Abstract
Central line-associated bloodstream infections (CLABSIs) can result in worse outcomes and high hospitalization cost for patients. This study aimed to assess the effectiveness of multi-department cooperation, intelligent prevention, and supervision (MDCIPS) in reducing the incidence of CLABSIs and improving the clinical outcomes of the patients. Key issues were identified through a literature review and survey on the status quo. A MDCIPS model was thus built. A total of 440 patients with indwelling central venous catheters (CVCs) were enrolled in the study. The control group (n = 219) received conventional infection-control managements, while the intervention group (n = 221) received MDCIPS interventions in addition to conventional infection-control managements. The number of CLABSIs patients, incidence of CLABSIs, average length of hospital stay, average total hospitalization cost, and disease outcomes were compared between the two groups. The intervention group had a significant reduction in the number and incidence of CLABSIs (0[0%] vs. 4[1.33%], P < 0.05). Two of the four patients with CLABSIs in the control group died. The average length of hospital stay was significantly longer in the control group than the intervention group (17 days vs. 13 days, P < 0.001). The average hospitalization cost in the control group was much higher than that in the intervention group (92.8 thousand yuan vs. 65.2 thousand yuan, P < 0.001). Patient outcome was improved in the intervention group than the control group (P = 0.001). In summary, the MDCIPS model effectively reduces the incidence of CLABSIs, alleviates the patients’ economic burden, and improves the clinical outcomes of the patients.
Supplementary Information
The online version contains supplementary material available at 10.1007/s12288-024-01760-8.
Keywords: Central Venous Catheter, Bloodstream Infection, Multisectoral Cooperation, Intelligent Monitoring, Regulation
Introduction
Central venous catheters (CVCs) offer an important vascular pathway for delivering intravenous therapy, hemodynamic monitoring, and emergency rescue in critically ill patients [1, 2]. CVC placement is an invasive procedure and usually associated with high frequency and prolonged duration of indwelling. In addition, patients requiring a CVC placement generally have severe underlying diseases. Therefore, any incidents occurring in CVC indwelling and usage may lead to central line-associated bloodstream infections (CLABSIs) [3]. CLABSIs can result in a dramatic increase in mortality, length of hospital stay, and hospitalization cost. It is of importance, therefore to reduce the incidence of CLABSIs [4–6]. At present, the primary measures to prevent CLABSIs at home and abroad include the following: deliver CLABSIs-related training, education, capacity assessment, and simulation training; use a checklist for the catheterization procedure; optimize catheter site selection; use the aseptic technique; and tighten preoperative and postoperative supervision and infection prevention [7, 8]. The combined use of several measures is the favored option under most circumstances [8]; however, a comprehensive and systematic management mode for CLABSIs has not been established. Studies have shown [9, 10] that the incidence of CLABSIs has been soaring during the COVID-19 epidemic in the past 3 years. There is an urgent need to innovate the CLABSIs management method and adopt more effective methods to reduce the incidence of CLABSIs.
The management team at our hospital has proposed a novel management mode, known as multi-department cooperation, intelligent prevention, and supervision (MDCIPS), based on a status quo survey of CLABSIs, primary cause analysis, and the rectifying measures already used. The novel management mode helps to raise the skills of healthcare workers and improve their compliance with the regulations to standardize CLABSIs prevention and control, thereby reducing the incidence of CLABSIs [11–15]. This paper reviews the application effect of this novel model at our hospital.
Methods
Subjects
This was a prospective study. Convenience sampling was performed, and the multi-department inpatient ward at a tertiary hospital (our hospital) was chosen as the study site. The inclusion criteria were as follows: ①having indwelling CVCs due to various reasons, and having been managed to prevent CLABSIs following the Guidelines for the Prevention of Intravascular Catheter-related Infections (2021 edition)[16]; ② the duration of CVC indwelling from the time of CVC placement to its removal ≥ 48 h; ③ aged ≥ 18 years; and ④ having intact case data. The exclusion criteria were as follows: ① having CVCs inserted at other hospitals; ② already having a CLABSIs upon admission; ③ combined with skin infections; and ④ having multidrug-resistant infections. According to the above criteria, 440 patients were considered eligible. Patients (n = 219) who were admitted to the hospital from July to December 2020 constituted the control group. Patients who were admitted to the hospital from January to June 2021 constituted the intervention group. The present study was reviewed and approved by the hospital's Ethics Committee (approval no. R201807). The patients were informed of how MDCIPS was implemented and gave written informed consent.
We followed the recommendations in "Administrative Measures for Drug Registration", which say that at least 100 subjects should be enrolled in each group in a blind randomized controlled trial. Assuming that the dropout rate/elimination rate was below 20%, the sample size was set to 120 in each group, totaling 240 in this study. Appropriate number of patients were included.
