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As mentioned in the previous section, a study of intensive care nurses found that those with a lower patient ratio achieved better CLABSI prevention compliance (Aloush, 2018). High patient ratios are a significant concern, especially in the NICU where nurses face "severe workloads and emotional stress" (Aloush, 2018). Two seriously ill neonates require incredible amounts of attention, time, and care from the nurse. Assigning NICU nurses one critical patient would provide them with the space to perform excellent CLABSI prevention measures, which ultimately would lead to better patient outcomes.

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The previous section discussed how nurse perceptions and attitudes contribute to CLABSI bundle compliance. To have the perception that one should adhere to these bundles, the nurse must have knowledge of the severity of CLABSIs and the factors which can affect it. One survey "showed that 85% of the [medical staff] were not convinced of the specific benefit of intensified hand hygiene for preventing CLABSI" (Schmid, 2018). It is likely that if they do not see the benefit of hand hygiene, they will not comply with new hand-washing protocols. Therefore, when bundles or protocols are implemented, nurses need to be educated on the research supporting them.

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During insertion and maintenance of a central line, sterile technique is used. Sterile technique is a set of specific steps taken to eliminate microorganisms from contaminating a procedure. During insertion of the central line, the specially trained nurse or other healthcare professional will don a sterile gown and gloves, have a sterile drape surrounding the area in which the line will be placed, and will use instruments that are specifically within a sterile field. During a dressing change, the nurse will remove the old dressing with a regular glove, don sterile gloves, cleanse the area with an antiseptic, and replace the dressing (Barnett, 2018).

Nurses frequently assist with central line insertions and almost exclusively perform central line dressing changes. Part of being a leader is working with others as a team. Assisting with donning sterile gowns and monitoring for potential breaks in sterility are extremely important tasks of the nurse. As I prepare to enter the nursing field, I want to first of all demonstrate my efficiency in performing sterile procedures, and then I want to teach others how to do the same. I will tell anyone observing sterile technique to vocalize any safety breaches. As a leader, I want to make each individual on our team feel confident to speak up.

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The Institute for Healthcare Improvement (IHI) (2022) describes a culture of safety as a place where health care workers discuss safety concerns with others, address unsafe practices, and divulge unsafe experiences without fear of reprimand. Within a culture of safety, safety is the norm and not the exception.

This concept is vital to my development as a leader in nursing. As a NICU nurse, I will prioritize safety in all situations, regardless of how others may feel about it. My goal is to educate and encourage others to exceed safety standards. I want to be an active creator of a culture of safety in my unit.

The IHI (2022) recommends developing a system for reporting incidences in which a safety event could have occurred. For example, if a nurse almost administered the wrong medication to a patient, but the computer scanning system alerted the nurse to the error, the nurse can report this event. Why is this important? By collecting data on such instances, perhaps a pattern could be identified and interventions done to prevent errors in the future. In the NICU in which I work, if such a system does not exist, I will advocate to the nursing management for one to be made. I believe that being a good leader means being a proponent of change.

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In 2016, there were 23,500 CLABSIs in the United States. The healthcare cost associated with each CLABSI is $48,000 (Chopra, n.d.). That means that in 2016, more than $1.1 trillion was spent on CLABSI treatment and complications.

In addition to the financial burden of CLABSIs, these infections are detrimental to patients diagnosed with them. Regardless of age, CLABSIs can cause longer hospital stays and increase morbidity and mortality (Chopra, n.d.).

Between 2008 and 2016, the prevalence of CLABSIs have dropped nearly in half (Chopra, n.d.). However, these rates are now plateauing, suggesting that novel interventions are necessary to continue the desired downward trend (Hsu, 2020).

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NICU babies are especially susceptible to hospital-acquired infections, with the most frequently diagnosed type being CLABSIs (Jansen, 2021). Bannatyne (2018) explains that "the risk of CLABSI is significantly increased in patients with lower gestational age and birth weight, as they exhibit poor skin integrity, an immature immune system, and require the prolonged use of central lines." CLABSIs are a significant risk factor for late-onset sepsis in neonates (Schmid, 2018) (Bannatyne, 2018). This contributes to increased mortality. The video above demonstrates the anchoring of an umbilical central catheter, which is one of the most common central line seen in NICUs. Below is a picture of a peripherally inserted central catheter, another frequently used central line in the NICU (Bannatyne, 2018).

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NICU Procedures:  Bridge for securing umbilical venous and arterial catheters

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As previously discussed, a critical time for a CLABSI infection to develop is during insertion. When a central line is being inserted, proper hand hygiene and sterility are paramount. However, what happens when the sterile field is contaminated? Schmid (2018) explains that in five of the studies they reviewed, if that occurred, "the assisting staff... were entitled to stop catheter insertion." This is incredibly important. Empowering nurses, whether it be specially trained nurses who are inserting the central lines or staff nurses in the NICU, to stop an unsafe procedure will lead to better patient outcomes.

Nurses can be empowered by their leadership and management. The first step in empowerment is education (Steinmann, 2018). Therefore, for example, nurse managers should provide adequate education about maintaining sterility during a procedure. Continuing education or skills courses can provide nurses opportunities to practice keeping a sterile field. If nurses feel confident in their ability to recognize a break in sterility, they may be more likely to voice concerns during a central line placement that becomes contaminated.

