Central Line Catheter Patients

Benefits of Practicing Bundle Care Concept in Central Line Catheter Patients

Abstract

Healthcare associated infections especially central line associated blood stream infections (CLABSI) have shown to pose great threat to the safety of the patients. The studies conducted in this field during the last two decades have helped the healthcare professionals to improve the knowledge about the pathogenesis of central line associated infection. This has helped the healthcare professionals to focus attention on reducing healthcare professional’s exposure to the infectious agents. Even though some of the best practices have been developed to reduce the morbidity and mortality associated with these infections, due to non-compliance to these best practices by some health professionals have reduced the efforts of healthcare industry to reduce the infection rate from reaching zero. The patients who are on central line catheter are usually more vulnerable to infection than patients with short peripheral catheter and as these catheters are more frequently accessed, it increases their exposure to microorganisms. Education programs aiming to improve healthcare professional’s compliance to best practice protocols have shown to reduce central line infections. The Institute of Healthcare Improvement suggests the idea of practicing bundle care concept in reducing the incidence of central line infections. The components of bundle care include the following: hand hygiene; catheter site selection; practice of maximal precaution barrier; daily review of central line and use of chlorohexidine skin antisepsis. The paper aims at educating the healthcare professionals about the importance of practicing bundle care concept in reducing central line infection in patients

Keywords: Healthcare associated infection, Central line associated blood stream infection, practice of bundle care concept, and evidence based practice.

Problem Statement

Central line associated blood steam infection is one of the most common and deadly type of healthcare associated infections with a mortality rate ranging from 12 to 25 percent (MMWR, 2005). Factors like underlying infections, use of invasive devices and patient’s poor immune system puts the hospitalized patients especially those in Intensive Care Units at a high risk of above infection (MMWR, 2005). To develop an effective strategy to combat the CLABSI, it is necessary to understand how the organism enters the blood stream. It could be during one of the following stages

  • During catheter insertion
  • When catheter is accessed for medication, tubing and flushing or during cap changes.
  • Infection in other parts of body
  • Contaminates fluid or medication is other chances of acquiring blood stream infection
  • Prolong usage of centerline catheters
  • Selection of insertion site
  • Hub manipulation is a common source of infection in long term catheters (Hardaway, 2006).

The CLABSI extends the hospital stay for the patients. It also reduces the quality of life of the patient. It also increases the financial burden of the individual. It is estimated the individual has an additional healthcare cost that ranges about $33,000 to $75,000 for each infective episode (Jackson et al., 2012). Studies conducted by Earsing, Hobson, and White (2005) found that there are approximately 5.3 CLABSIs per 1000 catheter days and the mortality associated with these infections approximately 14,000 deaths annually. According to the reports from CDC, it has been found that if the blood stream infections of all patients from the various hospitals are tallied up, the number of CLABSI’s would almost be 250,000/year (Hardaway, 2006).

In the current healthcare settings the CLABSI increases the workload on the nursing professionals. The nurses might not get enough time to provide a holistic care to the patients on time due to the understaffing in healthcare facilities. This will reduce the patient satisfaction. This will also reduce the satisfaction of nursing professionals as they see a better patient outcome even after providing a great job to the best of their ability.

The Institute for Healthcare Improvement suggests care bundles should be applied to have better outcomes for patients who are infected by CLABSI (Hadaway, 2006). The Care bundle consists of five components. They are

  • Hand Hygiene
  • Chlorohexidine skin antisepsis
  • Maximal barrier precaution
  • Optimal catheter selection
  • Daily review of the need for catheter line

Even though each of these components individually improves the patient condition, the Institute of Health Improvement suggests that when they are applied together they produce a better outcome than when they are applied individually. Application of bundle cares in various hospitals has shown a drastic reduction in central line infection in patients. It has also found that the ICU’ that has implemented the bundle care practices has almost reduced the catheter related blood stream infections (Earsing, Hobson, & White, 2005). Studies by McPeake et al. (2012) suggest that a checklist could also be implemented to ensure that all procedures are compliant with the policies and guidelines. Even though CLABSI is a deadly type of healthcare associated infection, various studies have proven that the application of bundle care can improve the patient outcome.

In an adult patient with a central line catheter after a cardiac surgery (P), will implementing a bundle sterile policy (I), Just as compared to providing routine standard clean technique, using a sterile dressing change and bundle care(C), reduce the blood pathogens and blood stream infections (O), during a 12 month period (T).

The various innovations that have developed in the healthcare market during the last few decades have assisted the healthcare professionals in developing various strategies aimed at early detection prevention and treatment of various diseases. The budgetary constraints place the policy makers in dilemma when they have to a decision on whether to finance technological innovations in healthcare to expand the existing technology or invest in a new technology. A study by Tarricone et al. (2010) states that healthcare associated infections that are associated with increased mortality and morbidity rate is one of the serious patient  safety issue in healthcare industry affecting more than 1.4 million people around the world. Among the various healthcare associated infections, the infections that are associated with the presence of invasive devices like central line are really lethal that even lead to disability and even death. This is one reason why Institute for Healthcare Improvement has identified initiatives to reduce the occurrence of central line infections as one of the six major agendas in 100,000 Lives, which aims in reducing the avoidable patient death and complications (Hadaway, 2006). Study by Hadaway (2006) also points out that in the recent years the catheter related infections are more found in non ICU units than in ICU units since more catheter patients are provided with nursing care in non-ICU settings.

