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Two Curricular Concepts:
1. Sterile technique

"Aseptic technique is recommended for all instances of insertion and care for central venous catheters" (Joint Commission, 2013).

Involves protective equipment such as: sterile gloves, sterile drape, mask, and sterile gown.

Include controlling the environment such as leaving the door closed during the sterile procedure.

(Joint Commission, 2013)

2.  Patient Education

Explain to patient the indication of having a central venous catheter.

Inform patient of the signs and symptoms of infection, and report to provider if found.

Teach patient the importance of keeping insertion site clean and dry.

Leadership Role
The concepts stated above have prepared me to assume a leadership role as I transition to professional practice in the following ways:

After understanding the seriousness of CLABSIs and learning ways to prevent them,  I can take on the leadership role by joining the Quality Improvement team in order to facilitate the adherence of healthcare personnel following the guidelines in regards to caring for patients with central venous catheters. I can suggest improvement to the guidelines that are already in practice and provide education to patients who are unsure of how to maintain their central access device. By doing this, I can help decrease CLABSI rates and healthcare costs.

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What is a CLABSI?
According to Haddadin and Regunath (2019), a CLABSI is "defined as a laboratory-confirmed bloodstream infection not related to an infection at another site that develops within 48 hours of central line placement." This type of infection is acquired when a central line, such as a peripherally inserted central catheter (PICC), subclavian line, or internal jugular line, becomes infected, resulting in a bloodstream infection (CDC, 2011a).

I chose this topic because I am doing my preceptorship on the Advance Heart Failure floor where majority of the patients have PICC lines. I wanted to explore the different preventative measures one could take in regards to preventing a bloodstream infection for patients who have central venous catheters.

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Central Line Associated Blood Stream Infections (CLABSI)
According to Haddadin and Regunath (2019), "CLABSIs are the most costly [healthcare associated infection], accounting for approximately $46,000 per case." When a central venous catheters insertion turns into a CLABSI, this results in "prolonged hospital stays" and increased mortality rates (Haddadin & Regunath, 2019). This article supports that most CLABSIs occur in intensive care units, accounting for a CLABSI rate of "0.8 per 1,000 central line days" (Haddadin & Regunath, 2019). There are measures to prevent a CLABSI from occurring such as: hand hygiene, using aseptic technique, and removing central lines that are not necessary (Haddadin & Regunath, 2019).

Nurses' Compliance with CLABSI Prevention Guidelines
In order to prevent CLABSIs, nurses must strictly adhere to the CLABSI prevention guidelines. In this article, Aloush and Alsaraireh (2018) aimed to determine what factors increase or decrease nurse compliance to CLABSI prevention strategies. According to Aloush and Alsaraireh (2018), it was found that the nurse-to-patient ratio was a significant factor in compliance. In fact, "nurses who work with a 1:1 ratio were 6.3 times more likely to comply with CLABSI prevention guidelines" (Aloush & Alsaraireh, 2018).

CLABSI: Not Just an ICU Problem
According to Whited and Lowe (2013), in order to prevent or reduce CLASBI rates "implementation of care bundles, educational programs for staff central lines and prevention of infection, recognizing risk factors for infection, and implementation of CDC guidelines for maintaining central lines should be a common practice." Furthermore, non- ICU patients should follow practices that are implemented in the ICU in order to prevent CLABSI occurrences (Whited and Lowe, 2013).

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1. Remove Central Lines ASAP

Nurses should ask providers daily if central line catheters can be removed

"Perform daily audits to assess whether each central line is still needed" (CDC, 2011b).

The most effective way to reduce CLABSIs is to reduce or completely remove the exposure of central lines.

(AHRQ, 2013)
2. Maintain aseptic technique

Perform hand hygiene before insertion of the central line catheter

"Use maximal sterile barrier precautions" when inserting and maintaining central catheter.

