Paper on Preventing Central Line-Associated Bloodstream Infections: The Role of Evidence-Based Nursing Practice

Introduction

A central Line-Associated is a type of Hospital-acquired infection that occurs when bacteria enter the bloodstream via a central line. A central line, also known as a central venous catheter (CVC) is a long thin tube inserted through a patient’s vein, often in the neck, arm, chest, and groin until it reaches a larger vein close to the heart (Ider et al., 2012). Its purpose is to take blood samples and deliver nutrition, medication, Intravenous (IV) fluids, and chemotherapy. CLASBI is mainly caused by contamination of the central line that allows bacteria to multiply and find their way into the bloodstream (Mermel, McCormick, Springman, & Maki, 2011). Ways through which contamination of the central venous catheter can occur include contamination on insertion; hub colonization of the central venous access devices (CVAD); the skin flora of the patient; hematogenous spread from other sites; and non-contact dressing (Pronovost et al., 2006).

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Various risk factors such as immunosuppression, poor nutrition, impaired skin integrity, the position of the central line, lengthy hospitalization prior to venous catheterization, and multiple invasive procedures also increase the risk of CLASBI (Ider et al., 2012). Symptoms include fever, chills, increased heart rate, redness, swelling or tenderness of the skin around the catheter, and drainage from the catheter site. According to Domachowske & Suryadevara (2020), CLASBI accounts for nearly 9% of all hospital-acquired infections. This problem can cause deaths, prolonged hospital stays, and high-cost burdens to the hospital. Although it is preventable, it continues to be a problem for many hospitals.

To prevent CLASBI, the Centre for Disease Control (CDC) provides guidelines for the prevention of intravascular catheter-related infection. These guidelines include a recommendation for the education of Registered Nurses on appropriate catheter insertion and maintenance, hand washing, routine monitoring of the rates of CLASBI, use of the aseptic method and maximal sterile barrier, disinfection of the catheter hub, the use of bundle approach and specialized infusion therapy team as well as the use of sterile dressing and early removal of central lines (Yaseen et al., 2016). Nurses play a significant role in the care and maintenance of the insertion site of the central line catheter. Their compliance with evidence-based practice is essential for minimizing CLASBI incidence and improving the outcomes of the patients (Yaseen et al., 2016). Several studies have shown that inadequate knowledge and skills are among the significant challenges for implementing evidence-based nursing practice.

Therefore, the primary goal of this essay is to evaluate the current nursing practice for CLASBI prevention and identify barriers to implementing the best practice. The purpose of the essay is to identify a CLASBI as a clinical issue upon which nurses have the ability to resolve or have a positive impact. With a focus on the diversity and the variation of cultural values of a particular population, the essay will develop a plan for addressing CLASBI. Also, with the incorporation of other disciplines from the healthcare team, the paper will describe the role the Registered Nurse who has passed the National Council Licensure Examination (NCLEX-RN) has in the execution of an ethically sound plan.

Importance

Central lines are commonly used in patients under critical conditions and offer several benefits to peripheral intravenous access. However, indwelling CVCs can result in stream infections, with the risk increasing with various characteristics such as catheter location, catheter choice, catheter maintenance, and insertion technique (Domachowske & Suryadevara, 2020). Evidence-based guidelines have helped in the reduction in the incidence of bloodstream infections associated with catheter lines. The combination of guideline implementation and current technologies can further reduce morbidity and mortality from CVC-related infections (Yaseen et al., 2016). Reducing the rates of CLABSI improves the quality and safety of patient care and positively impacts the financial stability of hospitals.

Besides, the reduction of CLABSI rates can create positive social change by improving patient outcomes. This is possible with advanced nursing knowledge. According to Ider et al. (2012), when nurses are competent and adhere to the best practices, they impact CLABSI incidence. Promoting positive social change involves impacting society positively and solving problems to change lives. Registered nurses can affect positive social change by implementing and sustaining efforts that promote patient outcomes (Ider et al., 2012). This clinical issue contributes to the knowledge that reinforces evidence-based practice in the healthcare industry. As such, it encourages registered nurses to take action needed to reduce CLABSI rates. Doing so improves patient outcomes significantly.

Leaving the clinical issue unresolved can increase the mortality rates caused by CLABSI, lead to lengthy hospital stays, and create a high-cost burden to the healthcare organization due to increased bloodstream infections. In other words, it would reduce the quality and safety of patient care and negatively impact the financial stability of hospitals. That is why registered nurses are engaged in evidence-based practices to help them find solutions to this clinical issue.

Patient Population

This clinical issue impacts any patient at risk of CLABSI. This includes critically ill patients in need of fluid resuscitation, kidney dialysis, long-term antibiotics, chemotherapy for cancer, and a lot of blood tests and blood transfusions (Domachowske & Suryadevara, 2020). Such patients need CVC to pass fluids or drugs to one of their large veins. This clinical issue will also impact patients who require prolonged intravenous therapies for more reliable vascular access. The fact that these patients need CVC to promote their outcome puts them at a higher risk of CLASBI.

