A CAUSAL-COMPARATIVE EXAMINATION OF CLABSI, VASCULAR ACCESS TEAMS AND HOSPITAL TYPES

The purpose of this quantitative causal-comparative study was to determine if there is a difference in reported CLABSI rates based on hospital type and if there was a difference in reported CLABSI rates based on the presence or absence of a vascular access team in a random sample of 3700 hospitals in the United States. Prior studies have examined how healthcare organizations have attempted to improve vascular access device related infection, yet there is little research regarding the difference a vascular access team model has on the healthcare organization (Krein et al., 2019). Krein et al. (2019) further highlighted the need to better understand the model, role, composition, and practice of vascular access/ PICC teams which may impact patient outcome. Rajaram et al. (2015) identified a correlation between hospital type and size with nosocomial infections (CAUTI and CLABSI) yet did not identify these independently, nor was there a correlation as to what type, if any; vascular access team model was utilized.

Healthcare leaders are struggling to incorporate processes that augment healthcare efficiency, reduce patient harm and optimize patient outcome (Marschall et al., 2014; PorterO’Grady & Malloch, 2016; Zingg et al., 2015). Vascular access device insertion and use are high volume, high risk, and problem prone, requiring skilled operators to ensure the highest level of procedural compliance to reduce patient harm (Davis et al., 2016). As healthcare organizations attempt to consolidate care costs, optimize workflow, and patient throughput, a better understanding of vascular access team models may aide healthcare leadership with developmental and implementation of multi-modal strategies 108 (Hessels & Larson, 2016; Lawson, 2015; Patel et al., 2019; Rosen et al., 2018; Young, 2017; Zingg et al., 2015).

This study was guided by two research questions and corresponding hypotheses. The research questions addressed the difference in reported CLABSI rates based on hospital type (teaching and non-teaching) for hospitals with a vascular access team and if there was a difference in reported CLABSI rates based on a vascular access team present or absence. Both questions were answered by using a two-way analysis of variance (ANOVA) and a t-test was used to investigate the relationships. Both tests compare the means between groups and determine whether any of those means are statistically significantly different from each other.

Clinical practice variations between hospital type and size demonstrate an increased risk of CLABSI therefore, understanding how a team may aide in clinical practice variations and promote a standardized procedural process might be beneficial (Rajaram et al., 2015). Knowing that adherence to evidence-based practices decreases variation in CVAD insertion, and maintenance practice, may significantly improve the overall quality of care (Akinwole, 2015; Stone et al., 2014; Valencia et al., 2016), the possible team present contribution for risk reduction was explored. The result of this study may aide hospital leadership regardless of hospital type to better understand the difference a vascular access team model has on HAI reduction. The remainder of this chapter provides a comprehensive summary of the study. The study findings are discussed, and conclusions are presented. This chapter addresses the implications of the study from theoretical and practical perspectives. Future implications are also addressed. Finally, recommendations for future research are presented.

SUMMARY OF THE STUDY

The purpose of this study was to determine if there is a difference in reported CLABSI rates based on hospital type and if there was a difference in reported CLABSI rates based on the presence or absence of a vascular access team in a random sample of 3700 hospitals in the United States. To understand if there is a difference in reported CLABSI, the researcher investigated the background of the study topic. Previous studies have shown that various healthcare teams play a role in the improvement of patient outcomes (Alexandrou et al., 2014; Davies et al., 2018; Johnson et at., 2017; Krein et al., 2019; Ulrich & Crider, 2017). Marschall et al. (2014) recognized that IV therapy teams responsible for peripheral IV insertion and maintenance reduce the risk of infection, yet few studies identified the impact of such teams on CLABSI rates. Rajaram et al. (2015) identified a correlation between hospital type and size with nosocomial infections (CAUTI and CLABSI) yet did not identify these independently, nor was there correlation as to what type, if any; vascular access team model was utilized.

