate the success of the change (Sullivan, 2013, p. 57).

Ronald Lippitt is the author of perhaps the most popular change model, which expanded upon

Kurt Lewins three stage change model where change agents go through a process of unfreezing,

moving and refreezing forces to provide a catalyst for lasting changes (Mitchell, 2013). Lippitt

took these three steps and translated them into seven phases that more clearly define the actions

of the change agent. This change theory is frequently used in nursing because Lippitt adopted the
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framework and language of the nursing process in his model, which makes it especially

accessible and easy for nurses to understand. The seven phases of Lippitts change theory are to

diagnose the problem, assess motivation and capacity for change, assess change agents

motivation and resources, select progressive change object, choose appropriate role of the change

agent, maintain change and terminate the helping relationship (Mitchell, 2013).

Healthcare workers could use Lippitts change model to better their safety performance

and reduce CLABSIs by using the seven steps as scaffolding to prepare for and implement their

chosen interventions, mainly educational programs and the central line bundle tool. The change

agent has already diagnosed the problem: the high prevalence of CLABSIs. The motivation to

facilitate change is mostly centered on patient care, since CLABSIs have a tremendous negative

impact on patient outcomes, including prolonged hospital stays and increased rates of mortality;

the hospital also has a financial incentive to make a change because the costs to treat a CLABSI

cannot be billed to the patients insurance since it is a nosocomial infection, which raises their

operating costs (Rutkoff, 2014). The change agents motivation can be linked to a desire to

increase patient satisfaction or could come from mandates from outside organizations like the

Joint Commission. Resources for the change agent may be found in research and evidence based

practice studies that offer solutions to common issues that healthcare facilities face, like

CLABSIs. Once the research about CLABSI prevention recommendations has been done, the

change agent selects progressive change objects, in this case the adoption of a central line bundle

and increased education about CLABSIs and their prevention for the healthcare members.

Choosing the change agents role and maintaining the change will depend upon what

specific restraining forces are identified in the facility, because there is not a universal, best

implementation method that works the same in every hospital. In order to be as successful as
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possible, the change agent will have to have exceptional communication skills and tailor his or

her problem solving strategies to the healthcare setting and teams, paying close attention to any

specific healthcare worker that may be a restraining force to the change. It is imperative that the

change agent also be proactive in evaluating the change outcome (decreasing the rate of

CLABSIs) in order to address any issues that arise and maintain the change in CLABSIs

prevention policies. This constant evaluation will also help the change agent know the

appropriate time to terminate the helping relationships and move on to other changes that need

attention.

Anticipated Resistance to the Change

In the hospital setting, as well as every other facet of life, change is unavoidable.

Individual's reactions to change are highly personal and vary with each situation. Unfortunately

some individuals are resistant to any or all change despite the potential benefits. Some may

oppose the initiatives to prevent CLABSIs because they do not trust that these initiatives will

reduce their occurrence. Despite the presence of several reliable studies and other evidence,

some individuals may still reject the strategies or even that the problem exists.

Resistance can have a tremendous impact on the implementation of policies, so it is vital

that the root of the problem is found. One potential reason may be that the resisters may not fully

comprehend the solution or problem (Sullivan, 2013). The strategies to decrease nosocomial

infections associated with central lines includes five components. One of the components

includes selecting the ideal catheter for each patient. Some health care professionals may feel

worried that they will not choose the optimal catheter. Coneley (2017) found that most if the

nurses who resisted strategies to prevent CLABSIs did so because traditions and pressure from

their peers. These strong forces are challenging to overcome but cannot be overlooked.
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Other reasons for opposition may include the fear of the evaluation process or a sense of

failure. Sullivan (2013) also has found that individuals may resist change because they benefit

from the existing model, disapprove of those executing the new policies or procedures, or lack

trust in the organization as a whole. It is important to recognize those that are against instituting

the new measures. Sullivan (2013) established guidelines to manage those who oppose the

upcoming changes. These recommendations state that both verbal and nonverbal cues should be

carefully monitored so that the resistors can be noted. The reason they disapprove of the new

CLABSI protocols should be found. Nurses may be resistant to the change because they feel that

their way of managing central lines is better for patient outcomes, or more efficient than the new

system that is being implemented. If they have any misconceptions, they should be corrected.

One must also be open to new ideas or revisions of the plan. The insight may strengthen the

original strategies; however, one must remain clear about aspects that are not going altered.

Next, the consequences of not adhering to the new policies must be presented to the

individual. The positive consequences should also be reiterated. Those who approve should be

in direct contact with those who do not. An atmosphere of trust and respect should be

demonstrated among all team members. A diversion may also be used to shift the focus of

opponents. An external threat, such as competition with other hospitals or laws that allow

insurance companies to refuse to reimburse nosocomial infections, can be an excellent way to

unify all of those involved (Sullivan, 2013). Overcoming resistance can be challenging,

however, these techniques to overcome the upcoming changes can be a vital part of the

implementation process.
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Feedback Mechanisms and Evaluation

Feedback mechanisms for the staff to be able to voice their opinions on CLABSI

prevention will be address through meetings, suggestions, emails, and presentations. At the

monthly unit meetings staff members will be given time to reflect on the current issues with

CLABSI on the unit. Feedback on the current method of prevent can be reviewed along with

suggestions on new methods. Staff members can also voice their opinions through emails and/ or

having a suggestion box on their thoughts of the current evaluation methods. Another form of

feedback is a presentation of the comparison of the units progress that can be discussed during

the monthly meetings.