As noted, CLASBI is a laboratory-confirmed bloodstream infection that occurs when bacteria enter the bloodstream through a CVC. Therefore, in terms of the patient population impacted by CLASBI, this clinical issue will impact any patient receiving medication through the central line. This cuts across every patient regardless of age, gender, or other demographic factors. However, the different cultural values of the patient population will affect the proposed solution to CLABSI. For instance, patients whose cultures disregard clinical interventions will not see the intervention of the proposed solution.

Proposed Solution

One of the best solutions to CLABSI is the use of the central line bundle. The central line bundle refers to a collection of evidence-based interventions for patients with central intravascular catheters that promote patient outcomes when implemented together. The central line bundle has five primary components: proper hand hygiene, maximal barrier precautions, chlorhexidine skin antisepsis, and daily review of line necessity (Weeks et al., 2014). Proper hand hygiene helps prevent contamination of CVC sites and bloodstream infections that are likely to occur. Hand hygiene should be observed before and after the following practices: palpating catheter insertion sites, inserting, accessing, replacing, repairing, or dressing an IV catheter; and invasive procedures (Yaseen et al., 2016).

Maximal barrier precautions mean strict adherence to hand hygiene accompanied by wearing a mask, cap, and sterile gown and gloves (Raad et al., 2014). These precautions are similar to those of surgical procedures that carry an infection risk. For the patients, maximal barrier precautions entail covering the entire body of the patient with a sterile drape, leaving a small opening for the insertion site (Raad et al., 2014). Pronovost et al. (2006) postulated that the risk of CLABSI is high if maximal barrier precautions are not applied.

The application of the central line bundle has shown a remarkable decrease in the rate of CLABSI. Yaseen et al. (2016) demonstrated that Intensive Care Units (ICUs) that have executed comprehensive interventions similar to the central line bundle have succeeded in reducing CLABSI. Pronovost et al. (2010) reported a 66% decrease in CLABSI rates over two decades in a state-wide effort in Michigan due to the application of a central line bundle in the region's healthcare organizations.

Further evidence from Pronovost et al. (2006) demonstrated that the central line bundle reduced the rate of CLABSI by approximately 74% state-wide. In the same context, a state-wide ICU collaborative in Hawaii that focused on multifaceted CLABSI prevention efforts reduced the average rate of this clinical issue from about 1.5 infections per 1000 catheter days to around 0.6 infections per 1000 catheter days (Yaseen et al., 2016). Weeks et al. (2014) outlined that the success of the central line bundle is due to a blend of mindfulness that occurs when frequently using the components of the bundle. For instance, studies by Mermel et al. (2011) and Raad et al. (2014) have demonstrated that the maximal barrier precaution significantly lowers the risks of developing CLABSI.

Regarding ethical considerations, ethical approval will not be obtained because this will be a quality improvement plan, where all interventions of the central line bundles will be authorized by evidence-based research.

Goals

Despite being preventable, CLABSI causes thousands of deaths annually and increases healthcare costs. Due to the increased rates of CLABSI, the primary goal of nurses will be to design a plan to address this healthcare problem. To prevent this clinical issue, the nurses will aim to form a multidisciplinary team led by the director of infection prevention and control in nursing in the healthcare unit (long-term goal). Other members to be included will be the practitioners of infection control who act as the team coordinator to plan meetings, ICU doctors, nurses and team leaders. Nurses, preferably, NCLEX –RNs will be given priority to participate in the prevention and control program because they possess the knowledge, skills, and expertise needed to address the clinical issue. The nurses will verify whether healthcare workers have adequate knowledge and skills to measure this objective.

The team will also aim to adopt the Institute of Healthcare Improvement (IHI) central line bundle to reduce the CLABSI rate in patients (short-term goal). To do so, the team will conduct educational sessions for all healthcare workers before implementing the central line bundle. The learning sessions will include the details of the components of the central line bundle and the scientific proof to show the value of this solution in the prevention of CLABSI. Special sessions will be carried out for the team leaders to monitor the central line insertion process.

In addition to the above strategies, nurses will educate patients on their increased infection risk, notable symptoms, and how to prevent CLABSI. Besides, the nurses will adjust central line supply levels to meet daily needs. Nurses will also provide a daily with a daily chlorhexidine bath for all patients with CVC. To achieve this, they will advise the logistics department to maintain the supply of chlorhexidine-containing swabs used for the preparation of the CVC insertion line. As part of the follow-up, the nurses will monitor central lines bi-weekly in the electronic health records of the patients. The length of hospitalizations and the healthcare cost will also be determined to measure the success of this goal.