Running head: PREVENTING CLABSIS 1

Preventing Central Line Associated Bloodstream Infections:

The Significance of Care Bundles in the Intensive Care Setting

Erika C. Bell

Westminster College
PREVENTING CLABSIS 2

Central lines can be very useful when administering several different medications and

fluids at once, especially when in the intensive care unit. However, when a patient has a central

line, it significantly increases the risk for infection. The central line catheter provides bacteria

with the opportunity to enter the bloodstream and cause serious and sometimes fatal infections.

According to the Centers for Disease Control and Prevention (2011), central line

associated bloodstream infections (CLABSIs) are defined as serious infections that occur when

pathogens enter the bloodstream through a central line. These infections cause thousands of

deaths every year. The mortality rate for central line infections ranges between 4% and 20%,

with the average cost per CLABSI reported around $45,685 per patient (Bakdash, Drews, &

Gleed, 2017). However, the incidence of central line associated bloodstream infections in the

ICU has decreased significantly in the past 5 years. This dramatic decrease in the number of

CLABSIs can be attributed to the CLABSI bundle, which is a set of guidelines created by the

Center for Disease control (along with other organizations), which has been proven to

significantly decrease the incidence of central line infections.

The CLABSI bundle is the current standard of care when it comes to prevention of

central line infections. The bundle contains several different components including checklists for

the insertion, maintenance, and removal of central lines. For example, the checklist requires that

central line catheters be inserted using sterile technique and that a sterile dressing be placed over

the insertion site. The CLABSI bundle checklist also states that central line dressings be changed

immediately if they become wet or soiled. Some other recommendations include: changing the

IV tubing anywhere between 4-7 days, bathing ICU patients with chlorhexidine every day, and

scrubbing the access port with alcohol before every use.

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Although the CDC has created this set of guidelines to prevent the incidence of infection,

some hospitals are choosing to enforce additional requirements to try to reduce the risk further.

For example, an inpatient pediatric oncology unit in the Intermountain West has implemented

specific protocols based on research that was conducted on their own unit. By doing a five-year

study, researchers were able to identify the specific pathogens that were causing a majority of

CLABSIs. In this specific patient population, the most common pathogens were viridans group

streptococci and coagulase-negative staphylococci (Linder, Gerdy, Abouzelof, & Wilson, 2017).

With this information, they were able to conclude the organisms causing the infections were

commonly found on the skin or from the GI tract. Taking this into account, the project team

created a 1-2-3 mnemonic which reminded patients that they needed to take one shower, brush

their teeth twice, and get out of bed three times daily (Linder, et al., 2017). In addition to this,

patients also were required to have their linens changed every day. The thought behind this was

that by reducing the amount of pathogens on the patient’s skin and surroundings, the risk of

getting a central line infection would significantly decrease.

This protocol was implemented in addition to the current CDC recommendations

regarding central lines. This specific study concluded that the introduction of the new protocol

significantly reduced the amount of central line infections. Before the CDC bundles or new

protocol was introduced, the total number of CLABSI events was 156. With the implementation

of the bundles alone, the number of CLABSI events dropped to 44. Finally, with the addition of

the new protocol and the bundles, the number of CLABSI events decreased to 39 (Linder, et al.,

2017).

Another study conducted at Alder Hey Children’s Hospital in Liverpool, England yielded

similar results, which further strengthens the validity of the current practice related to this issue.
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This study was over a period of three years, during which researchers implemented a central

venous line care bundle that was very similar to the CDC care bundle. The central venous line

care bundle emphasized the importance of hand hygiene, catheter site inspection, dressing,

catheter injection ports, catheter access, and administration set replacement (Melville & Paulus,

2013). More specifically, the bundle required hand washing both before and after patient contact,

hourly inspections of the catheter site for signs of infection, maintenance of a clean and dry

dressing, scrubbing ports with alcohol prior to access, and the replacement of the administration

set per hospital protocol.

Using an audit system, the research concluded there was a decrease of over 50% in

CLABSI rates from the first year following implementation to the third year of the study. This

study was able to further confirm the efficacy of central line bundle kits in reducing central line

infection rates.

In addition to the studies that focus on the efficacy of the care bundles themselves, there

have also been studies conducted which emphasize the importance of how the bundles are

implemented into the care setting. For example, one study that was conducted at St. Jude

Children’s Research Hospital talked about how they used a technique called leadership rounding

to successfully implement and sustain CLABSI prevention. The leadership line care rounds were

conducted on inpatient units using an audit tool to evaluate how well the nurses were complying

with the tasks of the care bundles. There was a team established that included an infection

“preventionist”, line care nurse, nursing quality staff, CLABSI physician, and the unit nurse

manager (Owings et al., 2017).

During the leadership line care rounds the team would directly observe the nurse to

ensure the CLABSI bundles were being implemented properly. After this observation, they
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would be able to provide either positive feedback or constructive criticism to the nurse about

how they could improve for the next time. Not only would the team directly observe the nurse

providing the care, but they would also set aside time to meet with the nurses in private, which

gave the nurses a chance to ask questions and share concerns they may have about the care

bundles. By providing a safe space, patient caregivers were able to report barriers to the

successful implementation of the care bundles. This study was able to conclude that not only

were the care bundles an effective way to reduce CLABSIs, but that the leadership line care

rounds also significantly contributed to the decrease of infections (Owings et al., 2017).

