Nursing Knowledge and Practice in Prevention of Central Line Associated Bloodstream Infections Outside the ICU: From Survey to Computer Based Teaching Module

Background: Central line associated bloodstream infections (CLABSI) in hospitalized patients lead to increased length of stay, morbidity and mortality. Interventions have previously focused on central line insertion, especially in the ICU setting. We focused on central line care and maintenance post insertion by assessing the knowledge and practices of nursing staff in prevention of CLABSI on patient units outside the ICU. Objective: 1) Determine nursing knowledge gaps with regard to central line care and maintenance, 2) Create best practice guidelines for line care and disseminate this information to nursing through various educational interventions, 3) Measure the effect of education and feedback of CLABSI rates on the mean rate of CLABSI. Methods: Thirty eight non ICU units at six hospitals in the Rochester, NY area participated in the project. The approach consisted of: 1) A survey of nurses' observations of central line insertion procedures and of their practices in maintaining and accessing central lines, 2) Observation of nurses’ practices in line maintenance and access, 3) Review of existing hospital policies, and 4) Creation of a best practice “Line Care Protocol” based on deficiencies identified in the survey and in hospital central line care policies. Educational interventions included Nursing Grand Rounds followed by a computer based training (CBT) module. Data on central line related bloodstream infections was collected during the 18 months of the project and results were shared with each unit on a quarterly basis. Results: 217 nurses responded to the survey. Major gaps in knowledge and practices identified:  67% stated that they changed the semi-permeable dressing within 5-7 days, 46% used the proper method of cleaning the insertion site with 2% chlorhexidine, 34% either did not pay attention or only swiped once the central line needleless access device before accessing, while only 18% scrubbed the needleless access device for 10 seconds, and 80% changed the device at the recommended frequency. All hospital policies lacked detailed information on central line access, and they did not address assessment of continued line necessity. Audits of the nurses’ practices identified cleaning of the needleless access device as one of the major deficits. Preliminary results after the initial education and feedback of CLABSI rates and before the full implementation of the CBT on all units, showed a drop of the mean of CLABSI rate from 2.81/1,000 line days (46 infections in 16,300 line days, 95% CI 2.0-3.6) to 2.1/1,000 line days (32 in 15,300 line days, 95% CI 1.4 – 2.8) though this did not reach statistical significance. Conclusions: Shifting the focus from central line insertion to line care and maintenance, and targeting nursing for education are both important measures for reducing CLABSI rates in units outside the ICU.