Improving Maintenance of Central Line Dressing to Reduce Risk of Central Line-Associated Bloodstream Infections in an Acute-Care Setting

Abstract

Background

Central line-associated bloodstream infections (CLABSI) increase morbidity, mortality, and healthcare costs. Central venous access device (CVAD) dressing integrity is critical to prevent CLABSI. From the First Quarter to the Third Quarter of 2023, CLABSI rates related to disruption in CVAD dressing integrity increased significantly at our facility. Despite the delivery of education, competency validation, and checklist implementation, CLABSI rates remained high, making this our top strategic priority.

The purpose of this quality improvement initiative was to determine if gum mastic adhesive and hemostatic powder would improve dressing integrity and decrease CLABSI rates related to disruption of central line dressings.

Methods

With pre- and post-CVAD dressing data, utilizing rapid Plan-Do-Study-Act methodology to drive improvement, this quality improvement initiative was conducted in a 603-bed, tertiary level I trauma center. A multidisciplinary team was formed consisting of infection prevention, quality, nursing, and vascular access personnel, with the goal of improving central line dressing integrity and increasing dressing life. In-depth training included standardized CLABSI prevention bundles and central line dressing change guidelines to include the application of gum mastic adhesive and topical hemostatic product, and was tested on pilot units before implementation.

Results

Bleeding at the central line insertion site reduced by 23.6% with the use of a hemostatic powder. Central line dressing integrity was improved by 33.5% with the use of a liquid gum mastic adhesive and dressing life improved by 140.7%. Additionally, there was only 1 CLASBI and no medical adhesive-related skin injuries reported since the implementation of the bundle (October 2023).

Conclusion

Topical hemostatic powder and liquid gum mastic adhesive paired with the adhesive remover for safe removal were shown to be effective in improving integrity in central line dressings for the prevention of CLABSIs. In October 2023, the dressing change integrity bundle was scaled to all units within the facility.

Introduction

Central line-associated bloodstream infections (CLABSI) in health care affect thousands of patients annually in the US, increase morbidity and mortality, health care costs, and patients’ length of stay, according to the Centers for Disease Control and Prevention.^1,2 In response, a collaboration led by the Society for Healthcare Epidemiology of America with Infectious Diseases Society of America, the Association for Professionals in Infection Control and Epidemiology, the American Hospital Association, and the Joint Commission created and recently updated their expert guidance document.³ This multidisciplinary organizational practice recommendation includes CVAD dressing maintenance strategies supported by high or moderate quality levels of evidence (Table 1).

Table 1.

Strategies for Nurses for Maintaining a CDI CVAD Dressing to Reduce CLABSIs in Acute Care Settings, Adapted From the SHEA Recommendations³

Strategies included:
1. Ensuring appropriate Intensive care unit (ICU) nurse:patient ratios
2. For all patients over 2 months of age, chlorhexidine-containing dressings for CVCs
3. Recommend dressing changes for non-tunneled CVC at least every 7 days or immediately if the dressing is compromised (loose or lifted dressing), damp, or soiled.
4. Establish regular surveillance programs for CLABSIs across all acute care settings

Our facility established a surveillance program for health care-associated infections (HAIs), and in 2017, CLABSI monitoring was added. From late 2022 to mid-2023, CLABSI rates increased in our single facility acute care setting that was utilizing the chlorhexidine gluconate (CHG) disc in addition to transparent film dressings. Despite the delivery of nursing education, competency validation, and checklist implementation through August 2023, CLABSI rates were 3 times higher than our internal goal, making this the number 1 strategic priority for our facility. The infection prevention team performed direct observation audits of CLABSI prevention bundle compliance on 340 central lines between May and September 2023. Analysis of the data revealed low compliance of clean, dry, and intact (CDI) central venous access device (CVAD) dressings for the following reasons: (1) dressing was compromised by lifting and peeling or by bleeding at the catheter insertion site, and (2) the average length of time the dressing remained intact was shorter than the recommended interval of 7 days for changing non-gauze dressings. Table 2 lists the reasons and coinciding metric for the project’s identified reasons for low CDI CVAD dressing compliance.

Table 2.

