April 21, 2023 1
Linking Blood Stream Infections to Intensive
Care Nursing Context of Care and Process
Jill A. Marsteller, PhD, MPP; J. Bryan Sexton, PhD, MA; Yea-Jen Hsu, MHA, PhD Candidate; Chun-Ju
Hsiao, PhD, MPH; David Thompson, DNSc, MS, RN
Funded by the Interdisciplinary Nursing Quality Research Initiative, a national program of the Robert Wood Johnson Foundation
Unpublished data—Not for circulation
April 21, 2023 2
Background Central-Line Associated Blood Stream Infections
(CLABSI) are among the most common and most serious types of hospital-acquired infections
Between 9,600 and 20,000 patients are estimated to die from CLABSIs annually in the US
The estimated cost of treating CLABSIs ranges from $296 million to $2.3 billion
The risks for CLABSIs are especially great for patients in ICUs, 48% of patients in ICUs have indwelling central venous
catheters Approximately 15 million central line days per year in U.S.
ICUs CLABSI are most often preventable
Unpublished data—Not for circulation
April 21, 2023 3
How was this different from Keystone ICU? Pronovost et al. 2006 NEJM reported
results of Keystone ICU project in Michigan ICUs (also New Yorker article)
This project was different because: Randomized controlled trial Acknowledged the key nursing role Collected contextual measures
Team Checkup Tool and interviews w/ teams NQF nursing quality measures
Unpublished data—Not for circulation
April 21, 2023 4
Study Population 45 adult ICUs in 35 hospitals across two affiliated faith-
based health care systems (East n=35 ICUs and West n=10) The hospitals included in this study represent 12 states and
are all community non-profit religious hospitals Religious hospitals provide health care for one-fifth of all
Americans
Unpublished data—Not for circulation
April 21, 2023 5
Adventist-QSRGICU Patient Safety Intervention
Comprehensive Unit-based Safety Program (CUSP)
CLABSI-Prevention Bundle
Unpublished data—Not for circulation
April 21, 2023 6
CUSP Evaluate the culture of safety Educate the staff on science of safety Encourage staff to identify how the next patient
might be harmed Assign an executive to adopt the unit a) Learn from one system defect in the work
environment per month; b) Implement one teamwork tool every 2 months (daily goals; morning briefing; shadowing; culture check up)
Re-evaluate culture
Unpublished data—Not for circulation
April 21, 2023 7
CLABSI Prevention Washing hands before inserting a central
line Removing unnecessary lines Cleansing the site with chlorhexidine Using full barrier precautions Avoiding the femoral site for line
placement (some preference for the subclavian site)
Unpublished data—Not for circulation
April 21, 2023 8
Study Design Phased, clustered randomized
controlled trial ICUs randomized by hospital into
intervention (23 ICUs) and control (22 ICUs) conditions for the first seven months (then control became Intervention II)
Analyses: test of the intervention
Unpublished data—Not for circulation
April 21, 2023 9
Conceptual Framework
StructureProcess
OutcomesBeds ize
Skill M ix*
Previous Exposure to Intervention
*NQF Nurs ing Quality Indicators
Fidelity to CLA BS I
Bundle
Fidelity to CUS P
Nurs ing Hours per Day*
Activities o f Q I Team
CLABS I infections*
Annual Nurse Turnover*
ContextSAQ
Nurs ing Prac tice Env ironment*Implemen tation Barr iers / Fac ilita tors
Unpublished data—Not for circulation
April 21, 2023 10
Data Collection and Measures Laboratory Confirmed CLABSI andLine
Days Team Check-up Tool Nursing turnover, skill mix, RN hours per
patient day, PES-NWI SAQ Exposure to elements of the intervention ICU Length of stay ICU Mortality ICU Charges
Unpublished data—Not for circulation
April 21, 2023 11
RCT analysis Intervention I group started March 2007 Control group started the intervention in
Oct 2007 RCT compares post-intervention (Oct-Dec
2007) CLABSI rate, holding baseline (2006) rates constant (zero-inflated poisson regression)
Two groups equivalent at baseline on all measures except two (exposure to CUSP and to partnership with a senior executive)
Unpublished data—Not for circulation
April 21, 2023 12
The Effect of the Intervention: Model 1