A study by Schears (2012) revealed the fact one of the main reasons identified by healthcare professionals for the poor compliance to protocol was the limited availability of time due to staff shortage and the difficulty in remembering and practicing all protocols within the limited time. To overcome this barrier Akridge (2011) reminds the suggestion by CDC about developing and maintaining a cart that contains all the necessary items needed to provide the care based on bundle care concept. Study by Harnage (2007) also suggests that continuous monitoring of practices not only reduces the complications and infections related to catheter infection but also develops an accountability and ownership of practices among the healthcare professionals.

For any strategy to be implemented in a healthcare setting to have a better outcome in patients it should be introduced to the healthcare professionals based on the best evidences available.  A study by Eat and Jacoby (2005) showed that implementation of education program for the healthcare professions had a positive impact on reducing the incidence of central line infections as the in-services provided to the healthcare professional reminded them about the importance of being compliant to the best practice protocols in achieving better outcomes in patients. To make sure that the healthcare professionals are complying with the standards of practices and their commitment towards the patient safety staff evaluation should be done on regular basis.  

Developing an Implementation Plan

Blood stream infections, especially central line infection is a common hospital infection which is considered lethal and is considered as a major cause for patient mortality and morbidity. A study by Schears (2012) shows that the even though the incidence central line infection has been considerably reduced in the past two decades due of various efforts taken by healthcare professionals, the effort to achieve a zero compliance in central line infection has not reached its goal due to the lack of compliance in adopting the best practices. Recent monthly audits conducted in the author’s healthcare facility showed that there is an increase in central line infection rate in the author’s unit. This was raised as concern in the unit as central line infections reduced the patient safety, quality of life and also creates financial burden to the patient and to the organization. A study by McPeake et al. (2012) shows that central line infection increases the hospital stay of the patient up to eight days along with additional hospital expense of around 20,000 USD for each occurrence and carry a mortality rate between 12% to 25%.

As an attempt to reduce the central infection rate the author reviewed the practices that have been followed in the unit. The members of the healthcare team are aware of the fact that that the microorganism might enter the patient’s blood steam during catheter insertion; from an infection elsewhere in the body; while healthcare professional’s access the catheter for flushing and cap changes; through contaminated fluid and medications. As the healthcare professionals were aware of the various mode of transmission, the author also reviewed whether the nurses are taking proper measures to prevent infection at various stages of catheter usage. The best practices to prevent infection includes proper hand hygiene all the time; practicing maximal barrier precautions; cleaning the insertion site in the right way using chlorohexidine gluconate; choosing the right insertion site; using sterile dressing technique and regular monitoring of catheter (Hadaway, 2006). As it was not sure whether all the nurses uses all the components of infection prevention techniques properly the author decided to propose a plan to change the current practice of central line infection prevention procedures that is expected to increase the patient safety and reduce the financial burden on patients and the healthcare settings.

The author decided to propose the idea using the various components of infection prevention procedure as a bundle care pack along with the use of a checklist and initiation of a surveillance program. To this extent the author propose to conduct an education program to the entire health care professional in the unit about importance of providing bundle care to patients in preventing the chances of central line infection. As the changes in the US healthcare industry have increased the workload on the healthcare professional, the time spends with each patient has been considerably reduced and this might have affected the performance of health professionals in taking all precaution to prevent central line infections. To assist the healthcare professional to this extend the author would like to standardize and update the CVC insertion trolley’s that is currently used in the unit with all the necessary elements needed for the bundle care. In a study by McPeake et al. (2012) CVC insertion carts have been highly effective for health professionals in following the guidelines for CVC insertions. Study conducted by Dilek et al. (2012) shows that when various infection prevention interventions are applied together they deliver a better outcome than when these components are applied individually.

A report by MMWR in 2011 showed that due to the implementation bundle care practice in patients with catheter insertion there was a 58% reduction in infection during 2009 when compared to the catheter related infections in 2001. This is estimated to have saved around $414 million dollars in healthcare cost and saved around 6000 lives (Vital Signs, 2011). Study by Kaye et al. (2011) also shows that if proper measures are taken during catheter insertion and maintenance bundles are practiced properly central line infections could be prevented to a major extend. The implementation of the new policy will increase the patient safety and reduces the healthcare cost for both the patients and also to the healthcare facilities. The health care cost that is being saved by the prevention of central line infection also assist in reducing the financial burden that is developed on the US healthcare industry to a great extent and the savings could be used support new research programs that focus on improving patient safety and health.