Interventional Procedures
For the control group, the conventional management mode (Supplemental file: The intervention procedures.) was used to supervise the implementation of the CLABSIs prevention measures among healthcare workers.
For the intervention group, the MDCIPS model was implemented to urge the healthcare workers to carry out the same CLABSIs prevention measures as in the control group. Simply saying, the MDCIPS model (See supplemental file: The intervention procedures for details) consists of the following steps:
The CLABSIs prevention procedures and guidelines in China 2021 edition was first reviewed [16]. The management status of our hospital was surveyed, we analyzed the primary causes of CLABSIs and rectified measures.
(2) An MDCIPS model for quality improvement was then proposed after the literature review [11–18] and the survey on the status quo.
MDCIPS implementation
The Dean in charge leads and guides the formation of the MDCIPS team, which is placed under the administration by the nursing team. The MDCIPS team is composed of members from the Nosocomial Infection Management, Medical Affairs, Information, General Affairs, and Science and Education Departments, the intravenous therapy nursing team, and each clinical departments (including anesthesia department, critical care department, and all other departments involved with the patients) (Table 1). CLABSIs prevention and control regulations were revised and perfected with strict adherence to the prevention first principle [19]. Then, tiered training was provided to healthcare workers based on the knowledge-attitude-belief-practice (KABP) model combined with electronic learning (E-learning) [20]. Finally, the special task of CVC placement and maintenance quality management was configured in the "Nursing Assistant" mobile app and the “Jingyi Quality Management System on the computer terminal” (Jingyi Co. Ltd., Shanghai, China). Moreover, the Plan-Do-Check-Act cycle was introduced for in-depth problem analysis, continuous improvement, and improvement tracking. The length of time with indwelling CVCs, number of cases with CLABSIs, and incidence of CLABSIs in each ward area were subjected to real-time monitoring and management via the “Blue Dragonfly Nosocomial Infection Real-time Monitoring and Management Platform V7.0” (Hunan Blue Dragonfly Network Technology Co. LTD., Changsha, China).
Table 1.
Responsibilities and Division of Labor Among Members of the MDCIPS Team
| Responsibilities | Leading department | Cooperating department |
|---|---|---|
|
1. Multidisciplinary collaboration and intelligent co-management (1) Formulate multidisciplinary, cross-departmental cooperation system and workflow to promote the communication and cooperation between the departments; (2) Fully implement national standards and requirements related to CLABSI prevention and control; (3) Revolutionize the management mode and carry out routine supervision, inspection, prewarning, and management via the information technology tools |
Nursing department | Nosocomial Infection Management, Medical Affairs, Information, and General Affairs Departments, and each clinical department |
|
2. Tiered training (1) Offer training on CLABSI prevention and control guidelines, operation specification and requirements, and weak points already identified in CLABSI management; all healthcare workers receiving the training programs are required to pass the examination; (2) Provide on-site tutoring based on the department's specific needs to raise the awareness and capacities in CLABSI prevention and control; promote the implementation of relevant action strategies and initiatives |
Nosocomial Infection Management Department | Nursing, Medical Affairs, Science and Education, and General Affairs Department, and each clinical department |
|
3. Supervision and evaluation (1) Conduct continuous, effective supervision of quality management indicators related to CLABSIs; (2) Analyze the supervision results, assess the implementation effect, and push forward with the rectification of the identified problems |
Nosocomial Infection Management Department | Nursing, Medical Affairs, and Information Departments, Evaluation Office, and each clinical department |
|
4. Prevention and continuous improvement (1) Conduct a comprehensive survey on CLABSI prevention and control within the entire hospital; (2) Be committed to the prevention first principle, and guide and supervise the implementation of the norms and specifications across the departments; (3) Inspect the execution of the CLABSI prevention and control standards and measures, look for and analyze the existing problems and causes of such problems, adjust the countermeasures and strategies in a timely fashion, and ensure continuous improvement of PDCA quality |
Nursing department | Nosocomial Infection Management, Medical Affairs, and Information Departments, and each clinical department |
Survey Tools and Data Collection
Our research group designed a general information questionnaire based on a review of the literature [21]. The following information was collected from eligible patients: ①gender, age, principal diagnosis, white blood cell count, neutrophil count, and length of hospital stay; and ②the CVC-related information included catheter type, model, number of lumens, date of catheter indwelling, catheter site, dressing used to immobilize the catheter, date of catheter removal, and total length of time with catheter indwelling.