IRR (95% CI) P valuePoissonIntervention status Control group 1.00 Intervention group 0.19 (0.06 to 0.58) 0.004
System East 1.00 West 10.38 (2.96 to 36.34) 0.000
ln(Baseline CLABSI rate+1) 0.95 (0.57 to 1.58) 0.844 Coef. (95% CI) P valueLogit Volunteer system East West 66.56 (62.05 to 71.06) 0.000
No. of ICU beds 1-10 >10 98.04 (90.87 to 105.22) 0.000
Baseline CLABSI count -32.38 (-34.63 to -30.14) 0.000constant -18.02 (-21.90 to -14.14) 0.000Model fit AIC 84.2 BIC 98.6
Vuong test 0.006
Unpublished data—Not for circulation
The Effect of the Intervention: Model 2
April 21, 2023 13
IRR (95% CI) P valuePoissonIntervention status Control group 1.00 Intervention group 0.31 (0.10 to 0.92) 0.035
Volunteer system East 1.00 West 6.37 (2.33 to 17.40) 0.000
Exposure to ECUSP 0.75 (0.84 to 1.16) 0.193Partnership with an ICU by a senior executive for the BSI-reduction effort
0.87 (0.62 to 1.22) 0.408
ln(Baseline CLABSI rate+1) 1.03 (0.62 to 1.72) 0.908 Coef. (95% CI) P valueLogit Volunteer system East West 67.26 (62.52 to 72.01) 0.000
No. of ICU beds 1-10 >10 98.72 (91.85 to 105.58) 0.000
Baseline CLABSI count -31.82 (-33.88 to -29.76) 0.000constant -19.49 (-24.09 to -14.88) 0.000Model fit AIC 84.8 BIC 102.9
Vuong test 0.002
Unpublished data—Not for circulation
April 21, 2023 14
No. of Bloodstream Infections per 1000 catheter-Days
BaselineAfter
implementation
Median (interquartile range)
Overall 1.89 (0.72 - 4.18) 0.00 (0.00 - 2.48)
Intervention status
Control 1.78 (0.00 - 3.80) 0.00 (0.00 - 2.89)
Intervention 2.56 (0.74 - 5.87) 0.00 (0.00 - 1.50)
System
East 1.67 (0.29 - 3.80) 0.00 (0.00 - 2.48)
West 3.77 (1.03 - 7.12) 0.00 (0.00 - 5.66)
Unpublished data—Not for circulation
April 21, 2023 15
Quarterly BSIs per 1000 line days
Intervention 1 (n=23) Intervention 2 (n=22)
BSI rate IRR % of reduction BSI rate IRR
% of reduction
Baseline (2006) 4.48 1.00 2.71 1.00
Mar 07 4.71 1.05 5% -
1st Q (Apr-Jun 07) 1.12 0.25 -80% -
2nd Q (Jul-Sep 07) 1.83 0.41 16% -
3rd Q (Oct-Dec 07) 1.33 0.30 -11% 2.16 0.79 -21%
4th Q (Jan-Mar 08) 0.96 0.21 -8% 0.56 0.21 -59%
5th Q (Apr-Jun 08) 0.88 0.20 -2% 0.52 0.19 -2%
6th Q (Jul-Sep 08) 0.85 0.19 -1% 0.83 0.31 12%
BSI rate reduction from baseline to 6th quarter
-81% -69%
Unpublished data—Not for circulation
April 21, 2023 16
Challenges of the Design Controls knew they would also be
implementing In interviews, some controls told us they
had gotten started early Controls did not report during control
period—so “post” period is actually first 3 mo.s of intervention
Education delivery was better 2nd time
Unpublished data—Not for circulation
April 21, 2023 17
Staff Use (1)
Unpublished data—Not for circulation
April 21, 2023 18
Staff Use (2)
Unpublished data—Not for circulation
Estimated Lives Saved over 2006 ~20% of people acquiring CLABSI will die
from the infection An estimated 35 to 36 people died in 2
systems in 2006 If rate in quarter ending August 2008 stays
the same over a year, only an estimated 12 people would die of CLABSIs June 2008-May 2009
A 66% reduction
* Preliminary estimates
Unpublished data—Not for circulation
Estimated Cost Savings BSIs cost an estimated ~$45,000 per
infectionReduced BSIs could have saved
as much as $5,850,000 across the two systems!!
Unpublished data—Not for circulation
April 21, 2023 21
Conclusions The CLABSI evidence-based practice bundle
reduces bloodstream infections and zero can be achieved for long periods of time
The bundle can be implemented effectively as a nursing-driven protocol for interdisciplinary team management of central line placement and maintenance
Despite the promising results there were many barriers to implementation, such as physician engagement; adherence to protocol
Difficult to achieve team compliance with monthly reporting by all team members
Unpublished data—Not for circulation
April 21, 2023 22
Policy/ Managerial Implications CMS has said it will not pay for CLABSI
above the normal IPPS payment for the case starting Oct. 1, 2008 (Deficit Reduction Act of 2005)
Assumes all infections can be prevented All hospitals will need to implement
CLABSI prevention strategies QI teams need education, attention from
and support of senior management, BoD
Unpublished data—Not for circulation