The researcher reviewed and synthesized theoretical foundations and models that provided the conceptual framework for this research. The structure-process-outcome theoretical model was used in this research to provide a framework for evaluating healthcare outcomes (Donabedian, 1969). The Donabedian model has been used to evaluate health care quality in a variety of health care settings (Chou et al., 2008; Holt et al., 2014; Issel & Bekemeier, 2010; Watkins et al., 2010; Wübker, 2007). Donabedian’s theory focused on three primary categories: structure, process, and outcome (Donabedian, 2003).

The researcher extended Donabedian’s theory by applying the framework to healthcare outcomes as it relates to hospital types and the presence of a vascular access team within U.S. hospitals. Donabedian defines structure as the professional and organizational resources associated with the provision of health care, for this study Structure referred to the characteristics of the location in which healthcare is provided (Donabedian, 1969, 1988) and was referred to as characteristics of U.S. hospitals providing healthcare to Medicare beneficiaries. Process refers to the things done to and for the patient such as interactions between patient and clinician or team, which involves care delivery. Outcome will refer to the measured U.S. hospitals reported CLABSI rates. Outcome is the desired result of care provided by the health practitioner (Donabedian, 1969, 1988) or the effect of healthcare delivery (Donabedian, 1969, 1988).

A review of the literature provided an in-depth investigation of empirical research focused on the impact of healthcare team models. This review also focused on empirical data regarding the impact of team models as it relates to the work environment

and patient outcomes. The literature review examined the background of the study, how the theoretical framework related to the variables of the study as well as a historical perspective of the evolution of infusion and vascular access teams and its impact on patient outcome, and the development of outcome reporting through the Centers for Medicare and Medicaid Services, and its impact on healthcare delivery. In addition, current literature regarding Donabedian’s (1969) structure-process-outcome (SPO) framework was reviewed.

This study was conducted using the quantitative methodology with a causal comparative design to answer the two research questions. As Ingham-Broomfield (2014) explained, quantitative research is used when researchers want to use statistics to describe and summarize data. The causal-comparative design is used when the researcher wants to determine if the independent variable affected the dependent variable by comparing two or more groups of individuals (Salkind, 2010). To examine whether hospital type, or vascular access team presence made a difference in reported CLABSI rates, the following research questions and hypotheses were developed.

RQ1: Is there a difference in reported CLABSI rates based on hospital type (teaching and non-teaching) for hospitals with a vascular access team?

H01: There is no statistically significant difference in reported CLABSI rates based on hospital type (teaching and nonteaching) for hospitals with a vascular access team?

H1a: There is a statistically significant difference in reported CLABSI rates based on hospital type (teaching and nonteaching) for hospitals with a vascular access team?

RQ2: Is there a difference in reported

CLABSI rates based on a vascular access team present or absence?

H02: There is no statistically significant difference in reported CLABSI rates based on a vascular access team present or absent.

H2a: There is a statistically significant difference in reported CLABSI rate based on a vascular access team present or absent.

The researcher used a stratified random sampling technique. A stratified sampling technique aligned with the study design and research questions. The data analysis included both descriptive and inferential statistics. The descriptive analysis provided an understanding of the sample characteristics. A two-way ANOVA was utilized to answer both research questions. Both research questions rejected the null hypothesis. In Chapter 5, the researcher examined the results of the data analysis, explained the findings in alignment with the research questions, and outlines conclusions drawn from the findings. Theoretical, practical and future implications were also discussed. Lastly, the researcher provided recommendations for practice and future research based on the findings and conclusions. The final data sample for this study included 128 hospitals participating in mandatory HAI reporting. This included 64 teaching and 64 non-teaching hospitals. The data collection instruments for this causal-comparative research included the Hospital Compare open access database (CMS.gov) and a phone inquiry. Hospital Compare reports information on quality measures including HAIs and patient satisfaction for over 3000 hospitals nationwide (CMS.gov). Reported HAI scores from a random sample of hospitals from 2016-2017 was examined. Hospital specific vascular access team detail was collected using a phone inquiry.