Patient general information, average length of hospital stay, total hospitalization cost, and disease outcomes were extracted from the hospital information system (HIS). If the data were unavailable from the HIS, the medical records were searched. The number of cases with CLABSIs and the total length of time with an indwelling CVC in each ward area were extracted using the "Blue Dragonfly Nosocomial Infection Real-time Monitoring and Management Platform V7.0".
Patient Assessment Indicators
CLABSIs were diagnosed if any of the following conditions were met [22]: (1) pus, diffuse erythema, or cellulitis at the puncture site; (2) pain and diffuse erythema along the orientation of the catheter caused by non-physicochemical factors; (3) unexplainable fevers, chills, or local tenderness; and (4) the catheter tip was positive in the microbial pathogen culture. Bacterial count in blood cultures at the puncture site ≥ 100 cfu/ml, 4–10 times the bacterial count in blood cultures from the contralateral side, or the same bacteria detected in blood cultures from the contralateral side.
The incidence of CLABSIs (‰) was defined as the permillage of the cases with a CLABSIs to the total number of days with an indwelling CVC [23].
Average length of stay was defined as the average length of hospital stay per patient in a given period. It was a comprehensive index to evaluate medical benefit and efficiency, medical quality, and technical level. It was equal to the ratio of “total bed days occupied by patients” to “number of discharged patients” [24].
Total hospitalization cost referred to the medical expenses spent by patients in hospital, which reflects the utilization of medical and health resources and the direct disease economic burden of patients [25].
Disease outcomes referred to the outcomes of the disease, including cure, improvement, uncured, death and others.
Quality Control
The program's inception was marked by a kickoff meeting, spearheaded by the director of the MDCIPS program. The department heads involved in the program were informed of the study plan and time schedule in this meeting. Moreover, the personnel executing the program were trained on MDCIPS, responsibilities assigned to them, operation specifications, content, and supervision style. Proficiency was expected for all members participating in the training. The subjects were selected in strict accordance with the inclusion and exclusion criteria. One graduate student was assigned to collect and sort out the data after passing the examination. The same brand of CVCs was used for all patients (disposable 7F double-lumen CVC set; Zhuhai Fornia Medical Equipment Co., Ltd., Zhuhai, China; and C.R. Bard 7655405, single lumen Groshong NXT ClearVue PICC; BARD SHANNON LIMITED, New Jersey, USA). In addition, the same dressing for immobilizing catheters (#4008, 10 × 12 cm; Smith & Nephew PLC, London, England) and immobilization method were used. CLABSIs were diagnosed after discussion between the Nosocomial Infection Management Department and the clinical departments. The medical records of patients diagnosed with CLABSIs were retrieved and rechecked. The data were entered by two researchers. Logical checks were performed. Sampling inspection was conducted for 10% of the entered data. The qualification rate was ≥ 99.5% to consider the entered data adequately accurate.
Statistical Method
Statistical analyses were conducted using SPSS 25.0. Measurement data obeying a normal distribution were expressed as the mean ± standard deviation. Intergroup comparisons were performed using an independent-samples t-test. The measurement data not obeying a normal distribution are expressed as percentiles. The intergroup comparison of these data was performed using Mann–Whitney U test. Enumeration data are expressed as percentages. The intergroup comparison of these data was performed using the chi-square test or Fisher's exact test. A p-value < 0.05 indicated statistical significance.
Results
Comparison of Baseline Information Between the Two Groups
The control group included 219 patients, and the intervention group included 221 patients. The two groups were comparable in age, gender distribution, disease diagnoses, catheter type, catheter site, length of time with an indwelling catheter, and mean white blood cell and neutrophil counts (P > 0.05; Table 2).
Table 2.