Another similar article also addressed the importance of how the bundles were

implemented rather than whether or not they were effective. A study that took place in a surgical

ICU implemented central line care bundles using a technique called peer tutoring. The peer

tutoring was defined as a “learning by teaching” method in which staff members were able to

learn a skill, and then teach the skill to one of their peers. The idea behind this is forms of active

learning are more beneficial than passive learning. In fact, this study was able to conclude that

90% of the content of a specific subject was retained when a person tried to teach the

information to someone else (Park, Ko, An, Bang, & Chung, 2017).

Healthcare providers in this study were also provided with a chance to talk to their

administrators about concerns or questions they had regarding the implementation. By having

this opportunity to express concerns, changes were made to increase the efficacy of the bundles.

Overall, the study concluded that peer tutoring was an effective way to implement central line

bundles and reduce CLABSIs (Park et al., 2017)

Regarding cultural barriers pertaining to the implementation of central line bundles, I was

not able to find much information. I do not believe there would be any strong cultural or ethical
PREVENTING CLABSIS 6

dilemmas when it comes to preventing central line infections. The only impacts on the patient I

can think of are positive and include decreased length of hospital admission, decreased amount

of money in hospital bills, and an overall decrease in patient mortality rate.

Currently these recommended guidelines are being implemented in this clinical area. In

fact, one of the studies I have already referenced and summarized earlier was conducted at

Primary Children’s Hospital in Salt Lake City (Linder et al., 2017). In addition to this study, I

was able to find another one, which was conducted in Salt Lake City at the VA Medical Center

that I referenced previously (Bakdash et al., 2017).

Not only have I been able to find studies related to this topic that have happened in this

area, but I have been able to see the implementation firsthand at my work and in various clinical

settings. Prevention of central line infections using care bundles has become the standard of

practice at every hospital where I have had a clinical. Several hospitals have set up their own

protocols and even have certain checklists that they use to ensure proper implementation of

cares. At the hospital I work at, accountability is maintained using an audit system in which a

member of the clinical staff is able to come around to certain nurses to make sure that protocol is

being followed properly.

Although the care bundles are an effective way to reduce the risk of acquiring a central

line infection, there are some potential barriers that may affect adherence and compliance with

recommended protocol. One barrier would be how time consuming and numerous the bundle

cares can be. It could be difficult for a nurse to have to fit these cares into their already busy

schedule during the shift. Another potential barrier would be lack of experienced nurses. Having

to perform a sterile dressing change is a very complex task that requires precision and practice.
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Overall, central line associated bloodstream infections can be extremely serious and even

life threatening. The current recommendation for prevention of CLABSIs includes the

implementation of central line care bundle kits. Current research has been able to prove that

these care bundles are successful at decreasing the incidence of central line infections, which has

also been able to decrease patient mortality rates.

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References

Checklist for CLABSI12-11 - Centers for Disease Control ... (n.d.). Retrieved November 28,

2017, from

https://www.bing.com/cr?IG=F48F493839CB40A19077E6DDA313261A&CID=015A4

080E5B16FE412434BC8E4B76E6F&rd=1&h=P2wWh2iXebBxhD6u3qiMr4okWkoQw

aa3Dn4TgS_dcdc&v=1&r=https%3a%2f%2fwww.cdc.gov%2fHAI%2fpdfs%2fbsi%2fc

hecklist-for-CLABSI.pdf&p=DevEx,5067.1

Drews, F., Bakdash, J., & Gleed, J. (2017). Improving central line maintenance to reduce central

line-associated bloodstream infections. American Journal of Infection Control,45, 1224-

1230. Retrieved November 27, 2017, from www.ajicjournal.org.

Healthcare-associated Infections. (2010, April 01). Retrieved November 28, 2017, from

https://www.cdc.gov/hai/bsi/clabsi-resources.html

Linder, L., Gerdy, C., Abouzelof, R., & Wilson, A. (2017). Using Practice-Based Evidence to

Improve Supportive Care Practices to Reduce Central Line–Associated Bloodstream

Infections in a Pediatric Oncology Unit. Journal of Pediatric Oncology Nursing,34(3),

185-195. Retrieved November 27, 2017, from

http://journals.sagepub.com/doi/10.1177/1043454216676838

Melville, S., & Paulus, S. (2014). Impact of a central venous line care bundle on rates of central

line associated blood stream infection (CLABSI) in hospitalised children. Journal of

Infection Prevention,15(4), 139-141. Retrieved November 27, 2017, from

http://www.sagepub.co.uk/journalsPermissions.nav

Owings, A., Graves, J., Johnson, S., Gilliam, C., Gipson, M., & Hakim, H. (2017). Leadership

line care rounds: Application of the engage, educate, execute, and evaluate improvement
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model for the prevention of central line–associated bloodstream infections in children

with cancer. American Journal of Infection Control. Retrieved November 27, 2017, from

http://www.ajicjournal.org/article/S0196-6553(17)31038-6/fulltext

Park, S., Ko, S., An, H., Bang, J., & Chung, W. (2017). Implementation of central line-associated

bloodstream infection prevention bundles in a surgical intensive care unit using peer

tutoring. Antimicrobial Resistance & Infection Control,6(103). doi:10.1186/s13756-017-

0263-3