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Running head: CLABSI
Implementation of the AACN Synergy Model of Patient Care to Central Line-Associated
Bloodstream Infections in the Oncology Population
Erica Quigley
University of Central Florida
College of Nursing
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CLABSI
Abstract
Oncology patients are at an increased risk for central line-associated bloodstream
infections and resulting complications. Oncology patients have many unique risk factors
that predispose them to increased rates of CLABSI. This vulnerable population cannot be
treated with the same interventions and preventative care as patients with separate
diagnoses. A significant contributor is the fact that oncology patients are recurrently
neutropenic as a result of different treatment regimens and often from the pathological
process itself. CLABSI has a 12-25% mortality rate. Each case of CLABSI costs
approximately $26,000. CLABSI adds 300 million to 2.3 billion dollars every year to
healthcare costs. As leaders at the point of care, nurses are in a unique position to
influence CLABSI rates in the oncology population. Cost is greatly affected by CLABSI
rates. Hospital reimbursement and public reputation considerably contribute to monetary
incentives for institutions. The intended outcome is reduction of CLABSI in the oncology
population. One way of achieving this significant aim is through the implementation of
nursing educational strategies. The AACN Synergy Model for Patient Care may be
utilized to implement education as intervention and meet patient needs. The purpose of
the model is to allow identified patient needs to drive nursing core competencies.
Synergy may be achieved when the nurses’ competencies complement the needs of the
patient. Proper education of nurses may improve CLABSI rates and complications. With
implementation of the Synergy Model, morbidity and mortality in the oncology
population can be decreased.
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CLABSI
Implementation of the AACN Synergy Model of Patient Care to Central Line-Associated
Bloodstream Infections in the Oncology Population
Background
Central venous catheters (CVC) are essential to the treatment and care of patients
in the oncology population (Kelly et al., 2011). CVC’s are needed to administer caustic
chemotherapy agents, blood products, parenteral nutrition, and perform frequent
veinipuncture. Central line-associated bloodstream infections (CLABSI) are always an
associated risk for patients with these devices. However, the incidence of CLABSI
occurring in the oncologic population is alarmingly high. CLABSI, as defined by the
CDC, is “a recognized pathogen cultured from 1 or more blood cultures, and organism
cultured is not related to infection at another site” (Horan, Andrus, & Dudeck, 2012, pg
17). A significant contributor is the fact that oncology patients are recurrently
neutropenic as a result of different treatment regimens and often from the pathological
process itself, especially in hematological malignancies (Kelly et al., 2011). High-dose
chemotherapy, radiation, and immunosuppressive agents; as used in the bone-marrow
transplant population, are frequent contributors to neutropenia. Neutropenia is defined as
an absolute neutrophil count less than 500 with the mean neutropenic episode lasting ten
days (Carlisle, Gucalp, & Wiernik, 1993). These risk factors also contribute to bacteria
translocation, superinfection, and mucus membrane disruption. Immune dysfunction is a
significant problem leading to increased complications, morbidity, and mortality.
A Review of Recent Literature
Cancer patients are one of the most susceptible in-patient populations to
nosocomial infection (Carlisle et al., 1993). A study conducted at The Albert Einstein
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Cancer Center at the Montefiore Medical Center examined the rates of nosocomial
infection in neutropenic cancer patients. These patient diagnoses consisted of leukemias,
lymphomas, hematologic malignancies, and solid tumors. Out of 920 patients, 444
nosocomial infections occurred which equates to 48.3 infections per 100 patients. Out of
this group, 43 patients’ source of infection was from the venous access device. The study
concludes that neutropenia is a significant risk factor in the development of nosocomial
infection in systemic and site-specific locations
A retrospective case-controlled study was performed at the Children’s Hospital
Boston to associate rate and risk factors of CLABSI in pediatric hematology/oncology
patients (Kelly et al., 2011). The purpose of this study was to identify a vulnerable
population at an increased risk for CLABSI so specific interventions can be applied. The
research population consisted of 54 patients with a malignancy and 108 patient control
subjects. The potential risk factors examined included patient variability, type of cancer,
blood product administration, treatments, central venous catheter characteristics, and line
preservation. There were 3.4 CLABSI in the research group per 1,000 catheter days with
a total of 54 CLABSI. Acute lymphocytic leukemia was the most common diagnoses
with CLABSI followed by stem cell transplant patients. Majority of the central venous
catheter type with CLABSI was an implanted port. A myriad of pathogens were cultured
from the catheters with 58% as gram-positive bacteria, 32% gram-negative bacteria, and
10% yeast. The most common organism in the cases of infection was Enterococcus
faecicum. It was also noted that recent blood product transfusion and an increased
incidence of CLABSI was observed. Oncology patients have many unique risk factors
that predispose them to an increased risk of CLABSI. This vulnerable population cannot
CLABSI
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be treated with the same interventions and preventative care as patients with separate
diagnoses.
