linking blood stream infections to intensive care nursing context of care and process

April 21, 2023 1

Linking Blood Stream Infections to Intensive

Care Nursing Context of Care and Process

Jill A. Marsteller, PhD, MPP; J. Bryan Sexton, PhD, MA; Yea-Jen Hsu, MHA, PhD Candidate; Chun-Ju

Hsiao, PhD, MPH; David Thompson, DNSc, MS, RN

Funded by the Interdisciplinary Nursing Quality Research Initiative, a national program of the Robert Wood Johnson Foundation

Unpublished data—Not for circulation

April 21, 2023 2

Background Central-Line Associated Blood Stream Infections

(CLABSI) are among the most common and most serious types of hospital-acquired infections

Between 9,600 and 20,000 patients are estimated to die from CLABSIs annually in the US

The estimated cost of treating CLABSIs ranges from $296 million to $2.3 billion

The risks for CLABSIs are especially great for patients in ICUs, 48% of patients in ICUs have indwelling central venous

catheters Approximately 15 million central line days per year in U.S.

ICUs CLABSI are most often preventable


April 21, 2023 3

How was this different from Keystone ICU? Pronovost et al. 2006 NEJM reported

results of Keystone ICU project in Michigan ICUs (also New Yorker article)

This project was different because: Randomized controlled trial Acknowledged the key nursing role Collected contextual measures

Team Checkup Tool and interviews w/ teams NQF nursing quality measures


April 21, 2023 4

Study Population 45 adult ICUs in 35 hospitals across two affiliated faith-

based health care systems (East n=35 ICUs and West n=10) The hospitals included in this study represent 12 states and

are all community non-profit religious hospitals Religious hospitals provide health care for one-fifth of all

Americans


April 21, 2023 5

Adventist-QSRGICU Patient Safety Intervention

Comprehensive Unit-based Safety Program (CUSP)

CLABSI-Prevention Bundle


April 21, 2023 6

CUSP Evaluate the culture of safety Educate the staff on science of safety Encourage staff to identify how the next patient

might be harmed Assign an executive to adopt the unit a) Learn from one system defect in the work

environment per month; b) Implement one teamwork tool every 2 months (daily goals; morning briefing; shadowing; culture check up)

Re-evaluate culture


April 21, 2023 7

CLABSI Prevention Washing hands before inserting a central

line Removing unnecessary lines Cleansing the site with chlorhexidine Using full barrier precautions Avoiding the femoral site for line

placement (some preference for the subclavian site)


April 21, 2023 8

Study Design Phased, clustered randomized

controlled trial ICUs randomized by hospital into

intervention (23 ICUs) and control (22 ICUs) conditions for the first seven months (then control became Intervention II)

Analyses: test of the intervention


April 21, 2023 9

Conceptual Framework

StructureProcess

OutcomesBeds ize

Skill M ix*

Previous Exposure to Intervention

*NQF Nurs ing Quality Indicators

Fidelity to CLA BS I

Bundle

Fidelity to CUS P

Nurs ing Hours per Day*

Activities o f Q I Team

CLABS I infections*

Annual Nurse Turnover*

ContextSAQ

Nurs ing Prac tice Env ironment*Implemen tation Barr iers / Fac ilita tors


April 21, 2023 10

Data Collection and Measures Laboratory Confirmed CLABSI andLine

Days Team Check-up Tool Nursing turnover, skill mix, RN hours per

patient day, PES-NWI SAQ Exposure to elements of the intervention ICU Length of stay ICU Mortality ICU Charges


April 21, 2023 11

RCT analysis Intervention I group started March 2007 Control group started the intervention in

Oct 2007 RCT compares post-intervention (Oct-Dec

2007) CLABSI rate, holding baseline (2006) rates constant (zero-inflated poisson regression)

Two groups equivalent at baseline on all measures except two (exposure to CUSP and to partnership with a senior executive)


April 21, 2023 12

The Effect of the Intervention: Model 1

IRR (95% CI) P valuePoissonIntervention status Control group 1.00 Intervention group 0.19 (0.06 to 0.58) 0.004

System East 1.00 West 10.38 (2.96 to 36.34) 0.000

ln(Baseline CLABSI rate+1) 0.95 (0.57 to 1.58) 0.844 Coef. (95% CI) P valueLogit Volunteer system East West 66.56 (62.05 to 71.06) 0.000

