Abstract

Every year central line associated bloodstream infections (CLABSI) affect people around the world and the healthcare system. Researchers has shown that prevention has been made in hospitals in multiples published studies. The purpose of this research paper is to evaluate the evidences and distinguish the differences along with similarity between the two research studies. A second purpose is to propose additional solution contributing to the next of nursing in order to improve the quality of care. A qualitative study by McAlearney & Hefner (2014) reflects and compares the importance of infection control professionals and frontline staffs in facilitating CLABSI prevention. A quantitative study by Ista el al. (2016) illustrates the effectiveness of bundle implementation in ICU patients at various ages. The researchers presented qualitative study’s result concluded that both frontline staff and ICPs are important in preventing patient from CLABSI. Meanwhile, the researchers presented the results of quantitative study inferred that implementation of central lines bundles plays significant role in reducing CLABSI in ICU patients. More than that, the authors of quantitative also indicated findings that the bundles are equally effective in different countries as well as cost-saving.

Keywords:  prevention, bundles, staffs, ClABSI, ICU patients

Introduction

 It is estimated that 30,100 central line-associated bloodstream infections (CLABSIs) occur each year in the U.S. intensive care unit (ICUs) (Centers for Disease Control and Prevention [CDC], 2015). The patient mortality rates associated with CLABSI ranges from 12 to 25% (Health Research & Educational Trust, 2017). CLABSIs are the most costly healthcare-associated infections costing upwards of $46,000 per case (Haddadin & Regunath, 2017). Patients that become infected through central lines spend an additional of 7 to 21 days on average at the hospital, a significant increase in hospital expenses, and increased morbidity and mortality rates (Moyle, 2017). Central line- associated bloodstream infections are one of the most common and preventable healthcare-associated infections (Moyle, 2017). Even though CLABSI results in a thousand of deaths each year and makes a name for itself as the most costly healthcare associated infection, accounting for approximately $46,000 per case, this catastrophe is preventable. In a battle of fighting against CLABSI, different individuals and different healthcare teams may have contradicting opinions about how to reduce and prevent this infection. Prevention is better than cure and it roots from the change in the behavior of healthcare professionals through many aspects. Performing hand hygiene and following strict protocol when inserting the line are the simplest steps that saves another patient from the touch of CLABSI.

Background

 Most cases of CLABSIs are preventable with proper aseptic techniques, surveillance, and management strategies (Haddadin & Regunath, 2018). CLABSI is an infection that occurs when bacteria or virus enters the bloodstream through the central line. Central lines access a major vein such as the internal jugular, subclavian, or femoral vein which allows the catheter to remain in place for weeks or months increasing the susceptibility for an infection (CDC, 2015). Haddadin and Regunath (2018) found out that CLABSI is defined as a laboratory-confirmed bloodstream infection not related to an infection at another site that develops within 48 hours of a central line placement. Causes of CLABSIs include contamination on insertion, patient’s skin flora, hematogenous infection, and CVAD hub colonization (Moyle, 2017). Risk factors for developing CLABSIs include immunosuppression, age, poor nutrition, impaired skin integrity, healthcare workers using poor hand hygiene, non-adherence to aseptic technique, and prolong duration of the catheter (Moyle, 2017). Symptoms for localized infections include redness, swelling, and discharge at central line exit site (Haddadin & Regunath, 2017). Symptoms for systemic infections include fever, hypotension, tachycardia, diaphoresis, and altered cognitive state (Haddadin & Regunath, 2017). Early identification of symptoms and safety precautions are one of the many crucial factors in preventing central line-associated blood infections.

Methods

 The qualitative article written by McAlearney and Hefner (2014) was found in the American Journal of Infection Control through the Rutgers Library. The search criteria for this article was qualitative research related to CLABSI, CLABSI prevention, English, and within five years of 2018. The inclusion criteria for this study was frontline nurses and infection control professionals who worked in hospitals that participated in the same Agency for Healthcare Research and Quality (AHRQ) CLABSI prevention initiative cohort.

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 The quantitative article written by Ista et al. (2016) was found in ScienceDirect through the Rutgers Library. The search criteria for this article was quantitative research related to CLABSI, CLABSI prevention, English, and within five years of 2018. The inclusion criteria for this study were articles published between January 1, 1990, and June 30, 2015, studies that reported implementation of central-line bundle in an ICU setting with documentation of the CLABSI incidence expressed per 1,000 catheter-days, made a comparison using a randomized or nonrandomized study design, or interrupted series, and described an intervention such as education or feedback to improve the care process.