The researcher formulated two research questions to determine if there is a difference in reported CLABSI rates based on hospital type and if there was a difference in reported CLABSI rates based on the presence or absence of a vascular access team in a random sample of 3700 hospitals in the United States. To address the two research questions, the researcher conducted a two-way ANOVA. A paired t-test was also conducted for research question two. The causal-comparative design used for this study determines whether the independent variable affected the dependent variable by comparing two or more groups of individuals (Salkind, 2010). The following shows how the findings aligned with each research question and hypothesis.

RESEARCH QUESTION 1

The first research question addressed the significant mean difference between reported CLABSI rates based on hospital type (teaching and nonteaching) for hospitals with a vascular access team. A two-way analysis of variance (ANOVA) was used to answer this question. The ANOVA was examined based on an alpha value of 0.05. The results of the ANOVA were significant, F(2, 125) = 16.54, p < .001, indicating there were significant differences in reported CLABSI among the levels of hospital type teaching or non-teaching and team present or absent (Table 3). The main effect, hospital type was significant, F(1, 125) = 24.54, p < .001, ηp 2 = 0.16, indicating there were significant differences in reported CLABSI by hospital type. The main effect, team present or absent was also significant, F(1, 125) = 8.54, p = .004, ηp 2 = 0.06, indicating there were significant differences in reported CLABSI by team present or absent. Thus, accepting the alternative hypothesis and rejecting the null hypothesis. In a study by Rajaram et al. (2015) the authors identified a correlation between hospital type and size with nosocomial infections (CAUTI and CLABSI) yet did not identify these independently, nor was there correlation as to what type, if any; vascular access team model was utilized. The results of this research suggest that having a vascular access team regardless of hospital type does positively impact infection outcomes. These results should guide healthcare leaders seeking to implement evidence based guidelines and infection risk reductions strategies throughout healthcare organizations.

RESEARCH QUESTION 2

team present or absence. A two-way analysis of variance (ANOVA) and a paired t-test was used to answer this question. The results showed there was a significant mean difference between a team being present or absent determined by two-way ANOVA, F(1, 125) = 8.54, p = .004, ηp 2 = 0.06, in addition, the paired t-tests demonstrated the main effect of team absent (M = 21.23, SD = 14.44), was significantly larger than for team present (M = 13.88, SD = 17.38), p = .004 thus, accepting the alternative hypothesis and rejecting the null hypothesis.

Previous studies have shown that various healthcare teams play a role in the improvement of patient outcomes (Alexandrou et al., 2014; Davies et al., 2018; Johnson et at., 2017; Krein et al., 2019; Ulrich & Crider, 2017). According to Chopra et al. (2017), vascular access and infusion nurses who generally receive additional training in inserting and maintaining a range of intravenous (IV) devices, serve a critical role in providing safe and reliable vascular access. Davis et al. (2016) identified vascular access as being a high-volume/high-risk invasive procedure requiring specialized training and expertise to ensure positive outcomes. Alexandrou et al. (2014) emphasized that a centralized vascular access service with a small number of specifically trained personnel may be more important to procedural success than clinician grade. Specialized training includes both peripheral and central venous access catheter insertion and care (Chopra et al., 2017). Krein et al. (2019) recommended that nurse peripherally inserted central catheter (PICC) teams play an integral role in PICC usage, and device selection suggesting that use of such teams may promote key practices to prevent reported CLABSI.

As healthcare organizations attempt to consolidate care costs, optimize workflow, and patient throughput, a better understanding of vascular access team models may aide healthcare leadership with developmental and implementation of multi-modal strategies (Hessels & Larson, 2016; Lawson, 2015; Patel et al. 2019; Rosen et al. 2018; Young, 2017; Zingg et al. 2015). Employing structured practice and processes for vascular access procedures should include: (a) patient assessment, (b) device insertion, (c) maintenance, and removal may reduce hospital risk (Moureau, 2017; Moureau & Chopra, 2016; Savage et al., 2019). Furthermore, the significance of these study findings may aide health care leaders with a better understanding of the relationship between hospital type, the presence of a vascular access team and reported CLABSI rates.