An additional study performed at the Cleveland Clinic was utilized to create a
definition of CLABSI specific to the oncology population to enhance surveillance
according to the specific, distinctive risk factors inherent in cancer patients (DiGiorgio et
al., 2012). The criterion that was incorporated into the all-encompassing CLABSI
definition included Streptococci, Enterococcus, Enterobacteriaceae, or Candidia
CLABSI infections as a result of translocation. The translocation occurring from resultant
mucositis, bone marrow transplant patients with graft-verse-host disease of the
gastrointestinal tract, and high-dose chemotherapy treatments causing neutropenia.
Incorporating the new definition, it was found that there were 2 CLABSI per 1,000
patient days on the bone marrow transplant unit, and 8.2 CLABSI per 1,000 patient days
on the leukemia unit. The most common organisms identified were Staphylococcus,
Pseudomonas aeruginosa, and Staphylococcus aureus. When utilizing the traditional
CLABSI defining criteria, enteric pathogens were recognized as the most common
causative organism. This study indicates the need for alternative measures for diagnosing
and prevention of CLABSI in the cancer population. The risk factors in this vulnerable
population must be taken into account and surveillance measures modified to fit these
specific needs.
Complications
Many complications arise from CLABSI and greatly contribute to the mortality
and morbidity of cancer patients (Nichols & Raad, 1999). Cancer patients have a distinct
disadvantage due to their innate inability to fight off infection. These patients also have
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many other health concerns from the cancer process or treatment affecting their ability to
overcome the infectious process that may lead to life-threatening septicemia. Major
concerns include pancytopenia, malnutrition, mucositis, fatigue, nausea, vomiting,
diarrhea, endocrine abnormalities, electrolyte dysfunction, lymphadema, and
superinfections. It is proven that weight loss of 10% or more as well as protein depletion
greatly contributes to the risk of associated infection. Persistent infection in these patients
may lead to supprative thrombophlebitis, infective endocarditis, or overwhelming sepsis
(Han, Liang, & Marschall, 2010).
Nursing Implications
Nurses are in a unique position to influence CLABSI rates in the oncology
population. Nurses make-up the largest part of the inpatient hospital staff and are the
leaders at the point of care. Educating nurses to implement the best evidence-based
practice in regards to CLABSI prevention can greatly impact change. In early 2009, a
research study was completed on 158 hospitals across Pennsylvania (Dumont &
Nesselrodt, 2012). A portion of these institutions implemented a central line care bundle
that incorporated the latest evidence-based practice on central line care. The bundle relied
heavily on nursing interventions and assessment. It was found that the average CLABSI
rate of the hospitals who did not implement the bundle was 3.33 CLABSI per 1,000
patient days, and the hospitals that did incorporate the care bundle was 0.51 CLABSI per
1,000 patient days. The most common sources of contamination can be easily prevented
through superior nursing care and dissemination of information on best practices. These
sources include the time of catheter insertion, contamination of the hub or lumen,
hematogenously seeded infections, and contaminated infusate.
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CLABSI
Problem Statement
Oncology patients are at an increased risk for central line-associated bloodstream
infections and resulting complications.