Analysis

Qualitative Research

 The purpose of this article was to determine if infection control professionals (ICPs) and frontline staff had different perspectives about the facilitators and challenges of central line-associated bloodstream infection (CLABSI) prevention program success. The key concepts in the study were clearly defined. The key concepts were education, leadership, data and technology, and standardization of clinical process. These key concepts were presented to ICPs and frontline nursing staffs to determine the similarities and difference in perspectives. The results from the data analysis further divided each key concept into subthemes to emphasize the common ideas shared among ICPs and the frontline nursing staff. The study design was exploratory-descriptive in the qualitative research primarily as evidenced by obtaining information required to begin intervention for a specific problem. The researchers are exploring CLABSI challenges from the perspective of ICPs and frontline nurses, which is a unique study comparison influenced by the roles in health care. The qualitative study approached both sides of the participant groups and was able to address the focus of the study which was challenges of CLABSI prevention. The sample included 50 frontline nurses and 26 infection control professionals who worked in hospitals that participated in the same AHRQ CLABSI prevention initiative cohort across eight hospitals (McAlearney & Hefner, 2014).

 The outcomes of the qualitative study highlighted the differences in perspectives between ICPs and frontline nursing staff. ICPs and frontline nursing staffs focused on different aspects within three of the four presented factors regarding CLABSI prevention. When it came to education, ICPs focused on continuing education program that included more than learning from mistakes, whereas frontline staffs emphasized the importance of continuous reeducation in terms of clinical protocols. For leadership, ICPs focused on a fully supportive hospital management, whereas frontline nurses on the other hand discussed the importance of approachability and interpersonal skills by the hospital management. With data and technology, ICPs emphasized the difficulty of retrieving data and the importance of new technologies to reduce infection rates. As expressed by one ICP, “It is not always easy and sometimes you have to go in a roundabout way or kind of in the back door, because certain computer systems don’t communicate” (McAlearney & Hefner, 2014, p. 220). The distinction between ICPs and the frontline staff opens up avenues to explore in the development of interventions to reduce CLABSI.

 This study offers a very unique approach to the perspectives of two different groups and identified differences in perceptions about factors that facilitate CLABSI program success (McAlearney & Hefner, 2017). The study’s in-depth analysis of the interviews demonstrates a profound understanding of the emergent themes and subthemes presented by the ICPs and frontline staff. The interview process was systematized with informants following a standard interview guide to ensure consistency in data collected.

As part of the study, the data collection includes:

 All interviews were recorded and then transcribed verbatim to ensure accuracy and               reliability. Data collected entered a coding dictionary with main coding themes and               specific sub codes with detailed definitions specifying when to apply these codes. The               research team met periodically to discuss issues resolved discrepancies and develop               new codes and definitions. (McAlearney & Hefner, 2017, p. 217)

One weakness in the study is a lack of statistical representation. McAlearney & Hefner (2014) used terms such as “often mentioned,” “frequently mentioned,” “commonly noted,” and “typically noted” when discussing the perspectives of ICPs and frontline staffs.

Quantitative Research

 The purpose of this article is to assess the effectiveness of implementing central line bundles to prevent CLABSIs in adult, pediatric, neonatal patients in ICUs. A subsequent purpose after data analysis was the cost saving and effectiveness in geographical variation. The key concepts in the study were clearly defined. The key concepts included insertion bundle, maintenance bundle, country, patient population, sex, age, severity of illness score, implementation strategies, number of infections, catheter-days, compliance measures, and cost.

 The study design was descriptive. The study is observational in nature, identifying the effectiveness of central line bundles through precision of measurement, current evidence, and clarifies relationships for future studies. The sample included 2370 ICUs patients in 96 selected studies after inclusion and exclusion criteria were implemented. The sample consisted of patients in adult, pediatric, and neonatal groups. There were 2216 adult, 79 pediatric, and 75 neonatal patients. The population came 57% from USA, 14% from Europe, 12% from Latin America, 9% from Asia, and 7% from other regions (Ista et al., 2016).

 The outcome of the quantitative study concluded a significant reduction in CLABSI incidence across adult, pediatric, and neonatal ICUs when implementing central line bundles. The researchers noted that there was no significant risk reduction between geographical aspects which were low to medium-income countries and high-income countries. Researchers state that healthcare providers should follow strict protocol or checklist compliance in order to achieve the best outcome of the bundle implementation, which means nurses are “empowered to stop the procedure if a physician breached protocol” (Ista et al., 2016, p. 730). Hand hygiene practice was noted to contribute to CLABSI reduction in the ICU population in approximately half of the included studies. The central line bundles were also reported as cost effective with an estimated $42,609 savings per each case of CLABSIs (Ista et al., 2016).

