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
July 12, 2016
Unpublished data—Not for circulation
1
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
July 12, 2016
Unpublished data—Not for circulation
2
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


July 12, 2016
Team Checkup Tool and interviews w/ teams
NQF nursing quality measures
Unpublished data—Not for circulation
3
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

July 12, 2016
Unpublished data—Not for circulation
4
Adventist-QSRG
ICU Patient Safety Intervention
Comprehensive
Unit-based Safety
Program (CUSP)
July 12, 2016
CLABSIPrevention
Bundle
Unpublished data—Not for circulation
5
CUSP





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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
July 12, 2016
Unpublished data—Not for circulation
6
CLABSI Prevention


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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)
July 12, 2016
Unpublished data—Not for circulation
7
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

July 12, 2016
Unpublished data—Not for circulation
8
Conceptual Framework
Structure
Beds iz e
Sk ill M ix *
Process
Outcomes
Fidelity to CLA BS I
Bundle
CLABS I
infec tions *
Fidelity to CUS P
Prev ious
Ex pos ure to
Interv ention
Context
Nurs ing Hours per Day *
Ac tiv ities o f Q I Team
Annual Nurs e
Turnov er*
SAQ
Nurs ing Prac tic e Env ironment*
Implemen tation Barriers / Fac ilita tors
*NQF Nurs ing Quality Indic ators
July 12, 2016
Unpublished data—Not for circulation
9
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

July 12, 2016
Unpublished data—Not for circulation
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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)

July 12, 2016
Unpublished data—Not for circulation
11
The Effect of the Intervention: Model 1
Poisson
Intervention status
Control group
Intervention group
System
East
West
ln(Baseline CLABSI rate+1)
Logit
Volunteer system
East
West
No. of ICU beds
1-10
>10
Baseline CLABSI count
constant
Model fit
AIC
BIC
Vuong test
July 12, 2016
IRR
(95% CI)
P value
1.00
0.19
(0.06 to 0.58)
0.004
1.00
10.38
0.95
Coef.
(2.96 to 36.34)
(0.57 to 1.58)
(95% CI)
0.000
0.844
P value
66.56
(62.05 to 71.06)
0.000
98.04
-32.38
-18.02
(90.87 to 105.22)
(-34.63 to -30.14)
(-21.90 to -14.14)
0.000
0.000
0.000
84.2
98.6
0.006
Unpublished data—Not for circulation
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The Effect of the Intervention: Model 2
Poisson
Intervention status
Control group
Intervention group
Volunteer system
East
West
Exposure to ECUSP
Partnership with an ICU by a senior executive
for the BSI-reduction effort
ln(Baseline CLABSI rate+1)
Unpublished
data—Not
for
circulation
July 12, 2016
Logit
Volunteer system
East
West
No. of ICU beds
1-10
>10
Baseline CLABSI count
constant
Model fit
AIC
BIC
Vuong test
IRR
(95% CI)
P value
1.00
0.31
(0.10 to 0.92)
0.035
1.00
6.37
0.75
0.87
(2.33 to 17.40)
(0.84 to 1.16)
(0.62 to 1.22)
0.000
0.193
0.408
1.03
Coef.
(0.62 to 1.72)
(95% CI)
0.908
P value
67.26
(62.52 to 72.01)
0.000
98.72
-31.82
-19.49
(91.85 to 105.58)
(-33.88 to -29.76)
(-24.09 to -14.88)
0.000
0.000
0.000
84.8
102.9
0.002
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No. of Bloodstream Infections
per 1000 catheter-Days
Baseline
After implementation
Median (interquartile range)
Overall
1.89 (0.72 - 4.18)
0.00 (0.00 - 2.48)
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)
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)
Intervention status
System
July 12, 2016
Unpublished data—Not for circulation
14
Quarterly BSIs per 1000 line days
Intervention 1 (n=23)
Baseline (2006)
Mar 07
1st Q (Apr-Jun 07)
2nd Q (Jul-Sep 07)
3rd Q (Oct-Dec 07)
4th Q (Jan-Mar 08)
5th Q (Apr-Jun 08)
6th Q (Jul-Sep 08)
BSI rate reduction
from baseline to 6th
quarter
July 12, 2016
BSI rate
4.48
4.71
1.12
1.83
1.33
0.96
0.88
0.85
IRR % of reduction
1.00
1.05
5%
0.25
-80%
0.41
16%
0.30
-11%
0.21
-8%
0.20
-2%
0.19
-1%
Intervention 2 (n=22)
BSI
rate
2.71
2.16
0.56
0.52
0.83
IRR
1.00
0.79
0.21
0.19
0.31
-81%
Unpublished data—Not for circulation
% of
reduction
-21%
-59%
-2%
12%
-69%
15
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

July 12, 2016
Unpublished data—Not for circulation
16
Staff Use (1)
July 12, 2016
Unpublished data—Not for circulation
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Staff Use (2)
July 12, 2016
Unpublished data—Not for circulation
18
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
Unpublished data—Not for circulation
* Preliminary estimates
Estimated Cost Savings

BSIs cost an estimated ~$45,000 per
infection
 Reduced
BSIs could have saved
as much as $5,850,000 across
the two systems!!
Unpublished data—Not for circulation
Conclusions

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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
July 12, 2016
Unpublished data—Not for circulation
21
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

July 12, 2016
Unpublished data—Not for circulation
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