Evidence-Based Practices, No CLABSIs Achieved Through Quality Improvement

Staff turnover was another problematic issue. Newly hired CNAs lacked acute care experience and knowledge regarding the importance of bathing patients daily. A bathing competency was created to assure bed baths were completed correctly. Current guidelines for care of oncology patients with CVADs recommend washing daily with chlorhexidine gluconate (CHG). This was not the current practice on the unit and was therefore incorporated into the implemented changes.

A sudden increase in CLABSI rates was also previously noted by the hospital’s intensive care unit (ICU) team. After the hospital’s ICU team met with the unit’s leadership team to share their success in reducing line infections, the ICU team also instituted CHG bathing per evidenced-based practices described in the literature.⁴

The nurse survey identified several other variances in central line access device care practices: use of sterile vs clean gloves, frequency of IV tubing changes, and overall frequency of central line dressing changes and changes if nonocclusive or soiled. After the survey was completed, the VAD team presented the questionnaire with the correct answers and the survey results, thus educating the staff about current policy and national recommendations.

Central line auditing for each shift ensued to assure all basic measures were being followed, including central line tubing and dressing changes, as well as daily CHG bathing and bed linen changes. Real-time conversations occurred with the staff to identify barriers to optimal line care and opportunities to educate patients about the new bathing process. As part of the bedside report process, staff noted the central line dressing integrity and date change, the IV tubing label, and confirmed the patient bathed with CHG.

The leadership team rounded to assure bedside report occurred and addresse any deviations in real-time. Bedside shift report was identified as one of the critical factors to the overall communication process about central line management. The team discovered many staff avoided morning bedside shift report in fear of waking the patient. 

The most influential component of the project was bringing the unit’s CLABSI rate to the forefront. When the issue was first identified, a real patient story and the significant impact the CLABSI had had on the patient, his family, and the unit was shared in a staff meeting. An important factor was to include all float staff in communications to assure that they, too, understood the new processes that were being implemented on the unit. This was accomplished by talking about the number of days since the last CLABSI in the unit huddles held before each shift. Float staff were identified and taught the new bathing process to assure they were in align with the unit’s implementation of evidenced-based standards. A Gemba board was posted next to the unit time clock, showing the number of days since the last CLABSI and current quality data reflecting the evidence and policy-based line care on the unit. Soon, even the patients walking on the unit were drawn to the board and congratulated the staff on the work that was being done to prevent CLABSIs.