No. of ICU beds 1-10 >10 98.04 (90.87 to 105.22) 0.000

Baseline CLABSI count -32.38 (-34.63 to -30.14) 0.000constant -18.02 (-21.90 to -14.14) 0.000Model fit AIC 84.2 BIC 98.6

Vuong test 0.006


The Effect of the Intervention: Model 2

April 21, 2023 13

IRR (95% CI) P valuePoissonIntervention status Control group 1.00 Intervention group 0.31 (0.10 to 0.92) 0.035

Volunteer system East 1.00 West 6.37 (2.33 to 17.40) 0.000

Exposure to ECUSP 0.75 (0.84 to 1.16) 0.193Partnership with an ICU by a senior executive for the BSI-reduction effort

0.87 (0.62 to 1.22) 0.408

ln(Baseline CLABSI rate+1) 1.03 (0.62 to 1.72) 0.908 Coef. (95% CI) P valueLogit Volunteer system East West 67.26 (62.52 to 72.01) 0.000

No. of ICU beds 1-10 >10 98.72 (91.85 to 105.58) 0.000

Baseline CLABSI count -31.82 (-33.88 to -29.76) 0.000constant -19.49 (-24.09 to -14.88) 0.000Model fit AIC 84.8 BIC 102.9

Vuong test 0.002


April 21, 2023 14

No. of Bloodstream Infections per 1000 catheter-Days

BaselineAfter

implementation

Median (interquartile range)

Overall 1.89 (0.72 - 4.18) 0.00 (0.00 - 2.48)

Intervention status

Control 1.78 (0.00 - 3.80) 0.00 (0.00 - 2.89)

Intervention 2.56 (0.74 - 5.87) 0.00 (0.00 - 1.50)

System

East 1.67 (0.29 - 3.80) 0.00 (0.00 - 2.48)

West 3.77 (1.03 - 7.12) 0.00 (0.00 - 5.66)


April 21, 2023 15

Quarterly BSIs per 1000 line days

Intervention 1 (n=23) Intervention 2 (n=22)

BSI rate IRR % of reduction BSI rate IRR

% of reduction

Baseline (2006) 4.48 1.00 2.71 1.00

Mar 07 4.71 1.05 5% -

1st Q (Apr-Jun 07) 1.12 0.25 -80% -

2nd Q (Jul-Sep 07) 1.83 0.41 16% -

3rd Q (Oct-Dec 07) 1.33 0.30 -11% 2.16 0.79 -21%

4th Q (Jan-Mar 08) 0.96 0.21 -8% 0.56 0.21 -59%

5th Q (Apr-Jun 08) 0.88 0.20 -2% 0.52 0.19 -2%

6th Q (Jul-Sep 08) 0.85 0.19 -1% 0.83 0.31 12%

BSI rate reduction from baseline to 6th quarter

-81% -69%


April 21, 2023 16

Challenges of the Design Controls knew they would also be

implementing In interviews, some controls told us they

had gotten started early Controls did not report during control

period—so “post” period is actually first 3 mo.s of intervention

Education delivery was better 2nd time


April 21, 2023 17

Staff Use (1)


April 21, 2023 18

Staff Use (2)


Estimated Lives Saved over 2006 ~20% of people acquiring CLABSI will die

from the infection An estimated 35 to 36 people died in 2

systems in 2006 If rate in quarter ending August 2008 stays

the same over a year, only an estimated 12 people would die of CLABSIs June 2008-May 2009

A 66% reduction

* Preliminary estimates


Estimated Cost Savings BSIs cost an estimated ~$45,000 per

infectionReduced BSIs could have saved

as much as $5,850,000 across the two systems!!


April 21, 2023 21

Conclusions The CLABSI evidence-based practice bundle

reduces bloodstream infections and zero can be achieved for long periods of time

The bundle can be implemented effectively as a nursing-driven protocol for interdisciplinary team management of central line placement and maintenance

Despite the promising results there were many barriers to implementation, such as physician engagement; adherence to protocol

Difficult to achieve team compliance with monthly reporting by all team members


April 21, 2023 22

Policy/ Managerial Implications CMS has said it will not pay for CLABSI

above the normal IPPS payment for the case starting Oct. 1, 2008 (Deficit Reduction Act of 2005)

Assumes all infections can be prevented All hospitals will need to implement

CLABSI prevention strategies QI teams need education, attention from

and support of senior management, BoD


linking blood stream infections to intensive care nursing context of care and process

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