The new policy could be integrated to the current workflow once proper education is provided to all the health professional regarding the importance of practicing bundle care while taking care of patients with central line. The education about providing bundle care practices to patients could be provided to healthcare professional through the in-service programs that is conducted within the healthcare settings. To make sure that all the healthcare professionals are completed the in-service program it might need to be conducted at various days during a two to three week time period. The Chief Nursing Officer and Nurse Managers should be responsible for making sure that all the healthcare professionals are participating in the education program. Apart from that Nurse Managers should also make sure that the proposed changes are being practiced properly in the unit. The healthcare professional should also be made self accountable to make sure that they are participating in the education program and implementing the necessary changes to their daily nursing practices.

For educating the staff regarding the new policy they should be provided with necessary pamphlets, handouts and power point presentation that describe about current policy, defects of current policy and the new policy that is going to be implemented to improve the  nursing care and patient safety. With the latest technologies effort could be taken to install PowerPoint presentations   or mobile applications that could be installed on each individuals handheld devices, so that they could review at any time. A study by Wells (2007) shows that information technology plays an important role in practicing evidence based medicine and many of the healthcare practitioners use the service of handheld devices to provide better real time access at patient’s bedside.  A survey could be done among the participants before and after the education program to evaluate the knowledge of participants regarding the importance of providing bundle care services to patients with central line catheter.

The cost for conducting the education program among the healthcare professional regarding the importance of new policy will be only a small percentage when comparing to the savings in healthcare cost that could be achieved by preventing the occurrence of central line infection. The Nurse Managers should be made in-charge to initiate and oversee the new changes. If the new policy is found successful in the author’s unit after the evaluation, the author likes to seek the help of project management office to expand the new policy in the other units in the facility. A study by Lavoie-Tremblay et al. (2012) shows that transition support office in a healthcare settings will assist the organizations in implementing new policies, services and improve the existing services to facilitate the integration of evidence based practices within the healthcare settings.

To implement a new policy within an organization an approval is necessary from the top management and the fellow staff. Before submitting the new policy before the top management of the institution, a small discussion could be conducted among the coworkers in the unit to get receive a feed back about the new policy and to see anyone has any more suggestions based on any evidence based studies. This way the complaint about not taking the coworkers into trust could be avoided and it might help in implementing the plan in the unit once it is being approved by the management. For any new policy to be implemented in the healthcare settings it should be approved by the board of directors of the institution. When new policies and procedures need to be approved by the management it should be presented to the board through the chief nursing officer. A study by Mastal, Joshi, and Schulke (2007) states that even though chief nursing officers were never seen as a member of board of trustee in the healthcare management in the past, the recent changes in US healthcare industry has positioned the chief nurse officers member of board of trustees to represent the nurses in policy making to provide better healthcare services. Even though chief nursing officers are not involved in the strategic decision makings in the administrative board they could use their leadership skills to educate the board members about the various steps to be taken about improving the patient safety (Mastal, Joshi, & Schulke, 2007). So the chief nursing officer   once convinced about the new policy changes could submit the proposal to the board members for the approval. The board members who might give more preference to the financial constraints could compare the expenditure on training program against the healthcare cost savings that could be achieved by reducing the chances of central line infection in bundle care practices are implemented among catheter inserted patients. US healthcare industry was able to save almost an amount of $1.8 billion during an eight period starting from the year 2001 (Vital Signs, 2011). This information should be of great interest for the stake holders when taking a decision about implementing the new policy towards reducing the central line infection in patients in the institution.

Healthcare professionals, healthcare leaders, and the top management of the healthcare facilities should work like hand and gloves in implementing new policies and procedures that improve patient safety and in turn improve working atmosphere of the healthcare facility as better patient outcomes improves the satisfaction of healthcare professionals who work in the facility.

Incorporating the Germ Theory

Theories consist of a set of interrelated concepts that give a systemic view of an observable fact that is predictive and explanatory in nature (“Application of theory,” 2012).Various theories in nursing profession act as the foundation of nursing practice, help the nurses to assess the patient condition and also help them in identifying the needs of the patients (“Application of theory,” 2012). The author uses the “Germ Theory of Diseases” to support the new interventions proposed by author to reduce chances of central line infections in patients. The Germ theory, which is considered as the cornerstone of modern medicine is also known as pathogenic theory states that specific microscopic organisms are responsible for specific diseases (” Germ Theory,” 2011). The Germ Theory explains the mode of disease transmission and the methods to be taken to prevent the disease transmission along with the steps to be taken to prevent certain diseases (“Germ Theory,” 2012).