Significance
There are approximately 1.8 million nosocomial infections every year in the
United States (Nichols & Raad, 1999). This equates to a surfeit of over 7.5 million inpatient days and over 88,000 deaths. CLABSI has a 12-25% mortality rate (Dumont &
Nesselrodt, 2012). Each case of CLABSI costs approximately $26,000. CLABSI adds
300 million to 2.3 billion dollars every year to healthcare costs (The Joint Commission,
2011). Usually, hospitals must absorb the expense, as they are not reimbursed for these
complications. CLABSI is clearly a significant problem in healthcare. It is even more
detrimental to oncology patients as they are susceptible to infection and have an
increased number of complications.
Additionally, hospitals are held accountable for nosocomial infections monetarily
(The Joint Commission, 2011). Hospitals must provide adequate surveillance and
benchmarking of CLABSI rates. Institutions are further penalized with a reduction in
Medicare income for not presenting data according to the NHSN standards. CLABSI
rates are subject to mandatory public reporting. This has great implications regarding the
institutions reputation as well as financial motivations. There is an illustrious amount of
liability within each inpatient institution and this data has important implications and
complications in healthcare.
Furthermore, the Joint Commission has standards that must be attained and met
per institution protocol (The Joint Commission, 2011). The requirements state that each
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CLABSI
institution must execute prevention and control interventions to reduce or eradicate
CLABSI rates. Each institution must provide surveillance. Data on CLABSI rates,
outcomes, and prevention policies are reported to essential personnel. This regulatory
agency has a great impact on hospital policy and management. Requirements are
important contributory factors to recognizing CLABSI rates and providing appropriate
interventions to counteract. These factors are important motivators in decreasing
CLABSI, especially in vulnerable populations where complications, risks, and cost is
exponentially increased. Hospital reimbursement, readmission rates, and morbidity and
mortality are key factors in the surveillance of CLABSI in the oncology population.
Specific Aims
The intended outcome is reduction of CLABSI in oncology patients. This
vulnerable population requires specific assessment, intervention, and monitoring (Kerfoot
et al., 2006). Improved CLABSI outcomes may have a considerable impact on morbidity
and mortality in oncology patients. There are a myriad of interventions to accomplish
reduction in CLABSI. However, proposed nursing educational strategies may greatly
decrease CLABSI and resultant complications (Parra et al., 2010). The current CDC
guidelines have specific recommendations for CLABSI care and maintenance. In the
oncology population, it is especially vital to adhere to these precautions while
maintaining strict aseptic technique due to the depressed immune response in these
patients (Horvath et al., 2009). It takes experience and training for nurses to become
familiar with the specific needs and risks associated with cancer and treatments.
Education and mentoring of oncology caregivers may improve CLABSI awareness and
decrease rates of infection.
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CLABSI
To emphasize the need for knowledge and understanding of CLABSI in the
oncology population, several cancer centers’ policies for CLABSI prevention were
reviewed (Mayfield et al., 2006). The review studied 14 different cancer center
guidelines. The individual facilities’ policies were then compared to the current,
evidence-based CDC recommendations to ensure all facets were included. The
recommendations assessed required central line insertion and maintenance education,
intermittent reassessment of knowledge, aseptic technique, preferred site, and
antimicrobial prophylaxis. Out of these facilities, only 50% of current recommendations
were included in policy and therefore, in adherence to the CDC best practice guidelines.
It was also found that policy differed from interventions routinely performed in actual
clinical practice. These results clearly indicate a need for education of updated policy,
education of healthcare personnel, and continued outcomes assessment.
Conceptual Framework
To delineate consistent, high-quality care throughout inpatient facilities, the
American Association of Critical Care Nurses (AACN) developed a conceptual model for
nursing practice (Kerfoot et al., 2006). This model, termed the AACN Synergy Model for
Patient Care, is defined by matching nursing care with specific, recognized patient needs.
The purpose of the model is to allow identified patient needs to drive nursing core
competencies. Education of nurses on these specific needs and alignment of skills may
improve patient outcomes. Care is personalized for the patient population and highquality care is delivered. Synergy may be achieved when the nurses’ competencies
complement the needs of the patient.
