Paper Presentation: Evidence-Based Practice Projects and Quality Improvement Initiatives — Bundles and Spreadsheets: Evidence-Based CLABSI Reduction and the Challenge of MBIs (210-1)

5:00 – 5:20 pm Thursday, September 5

The inpatient hematology/oncology and stem cell transplant units at an urban children’s hospital had experienced multiple years above the Solutions for Patient Safety (SPS) baseline central line-associated bloodstream infection (CLABSI) rates, including and excluding mucosal barrier injury (MBI) events. Two clinical nurse specialists (CNSs)—one focused on hospital-acquired infections, another focused on the inpatient cancer center—decided to approach their local policies and outcomes data critically.

The purpose of the project was to reduce CLABSI and MBI numbers/rates by integrating the evidence into central line management policies and integrating the local clinical evidence into guided recommendations, interventions, and education. The hospital-acquired-infections (HAI) CNS evaluated recent evidence and best practice recommendations from multiple professional organizations, including the Oncology Nursing Society, the American Vascular Nurses Association, and the Infusion Nurses Society, while being involved in local and system policy updates. While this was being done, the cancer center CNS compiled a robust spreadsheet of infections, associated variables, and historical data while providing frequent feedback to staff, the HAI CNS, and infection prevention. Post-infection huddles were initiated by the cancer center CNS after each positive culture event, and findings were disseminated locally. A review of the data from prior years revealed that nearly 75% of all infections noted on the cancer center were associated with premature dressing changes and receipt of blood products within 72 hours of the event. The policy updates, including differences in needleless connector change frequency based on evidence and product recommendations, went live across the system in the summer of 2017, though the CNSs lobbied executive leadership to hold off until January 2018 for an entire year of pre/post comparison. Along with the policy updates, the cancer center CNS led real-time and staff meeting discussions on central line assessments as the hospital’s education from years prior spoke to maintaining a “pristine” dressing at all times, likely leading to many early dressing changes. Oral hygiene through elements of the SPS bundle was emphasized. In 2018, the cancer center’s combined CLABSI rate was 0.6, significantly down from 2.84 in 2016 and 2.65 in 2017. The raw decrease in CLABSIs from 2016 to 2018 was 21 to 18 to 5. The variation in organisms has also decreased, from 23 different organisms in 2016, 14 in 2017, and 10 in 2018 (6 speciated as MBI organisms). The policy changes did require more frequent needleless connector changes. One update required a change within 4 hours of receiving blood products; previously, no changes were required. The rates decreased despite giving only 19 fewer blood products in 2018 than in 2017. The cancer center, like many others, still struggles with mucosal barrier injury (MBI) CLABSIs with overall totals remaining above 20 per year. The presentation will also address local challenges with virdans group streptococcal infections.