When evaluating the processes to prevent CLABSI the core measures of the hospital will

be evaluated. The desired outcome will be a decrease in the number and frequency of CLABSIs.

Staff will be evaluated using the insertion checklist during the audit. The measureable outcome

of the checklist will include: knowledge, hand hygiene, aseptic technique, maximal sterile barrier

precautions, use of insertion checklist, the insertion process, and proper maintenance (The Joint

Commission, 2017). After the audits staff members will have the chance to meet one on one with

the auditor to review their performance. During the meeting feedback will be given on the

strengths and weakness. A plan of improvement maybe made if needed depending on the

outcome.

Conclusion

In conclusion, Central Line Associated Blood Infections (CLABSI) pose a real threat to

our patients. While central lines provide efficient and easy access to a patients bloodstream to

provide life-saving medications, it can also cause infections and increase the rate of mortality.

Health care workers can use research and evidence based practice recommendations by outside
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agencies like The Joint Commission to improve their safety performance and patient outcomes.

These changes can be made in the context of a change model or theory that helps change agents

plan out the change process, take advantage of driving forces and anticipate restraining forces,

therefore making the change more effective. By quickly adapting to change, implementing the

central line bundle, and encouraging our co-workers and doctors to adopt the change, we can

decrease the percentages of these life-threatening infections. Evaluation of strengths and

weaknesses is needed to implement the change and achieve improvement. Resistance will be

met, but implementing education and feedback mechanisms will ease the transition to greater

compliance and a decrease in CLABSI.

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References

Conley, S. B., Buckley, P. V., Magarace, L., Hsieh, C., & Pedulla, L. (2017). Standardizing Best

Nursing Practice for Implanted Ports: Applying Evidence-based Professional Guidelines

to Prevent Central Line-Associated Bloodstream Infections. Journal of Infusion Nursing,

40(3), 165-174

Marschall, J., Mermel, L., Fakih, M., Hadaway, L., Kallen, A., OGrady, N., . . . Yokoe, D.

(2014). Strategies to Prevent Central LineAssociated Bloodstream Infections in Acute

Care Hospitals: 2014 Update. Infection Control and Hospital Epidemiology, 35(7), 753-

771. doi:10.1086/676533.

Mitchell, G. (2013). Selecting the best theory to implement planned change . Nursing

Managment - UK, 20(1), 32-37. Retrieved from

http://home.nwciowa.edu/publicdownload/Nursing%20Department%5CNUR310%5CSel

ecting%20the%20Best%20Theory%20to%20Implement%20Planned%20Change.pdf

Rutkoff, G. S. (2014). The Influence of an Antimicrobial Peripherally Inserted Central Catheter

on Central Line-Associated Bloodstream Infections in a Hospital Environment. Journal

of The Association For Vascular Access, 19(3), 172-179. Doi:

10.1016/j.java.2014.06.002

Sullivan, E. (2013). Effective leadership and management in nursing (8 ed.). Boston: Pearson.

The Joint Commission. (2017, June 26). Retrieved June 26, 2017, from

https://www.jointcommission.org/topics/clabsi_toolkit__chapter_3.aspx

Tools for Reducing Central Line-Associated Blood Stream Infections. (2013, January). Retrieved

from Agency for Healthcare Research and Quality:

https://www.ahrq.gov/professionals/education/curriculum-tools/clabsitools/index.html
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Grading Criteria % Comments Points

Identify a TJC safety goal that is relevant to 15

an area of concern at your place of

employment or clinical rotations. Describe a

situation that needs change. Identify data

related to the problem to be collected.

Identify an intervention to address the 15

problem. Develop a plan for data analysis

and plan the implementation process for the

intervention, Include the time frame and

resources.

Describe the leaders role for this PI process. 10

Identify potential supporters and opposers

and describe strategies to build a coalition of

supporters.

Using an appropriate change model or 15

theory, describe how this model or theory

could be used to prepare for change and to

implement the change process.

Describe anticipated resistance to the 10

proposed change and strategies to manage

resistance. Include a plan to stabilize the

change.
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Describe feedback mechanisms and the 10

evaluation process including measurable

outcomes.

Conclusion 5

Correct grammar, essay writing, spelling and 10

punctuation.

Correct use of APA format including 10

adherence to page limit (10 pages). Include

minimum 4 textbook or journal articles as

references. Include a copy of the rubric and

honor code. Submit through SafeAssign.

Final Grade 100

Honor Code:

I pledge to support the Honor System of Old Dominion University. I will refrain from

any for of academic dishonesty or deception, such as cheating or plagiarism. I am aware that as a

member of the academic community, it is my responsibility to turn in all suspected violations of

the Honor Code. I will report to a hearing if summonsed.

Raena Mayfield

Erin Keim

Sarah Larkin

Teresia Isiaho
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Cassandra Gallagher

Jordan Fredrickson

Amanda Elliott