Revisions DPI Project Proposal Chapter 1 – Introduction to the Project

Prevention of Central Line-Associated Bloodstream Infections (CLABSIs)

Prevention of Central Line-Associated Bloodstream Infections (CLABSIs) Comment by Kathryn Flynn:

Submitted by

Kerry Sean Murphy

DPI Project Proposal Chapter 1 – Introduction to the Project

Doctor of Nursing Practice

Grand Canyon University

Phoenix, Arizona

July 10, 2019

Chapter 1: Introduction to the Project

Vascular catheters are commonly used for both in-patient and out-patient cases to administer blood products, intravenous fluids, parenteral nutrition, and other types of medications. The use of catheters is, however linked to the risk of developing infections mainly caused by microorganisms found on the external surface of the instrument or in the fluid pathway during insertion or in the course of use. Notably, central venous catheters have been cited as the most frequent and the costliest cause of bloodstream infections (Haddadin & Regunath., 2019). A central line-associated bloodstream infection (CLABSI) mainly occurs within 48 hours after a catheter is inserted and can be a major cause of morbidity and mortality besides increasing the cost of healthcare both for the individual and the healthcare system in general (Iliopoulou, Anderson & Day, 2015).

Most CLABSIs cases are recorded in the ICU, but there are some cases which occur outside the ICU. CLABSIs can be prevented with the use of evidence-based guidelines about the insertion and maintenance of catheters. Past research studies have been unable to successfully link CLABSIs with a mortality given that patient deaths occur as a result of multiple causes, and the effect of health associated infection may not be apparent. However, there is a general agreement that CLABSIs is a major cause of patient deaths in both developed and developing countries (Tomlinson, 2015). The fact that CLABSIs cases are a major cause of illnesses, deaths and longer stays in hospitals mean that it is highly costly, and there is a need to find a solution as soon as possible. Comment by Kathryn Flynn: Are?

While there have been some improvements in reducing cases of CLABSIs, further efforts are required to prevent patients’ harm more so in non-critical care settings. Some of the measures which are in place to prevent CLABSI include ensuring procedural pause, aseptic techniques, hand hygiene, optimal site selection, use of chlorhexidine to protect the skin and taking maximal sterile precautions. Other measures include education on appropriate indications for central lines, including antibiotics indications & durations. There is also clear escalation protocols for hard stick IV/phlebotomy patients and clear de-escalation protocols for central lines that are no longer medically necessary. Many nurses employ consistent bi-annual education on CVC dressings/maintenance by product reps. In addition to these measures, this project proposes consistent quarterly CVC dressing/maintenance checkoffs for all nursing staff on direct patient care units. Comment by Kathryn Flynn: Oxford comma,

In this introductory chapter, the background of the project, problem statement, and the purpose of the project are given. Next, the clinical questions, criteria for advancing scientific knowledge, the significance of the project are provided. Lastly, the rationale for the methodology, nature of the project design, nature of the project design, as well as assumptions, limitations, and delimitations are given.

Background of the Project

The use of central lines is increasingly becoming popular for both inpatients and outpatients to provide venous access. These lines upset the integrity of the skin, making bacterial and fungal infections possible. CLABSIs may spread in the bloodstream causing hemodynamic changes or organ dysfunction and ultimate death of the patient. It is estimated that 90 percent of CLABSIs occurs from central lines, with approximately 48 percent of cases taking place in ICU. An estimated 82,000 CLABSIs cases and 28,000 attributable deaths occur every year (Tomlinson, 2015). In the U.S alone, it is estimated that 31,000 patients lose their lives annually due to CLABSIs. A compendium of strategies has been developed to prevent CLABSIs. These include a guideline for hospitals and care professionals to use when placing a central line. Comment by Kathryn Flynn: cite Comment by Kathryn Flynn: cite

A central line bundle consisting of five components has been established to improve patient’s outcomes (Iliopoulou, Anderson & Day, 2015). These components give better outcomes when implemented together as opposed to individually. They include hand hygiene, chlorhexidine antisepsis, maximal barrier precautions. Optimal site selection and daily reviews and prompt removal. It is important to note that this is not a comprehensive selection of all the care elements that should go together with central lines. On the central line, the bundle is intended to enhance collaboration and teamwork among healthcare professionals. Other elements may be recommended depending on the patient and the purpose of the central line (Olsen, Schwehm & Campbell, 2015). In essence, the use of the central line bundle has helped reduce cases of CLABSIs by about 66 percent. A multidisciplinary approach is always recommended when taking care of patients in the ICU. Such teams should be heterogeneous in composition but homogenous when it comes to the mindset. It is important to offer encouragement and commitment to such teams if the end goal is to be met. This way, cases of CLABSIs can be reduced if not eliminated, and deaths occurring due to hospital-related infections prevented. Comment by Kathryn Flynn: continue sentence, second part is sentence fragment Comment by Kathryn Flynn: cite