Reasons and Coinciding Metric for Low CDI CVAD Dressing Compliance

Contributing reasons for low compliance	Metric
CVAD dressing was compromised by lifting and peeling	63.8%
The CVAD dressing had bleeding at the insertion site that tracked up the line and extended beyond the chlorhexidine disc	82.26%
Average length of time the CVAD dressing remained intact	2.7 days

The average length of time for CVAD dressings to remain intact was gleaned from direct observation by the nurse leaders on the infection prevention and quality improvement (QI) team of the hospital, auditing all dressings facility-wide. Any bleeding that was observed tracking up the CVAD line at the insertion site or extending beyond the CHG-impregnated disc was reported, and training was completed with all observers guided by photographs included on the tip sheet (Figure 1). These case study photographs were used to establish intra-rater reliability prior to data collection (Figure 1).

Figure 1.

The tip sheet was created by nurse leaders for clinical nurses using the same case study photographs as in the leader training.

Additionally, the identified root cause analysis for each CLABSI yielded a common cause relating to CVAD dressing maintenance. Specifically, dressing disruption with peeling, lifting, and bleeding at the insertion site was associated with approximately 30% of CLABSI events. This resulted in intact CVAD dressings selected as the primary outcome for this project, with the secondary outcome CLABSIs associated with compromised dressings.

A multi-disciplinary team consisting of infection prevention, nursing, vascular access nurses, and providers was formed to improve dressing compliance and reduce CLABSIs related to compromised CVAD dressings. The team reviewed current guidelines along with our facility CVAD insertion, care, and maintenance policy, which was in alignment with current strategies and guidelines.^3,4 The 2022 strategies to prevent CLABSIs in acute care hospitals lists maintaining a CDI dressing as an essential practice.³ Further, another essential post-insertion practice is to immediately change dressings that are soiled, loose, or damp.³

Despite ongoing education efforts to improve dressing integrity and infection prevention along with competency validation from January through September 2023, significant improvements in performance and outcomes were not observed. As Devries and colleagues stated, while it is clear a CDI dressing is critical in the prevention of CLABSI, there is a lack of strategies and recommendations to achieve this.⁵

The team reviewed studies on maintenance of CVAD dressings and, based on our findings, determined that our risk reduction intervention would be focused on increasing dressing life rather than simply changing the dressing when compromised.^5,6 The team selected gum mastic adhesive and the accompanying removal product, as well as a hemostatic product to determine if these two interventions would improve dressing integrity and reduce CLABSIs related to CVAD dressing disruption.^4,5 The hemostatic product’s manufacturer instructions for use describe the action that the product creates as a barrier that is inconducive and inhospitable to microbial penetration. Both process and outcomes were assessed and reported to nursing, the vascular access team, and senior leaders to support practice change.

Methods

This QI initiative was conducted in a 603-bed tertiary hospital with an average of 24 817 annual central line device days. Three units were selected to pilot trial the products before house-wide implementation. The 3 units chosen for the pilot trial were selected based on their complex patient population, higher utilization of central lines, and challenges in maintaining CVAD dressing integrity, cleanliness, and low CLABSI rates. It was important to include varying levels of care represented in this initiative as well as different staffing models to more accurately measure progress across all service line types. The selected units for the pilot included one medical surgical unit, a progressive care unit, and an intensive care unit, resulting in a diversity of staffing ratios with LPNs not present on all units. All 3 units had stable leadership and charge nurses as well as bedside nurses who were highly engaged and willing to champion this initiative. To do this, The Institute of Healthcare Improvement Model for Improvement suggests using a series of Plan-Do-Study-Act (PDSA) cycles in a process called rapid cycle change.⁷ Literature suggests that QI is an applied science and, as such, the PDSA methodology follows similar principles as hypothesis testing in research. Each intervention is tested and studied while asking the following 3 questions: What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? In addition, developing a culture of inquiry aids in team engagement and root cause identification, leading to an acceleration in the improvement of patient outcomes.⁷