Consider choosing an insertion site that is least prone to infection; fore example, if possible avoid femoral artery.

Only use sterile devices to assess sterile port

Perform dressing changes using sterile technique

Follow guidelines in the CLABSI toolkit

(CDC, 2011b)

3. Educate

"Educate healthcare personnel regarding the indication for intravascular use."

Inform designated personnel of the proper procedure for inserting and maintaining a central line.

Teach infection control measures to healthcare personnel and patients to prevent infection.

Teach patient the signs and symptoms he/she may experience if central catheter is to become infected.

Frequently assess the knowledge of and adherence to guidelines regarding central venous line care and access.

(CDC, 2017)

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ANALYSIS 2: Importance of nurse involvement 

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ANALYSIS 2: Importance of nurse involvement 

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Nurses can help decrease the incidence of CLABSIs by "stopping the procedure if he/she observes a violation of evidence-based practices" (AHRQ, 2013). Furthermore, nurses can implement a checklist which can "monitor whether or not providers adhere to care processes" and "serve as an independent, redundant check to encourage physician adherence to evidence-based practices" (AHRQ, 2013). Nurses' involvement will help improve the incidence of CLABSI rates by being the front-line defense system and recognizing abnormalities or practices that are not within evidence-based practice standards.

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ANALYSIS 1: Nurses' current role
Currently, nurses are using the guidelines provided in the  Infusion Nursing Standards of Practice in order to reduce the number of CLABSIs. These standards include:

Site care and dressing changes (removal of the existing dressing, cleansing of the catheter-junction site with an appropriate anti-septic solution, and application of a sterile dressing).

Use of chlorhexidine gluconate solution when cleansing central venous site

Performing dressing changes every 5-7 days for transparent semipermeable dressings and every 2 days for gauze dressings

Wearing personal protective equipment (e.g. sterile gloves, mask) when performing dressing changes

Perform hand hygiene before donning on sterile gloves and after coming in contact with the patient

(Alexander, 2011).

Do these standards improve or exacerbate the issue?
These standards have been found to improve the issue. In 2016, "there 24% fewer CLABSI in Virginia acute care hospitals" (VDH, 2019).

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What is the problem?
The CDC (2016) states that CLABSIs "result in thousands of deaths each year." CLABSIs have been found to have an 18% annual mortality rate associated with them (AHRQ, n.d.). Furthermore, CLABSIs adds "billions of dollars in added costs to the U.S. healthcare system" (CDC, 2016).

Who is directly affected?
Those who are directly affected are the people who have an inserted central line placed. Patients in intensive care units (ICU) are especially susceptible, considering that "48% of of ICU patients have indwelling central venous catheters" (AHRQ, n.d.).

How?
"Within 7 to 10 days of central venous catheter placement, bacteria on the skin surfaces migrate along the external surface of the catheter from the skin exit site towards the intravascular space" (Haddadin & Regunath, 2019).

Where?
CLABSIs can occur just about anywhere. As stated before, CLABSIs are mostly known to occur in intensive care units and hospital settings. However, CLABSIs can occur outside of the ICU such as in a patient's home or environment if the patient is discharged with a central venous catheter (AHRQ, n.d.).

When?
After placement of the central venous line, a CLABSI can develop within 48 hours (Haddadin & Regunath, 2019).

Why?
There are multiple reasons why a CLABSI develops. Either the health care provider did not maintain proper aseptic technique when inserting the central venous catheter or the patient lives in an environment that promotes the spread of bacteria (CDC, 2010).

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Some challenges or barriers for nurse involvement in the issue of CLABSI includes: years of experience, nurse-to-patient ratio, lack of education, and availability of resources (Aloush & Alsaraireh, 2018). A nurse with less years of experience may not have the skills or education compared to a nurse with 10 years experience in regards to preventing CLABSIs. Also, a high nurse-to-patient ratio and lack of resources can contribute to an increase risk of patients developing CLABSIs.