 By pooling statistics from previous studies into a single quantitative analysis, researchers have found out some interesting findings. The multifaceted bundles, implementation in low-income and middle-income countries, and in hospital settings with restricted resources were as effective as in high-income countries. Ista and colleagues (2016) also reported that the central line bundles intervention is cost-saving. The outcome of study gives a hint of maximizing the effectiveness of care bundles; such information would initiate further question for potential research studies: Will health-care professionals’ perfect compliance with all bundle elements help reduce catheter-related infections to zero? This intriguing point was brought up in a project published in BMJ Quality Improvement Reports. The multidisciplinary CLABSI Elimination Team cooperated to adopt care bundles. The data was analyzed quarterly then presented to the concerned teams as well as the Infection Control Committee. As a consequence, the ultimate target of zero CLABSI was achieved in the year 2014 and maintained throughout the year 2015 (Yasee et al., 2016). At the end of the discussion, Ista and colleagues (2016) again concluded that the effectiveness of central-line bundles is “no longer open to debate” because it was shown clearly in the study.

 Even though central-line bundles are shown effective according to all the included studies, there are some limitations to the research study overall. In aspect of the content, researchers collected a large number of publications on the effectiveness of insertion and maintenance bundles to prove that this implementation receive an increasing attention due to its great impact. However, this finding will be different as time moves on since researchers only focus on studies published in a period of time frame. Therefore, it would be time consuming to gather new effectiveness studies again. Instead, researchers may consider shifting to another direction such as focusing on a specific aspect of the bundle deals such as research on Chlorhexidine gluconate preparations. An extensive monitoring (the number of CLABSIs per 1000 catheter-days) can also be downgraded to a monitoring of once every three months to create a high protocol compliance and a low sustained infection (Ista et al.,2016).

 Another limitation is that there are other important components of the bundles, but only the effect of hand hygiene receive attention in the outcome of study. Ista et al. (2016) also pointed out that “large proportion of studies were single-centre studies in adult ICUs, and most were undertaken in the USA” (p. 730). This leads to the lack of universality and acts as a threat to validity of the research study. Burns, Gray, and Grove (2014) mentioned, “Researchers who gather data from subjects across a variety of settings have a more representative sample of the target population than those limiting the study to a single setting” (p. 252). Patients in a particular setting may be different from those who have the same problem in other settings. Their study is limited to the ICU setting. Haddadin and Regunath (2018) illustrated that 24% of non-ICU patients had central lines. Ziegler, Pellegrini and Safda (2015) conducted 18 studies on CLABSI and found out an interesting same point that a mixed population of medical and surgical patients can also be affected by CLABSI.  As a result, the setting identified in Ista et al’s published studies has a weakness due to lack of the representativeness of the sample. The studies examined by Ista and colleagues (2016) are quite heterogeneous.

Similarities and Differences

Main theme of both qualitative and quantitative studies used in this paper are about the central line associated bloodstream infection prevention. Nonetheless, the focus of each study is different. McAlearney and Hefner (2014) focus on identifying and comparing the roles of infection control professions and frontline staffs in facilitating prevention of CLABSI. Ista el al., (2016) measures the value of bundles implementation on CLABSI prevention. In other words, one study is about the implementation, another study is about the people who carry out those intervention. While McAlearney & Hefner (2014) conducted an interview to collect data to determine “facilitators of and barriers to CLABSI prevention efforts” as well as to compare the responses of ICPs and frontline staff (McAlearney & Hefner, 2014, p. 217), Ista and colleagues (2014) pool the studies reporting the implementation of central line bundles, put together and analyze them. Researchers of these two studies limit the setting as ICU.

RESULT

Qualitative Study

 The qualitative study provided strong and convincing evidence that there are truly challenges with CLABSI prevention as shown throughout the interviews. The comments from ICPs and frontline nurses were very insightful and proved differences in perspective on both ends. The design validity demonstrated accurate reflection of reality on concerning obstacles faced by both groups when dealing with CLABSI prevention. With the research design utilized to draw data   by listening to the people, a true accurate representation of the issues can be described and easily readable by the audience. In comparison to the quantitative study that displayed statistics and numbers, the qualitative article translates human behavior and emotion into data collection that concretely justifies the need for frontline nurses to be included in the implementation team when dealing with infection control guidelines and interventions (McAlearney & Hefner, 2014).