In 2017, a multidisciplinary standardized quality improvement weekly facility meeting model was established to accelerate improvement in patient outcomes utilizing a rapid PDSA methodology. ⁷ The Vice President of Quality and Chief Medical Officer identified key stakeholders needed to drive improvement in the top 3–5 strategic priorities, including HAIs. A standardized reporting template was created to assist the key stakeholders with data collection, root cause identification, and improved action planning using the 5 Whys and the Institute Safe Medication Practices (ISMP) Hierarchy of Effectiveness of Interventions.⁸ Key stakeholders reviewed their data daily, discussed possible root causes of process gaps, and brought action plans to weekly facility meetings. These stakeholders cited each intervention as low, medium, or high leverage interventions per the ISMP model to implement process/system-focused changes rather than create processes that are people-dependent.⁸ The CLABSI metric was added to the division-level QI weekly meeting where nursing leaders, infection preventionists, and quality professionals discussed root causes and action plans. A central line audit tool was created for data collection and a central line rounding process was implemented (Figure 2).

Figure 2.

The daily morning and night shift compliance checklist was developed for audits.

The bedside nurses were responsible for reviewing their central lines during bedside shift reports, the nursing leaders rounded on all devices every shift, and infection preventionists performed daily audits on every central line including weekends and holidays. All units were compliant with these daily dressing audits.

Initial data revealed that in 2022, 67.9% of CLABSIs in the 3 units were related to a lack of central line dressing integrity due to post-insertion site bleeding and peeling of the dressing. The educational workshop included an in-person didactic session and hands-on infection prevention session provided by the product representatives to ensure competencies were achieved beginning September 2023. To reinforce nursing education and to standardize the assessment and consistency of recognizing bleeding at the insertion site, a standardized tip sheet with graphics and photographs outlined guidelines around what constitutes a CDI CVAD dressing. The tip sheet was updated as users gave feedback and revealed the positive impact this had on standardizing the assessment and recognition of intact dressings. Education was provided, instructions for use were posted in multiple areas on each unit, and signatures were collected after education was delivered. As a part of the QI methodology, outcome, process, and balancing measures are a critical part of knowing if we have made a difference, what the impact of those changes implemented are, if we have met our aim, and what future action we should take.⁹ Outcome measures link back to original goals and indicate if the system is working.⁹ Process measures identify if the steps in the system are performing as planned.⁹ Balancing measures identify if changes are performing as designed or if there are new problems in other parts of the system created by the interventions, which are often referred to as unintended consequences of an initiative.⁹ In this QI initiative, the following metrics were developed and implemented:

1. Outcome measure: reduce CLABSI rates (50%) related to dressing disruption by the end of 2023

2. Process measure: improve dressing integrity and reduce or control bleeding at the insertion site to > 90% by the end of Q4 2023, and track the number of days since the last event on a weekly basis and share with the quality improvement team

3. Balancing measure: report any skin integrity issues and track them within the occurrence reporting system

Analysis

The Study step in the PDSA cycle involves the analysis of data.¹¹ For this initiative, we developed a run chart to display CLABSI rate data to determine the efficacy of the intervention using well-established rules. Commonly used in quality improvement, a run chart allows for visualization of quantitative data plotted over time to determine if the intervention tested produces random or non-random results. This was achieved by analyzing the data points for shifts, trends, runs, and astronomical points.^8,9 Additionally, the alpha was set at .05, and mean rates of CLABSIs for the time periods pre- and post-interventions were compared using the Wilcoxon Rank Sum Test/Mann-Whitney Test.

Ethical Considerations

Unit leaders, the vascular access team, and infection preventionists rounded on patients frequently to ensure early recognition of any complications relating to the use of gum mastic adhesive and hemostatic topical powder. During the rounding process, patients were asked for permission to assess their central line dressing, and it was explained to them that the process was for their safety. This allowed them to be a part of the educational process. The authors engaged the local Institutional Review Board (IRB) who determined this QI initiative did not require IRB oversight.

Results

CLABSI rates related to compromised dressings improved from 0.551 per 1000 device days from January through September 2023 to 0.051 per 1000 device days from October 2023 to May 2024. Bleeding at the central line insertion site was reduced by 23.6% with the use of a hemostatic powder. Central line dressing integrity was improved by 33.5% with the use of a liquid gum mastic adhesive, and dressing life increased from 2.7 days to 6.5 days indicating an improvement of 140.7%. Additionally, there was 1 CLASBI and no medical adhesive-related skin injuries reported since the implementation of the bundle (Figure 3).