A study by Hadaway (2006) shows that “the microorganisms that cause central line infections enter a patient’s body at various instances like time of catheter insertion; while accessing the catheter for medication administration, cap changes or during flushing; from an infection in other parts of the patient’s body or by contaminated fluid or medication”. Even the health professional that just perform the act of just taking the vital signs or lifting the patients could get infested with thousand of colony forming units of Klebsiella species in their hands (Hadaway, 2006, p.60). The above example shows the importance of being hygienic when taking care of patients with central line catheters. It should be noted that both patients and health professional should practice proper hygienic steps to reduce the chances of central line infections. The guidelines by CDC suggest the use of chlorohexidine as a preferred agent in cleaning catheter insertion sites for reducing the chances of central line infection (Hadaway, 2006).

The nurses should be educated about the importance of practicing hygienic acts along with other components of bundle care while taking care of patients with central line catheter. The nurses should be educated about decontaminating their fingertips before and contacting the patients; using maximal barrier precautions and rubbing the insertion site in the right way along with the right selection of insertion site (Hadaway, 2006).

The author will introduce an education session to the project to educate the nurses about the importance of including hygienic practices along with other components of bundle care for central line patients. Measures will be taken to make sure that peer reviewing will be conducted to make sure that health professionals are practicing the proposed changes during patient care.

Developing an Evaluation Plan

With the increasing emphasis on evidence based practice, introduction of latest technologies, and new and extended nursing roles have put the nurses of the current decade with a challenge of developing effective evaluation practices in the complex healthcare market (Walsh et al., 2007). Evaluation is a formal, systemic process in which one analyzes how well a policy or procedure in working now and what could be done to improve it if there are any flaws or defects. Evaluation is not a program to be conducted once to evaluate the success of a policy or procedure, but it should be conducted multiple times throughout the research program on a random basis, so as to improve the validity of the study. This paper looks into the importance of practicing bundle care concept in reducing the chances of central line infection in patients with catheter insertion.

Evaluating the Effectiveness of New Policy

To analyze the benefits of using bundle care concept in reducing the central infection rate among adults a study will be conducted in the author’s unit to identify the current practices along with the review of the monthly audits to identify the compliance of care that is being practiced in the unit. The study will be initiated once the approval (Appendix A) is obtained from the administrative and nursing leaders. A PowerPoint presentation will be provided to all the participants and provision will be given to install to the presentation in their mobile devices or laptops for the future reference. A group of nursing professional has given their consent to participate in the study and one of the senior nurses will be elected to act as the peer auditor and the audit tool (Appendix E) will be updated on a regular basis to make sure that the expectations are met. A pre and post evaluation (Appendix B & C) forms will be provided to the participants to analyze their knowledge, response, attitude and suggestions about the bundle care concept. The audit tool (Appendix E) will be used to analyze the benefits of practicing bundle care concept in reducing central line infection among adult to the current policy being practiced after a period of six month period once the new program is initiated.

Assessment of Variables

Bundle care concept is a policy of practicing the various precaution measures that prevents centerline infection as a bundle pack instead of practicing them separately the various components of bundle care includes practicing proper hand hygiene; practicing maximum precaution barriers; regular review of central line; use of chlorohexidine rubs for cleansing and proper selection of catheter insertion site. The above variables if practiced by the healthcare professionals in accordance to the best practices will assist in reducing the chances of central line infection in patients and thereby improve the patient’s quality of life and reduce the extended stay in hospitals. The results of the study could be affected by the noncompliance to the procedures and lack of proper documentation practices

Tools for Educating the Participants

Educating the health professional and patients about the importance of practicing bundle care concepts is the best way to retrieve the best results from the new practice. The education about the consequences about central line infection and the benefits of practicing the bundle care practice could be done through the PowerPoint presentation (Appendix F) provided and the audit. The information received though the PowerPoint presentation will also inspire the patients and family about the practicing the proper precaution measures during the treatment period.

Turnover Rate Among Staff

A survey conducted among the staff before the initiation of the project revealed the fact that one out of the ten staff did not believed in the idea that practicing bundle care will reduce the incidence of central line infection in patients. The above person did not believe that the above concept could be implemented in the current period of nursing shortage and also was not confident that physicians will be complying with the procedures initiated by nurses. There was no nurse turnover once the project was initiated and the entire healthcare professional including the physicians followed the followed the guidelines provided to reduce the central line infection rate. A study by O’Brien-Pallas et al. (2010) revealed the fact that appropriate training, a work environment that foster open communication, ongoing administrative support and a clear role definition will reduce the nurse turnover in health care facilities and facilitate better care for patients.

Assessment Tool to Evaluate the Success of the New Policy

An audit tool is necessary to analyze the success of a new policy. Here the audit tool “Appendix E” could be used to analyze the success of bundle care concept in reducing central line infection rate among adults during a six months time period. The audit tool also assists the nurses to comply with the best nursing practices to provide the best patient care. A review will be done among the patient using the patient review tool (Appendix G) to compare the results reviewed from the audit tool. The information from the audit tool could also be used to review the changes that need to be made to reduce the incidence of central line infection in patients. The advancement in technology and education provides the healthcare professionals with the opportunity to share their knowledge to the extended nursing community and to the rest of the society

Dissemination

Dissemination of findings from a nursing research to healthcare professional and various stake holders will assist in continuation and spread of evidence based practice in the healthcare industry around the world. A study by Oermann et al. (2010) states that for the findings from a study to make an impact on the current practices, the results from the study should be disseminated to the clinicians to evaluate the findings in their own settings. Publishing an article in a journal not only allow the clinician’s to read and analyze the results from the study, but also allow other researchers to cite these findings in their studies in the future, there by extending the findings beyond the original work (Oermann et al., 2010).

