The Fight Against CLABSIs

Central Line Associated Blood Stream Infection (CLABSI) prevention is an important nursing-sensitive indicator. In 2021, the Intensive Care Unit (ICU) at Loma Linda University Medical Center – Murrieta had an increase in our CLABSI rates, specifically in the ICU among our COVID-19 positive patients. Between August 2021 and December 2021, there were eight CLABSI infections in the ICU. Knowing how important CLABSI prevention is, the ICU team launched an initiative to eradicate CLABSI in the ICU. This initiative included both nursing and provider interventions. With this multidisciplinary approach, we identified areas of improvement in central line cares, documentation, line utilization, and blood culture stewardship.

Implementation of “Do No Harm: 0 CLABSI in 2022” was launched in January, starting with nursing education focusing on basics of line cares including improvements of documentation. Charge nurses and CLABSI champions continued with “Qshift in the Moment” auditing including one-on-one education for staff when areas of improvement were identified (dressing change needed, orange caps, etc.), as well as chart audits to focus on areas of improvement for nursing staff.

Line utilization was our next area of improvement, with strong commitment from both nursing and provider, to assess line necessity during multidisciplinary rounds on dayshift and nightshift rounds. Midline use in place of central lines for low dose vasopressors was implemented, as it was an area improvement based on evidence presented in medical and nursing journals indicating the midline use as a successful strategy in eliminating CLABSI. Provider interventions included trailing a process to use midlines instead of central lines for appropriate medications. This intervention, to date, has proven successful with zero negative outcomes for patients.

Blood culture stewardship was identified as an area to collaborate with providers and nursing staff. Blood culture contamination was a trend with patients, largely with COVID-19 patients. Education and attestation was given to staff with an opportunity for review and a skill checkoff on blood culture collection technique and implementation of a “Blood Culture Timeout.” The time out form provided a collaborative agreement and sign off with the intensivist, primary RN, and charge nurse (or CLABSI champion) to ensure that all the identified risk areas are addressed prior to culture draw. The time out form focused on individualized patient review for CLABSI risk (central venous catheter placement in the last 48 hours), discussion of alternate sources of infection, assessment of skin/wound integrity, review prior cultures or need of newly drawn cultures, and ensured a CHG bath is completed within 24 hours prior to culture being drawn.

Overall, these interventions have been successful. Since implementation, we have had zero CLABSIs in the ICU. Additional initiatives include implementation of house wide CLABSI Taskforce which focuses on education and support for identifying CLABSI risk, line utilization, line cares and dressing changes.