CLABSI
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The Synergy Model is directly applicable to the discipline of nursing and may be
pertinent to a multitude of different settings and institutions (Kaplow & Reed, 2008). The
Synergy Model for Patient Care is a logically represented nursing framework and may be
directly utilized in practice to improve patient outcomes in deficient areas. The Synergy
Model may allow nurses to expand on research of patients’ most significant needs and
how nursing can improve noted outcomes and standards of care. There are several key
assumptions the Synergy Model is based upon to effectively utilize the framework in
practice (Kerfoot, 2006). These assumptions include observing the patient as a whole,
holistic entity, inclusion of family and environment into patient rapport, consideration of
patient characteristics as undivided, restoration of the patient to a state of optimal health
as delineated by the patient’s own healthcare goals, optimization of outcomes, and
utilization of nursing skills and education in each clinical situation. While considering the
assumptions and concepts of the Synergy Model, a comprehensible path is set to meet
distinctive patient needs and personalize care.
Main Concepts
The concepts of the Synergy Model are clearly stated, defined, and are supported
by the health-illness continuum (Kaplow & Reed, 2008). The main concepts are based
upon nurse competencies, patient characteristics, and a healthy work environment.
Nurse competencies.
The eight nurse competencies employed in the Synergy Model include clinical
judgment, clinical inquiry, caring practices, response to diversity, advocacy and moral
agency, facilitation of learning, collaboration, and systems thinking (Kerfoot et al., 2006).
Clinical judgment is described as the utilization of critical thinking and skill acquisition
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into practice. Appropriate clinical judgment promotes the use of evidence-based practice
into clinical situations and decision-making. Clinical inquiry occurs as the nurse
questions reasoning behind interventions and conducts research to examine new,
innovative interventions to promote optimal patient care. Caring practices are an essential
component of the nursing profession. Caring encompasses empathy, compassion, and
creates a therapeutic patient environment. Response to diversity is the consideration of
each patient’s specific needs and healthcare goals. It is important for the nurse to
recognize individuality within each patient and adjust care accordingly while providing
culturally competent care. There are numerous instances where patients need nurses to
advocate for their best interests and needs. The patient ultimately makes their own
healthcare decisions and the nurse must support and advocate for these needs through the
advocacy and moral agency component of the framework. Facilitation of learning
includes education for patients, healthcare personnel, and families. It is essential for the
healthcare team to collaborate within each facility to promote continuity of care and
optimize outcomes. Lastly, systems thinking relates to the education and tools nurses
utilize to provide holistic patient care. These competencies are utilized in the framework
as an educational curriculum, development of nurses, and professional advancement. This
infrastructure allows nurses to progress to expert in their care of patients in regards to
specific, outlined patient needs. The nurse competencies are unique in that they
incorporate both the empirical and aesthetic aspects of the profession.
Patient characteristics.
There are eight patient characteristics are described in the Synergy Model
(Kerfoot et al., 2006). It is stated that the more compromised a patient’s health status is,
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the more intricate their needs and care will be. Thus education may be required for nurses
caring for complex patients for synergy to occur. The patient characteristics as stated by
the Synergy Model include resiliency, vulnerability, stability, complexity, resource
availability, participation in care, participation in decision-making, and predictability.
Resiliency is the ability of the patient to return to homeostasis after an insult.
Vulnerability is the patient’s innate defense against stressors. How the patient is able to
maintain a level of health is noted as stability. This may be affected by the patient’s
response to medical interventions. Complexity refers to the degree of system involvement
through physiological, psychological, or emotional stressors. The greater the amount of
resources, the better the patient outcomes. Resource availability may be defined as fiscal,
emotional, or technical. Participation in care and decision-making by the patient and
family may enhance quality and delivery of patient care. Health literacy and personal
healthcare goal setting are essential components to analyze. Finally, predictability is the
prognosis or ability to ascertain the clinical course of the patient’s illness. These
components of patient assessment may allow the nurse to identify specific patient needs.
The nurse may then focus on competencies that may influence positive outcomes and
provide for quality patient care. Individual professional development occurs and
appropriate workloads may be distributed to improve patient safety and create a positive
environment.