Comparison of Baseline Information Between the Two Groups of Patients (n = 440)
| Item | Control group (n = 219) | Intervention group (n = 221) | Z/χ2 -value | P-value |
|---|---|---|---|---|
| Age (year, ‾x ± s) | 70.1 ± 15.9 | 69.6 ± 17.9 | 0.340 | 0.734 |
| Gender [n, percentage (%)] | 0.116 | 0.734 | ||
| Male | 149(68.0) | 147(66.5) | ||
| Female | 70(32.0) | 74(33.5) | ||
| Disease composition [n, percentage (%)] | 12.247 | 0.093 | ||
| Malignant tumors | 15(6.8) | 16(7.2) | ||
| Infectious diseases | 33(15.1) | 19(8.6) | ||
| Respiratory diseases | 70(32.0) | 81(36.7) | ||
| Circulatory diseases | 20(9.1) | 31(14.0) | ||
| Digestive diseases | 14(6.4) | 19(8.6) | ||
| Urinary tract diseases | 10(4.6) | 3(1.4) | ||
| Neurologic disorders | 43(19.6) | 36(16.3) | ||
| Other | 14(6.4) | 16(7.2) | ||
| Catheterization site [n, percentage (%)] | 0.470 | 0.925 | ||
| Internal jugular vein | 95(43.4) | 93(42.1) | ||
| Subclavian vein | 44(20.1) | 46(20.8) | ||
| Femoral vein | 24(11.0) | 21(9.5) | ||
| Peripheral vein | 56(25.6) | 61(7.6) | ||
| Catheter type [n, percentage (%)] | 0.470 | 0.925 | ||
| Internal jugular CVC | 95(43.4) | 93(42.1) | ||
| Subclavian CVC | 44(20.1) | 46(20.8) | ||
| Femoral CVC | 24(11.0) | 21(9.5) | ||
| PICC | 56(25.6) | 61(7.6) | ||
| Length of catheter indwelling time (day, ‾x ± s) | 13.7 ± 11.3 | 15.7 ± 15.5 | -1.573 | 0.116 |
| White blood cell count (10ˆ9/L) | 10.1(6.81 ~ 14.66) | 9.32(6.27 ~ 13.85) | -1.234 | 0.217 |
| Neutrophil count (10ˆ9/L) | 8.1(5.27 ~ 12.82) | 7.52(4.92 ~ 12.01) | -1.157 | 0.247 |
Comparison of the Number of Patients with CLABSIs and the Incidence of CLABSIs
There were 4 patients with CLABSIs in the control group; the incidence was 1.33 cases per 1000 catheter days (1.33‰); None of the patients in the intervention group had CLABSIs (P < 0.05; Table 3).
Table 3.
Comparison of CLABSIs Between the Two Groups (n = 440)
| Item | Case (n) | Total length of indwelling CVC time (d) | Number of cases with CLABSIs (n) | Infection rate (‰) | P-value |
|---|---|---|---|---|---|
| Control group | 219 | 3003 | 4 | 1.33 | 0.046* |
| Intervention group | 221 | 3480 | 0 | 0 |
The total length of CVC indwelling time was the sum of time lengths of all patients with indwelling CVCs in the present group. 2. *Fisher's exact test
Comparison of the Average Length of Hospital Stay, Average Hospitalization Cost, and Disease Outcomes Between the Two Groups
The average length of hospital stay was 17 days in the control group, which is longer than 13 days in the intervention group (P < 0.001, Table 4). The average hospitalization cost of 92.8 thousand yuan in the control group was much higher than 65.2 thousand yuan in the intervention group (P < 0.001, Table 4). Patient outcome was improved in the intervention group than the control group (P = 0.001; Table 4).
Table 4.
Comparison of Average Length of Hospital Stay, Hospitalization Cost, and Disease Outcomes Between the Two Groups
| Item | Control group (n = 219) | Intervention group (n = 221) | Z/2 -value | P-value |
|---|---|---|---|---|
| Average length of hospital stay (day, ‾x ± s) | 23.6 ± 21.7 | 13.7 ± 8.1 | 6.329 | < 0.001 |
| Average hospitalization cost (ten thousand yuan, ‾x ± s) | 11.3 ± 9.9 | 7.5 ± 5.8 | 4.976 | < 0.001 |
| Outcome [n, (%)] | 18.731 | 0.001 | ||
| Cured | 5(2.3) | 10(4.5) | ||
| Improved | 104(47.5) | 142(64.3) | ||
| Not improved | 37(16.9) | 28(12.7) | ||
| Death | 63(28.8) | 38(17.2) | ||
| Other | 10(4.6) | 3(1.4) |
Among Four Patients with CLABSIs, There were Two Males and Two Females
One patient had a PICC and three patients had CVCs. The patients were 81.75 years of age on average. The average length of time with an indwelling catheter was 12.25 days. The average hospitalization cost was 198.5 thousand yuan. The average total length of hospital stay was 27.75 days. These results were significantly higher than in the remaining patients from the two groups. Two of four patients with CLABSIs died (Table 5).
Table 5.