Problem Statement

There is limited research on CLABSIs, especially regarding developing countries. Existing studies indicate that the rates of CLABSIs are higher for developing countries as compared with developed ones. Still, the latter countries also have worrying rates even though there are established guidelines to prevent, control, and reduce incidences of infections (Iliopoulou, Anderson & Day, 2015). Even though studies have substantiated CLABSIs as a significant health concern, the degree of efficacy of hygiene when handling patients who need catheter insertion needs improvement. This is even though guidelines have been established to help reduce cases of CLABSIs. More specifically there is an alarming trend that indicates that caregivers do not adhere completely to established guidelines which is one of the causes of CLABSIs (Duane, Ramanathan, Leavell, Mays & Ober, 2016). Also, poor training for nurses about hand hygiene and skin aseptic techniques has been a contributing factor to microbial infections as a result of CLABSI. This has, in turn, increased mortality rates for CVCs patients besides prolonging hospital stays and increasing the cost of care. While there are many guidelines in the literature regarding proper handling of vascular catheters, cases of CLABSI infections seem to remain high. This calls for the need for teaching proper CVC maintenance as the intervention to prevent CLABSI. Comment by Kathryn Flynn: is this pertinent if you’ve changed to maintenance? Comment by Kathryn Flynn: Back up assertion with citation

Purpose of the Project

The Purpose of this study is to explore the problem of CLABSIs and examine available measures to prevent, control, and reduce incidences. More importantly, the study examines the role of training both in school and on the job in helping to reduce associated health infections such as CLABSIs. In this context, the study realizes that nurses are poorly trained on how to maintain hand hygiene which coupled by factors such as lack of support from the management increases cases of CLABSIs(Al Hammadi et al. 2018). The present study looks at the role of training in reducing CLABSIs and what different stakeholders are doing to ensure that nurses are conversant with evidence-based practices for preventing CLABSIs. Comment by Kathryn Flynn: small p Comment by Kathryn Flynn: anthropomorphism; the researcher realizes.. Comment by Kathryn Flynn: see above comment; go through paper with this modification

In particular, this project proposes teaching proper CVC maintenance as an intervention to prevent CLABSI. It is expected that increasing the number and quality of training sessions about CVC maintenance would lead to a reduction in cases of CLABSI infections. The research will focus on nurses working in public health facilities in Webster, Texas. Several nurses will be randomly selected, and the number of CLABSI cases resulting from their handling of CVC cases noted. The nurses will then be taken through a training session stressing maintenance of CVCs. To determine the impact of the training, the nurses will be asked to perform CVC procedures post-training, and the number of CLABSI cases resulting from this compared with the number of cases before the training. The results from this project will be used to determine if increased training in CVC prevention can be used as a CLABSI prevention measure. Comment by Kathryn Flynn: specify to show acute care vs. local public health dept vs. long term care? Comment by Kathryn Flynn: Goes in methodology

Clinical Question

Engaging healthcare professionals to adopt hygienic practices is crucial in the fight against CLABSIs. However, it is even more important to ensure that nurses are well trained and conversant with the general guidelines of patient handling eliminate cases of health-related infections. Training ensures that best practices are followed during the insertion of catheters, dressing, assessment, and removal. While training especially on-the-job training may take time and adoption of practices prolonged, hospitals should ensure that nurses and other care professionals are informed on the best practices to avoid cases of CLABSIs. Staff training in CVC site care and maintenance will help reduce infections (Owings et al. 2017). Hospitals should, in this case, assess nurses’ understanding and competence when it comes to maintenance of CVC sites. Empowering nurses is also important to ensure commitment and willingness to communicate issues relating to patient care. The following clinical question guide this quantitative project: Comment by Kathryn Flynn: To?

Q: How does staff training of proper CVC maintenance reduce the incidence of CLABSIs?

Advancing Scientific Knowledge

Upon completion, this project is set to add to existing knowledge in the field of nursing and specifically the management and prevention of CLABSI. Nurses working in all settings requiring the use of vascular catheters already have varying knowledge regarding guidelines and safety measures to avoid central line blood infections. The proposed project seeks to add to this knowledge skills on proper CVC maintenance as the intervention to prevent CLABSI. Comment by Kathryn Flynn: Justify why you need to add; is what they know inadequate? Why?

The theoretical foundation upon which this project is based is the Quality Health Outcomes Model (QHOM). This framework is used to study healthcare quality and outlines relationships existing between interventions, characteristics, and outcomes of patients, and the characteristics of the healthcare system. The project seeks to bridge the gap existing in the literature regarding teaching proper CVC maintenance as the intervention to prevent CLABSI. This will be achieved by training a few nurses and observing if there is any improvement in how they handle CVC procedures.