Healthy work environment.
A healthy work environment is a key component in the implementation of the
Synergy Model (Kerfoot et al., 2006). A constructive environment may attribute to less
medical errors, efficient delivery of services, and less tension among healthcare
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personnel. The significant basics of a healthy work environment were described by the
AACN. These elements include enhanced communication, collaboration of the healthcare
team, effective decision-making, proper staffing for safety, recognition of employees, and
authentic leadership. These components may allow for an efficient, successful work
environment, which greatly contributes to the infrastructure of the Synergy Model.
Application of the Conceptual Framework to the Clinical Problem
Application of the Synergy Model may be utilized in the oncology setting. The
patient characteristics are complex and require very specific nurse education and
competencies (Kaplow & Reed, 2008). Nurses may be educated to provide for this
specialized care and thus improve patient outcomes. CLABSI has been identified as a
significant patient problem in this population. Proper education of nurses may improve
CLABSI rates and complications. The Synergy Model for Patient Care may be applied to
identify the risk factors for CLABSI in the oncology setting and educating nurses to meet
these needs through providing quality central line care.
A Review of Recent Literature
Performance of proper central line care is vital to the reduction of CLABSI rates.
The education of healthcare providers on CLABSI prevention is considered a priority by
the Center’s for Disease Control (Parra et al., 2010). To identify the significance of
evidenced-based education as the sole intervention for CLABSI prevention, data was
examined in three intensive care units (ICU) with acceptable baseline CLABSI rates.
This allowed the researchers to evaluate the effect of the single intervention with limited
extraneous variables. Observational, pre-intervention, and post-intervention studies were
completed in the three ICU settings. The researchers tested physicians and nurses on their
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baseline central line knowledge with a questionnaire. A lecture was then given on the
basic CLABSI prevention principles as delineated by the CDC guidelines. A postintervention questionnaire was administered six months later with no other interventions
performed during this time. The incidence of CLABSI was examined before and after the
educational intervention over a period of nine months. The incidence of CLABSI
significantly decreased in all three of the ICUs post-intervention. The CLABSI rates prior
to the intervention were 4.22 CLABSI per 1,000 CVC days as compared to 2.94 CLABSI
per 1,000 CVC days post-intervention. Overall, there was a 30.3% reduction in CLABSI
with the sole intervention of evidence-based education. Healthcare personnel commonly
state a lack of knowledge of current, evidence-based CLABSI guidelines. Application of
nurse education and competencies in areas of CLABSI occurrence could be a significant
step in reducing rates.
In the oncology population, hematopoietic stem cell transplant recipients (HSCT)
are especially vulnerable to infection from central lines (Barrell et al., 2012).
Enhancement of nurse competencies to improve CLABSI rates in this population was
examined at the Morgan Stanley Children’s Hospital. At this facility, it is protocol to
maintain a CVC for 100 days post HSCT. Researcher’s hypothesized CLABSI rates in
these patients may be reduced through standardizing procedures, training and education
of nurses and doctors in said procedures, and monitoring performance of interventions.
CLABSI rates were assessed pre-intervention and post-intervention. Staff was educated
on CVC maintenance practices and was periodically monitored completing these
interventions. A checklist was comprised to evaluate maintenance interventions so
assessment and tasks were standardized and uniform on the units. Participants in the
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study included 90 patients undergoing HSCT. The results displayed a significant increase
in compliance with recommended CVC maintenance practices. The rate of CLABSI
declined from 10.03 to 3.00 per 1,000 CVC days. Adherence to a standardized
maintenance protocol and continued education and evaluation of nurses significantly
reduced CLABSI rates and enhanced compliance in this vulnerable population.
An additional study conducted at a pediatric cancer center examined the rates of
CVC hub colonization in hematology-oncology and bone marrow transplant units
(Horvath et al., 2009). A comprehensive educational program was implemented as an
intervention to reduce colonization rates. The purpose of the study was to determine if the
education as intervention would decrease CLABSI rates, if CVC hub colonization would
be reduced post-intervention, to asses the knowledge of CVC care in staff nurses, and to
identify risk factors in this population. The patient population consisted of 51 catheter
hubs from 27 children in the hematology-oncology and bone marrow transplant units.