Stakeholders keeps themselves updated regularly about the latest research findings so as to take right decision in their policy making procedure. A study by Keown, Eerd, and Irvin (2008), states that the stakeholders need be updated regarding research progress throughout the research process. Once the research is completed steps could be taken to meet the stakeholders individually or in small groups to conduct an interactive session to address their concerns (Keown, Eerd, & Irvin, 2008). Further steps could be taken to disseminate the findings from the study to a wider audience by publishing the research study in nursing or medical journals.

A study by Adams and Titler (2010) shows that there is a growing awareness among the nurses around the world about the importance of providing nursing care based on the best available evidence based practices. Dissemination of findings from the study could be conveyed to the healthcare professionals by providing necessary information regarding the studies and by providing proper training and resource materials regarding the importance of implementing the new policy in the healthcare setting to achieve a better patient outcome (Redfern et al., 2003). The findings from the current study could be spread to a greater nursing community by publishing the study in reputed medical or nursing journals for the review of others. The advancement in technology has also enabled the researchers to publish their studies in electronic and printing media around the world within no time.

The findings from the research based studies should be disseminated for the review of other clinicians and stake holders as these results could be validated by others and may be used in their practices and further studies

Conclusion

The advancement in science and technology has made tremendous changes in the healthcare industry including nursing during the last two decades. The advancement made in the last two decades is more than the total advancement made in the healthcare industry in the last century. No one would have imagined couple of decades ago, that the healthcare industry would have made this much of advancement in medical care. This achievement is healthcare is achieved due to the focus on evidence based practice and the proper dissemination of research results among the policy makers and healthcare professionals. The advancement in information technology also has played an important role to that extent.

 Even though central line associated blood stream infections are considered to be one of the lethal infections among the healthcare associated infections, if proper precautions are taken on a timely manner it is found to be a preventable infections. To achieve this goal the healthcare professionals should comply with the best practices of nursing care throughout their career. Along with that nurses should focus more on evidence based practices to achieve more knowledge about the new innovations in healthcare in preventing catheter related infections and other diseases. The enthusiasm of a nurse professional to learn about the latest available evidence based practice and their ability to apply that knowledge towards the nursing practice for the safety of the patients will improve their nursing morale and public trust. The current study aimed at reducing the catheter related infections in healthcare setting by practicing the bundle care concept and the proposed changes were based on the identification of pathogenesis of the infection. Nurses play an important and frontline role in providing patient care. They have an important role in reducing the catheter related infection in patients and there by assist the CDC in achieving their aim of zero catheter infection rates in healthcare facilities by complying to the protocols bundle care concept while providing nursing care to the patients with catheter.

Review of Literature

Akridge, J. (2011). Preparation and dedication prevent central line infection. Healthcare     

           Purchasing News, 35(6), 36-44.Retrieved from EBSCOhost.com

               Article focuses on the importance of implementing the bundle techniques in reducing central line infection in patients. The article also focuses on the use of a checklist along with bundle care in improving the quality of care provided to the patients. This result is significant to nursing practice as it proves that bundle care produces better patient out come

Chua, C., Wisniewski, T., Ramos, A., Schlepp, M., Fildes, J., & Kuhls, D. (2010).

Multidisciplinary trauma intensive care unit checklist: Impact on infection rates. Journal of Trauma Nursing, 17(3), 163-166. doi:10.1097/JTN.0b013e3181fb38a6.Retrieved from EBSCOhost.com

   The article looks into the implementation of a multidisciplinary checklist while providing the bundle care to patients to reduce the various types of infection and its complications. One of the limitations of the study was that the researchers were not able to analyze the documents that gave details about the preventive behavior practiced in the healthcare setting before the current study was conducted. One of the advantages of the study was that it placed each and every team member of the multidisciplinary team responsible for implementing the bundle care to patients and reduces the blood stream infection rates in patients. The results from the current study shows that even though all the members of the members play an important role in infection control, the nurses play a pivotal role in reducing blood stream infections.

Dilek, A., Ulger, F., Esen, Ş., Acar, M., Leblebicioglu, H., & Rosenthal, V. D. (2012). Impact

          of education and process surveillance on device-associated health care-associated   

           infection rates in a Turkish ICU: Findings of the international nosocomial infection

           control consortium (INICC). Balkan Medical Journal, 29(1), 88-92.  

           doi:10.5152/balkanmedj.2011.028 Retrieved from EBSCOhost.com

              The article is trying to analyze the impact of healthcare associated infections from invasive medical devices in ICU particularly the central line infection. A prospective study was conducted in a medical surgical ICU of the University hospital in Turkey. The study showed that a educating the healthcare professionals about the importance of implementation of bundle care and applying surveillance program to evaluate the application of bundle care has a positive impact on reducing the rate of central line infection in patients.