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CLABSI bundles are evidence-based interventions, or tasks, with the goal of preventing CLABSIs from occurring. However, bundles are not enough. Another element of prevention is socioadaptive intervention (Chopra, n.d.) An example of a socioadaptive intervention was investigated above - nurse empowerment to intervene in unsafe catheter insertion procedures. Another example is "feedback [to nurses] provided regarding rates of CLABSI" (Chopra, n.d.).

Nurses perform those elements of CLABSI bundles which involve the maintenance of catheters. Besides the initial insertion, the integrity of the central line lies in the hands of the nursing staff. Therefore, it is important for them to know the current CLABSI rates and their compliance with the established care bundle on their unit.

A study of 171 intensive care nurses found that only seventy percent of them had "sufficient compliance", which was based on a scoring system designed by the study (Aloush, 2018). However, according to Chopra (n.d.), a ninety-five percent compliance rate is necessary to decrease CLABSIs. Nurses on each unit should be provided with their compliance rates at regular intervals, such as daily or weekly, and their target compliance should be at ninety-five percent or higher.

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Nurses almost exclusively provide direct care to patients in the NICU. Therefore, patient interactions which can lead to transmission of microorganisms often involve the nurse. As discussed in the literature review, there are many different elements which an organization or hospital unit may include in their CLABSI bundle. Many of these interventions are performed by the nurse. Therefore, the burden of improving CLABSI rates falls onto the nursing staff (Goldman, 2021).

Is nurse involvement improving or exacerbating the issue?

Nurses are instrumental to preventing CLABSIs. Their interventions and adherence to bundles of care drastically improve CLABSI incidence. However, following protocols for bundles of care are sometimes viewed as more of a requirement for nurses to avoid reprimand and less as an important tool to prevent CLABSI (Goldman, 2021). Thus, nursing attitudes towards CLABSI prevention can limit improvement. Healthcare organization leadership sets the tone for the seriousness of CLABSIs, so there need to be adjustments in perception of CLABSI severity from the executive level down to the frontline nurses (Goldman, 2021).

The importance of nurse involvement:

Contrasting the attitudes and perceptions of nursing staff regarding CLABSIs, there are external or environmental factors which affect how nurses intervene to prevent CLABSI. For example, insufficient nurse staffing is a risk factor for CLABSIs (Chopra, n.d.). In a study of 171 ICU nurses, it was determined that those with one patient "demonstrated superior compliance" with CLABSI prevention protocols when compared to nurses with two patients (Aloush, 2018). The implication of this is paramount. These findings suggest that when given the time to dedicate to CLABSI prevention, nurses perform exceptionally.

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The literature shows that having a specific bundle of preventative measures for direct care providers to perform "improv[es] process of care and patient outcomes" (Chopra, n.d.). These measures are derived from evidence-based research. A systematic review of twenty-seven studies determined that the effect of bundle implementation on CLABSIs in the NICU is statistically significant (Schmid, 2018).

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Central line-associated bloodstream infections, also known as CLABSIs, are a preventable serious complication of having a central venous catheter. Central lines are often utilized in intensive care units, where patients may require more fluid or medication support for an extended period of time. These catheters are placed in major veins under sterile technique. Organisms can enter the bloodstream via such catheters, placing the patient at high risk of infection (CDC, 2011).

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A patient is diagnosed with a CLABSI by positive blood cultures, if they have had a central line in place for two or more days and the sample was collected while the line is still in place or has been removed within the past day (Chopra, n.d.)

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https://docs.google.com/document/d/1R1XefPOY70uIWbSpJLPkGrbwLVhoggiv29nNLTSrido/edit

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CLABSI bundles have been in development over the last two decades. Bundles focus on the insertion and maintenance of the catheter. For example, the Institute for Healthcare Improvement developed a CLABSI bundle which included "hand hygiene, maximal barrier precautions, chlorhexidine skin antisepsis, optimal catheter site selection... and daily review of line necessity, with prompt removal of unnecessary lines (Griffin, 2012). Other examples of interventions included in CLABSI bundles are povidone-iodine antisepsis for neonates, sterile dressing changes, two-person dressing changes, regulated changing of the infusion tubing system, and scrubbing the catheter hub with an antiseptic solution (Schmid, 2018).

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A study by Bannatyne (2018) found that compliance with completing forms for insertion of central lines reduced CLABSI in the NICU. Similarly, this study surmised that compliance with forms for maintenance of CLABSIs can improve, and thus reduce CLABSI rates. Checklists or forms are a great tool to increase compliance with preventative protocols. Griffin (2012) explains that changes such as "checklists, revising the structure and process of daily multidisciplinary rounds, and use of daily goal sheets" lead to high bundle compliance.

Focusing on the CLABSI prevention goals during multidisciplinary rounds is important to shaping a team approach to this issue. If all members of the team are supportive and eager to reduce CLABSIs, nurses may feel more empowered to take initiative to adhere to bundles. Not only should rounds be conducted with various team members, but the team can work together to contribute to checklists and protocols to prevent CLABSI. According to Griffin (2012), "having bundles developed by [the] care teams... will improve the likelihood of the bundle's acceptance and success."