Quantitative Study

 Based on our analysis, this quantitative study is not adequate and strong enough due to the lack of contributing factors of CLABSI prevention. These contributing factors include the overall compliance to central lines bundles, the persistence of multidisciplinary team practice, and other bundles elements (Haddadin & Regunath, 2018). Although the researchers pointed out a couple key components of the maintenance bundles from included articles which are hand hygiene and combination of leadership, however, the effect of hand hygiene practice on the results is just a speculation due to insufficient evidences (Ista el al., 2016). Similarly, the effectiveness of the use of impregnated central venous catheters was reported in a few studies. Ista et al. (2016) briefly discussed strategies for implementation (e.g. checklist compliance, leadership; Ista et al.,2016) instead of providing details about how these affect CLABSI.  Making conclusion on the effectiveness of bundles implementation in preventing CLABSI based on numbers of studies makes the study less reliable. Because there is high possibility that some studies included information of previously published data, researchers may have to either make extra efforts to verify those studies or have to rely on the information provided by the authors.

DISCUSSION

Central venous catheter is considered life-saving for a majority of ICU patients (Yaseen et al., 2016). However, the use of these catheters has caused central line-associated bloodstream infection (CLABSI). CLABSI is a serious infection that results in thousands of deaths each year and prolonged hospital stays. Even so, this costly threat to patient safety can be prevented. According the Centers for Disease Control and Prevention, the adoption and implementation of evidence-based practice reduced the number of CLABSIs by 46% between 2008 and 2013 (Health Research & Educational Trust, 2017). Such information has indicated that progress has been made on the journey of preventing these deadly infections, yet more needs to be done. Prevention should occur in different care settings where patients may receive treatments through central line such as hemodialysis (outpatient setting), chemotherapy, as well as other non ICU settings (medical surgical unit). Use and implementation of infection prevention strategies will be more successful if they are adapted in multimodal approaches. As mentioned previously, to successfully implement CLABSI preventative measures, “it is important that frontline staff be included in any implementation team because they contribute a critical real-world perspective that may facilitate the success of patient safety interventions” (McAlearney & Hefner, 2014, p. 221).

 Saying is easy, but taking action is another story. Ongoing nursing research and nurses play an important role in preventing patients from acquiring central line-associated blood infections. The next step for nursing would involve implementing the large selection of quantitative research across multiple facilities to formulate a comprehensive understanding of  evidence-based practice related to CLABSIs.

References

Burns, N., Gray, J., & Grove, S. K. (2015). Understanding nursing research: Building an evidence-based practice (6th ed.). St. Louis, MO: Elsevier.

Centers for Disease Control and Prevention. (2015). Bloodstream infection event (central line-associated  bloodstream infection and non-central line-associated bloodstream infection). Retrieved from https://www.cdc.gov/hai/bsi/clabsi-resources.html

Haddadin, Y. & Regunath, H. (2018). Central Line Associated Blood Stream Infections (CLABSI). Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK430891/

Health Research & Educational Trust. (2017). Central Line-Associated Bloodstream Infections (CLABSI) Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Retrieved from http://www.hret-hiin.org/Resources/clabsi/17/central-line-      associated-bloodstream-infection-clabsi-change-package.pdf

Ista, E., van Der Hoven, B., Kornelisse, R., van Der Starre, C., Vos, M., Boersma, E., & Helder, O. (2016). Effectiveness of insertion and maintenance bundles to prevent central-line-associated bloodstream infections in critically ill patients of all ages: a systematic review and meta-analysis. The Lancet Infectious Diseases, 16(6), 724–734. https://doi.org/10.1016/S1473-3099(15)00409-0

McAlearney, A. S. & Hefner, J. L. (2014). Facilitating central line–associated bloodstream infection prevention: A qualitative study comparing perspectives of infection control professionals and frontline staff. American Journal of Infection Control, 43(10), 216-222. doi: https://doi.org/10.1016/j.ajic.2014.04.006

Moyle, S. (2017). Central Line-Associated Bloodstream Infections. Retrieved from https://www.ausmed.com/articles/central-line-associated-bloodstream-infections/

Yaseen, M., Al-Hameed, F., Osman, K., Al-Janadi, M., Al-Shamrani, M., Al-Saedi, A., & Al-              Thaqafi, A. (2016, August). A project to reduce the rate of central line associated bloodstream infection in ICU patients to a target of zero. BMJ Quality Improvement Reports, 5(1),1-4. doi: [10.1136/bmjquality.u212545.w4986]

Ziegler, M. J., Pellegrini, D. C., & Safda, N. (2015). Attributable mortality of central line associated bloodstream infection: systemic review and meta-analysis. Journal of Infectious Disease, 43(1), 29-36.doi:10.1007/s15010-014-0689-y