The staff nurses participated in in-service educational classes that outlined CVC
maintenance evidence-based practices and prevention strategies. Components of the
education included a didactic lecture, a video demonstration, and a simulation activity. A
pre- and post-educational intervention evaluation was also administered as an assessment
tool. Results of hub colonization were examined pre and post-intervention and displayed
a significant decrease in colonization after the education program. There were 27 hubs
examined for colonization. Findings displayed a 57%-36% reduction in positive
colonization of CVC hubs. Additionally, the post-intervention assessment scores
increased from a mean of 72%-87%. Post-educational intervention CLABSI rates were
3.35 per 1,000 CVC days compared to 5.59 per 1,000 CVC days prior to the intervention.
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CLABSI
Interestingly, CLABSI rates continued to decline to 2.51 CLABSI per 1,000 CVC days
12 months post-intervention, displaying evidence of a significant sustained decrease in
CLABSI rates on the units. This factor is attributed to continual feedback and
reinforcement of CVC maintenance education. The implementation of a structured,
evidence-based educational intervention enhanced nurses’ knowledge of CVC
maintenance and displayed a reduction in CLABSI rates. The application of nurse
competencies greatly attributed to addressing patient needs and optimizing outcomes and
quality care.
Summary and Conclusions
CLABSI is a considerable problem in the oncology population. A multitude of
factors contribute to CLABSI morbidity and mortality in this patient group. Cancer
patients are one of the most susceptible inpatient populations to nosocomial infection
(Carlisle et al., 1993). It is also understood that this vulnerable population cannot be
treated with the same interventions and preventative care as patients with separate
diagnoses as cancer patients have many distinctive needs that must be taken into
consideration (Kelly et al., 2011). Alternative measures for diagnosing and prevention of
CLABSI are needed to recognize the needs of this population and surveillance must be
adapted to fit these needs.
Goals for CLABSI rates include better surveillance to identify this vulnerable
population’s needs (Nichols & Raad, 1999). This population has a myriad of comorbidities and to decrease CLABSI rates would alleviate injury and complications.
Fewer inpatient readmissions and decreased length of stay would contribute to better
psychosocial outcomes. Cost is greatly affected by CLABSI rates. Hospital
CLABSI
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reimbursement and public reputation significantly contribute to monetary incentives for
institutions (The Joint Commission, 2011). Healthcare professionals need to be constantly
aware of this issue in clinical practice.
The intended outcome is reduction of CLABSI in the oncology population. One
way of achieving this significant aim is through the implementation of nursing
educational strategies (Parra et al., 2010). It takes experience and training for nurses to
become familiar with the specific needs and risks associated with cancer and treatments.
One intervention for the education of nurses is through the AACN Synergy Model for
Patient Care (Kerfoot et al., 2006). The Synergy Model is defined by matching nursing
care with specific, recognized patient needs. The purpose of the model is to allow
identified patient needs to drive nursing core competencies. Education of nurses on these
specific needs and alignment of skills may improve patient outcomes. Application of the
Synergy Model may be utilized in the oncology setting. The patient characteristics are
complex and require very specific nursing education and competencies. The Synergy
Model for Patient Care may be applied to identify the risk factors for CLABSI in the
oncology setting and educating nurses to meet these needs and provide quality central
line care. A multitude of studies have proved the effectiveness of utilizing education as
intervention and thus greatly improving CLABSI rates in the vulnerable, oncology
population (Horvath et al., 2009). With implementation of the Synergy Model, morbidity
and mortality in the oncology population is reduced. CLABSI and its resultant
complications is a significant issue for these vulnerable patients. Nurses are in a unique
position to promote CLABSI awareness and implementation of evidence-based practice
in the clinical setting. Nurses especially have the professional responsibility to be
CLABSI
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“bedside leaders” and promote the implementation of education as intervention to reduce
the rate of CLABSI in the oncology population.
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