            One of the limitations of the study was the design format of the study did not allow the researcher to make an accurate determination that the epidemiological mechanism s were the sole responsible factor for the striking decline in infection. The study has shown that providing basic education about infection control to health professionals, applying bundle care and providing proper feedback on infection can assist in reducing the rate of blood stream infections especially the central line infections. These results could be applied in nursing practice to improve the patient safety.

Earsing, K., Hobson, D., & White, K. (2005). Best-practice protocols: Preventing central line    

           infection. Nursing Management, 36(10), 18-18, 20, 22.Retrieved from EBSCOhost.com

            The article describes the issues related to central line infections and the best practices protocols to be followed in reducing the incidence of central line infections. The study was conducted to analyze the steps taken in Johns Hopkins Hospital to reduce the chances of infection. The study showed that the application of bundle care to patients drastically the central line infection over a period of six years. With the new implementation of bundle care the blood stream infection rates were brought well below the national level. This result is significant to nursing practice as it proves that bundle care produces better patient out come.

East, D., & Jacoby, K. (2005). The effect of a nursing staff education program on compliance

with central line care policy in the Cardiac Intensive Care Unit. Pediatric Nursing, 31(3),

182. Retrieved from EBSCOhost.com

The article is about the importance of staff education reducing the chances central line infection incidences in patients. The study was conducted in the south-west region of United States. The study showed an additional an educational program provided to the participants had a positive impact on them to comply with central line care policy adopted by the institution. One of the major limitations of the study was that the small sample size used for the study. The small number of sample size might be a hindrance in generalizing the result of this study. Even then the results from this study show that continuous staff education and annual competency evaluations should be conducted among nurses to reduce the incidence of central line infection in patients which in turn will improve patient safety and promote best practices among nurses.

Hadaway, L. (2006). Keeping central line infection at bay. Nursing, 36(4), 58-64. Retrieved from

EBSCOhost.com

The article defines the issues related to central line infection and also describes about various interventions that could be taken to prevent the occurrence of central line infection in patients. The article clearly explains how the central line infections occur in patients and the various measures that need to be taken to reduce the chances of infection. It clearly explains the benefit of protecting patients from central line infection and the need of educating nurses and other health care professionals about the need of applying bundle care to reduce the occurrences and controlling central line infection. The use of modern technologies and equipments is highly recommended. The study points out that the latest nursing and medical strategies assist the nursing professionals in reducing the incidence of central line infections.

Harnage, S. (2007). Achieving zero catheter related blood stream infections: 15 months success

             in a community based medical center. Journal of the Association for Vascular Access,

 12(4), 218-224. Retrieved from EBSCOhost.com

                 The article focuses on a study to identify the measures that helped to reduce blood stream infection rate to 0% during a period of fifteen months. The study was conducted in a community based medical center and a randomized quantitative design was used. One of the major strengths of this study is that the components of the bundle packs were analyzed as a bundle pack and individually to identify their effect in reducing the central line infections in patients. One of the limitations of the study was that the inability of researchers to correctly measure the incidence of blood steam infections in the first year of study.

                 The study showed that the incidences of central line infections are reduced to a nominal level when the various components of the bundle care are applied together than when they are applied individually. This result from this study is important to the nursing profession as it proved that combining various components of bundle care delivers a better outcome for the patient by reducing the incidence of central line infections.

Jackson, A., & Cooper, S. (2012). Zero central-line infections in a 550-bedded district general

           hospital. British Journal of Nursing, S24-8. Retrieved from EBSCOhosst.com

              The article describes the issues related to central line infections and the various new interventions that are developed globally to reduce the occurrence of infection. The study was conducted in a five fifty bed general hospital. The study found that application of bundle care along with the implementation of surveillance techniques which is used to report the occurrence of central line infection is a better intervention in reducing the occurrences of central line infections in patients. The study is significant to nursing practice as one could see that clubbing of multiple interventions is better in controlling central line infections and in improving patient safety.

Kaye, K. S., Marchaim, D., Chen, T., Chopra, T., Anderson, D. J., Choi, Y., & Schmader,

       K. E. (2011). Predictors of nosocomial bloodstream infections in older adults. Journal   

       of the American Geriatrics Society, 59(4), 622-627. doi:10.1111/j.1532-

      5415.2010.03289.x Retrieved from EBSCOhost.com

                The article is trying to identify the various predictors of blood stream infections in older adults and tries to identify a predication model to control the infection. The retrospective case control study was conducted in hospitals that came under the Duke Infection Control Outreach Network. The study identified various risk factors that might contribute to central line infections and the measures that need to be taken by healthcare professions to overcome these contributors. The study also compares the predictors of BSI in older adults to the general population also. The study reminds that it did not identify an intervention to decrease blood steam infection in high risk population like really aged adults.  One of the main findings from the study was that most of the blood stream infections are catheter related and the use of catheter maintenance bundle could drastically reduce the blood stream infections. This result from this study is significant to nursing profession as it proves that proper use of bundle reduces the chances of infection and improves patient safety.