Figure 3.

Facility-wide CLABSI rates per 1000 device days and intervention implementation are shown for the project.

Analysis of CLABSI for pre- and post-intervention time periods were compared using the Wilcoxon Rank Sum Test/Mann-Whitney U Test, revealing a P value of .017. This indicates statistical significance, suggesting a difference in pre- and post-intervention monthly CLABSI rates.

Standardization of dressing change criteria coupled with central line rounding, root cause analysis using the 5 Whys, use of ISMP Hierarchy of Effectiveness of Interventions for action planning and creation of a weekly, multidisciplinary QI team meeting approach resulted in improvement in CLABSI outcomes for our patients (Table 3).

Table 3.

The 3 PDSA Cycles for the Project

Q1 2023 #1 PDSA cycle increased rates CLABSI	Evaluation process, 5 whys, ISMP Hierarchy of effectiveness for action planning	Educate staff Rounding Realtime feedback Established and completed 100% clinical competencies for nursing staff	Evaluation showed no improvement	Plan needed revising as outcome not met
Q3 2023 #2 PDSA cycle	Evaluation process, 5 whys, ISMP Hierarchy of effectiveness for action planning	Hands-on education workshops	Evaluation showed no improvement	Plan needed revising as outcome not met
Q4 2023 #3 PDSA cycle	Evaluation process, 5 whys, ISMP Hierarchy of effectiveness for action planning, external evidence search	Leadership audits for CDI dressings Gum mastic or hemostatic powder Tip sheet for standardization of process and practice Established weekly QI & multidisciplinary meetings	Evaluation showed improvement	Plan to sustain

Discussion

Our initiative supports the evidence that CDI CVAD dressings can be an indicator of a patient’s risk for CLABSI. Our overall CLABSI rate did not decrease significantly due to other contributing factors, but we showed reduced CLABSIs related to dressing disruption (Figures 1 and 2). Our data aligns with the study by Devries et al, which showed that dressing integrity is a key element in preventing bloodstream infection in patients with vascular access devices.³ Doubling CVAD dressing life decreased dressing changes by more than 50%, which proved to be a nurse satisfier and decreased utilization of dressing change kits. Buy-in as well as highly engaged leaders and bedside staff were a critical element for this initiative. Without both a multidisciplinary approach to QI and buy-in from the bedside to the C-suite, this strategy may be difficult to replicate.

Limitations

A limitation of this QI initiative was the location of the products in the storerooms as the products are not included in standardized kits. As a result, there was variation in the process. To alleviate this barrier, the products were moved to bins directly next to dressing change kits and were regularly monitored to ensure ease of use. According to the manufacturer’s instructions for use, the hemostatic product used is designed to create a low pH and a hostile barrier to microbial penetration. However, this product was only used for patients who were at high risk for bleeding. Otherwise, the dressings only incorporated CHG discs. An additional limitation included a securement devices practice change, including subcutaneous securements which are primarily intended to reduce dislodgment.

Conclusion

CLABSI and other bloodstream infection prevention strategies remain a focus in the US. With the improvement observed in this project, the intervention was approved for implementation across facilities within our North Texas region. This included education, a tip sheet, rounding, real-time feedback, and the use of gum mastic and hemostatic powder.

The findings of this project suggest a relationship between improvement of dressing life and reduced CLABSI. However further research is needed to support the addition of methods to improve CVAD dressing life to strategies and guidelines. In this project, gum mastic adhesive, adhesive removal product, and hemostatic powder significantly improved CLABSIs relating to the prevailing root cause of our infections. Facilities must continue to identify root causes to implement additional action and improve CLABSI rates in the interest of patient safety. Hospital-acquired CLABSIs are multifactorial and require continued diligence in monitoring all potential root causes. Continued reinforcement and perceived value by leaders and bedside nurses are required to support the sustainability of this project.

Funding Statement

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare-affiliated entity.