Significance of the Project

This study seeks to add to existing knowledge about CLABSIs and the role of different stakeholders in ensuring the safety of CVC patients. As noted earlier, there are established guidelines that nurses are required to follow to ensure that patients are not exposed to microbial infections when undergoing treatment in the hospital (Al Hammadi et al. 2018). Arguably, these guidelines are, at times, not adhered to completely, which exposes patients to the risk of infections (Rosenblatt et al. 2017). Comment by Kathryn Flynn: Clarify and stay focused on what you are trying to do. Comment by Kathryn Flynn: Need more justification. Was this primary source?

Also, nurses lack enough knowhow when it comes to implementation of these guidelines, which coupled with lack of support and commitment on the side of the administration hinders the effort to ensure the safety of CVC patients. By examining how training and nurse empowerment contributes towards the reduction of cases of CLABSIs, this study seeks to identify ways in which hospitals and care providers can work collaboratively to ensure the safety of the patient. Comment by Kathryn Flynn: Back up assertion with citation Comment by Kathryn Flynn: This too. Are you referring to your setting? Is this an antecdotal perception? clarify Comment by Kathryn Flynn: Be specific; what will you do ?

An important implication of this study is that CLABSI cases will significantly reduce owing to the training. It is hoped that if the recommendations drawn from this study are applied across health facilities, cases of CLABSI will decline. This project fits within and will contribute to the current literature, and the clinical site practice since proper maintenance of CVC is nurse driven. The skills gained from the proposed teaching will be directly applied in the hospital when performing vascular catheter operations.

Rationale for Methodology

The current study will apply a mixed methods approach where elements of both qualitative and quantitative techniques will be used in data collection and analysis. The main objective of using this approach is to strengthen and/or expand conclusions thereby contributing to existing knowledge. The approach helps to heighten knowledge and increase the validity of the results. A mixed approach will also help to ensure convergence, correspondence, and corroboration of results (Guetterman, Fetters & Creswell, 2015). Further, it will help in ensuring complementarity besides expanding the range and breadth of inquiry. Comment by Kathryn Flynn: So, you will do what? Interview people and collect data? You’ll need to identify interventions to include in chapter.

The clinical question posed in this study is: How does staff training of proper CVC maintenance reduce the incidence of CLABSIs? From this question, the independent and dependent variables are “training of proper CVC maintenance” and “reduction in the incidence of CLABSI.” It is predicted that introducing the training will reduce CLABSI incidences. Thus, the two variables are negatively correlated. Comment by Kathryn Flynn: Expected to be

Nature of the Project Design

Before the training, data about the nurses’ prior experience will be collected from the supervisors. This information will include the number of CLABSI cases recorded over a given period. Closed-ended questionnaires will be administered to the sampled nurse supervisors. This type of questionnaires will ensure that data analysis is not overwhelming because the respondents are tied to specific answers. The questionnaires will be based on a Yes or No responses. The interview questionnaires will be acquired from the previous literature that handles the same issues in the study. Comment by Kathryn Flynn: State how it’s tracked Comment by Kathryn Flynn: Is it a validated tool? Specify how the questions are formulated.

For evidence-based practice in a healthcare setting, it is proper to have the nurses asked questions about the particular practices in relation with the staff training, reinforcement of the Central line catheter hub hygiene once it has been inserted, the cleansing of the site and cases of Central Line-Associated Blood-stream Infections. The process will assist in acquiring the observational, additional, and basic data that is targeted. A sample of 150 nurses will then be picked randomly from facilities whose supervisors will have been interviewed and taken through a short training on CVC maintenance. Their likelihood of causing CLABSI will be determined by comparing the number of infections caused in their care before and after the training. Comment by Kathryn Flynn: rephrase Comment by Kathryn Flynn: more specifics are needed for me to approve this. Also, reliability of results needs work. Just because nurses answer a certain way doesn’t mean it’s their fault that infection occurs. There has to be existing research that ties a tool to an outcome for use in the project. Otherwise, the assessment tool can be considered arbitrary.

Definition of Terms

The following terms are used operationally in this project:

CLABSI (Central Line-associated Bloodstream Infection). This is a primary laboratory-confirmed bloodstream infection in a patient with a central line at the time of (or within 48-hours before) the onset of symptoms, and the infection is not related to an infection from another site (California Department of Public Health, 2017).

Central Venous Catheters (CVCs). “A central venous catheter is a catheter with a tip that lies within the proximal third of the superior vena cava, the right atrium, or the inferior vena cava. Catheters can be inserted through a peripheral vein or a proximal central vein, most commonly the internal jugular, subclavian, or femoral vein” (Smith & Nolan, 2013).