McPeake, J., Cantwell, S., Malcolm G, ,., & Malcolm, D. (2012). Central line insertion

         bundle: Experiences and challenges in an adult ICU. Nursing in Critical Care, 17(3), 123-

        129. doi:10.1111/j.1478-5153.2012.00491.x. Retrieved from EBSCOhost.com

                  The article describes the issues and challenges faced by health professional related to central line infection in an intensive care unit and the measures taken to reduce the chances of infection. The study was conducted in an adult ICU in a Scottish hospital. It focuses on implementation of a multifaceted bundle care plan to reduce the incidence of central line infections. The study found that the infections could be reduced considerably by improving the reliability of the insertion bundle pack along with educating the nurses about the changes in processes measurement techniques. Study also proved that multifaceted bundle will assist in achieving zero blood stream infections in ICU which should be considered as good information for nurses and other healthcare professional. The result also proves that bundle packs assist in improving patient safety by the delivery of best available evidence practices. The study also suggest that the health professional should be ready to roll out new practices from the current bundle care practices based on the new evidences that are evolving that focus on patient safety.

Reduction in central line-associated bloodstream infections among patients in intensive care

           units — Pennsylvania, April 2001-March 2005. (2005). MMWR: Morbidity & Mortality

          Weekly Report, 54(40), 1013-1016. Retrieved from EBSCOhost.com           

               The article describes about the various inventions that need to be implemented in ICU patients to reduce the chance of occurrences of central line infection. The study was done among ICU patients in southwestern Pennsylvania. The study found out the importance of providing bundle care to patients in reducing the occurrence of central line infection. The findings are important to the nursing practice and patients as it showed that the simultaneous application of various components of bundle care results in a better outcome in patients than when they are applied separately.

Schears, G. J. (2012). Online surveys: A potential weapon against clinician non-

compliance. Journal of the Association for Vascular Access, 17(1), 38-41. doi:10.2309/java.17-1-5. Retrieved from EBSCOhost.com

The article is based on four surveys among the healthcare professional to identify the best practices that should be followed to reduce the occurrences of blood stream infections in patients. The study also analyzed factors that contributed for not maintaining the best practices to control the blood stream infections. One of the drawbacks of the study was that as this was a self assessment from the participants there is a great chance that the participants have under reported the non-compliance. As this was an anonymous survey that was conducted online there is an increased chance of accuracy in information provided by the participants and it should be considered as an advantage of the study.  The study showed the if proper measures are taken on time central line infections could be reduced to a great extent and this shows the importance of maintaining best practices in nursing profession. 

Smith, N. (2010). CNE: Continuing nursing education. Prevention of hemodialysis central line-

associated bloodstream infections in acutely ill individuals. Nephrology Nursing Journal,

37(5), 523-529. Retrieved from EBSCOhost.com

                 The article focuses on the measures taken in a Pacific Northwest medical center in reducing the chances of central line infections in patients. It focuses on the need of continuing education since 1960’s for nurses to keep up with the standards of central line care policy. Even though the article does not provide any statistical description, it mainly describes about the various steps for employee motivation which eventually focus on improvement of patient care. It also focuses on the various components of bundle care and describes the importance of each component in reducing incidence the central line infection. The article clearly explains to the readers that implementing various components of bundle care in nursing care reduces the chances of central line infection and thereby improving patient safety.

Tarricone, R., Torbica, A., Franzetti, F., & Rosenthal, V. (2010). Hospital costs of central line-

associated bloodstream infections and cost-effectiveness of closed vs. open infusion

containers. The case of Intensive Care Units in Italy. Cost Effectiveness & Resource Allocation. doi:10.1186/1478-7547-8-8. Retrieved from EBSCOhost.com

The aim of the study was to evaluate the healthcare cost associated with central line infection. Along with that the study also aimed to evaluate the cost effective ratio while using open infusion containers and closed infusion containers. A prospective case control study conducted in a 500 bed hospital for a period of two years in Italy and 1446 patients were enrolled for the study. The prospective case control study gives more accuracy for the results even though it is more expensive than other modes of research methods.

The study gave a clear picture of the health care cost associated with central line infection within the study population along with the options to compare the health cost related to central line infections in other populations. The study also found that closed infusion containers show improved effectiveness in controlling the chances of central line infections. It is also found that central line infections increase burden on both hospitals and patients by increasing the duration of hospital stay for patients. The results showed that strategies taken to reduce the chances of reducing the central line infection improved the patient outcome and also played an important role in reducing hospital expenditure.

