This article originally ran in the September 2016 issue of Hospital Peer Review
The author and editorial team have nothing to disclose.
A nursing-led program designed to get clinicians to follow best practices at a New York City hospital has significantly reduced the incidence of central line-associated bloodstream infections (CLABSIs) in neonatal, pediatric, and pediatric cardiac intensive care settings.
The “Clean It Like You Mean It!” program at Morgan Stanley Children’s Hospital, part of the New York-Presbyterian system, sought to limit CLABSIs because they are largely preventable if nurses and other clinicians follow the proper protocols, says Regan Morimoto, RN, CCRN, clinical nurse II at the hospital and one of the program leaders.
The program team consisted of Morimoto and another nurse from the pediatric intensive care unit (PICU), one nurse from the pediatric cardiac intensive care unit (PCICU), and one from the neonatal intensive care unit (NICU). They had the full support of management but carried out all the tasks in the initiative. They also were available around the clock for consultation.
“If a PICU nurse in the middle of the night saw a line that had some redness or was starting to get clotted, we would get a text or a picture. I could advise the nurse and the next day I could check it and talk to an attending about why it hadn’t been pulled yet,” Morimoto says. “The totally open communication among the staff was very important.”
The program used continuous education sessions, central line maintenance protocol, weekly surveillance, and a good dose of cheerleading by nurse champions to reduce CLABSIs. After a year, the results were impressive:
- The NICU CLABSI rate decreased by 55%. (The NICU did not fully participate in the program. The result lends more support to the effectiveness of the program.)
- The PICU CLABSI rate decreased by 21%.
- The pediatric cardiac intensive care unit CLABSI rate decreased by 100% to zero.
- The average length of stay (LOS) decreased by 4% (1.11 days) in the NICU and by 35% (4.87 days) in the PICU since 2013. It increased by 2% (0.32 days) in the PCICU.
- The total number of CLABSIs for all units decreased by 25%.
- These outcomes resulted in a fiscal effect of $37,134 over nine months, with a projected annual savings of $99,024.
Not Always an Easy Path
The first challenge was getting buy-in from the nurses, Morimoto says. They were all for reducing infections, but were wary about slowing the pace in the unit to scrub hubs on medication pumps and syringe lines.
The effort kicked off with a traveling CLABSI Carnival that visited each nursing unit in January and February 2014, providing cupcakes and freebies to get the nurses involved. The CLABSI Carnival appeared again during the hospital’s Nurses’ Week celebration. The project team met with more than 100 nurses and gave hands-on demonstrations of “Scrub the Hub” — the central message in the project encouraging nurses to pay extra attention to this detail with central lines. Nurses answered trivia questions on central line care, reviewed central line dressings and changes, learned about the use of alcohol-impregnated caps on needleless ports, and reviewed central line change policy and central line care.
Nurses took well to the effort as long as they felt their voices were heard when they wanted a central line pulled or had other input, Morimoto says.
“One of the first things we instituted was a two-person line dressing change, which was difficult because we don’t have resources nurses. That meant you had to pull a nurse who had their own workload to come watch you change the dressing,” Morimoto says. “But we thought it was very important to have another set of eyes, someone to speak up and say ‘you might not be sterile anymore.’”
The next hurdle involved residents and rotating staff. Residents start every two weeks, requiring that fresh education each time. In addition, some residents were coming off rotations where they had been instructed to order central line cultures but now had to be taught not to in the ICUs. Plus, they had to tell parents that the child would have a needlestick instead of using the central line.
The nursing team went to the fellows overseeing the residents and presented the CLABSI project, which resulted in better understanding when residents arrived for ICU rotations and better compliance during their stays. Afterward, a nurse disagreeing with a resident could call the fellow to make the final decision.
With the program originating with the ICU nurses, compliance was not immediate in other departments.
“We would leave our kid in radiology and they would come back with everything that was in the peripheral line now running through the central line with the same tubing. That was just horrifying to us,” Morimoto says. “We thought about going to the doctors, but instead we went to the nurses and begged them to be accountable for what’s going on with those lines. We would even send primed, brand-new, fresh lines done by us to them if they needed that, but we ended up getting good cooperation from the other nurses.”
Some services, like oncology, were resistant to the CLABSI project and did not want to change practices when a patient moved from the floor to the ICU. But attending physicians in the ICU stood up for the project and explained that there is no data to support daily central line cultures if the parent consents to peripheral cultures.
Reminder Hangtags on IV Poles
The “Clean It Like You Mean It!” program used a variety of methods to keep the message in front of nurses and reinforce the CLABSI prevention best practices. The team developed “Scrub the Hub” IV pole hangtags for all patients with central lines.
CLABSI prevention posters were placed in all three units, and the team provided CLABSI prevention education in groups and one-on-one.
The team also conducted weekly central line surveillance for 32 weeks, assessing more than 300 central lines for appearance, needleless caps, central line sites, and dressings.
At one point the team decided to take a break from taking blood cultures off the central line to see if contamination from nurse error had any influence on the CLABSI rate.
The policy at the hospital was not to take cultures from central lines, but doctors were ordering them because that option popped up when entering orders in the electronic record. The nursing team did not have the authority to stop the central line cultures, but they went to a critical care quality and safety meeting with all the attending physicians.
“We just asked if they would do what we want for a little while and just stop that practice so we can see if it makes any difference,” Morimoto says. “Because the CDC’s gold standard is to use peripheral lines for blood culturing, they were willing to stand behind us. We actually had some great results from not accessing our central lines and that was information we use to validate this change.”
The program was funded mostly with a $10,000 grant from the American Association of Critical-Care Nurses, with a good portion of those funds covering the off-duty time of nurses spent on the project. The hospital spent $2,752, with 25% of those funds spent on posters, 25% on staff gift giveaways, 22% on educational material, 12% on food, 9% on printed water bottles, and 7% on team shirts.
Morimoto suggests that any nurse-centric quality improvement project will be most successful if it originates or at least is driven by the nurses themselves.
“Ultimately we are the stopgap at the bedside and the last person who can ensure that we’re doing everything right,” Morimoto says. “I’m lucky to work in an ICU where our nurses feel empowered and don’t have any trouble saying ‘no’ to a doctor. The project succeeded in large part because the nurses cared and took ownership.”