Basic Information of Four Patients with CLABSIs
| Patient | Gender | Catheter type | Age (year) |
Length of time with indwelling catheters (day) | Hospitalization cost (ten thousand yuan) | Length of hospital stay (day) | Disease Outcome |
|---|---|---|---|---|---|---|---|
| NO.1 | Male | PICC | 79 | 6 | 12.05 | 17 | Death |
| NO.2 | Female | Internal jugular CVC | 83 | 13 | 24.48 | 36 | Improved |
| NO.3 | Male | Femoral CVC | 73 | 8 | 29.59 | 33 | Other |
| NO.4 | Female | Subclavian CVC | 92 | 22 | 12.21 | 25 | Death |
| Mean | 81.75 | 12.25 | 19.58 | 27.75 |
Discussion
MDCIPS Proves to be of High Scientific Value and Application
CLABSIs, as a common type of nosocomial infection, may easily result in patient deterioration, increasing the healthcare cost and mortality rate. Studies have shown that the incidence of CLABSIs is approximately 0.35‰-1.7‰ in foreign countries versus 6.8‰ in Asia [26, 27]. In the past two years, China has attached growing importance to the hazards of CLABSIs. Reducing the incidence of CLABSIs has thus become a new target of nursing quality improvement. The existing studies on CLABSIs at home and abroad are primarily focused on precautionary measures, features of infections, and risk factor analysis [28–31]. Reducing the incidence of CLABSIs by strengthening training and education, standardized operation, and execution of cluster care has been highlighted [20, 32]; however, systematic studies involving the management mode are limited.
The MDCIPS model is a novel type of quality improvement model integrating evidence, multi-department cooperation, and intelligent management. The application of this model in clinical practice is led by the department heads and implicates the participation of multiple departments. The MDCIPS model gave all-around supports to the standardized use of CVCs, the possibility and potential for close cooperation between the departments, the satisfaction of the KABP model combined with online and offline tiered training, and fully application of new tools such as mobile app and the nursing quality management system. This new management mode reduces the work burden and improves management efficiency, thus, has good applicability that has been demonstrated through practice.
MDCIPS Reduced the Incidence of CLABSIs
Studies have shown that the multi-department cooperation model does reduce the potential risk brought by CVC indwelling and the incidence of CLABSIs [11, 33]. In the present study, the incidence of CLABSIs was 0 in the intervention group, which was significantly lower compared with the control group (P < 0.05).
The conventional supervision by one department alone is replaced by multi-department collaborative management [32]. Previous researchers have suggested that personnel of intensive care unit have a lower level of compliance with the CLABSIs prevention guidelines [11]. Prevention education and supervision should be carried out regularly to improve compliance with the operation specification for CLABSIs, in order to reduce the incidence of CLABSIs [33, 34]. What’ more, an intelligent approach is used to realize the four-level quality supervision for CLABSIs prevention [35], which makes the management easy and convenient.
MDCIPS Reduced the Average Length of Hospital Stay and Hospitalization Cost in Patients with Indwelling CVCs, Thus Improving the Disease Outcomes
Cai et al. [6] reported that the average total healthcare cost for CLABSIs was 3528.6 USD. CLABSIs can result in a dramatic increase in mortality, length of hospital stay, and hospitalization cost [19, 22]. In our study the average length of hospital stay, average hospitalization cost, and the number of patients who did not improve and died were significantly greater in the control group than the intervention group. The disease outcome of the intervention group was significantly better than the control group (P < 0.001). Two of four patients with CLABSIs (50%) in the control group died, whereas no deaths were reported in the intervention group. MDCIPS has been proven to be effective in shortening the length of hospital stay and decreasing the hospitalization cost due to CLABSIs in our study. It has been demonstrated that the continuous quality improvement program does reduce the incidence of CLABSIs [36].
The MDCIPs model has some limitations. First, intelligent monitoring, quality supervision, and infection supervision are realized through different information systems. Second, the MDCIPS model was only applied in a single-center study. It is necessary to develop an information system integrating training, quality supervision, and CLABSIs supervision and strengthen the multi-center study of the MDCIPS model. Moreover, the allocation of the intervention was not randomized and potential measured or unmeasured confounding variables were not adequately accounted for in this study.
Conclusion
Clinical practice involving this MDCIPS model has demonstrated efficacy in reducing the potential risk of CLABSIs, relieving the patient economic burden and improving the patients’ outcome.
Supplementary Information
Below is the link to the electronic supplementary material.
Abbreviations
- CVC
Central Venous Catheter
- PICC
Peripherally-Inserted Central Catheter
- CLABSIs
Central Line-Associated Bloodstream Infection
- MDCIPS
Multi-Department Cooperation, Intelligent Prevention, and Supervision
- KABP
Knowledge-Attitude-Belief-Practice
Funding
This study was supported by Science Foundation of Hunan Province(N0.2019JJ80052), Scientific Research Project of Hunan Provincial Health Commission(N0.20201976), and Science Foundation of Changsha City (N0.kq2208435).
Data Availability
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Conflicts of Interests
The authors declare of no conflicts of interests.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Chuanfang Wu and Fan Dai contributed equally to this study.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.