Vital signs: central line–associated blood stream infections — United States, 2001, 2008, and

         2009. (2011). MMWR: Morbidity & Mortality Weekly Report, 60(8), 243-248. Retrieved

         from EBSCOhost.com

               The article discuss about the severity of central line infections in US healthcare market and the financial burden it puts into the lives of the general population. The article points out the efforts taken to educate the healthcare professionals about the importance of preventing central line infection and the introduction of bundle care packs have assisted in dramatically reducing the occurrence of central line infections. It also suggests about the need of proper monitoring and feedback on the improvement Article reinstates the need on continuous improvement of safety culture in healthcare settings in improving patient safety. One of the limitations of this study is that estimates were calculated rather than measured directly. Another limitation of this study could be that measures were not taken to verify whether institution reported this study is all the central line infections. This study is significant to musing practice as it reconfirmed the fact that even though central line infections are serious, they could be prevented by the application of various medical and nursing strategies.

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                                                                 Appendix A

Letter of Intent

MS Lisa Dowd

     Director of Nursing

     Dr. William O’ Benenson Rehabilitation Pavilion

     Flushing NY 11354    

     Ph:718 888 5200

Dear Ms Dowd,

    I am a student of Grand Canyon University, Arizona, pursuing my BSN-to-RN program. As a part of my education program I am required to conduct an educational intervention among nurses to identify the benefits of practicing bundle care concept in reducing the central line infection in adult patients. To this extent I am requesting your permission to conduct an in-service program presentation nurses in my unit. The in-service will include a PowerPoint presentation along with a pre and post evaluation review among the participants to analyze their attitude and response to the bundle care concept. A questionnaire will also be provided at the end of the presentation to analyze the knowledge earned by participants from the in-service program.

Thank you,

Sincerely

Appendix B

Pre Assessment Questionnaire

                                                                     How often you hear about Central line associated blood stream infection?  Please check mark the correct.              Always                 Frequently               Sometimes            Never
  Do you support the idea of blood sampling from CVC line?                            Yes                          No                Depends on each case                                                                         
  How often do you think the dressing for CVC should be changed? Please check mark.                 Three Days                           Weekly                During CVC removal         As needed  
  Anti Sepsis used for cleaning CVC site              Chlorohexidine Swab               Alcohol                Other                N/A  
  Frequency at which CVC care should be done? Please check mark the correct              Based on Physician order                     Daily            Whenever needed                                                 No Protocol  
  Cleaning Technique used during CVC care              Sterile Cleaning technique              Regular cleaning technique  
Please rate the staff compliance to CVC care (0-4) No complianceLittleMostlyExcellent   
Please rate the physician’s compliance during catheter insertion (0-4) No complianceLittleMostlyExcellent     

Appendix C

Evaluation of the Presentation

Achievement of the ProgramUnsatisfactory    Average     Good     Excellent
 How informative was the presentation?1           2                3                 4             5    
Identify the benefits of Bundle care concept1           2                3                 4             5    
Nurses role in promoting Bundle care concept1           2                3                 4             5    
B)Rate the knowledge level of the presenter  1           2                3                 4             5    
C)Clarity to follow the presentation  1           2                3                 4             5    
D)Easiness to follow the presentation  1           2                3                 4             5    
E)Rate the method implemented for teaching  1           2                3                 4             5    
F) Was the content relevant to the subject  1           2                3                 4             5    

Appendix D

Questionnaire

Describe the pathogenesis for CVC infection?   How often Central Line review should be performed?     Explain whether there is any relationship between the number of catheter days and site selection to CVC related infection?    Explain Maximum barrier precaution?     Explain bundle care concept for CVC care?   Explain the benefits of preventing CLABSI in patients?     Do you think the new policy could be implemented successfully?

Appendix E

Patient Name:  Medical Record #Age:CVC Insertion Date
Name of nurse who Performed care Name of the physician who performed Catheter Insertion 
 Please put (ü) for interventions performed, “X” for interventions NOT performed and “N/A” for interventions not required. 
Proper Hand Hygiene   
Practice Maximum   Barrier Precautions   
Wearing Gown   
Wearing Gloves   
Wearing Mask   
Wearing Cap     
      3)Use of Chlorohexidine                Rubs     
       4)Central line review   
       5) # of Catheter Days-          Please enter a number   
Signature of The designated person Name of the Person 

Appendix G

Patient Review

Please put (ü) for the respective answers  YesNoSomewhat
Where you aware about CVC infection and prevention care before your admission?     
Where you provided with CVC education after admission?     
Did the medical staff including the physician follow the aseptic guidelines as discussed in the PowerPoint?     
Did every healthcare professional practiced proper hand hygiene procedure before accessing CVC?     
Were you aware of the symptoms of CVC infection     
How satisfied are you with the physician regarding the CVC care provided? (Please rate between 0 to 5; 5 being the highest )   
How satisfied are you with the nurse regarding the CVC care provided? (Please rate between 0 to 5; 5 being the highest )   
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