Implementation and Maintenance of Practice Guidelines to Decrease Central Line Associated Bloodstream Infections by Minimizing Line Manipulation

Background: The adult blood and marrow transplant population is at high risk for central line associated bloodstream infections (CLABSI). CLABSI remains a large cause of morbidity, increased cost, prolonged hospitalization and mortality in this population. One source of these infections is line manipulation; specifically at the central venous access device (CVAD) needless hub. Several studies have consistently found yeast and heavy bacterial contamination on the surface of the CVAD hub. Our aim was to decrease line manipulation in order to decrease our unit’s CLABSI rate.

Implementation: In late 2010 our unit practice council created new guidelines for accessing and maintaining central lines. These guidelines included: patients on continuous IVs will not be disconnected to shower, walk, etc. and patients whose lines are accessed greater than two time a day (excluding labs) will remain connected continuously at a provider prescribed rate. Our definition of each access included one connection and disconnection.  Nursing staff were educated about the new guidelines via email and staff meetings. Providers were educated during a Blood and Marrow Transplant Program Quality Improvement Committee meeting. In February of 2012, these guidelines were revised to include the continuous connection of all neutropenic patients receiving any IV fluids or medications. When not neutropenic, we continued to have patients with greater than two accesses per day connected continuously.

Evaluation: During the 2010 calendar year our inpatient BMT unit had 13 CLABSI, resulting in a 3.35 CLABSI rate per 1000 patient days. During the 2011 calendar year our inpatient BMT unit had 5 CLABSI, resulting in a 1.27 CLABSI rate per 1000 patient days. There was a 62 percent reduction in CLABSI from 2010 to 2011. For the first nine months of the 2012 calendar year our inpatient BMT unit has had 3 CLABSI, resulting in a 1.07 CLABSI rate per 1000 patient days. There was a 16 percent reduction in CLABSI from 2011 to the first 3 quarters of 2012.

Discussion: We were able to successfully implement a best practice based intervention through creating new guidelines for accessing and maintaining central lines and saw a significant decrease in our CLABSI rate.