Assumptions

1. It is assumed that survey participants in this project do not give misleading information through their answers. Participants are expected to provide answers which are honest and to the best of their ability. This assumption is based on the fact that the participants are professionals working under oath to adhere to professional ethics at all times.

1. It is assumed that this project is an accurate representation of the current situation in many hospitals across the world, and specifically in adult wards in Phoenix, Arizona. The assumption is especially about those patients who have already undergone a CVC procedure.

Limitations and Delimitations

1. This project is limited by the possibility that some participants may give biased, false, or inaccurate information. The researcher does not have a way of knowing if the information collected is true, unbiased, or accurate. Further, the project is limited by funds and other resources because it is solely funded by the researcher.

1. The survey of nursing supervisors is delimited to only public urban hospitals in Webster, Texas, limiting the demographic sample. It would be practically impossible to survey a wider region with the resources and time available.

Summary and Organization of the Remainder of the Project

In the first chapter of this project, the background of the project, problem statement, and the purpose of the project are given. Next, the clinical questions, criteria for advancing scientific knowledge, the significance of the project are provided. Lastly, the rationale for the methodology, nature of the project design, nature of the project design, as well as assumptions, limitations, and delimitations are given. Chapter 2 will present a review of current evidence on the centrality of the practice improvement project literature review in research preparation. Chapter 3 will describe the methodology, design, and procedures for this investigation. Chapter 4 details how the data was analyzed and provided both a written and graphic summary of the results. Chapter 5 is an interpretation and discussion of the results, as they relate to the existing body of research related to the practice improvement project topic. Comment by Kathryn Flynn: Kerry, It’s good you got this in on time but more work is needed. Review comments, modify, and resubmit. Self evaluate in rubrics before resubmission. Thanks.

References Comment by Kathryn Flynn: Need 38 more references and add rubric for this section. You’ll need to self evaluate for next submission

Al Hammadi, A., et al. (2018, November). Accuracy of the NHSN central line-associated bloodstream infection (CLABSI) definition. In Open Forum Infectious Diseases (Vol. 5, No. Suppl 1, p. S3). Oxford University Press.

California Department of Public Health. (2017, April 21). Healthcare Associated Infections (HAI) Program. Retrieved from California Department of Public Health: https://www.cdph.ca.gov/Programs/CHCQ/HAI/Pages/CentralLine-associatedBloodstreamInfection(CLABSI).aspx

Duane, T. M., Ramanathan, R., Leavell, P., Mays, C., & Ober, J. (2016). CAUTIs and CLABSIs: Do physicians really know what they are? Surgical infections, 17(1), 13-16.

Guetterman, T. C., Fetters, M. D., & Creswell, J. W. (2015). Integrating quantitative and qualitative results in health science mixed methods research through joint displays. The Annals of Family Medicine, 13(6), 554-561.

Haddadin, Y., & Regunath., H. (2019, January 20). Central Line Associated Blood Stream Infections (CLABSI). Retrieved from nih.gov: https://www.ncbi.nlm.nih.gov/books/NBK430891/ Iliopoulou, K., Anderson, J., & Day, T. (2015). Behavioral influences of critical care physicians and nurses intention to implement preventive evidence-based measures towards central line-associated bloodstream infections (CLABSIS). Intensive care medicine experimental, 3(1), A890.

McKim, C. A. (2017). The value of mixed methods research: A mixed methods study. Journal of Mixed Methods Research, 11(2), 202-222.

Olsen, M., Schwehm, J., & Campbell, C. (2015). Reducing CLABSIs Through Team Empowerment: A 67% Reduction. American Journal of Owings, A., Gilliam, C., Glover, B., Gipson, M., Wright, D., Morgan, S., & Hakim, H. (2017). What to Do? What to Do? About Those Ambulatory CLABSIs?. American Journal of Infection Control, 45(6), S40.Infection Control, 43(6), S54.

Rosenblatt, J. et al. (2017). Comparative efficacies of antimicrobial catheter lock solutions for fungal biofilm eradication in an in vitro model of catheter-related fungemia. Journal of Fungi, 3(1), 7.

Smith, R. N., & Nolan, J. P. (2013). Central venous catheters. Clinical Review, 28-32.

Tomlinson, S. (2015). Impact on CLABSIs with bundle implementation and staff education. The Journal of the Association for Vascular Access, 20(4), 248.

Turkel, M. C., Watson, J., & Giovannoni, J. (2018). Caring Science or Science of Caring. Nursing science quarterly, 31(1), 66

Practice Hours Completion Statement DNP-955

I, Kerry Murphy, verify that I have completed (12) clock hours in association with the goals and objectives for this assignment. I have also tracked said practice hours in the Typhon Student Tracking System for verification purposes and will be sure that all approvals are in place from my faculty and practice mentor.