Staff attitudes towards checklists/guidelines for central line placement

Background: As part of an effort to improve a comprehensive central line infection prevention program, guidelines including a checklist were introduced in September 2009.  Other measures included antibiotic coated catheters (November 2009), minimization of blood cultures drawn through lines (February 2010), and daily documentation of medical necessity of a central line (June 2010).  Previous steps included use of ultrasound guidance for insertion, certification for inserters, use of chlorhexidine sponges, appropriate maintenance of catheters, transparent dressings, and removal of unnecessary lines.

Objective:  Assess attitudes towards the checklist/guidelines and address staff concerns to increase compliance with a goal of decreasing central line associated blood stream infections (CLABSI).

Methods: Web-based survey sent to nurses and providers who participate in line insertion. The inclusion criterion was participation in central line insertion in the preceding year. The survey was composed of questions exploring attitudes towards the checklist/guidelines and a quiz testing knowledge of the guidelines.

Results: The survey was sent to 970 nurses and 298 physicians. The inclusion criterion was fulfilled for 168 respondents. The responses from 94 nurses (9.7%) and 59 physicians (19.8%) were analyzed. Results are presented in Table 1. All nurses and 93.2% of physicians were aware of the guidelines, but 13.8% of nurses and 7% of physicians did not correctly understand the need for hat, mask, and full body draping during insertion. All other elements of the guidelines were correctly identified by 96.8-100% of respondents. The checklist was known to 97% of nurses and 89.5% of physicians. Significantly more nurses (77%) than physicians (45.1%) reported always using the checklist (p<0.001) with 100% of nurses and 80.4% of physicians considering that the checklist applied to them. The most common reasons for not using the checklist included patient too sick, time, difficulties finding the checklist, staffing issues, and forgetting. The checklist was felt to decrease errors by significantly more nurses (62.2%) than physicians (38.6%) (p=0.009). Compliance with the guidelines was felt to be improved by use of the checklist for 89.2% of nurses and 80.4% of physicians. The impact on patient safety was considered positive by 78.4% of nurses and 87.5% of physicians. Despite this, 50% of nurses and 37.5% of physicians felt that it contributed more to administrative burden than quality care. Transgressions were seen by 72% of nurses, but 87.8% felt comfortable enforcing the guidelines. The checklist was felt to help recall of the guidelines for 74.5% of physicians, 36.8% modified their practice in response, and 57.9% thought adherence can reduce infection.

Conclusions: We identified opportunities to improve knowledge of and adherence to the checklist/guidelines as part of a comprehensive strategy to decrease CLABSI.