CLABSI accounts for approximately 15% of HAIs and are serious yet avoidable outcomes that directly impact patient satisfaction and can be avoided with strict adherence to current evidencebased guidelines (Gorski et al., 2021; Marschall et al., 2014; O’grady et al., 2011). Understanding if a relationship exists between hospital type, vascular access team, and reported CLABSI rates might better prepare leaders in healthcare organizations to reduce HAIs. The results of this study do substantiate the findings from Alexandrou et al. (2014), Krein et al. (2019), Davis et al. (2016), and Chopra et al. (2017) in regard to use of a dedicated vascular access team. These results should guide healthcare leaders seeking to standardize practice through implementation of evidence-based guidelines and infection risk reductions strategies throughout healthcare organizations. This quantitative, causal-comparative study aimed to determine if there is a difference in reported CLABSI rates based on hospital type and if there was a difference in reported CLABSI rates based on the presence or absence of a vascular access team in a random sample of 3700 hospitals in the United States. The data analysis revealed a statistically significant difference in reported CLABSI rates based on both hospital type and the presence of a vascular access team. This section discusses what the research discovered, as well as how the finding could be interpreted based on the theoretical framework. Practical implication of a vascular access team model and future implications for new research are also discussed. Theoretical implications. The Donabedian theory has been used to identify the structural components and clinician-patient care processes that lead to patient outcomes. The researcher formulated two research questions and corresponding hypotheses to study if there was a difference in reported CLABSI rates based on hospital type (teaching and non-teaching) and vascular access team present or absent in U.S. hospitals. Donabedian’s theory. This conceptual framework has been used to evaluate health care quality in a variety of health care settings (Chou et al., 2008; Holt et al., 2014; Issel & Bekemeier, 2010; Watkins et al., 2010; Wübker, 2007). The structure of a healthcare organization is comprised of relatively stable VASCULAR ACCESS TEAMS SHOULD characteristics, to include the resources available, and the physical and BE AVAILABLE 24 HOURS A DAY, 7 DAYS organizational settings in which they work. A WEEK, WITH THE AUTONOMY TO Structures in healthcare referred to the physical IMPLEMENT AND MAINTAIN EVIDENCEand structural features of care settings (e.g., hospitals, employees, BASED PRACTICES TO OPTIMIZE operations, finance etc.). The structure affects CLABSI OUTCOMES processes and outcomes. For this research, the structural variables include; the vascular access team, teaching and non-teaching medical centers and U.S. hospitals and CLABSI rates reported into the Medicare and Medicaid pay-forperformance program. Care processes are interactions or activities that occur within and between health care clinicians and the target population they serve (Donabedian, 1980; Donabedian, 2003). Outcomes are the definitive validator of the effectiveness and quality of health care, which may include improvements in social, physical, and psychological function; patient attitudes and satisfaction; and health-related behavioral change (Donabedian, 2005). This study resulted in a statistical significance difference in hospital (structure) F(2, 125) = 16.54, p < .001, indicating there were significant differences in reported (outcome) CLABSI among the levels of hospital (structure) teaching and non-teaching and team (process) present was significantly smaller than for Absent (M = 21.23, SD = 14.44), p = .004.

The Donabedian theory has implications for healthcare optimization through care delivery model assessment regardless of hospital type, size or resources. Healthcare organizations continue to seek care processes that provide quality, efficient and standardized processes. This theory as demonstrated in this study continues to have real world implications outcome focused organizations seeking quality of care measures through acknowledgement and assessment of established structures and processes.

PRACTICAL IMPLICATIONS

A major practical implication drawn from this study is that healthcare leaders should consider the use of dedicated vascular access teams as a CLABSI improvement strategy regardless of hospital type. More specifically, they should consider teams as an essential strategy when seeking to standardize patient care related to vascular access device insertion and management. This practical application is supported by Alexandrou et al. (2014) and Johnson et al. (2017), who stipulated that vascular access/ infusion teams augment risk reduction efforts and improve patient safety. Teams with specialized training and expertise are required to ensure both patient safety and positive outcomes (Alexandrou et al., 2014; Chopra et al., 2017; Davis et al. 2016).

Another practical application is the opportunity to standardize care delivery, patient assessment and reduce overall costs to both teaching and non-teaching healthcare organizations. The presence of a vascular access team supports standardization practices to include; device insertion, care and maintenance and prompt device removal. The finding of this study along with that of Gunderson et al. (2016) support the practical application of vascular access teams as they have been shown to reduce supply costs, decreased the number of attempts to gain intravenous access, and increased time to treatments for patient care, and these teams are found to be beneficial to both patients and staff. According to McDiarmid et al. (2017) the use of standardized care and maintenance protocols demonstrated considerable benefits to patients with a low risk of major complications.

VASCULAR ACCESS TEAMS SHOULD BE AVAILABLE 24 HOURS A DAY, 7 DAYS A WEEK, WITH THE AUTONOMY TO IMPLEMENT AND MAINTAIN EVIDENCEBASED PRACTICES TO OPTIMIZE CLABSI OUTCOMES

FUTURE IMPLICATIONS

This study was instrumental by further filling in the gap of knowing the extent to which the presence of a vascular access team impacts reported CLABSI rates regardless of hospital type. More precisely, this study’s findings offer useful insight for healthcare leaders seeking strategies to further reduce reported CLABSI rates. Additional research is needed to further explore the team variables which may further impact patient outcomes (Legemaat et al., 2015). Furthermore, this study has helped reinforce the need for specialized vascular access teams. As healthcare organizations seek to reduce cost and standardize patient care, teams should be resourced to ensure timely, optimized patient care is achievable with the least amount of patient harm or risk. Additionally, future research should include a nationwide survey assessment of team resources, this quantitative research may demonstrate resource need to healthcare leaders who are required to rationalize resources and overall team design.

Strengths and weaknesses of the study. The strengths of this study were the focus on factors that can affect reported CLABSI rates within the United States teaching and non-teaching hospitals. Rajaram et al. (2015) identified a correlation between hospital type and size with nosocomial infections (CAUTI and CLABSI) yet did not identify these independently, nor was there correlation as to what type, if any; vascular access team model was utilized. This study reinforced the difference in reported CLABSI rates between hospitals types but also identified that the presence of a vascular access team has a significant impact on reported CLABSI rates regardless of hospital type. The study can aide healthcare organizations seeking resource options to reduce reported CLABSI rates.

The researcher identified two weaknesses of this study. First the study included the use of reported CLABSI rates from 2016-2017. In 2017, the NHSN system changed to SIR reporting to adjust for hospital characteristics and hospital designations. Second the study identified the presence or absence of a team at each randomly selected hospital. The research did not break down the type of team or team variables which may contribute to reported CLABSI rates.

There were several limitations to this study. The first limitation was the use of secondary data collected from a large mandatory reporting database. As described by Dubois et al., 2013; Smith, 2014; Zhan & Miller, 2003 the use of secondary data poses a fundamental risk due to potential data entry errors. The second limitation was the inability to control the environment related to the use of a phone inquiry (Baxter & Chua, 2008). The researcher used a phone inquiry to determine the use of a vascular access team. The final limitation was the study design. A causal comparative design examines a relationship between and dependent variables and there are often variables other than the independent variables that may impact the dependent variable (Salkind, 2010). This limits the ability to develop sound judgements related to cause and effect because the researcher does not directly influence the independent variables.

RECOMMENDATIONS

The results of this study provide insight into opportunities for future research and practice. This study examined if hospital type, or the presence of a vascular access team made a difference in reported CLABSI rates. By examining reported CLABSI rates, hospital type and the presence or absence of a vascular access team. Based on this study, the researcher offers the following recommendations for future research and practice.