Use of Implementation Science for a Sustained Reduction of Central-Line–Associated Bloodstream Infections in a High-Volume, Regional Burn Unit

Abstract

OBJECTIVE We describe the use of implementation science at the unit level and organizational level to guide an intervention to reduce central-line-associated bloodstream infections (CLABSIs) in a high-volume, regional, burn intensive care unit (BICU). DESIGN A single center observational quasi-experimental study. SETTING A regional BICU in Maryland serving 300-400 burn patients annually. INTERVENTIONS In 2011, an organizational-level and unit-level intervention was implemented to reduce the rates of CLABSI in a high-risk patient population in the BICU. At the organization level, leaders declared a goal of zero infections, created an infrastructure to support improvement efforts by creating a coordinating team, and engaged bedside staff. Performance data were transparently shared. At the unit level, the Comprehensive Unit-based Safety Program (CUSP)/ Translating Research Into Practice (TRIP) model was used. A series of interventions were implemented: development of new blood culture procurement criteria, implementation of chlorhexidine bathing and chlorhexidine dressings, use of alcohol impregnated caps, routine performance of root-cause analysis with executive engagement, and routine central venous catheter changes. RESULTS The use of an implementation science framework to guide multiple interventions resulted in the reduction of CLABSI rates from 15.5 per 1,000 central-line days to zero with a sustained rate of zero CLABSIs over 3 years (rate difference, 15.5; 95% confidence interval, 8.54-22.48). CONCLUSIONS CLABSIs in high-risk units may be preventable with the a use a structured organizational and unit-level paradigm. Infect Control Hosp Epidemiol 2017;38:1306-1311.

A Scoping Review of Implementation Science in Adult Critical Care Settings

“…Supplemental Table 1 ( http://links.lww.com/CCX/A456 ) provides an overview of the studies included in the review according to the design categories. Studies using IS designs were conducted most often in the United States ( n = 9) ( 14 – 22 ) and Canada ( n = 7) ( 23 – 29 ) followed by Australia ( n = 2) ( 30 , 31 ), the Netherlands ( n = 1) ( 32 ), and the United Kingdom ( n = 1) ( 33 ). Within the PI category, studies were conducted most frequently in the United States ( n = 25) ( 34 – 59 ) followed by Canada ( n = 3) ( 60 – 62 ), Spain ( n = 3) ( 63 – 65 ), Germany ( n = 2) ( 66 , 67 ), Norway ( n = 2) ( 68 , 69 ), and one study each from South Africa ( 70 ), Argentina ( 71 ), China ( 72 ), France ( 73 ), The Netherlands ( 74 ), Saudi Arabia ( 75 ), and the United Kingdom ( 56 ).…”

“…The studies addressed a variety of EBPs, classified into 18 categories. The most common EBPs included: ventilator-associated pneumonia (VAP) prevention bundles (12/82, 14.6%) ( 14 , 33 , 39 , 49 , 54 , 55 , 57 , 59 , 60 , 63 , 73 , 86 ), nutritional support/management protocols (9/82, 10.9%) ( 25 , 26 , 30 , 35 , 38 , 40 , 61 , 88 , 90 ), the Awakening and Breathing Coordination, Delirium Monitoring/Management, and Early Exercise/Mobility (ABCDE/ABCDEF) bundle (7/82, 8.5%) ( 15 – 19 , 47 , 76 ), central line-associated bloodstream infection (CLABSI) prevention bundles (6/82, 7.3%) ( 22 , 37 , 42 , 52 , 53 , 80 ), and mechanical ventilation liberation/weaning protocols (6/82, 7.3%) ( 36 , 62 , 69 , 72 , 90 , 93 ). Sixteen studies involved ICU mobilization protocols (4/82, 4.8%) ( 34 , 46 , 70 , 78 ), use of checklists (4/82, 4.8%) ( 41 , 81 , 84 , 89 ), hand hygiene/infection control bundles ( n = 4/82, 4.8%) ( 21 , 66 , 71 , 95 ), and initiatives targeting multiple EBPs (4/82, 4.8%) ( 24 , 51 , 56 , 77 ).…”

“…Sixteen studies involved ICU mobilization protocols (4/82, 4.8%) ( 34 , 46 , 70 , 78 ), use of checklists (4/82, 4.8%) ( 41 , 81 , 84 , 89 ), hand hygiene/infection control bundles ( n = 4/82, 4.8%) ( 21 , 66 , 71 , 95 ), and initiatives targeting multiple EBPs (4/82, 4.8%) ( 24 , 51 , 56 , 77 ). The remaining studies focused on antibiotic stewardship (3/82, 3.6%) ( 22 , 65 , 67 ), analgesia/sedation protocols (3/82, 3.6%) ( 68 , 75 , 96 ), palliative/end-of-life care bundles (3/82, 3.6%) ( 20 , 32 , 85 ), pressure ulcer prevention (3/82, 3.6%) ( 43 , 83 , 94 ), venous thromboembolism (VTE) prophylaxis (2/82, 2.4%) ( 28 , 29 ), laboratory reduction guidelines (2/82, 2.4%) ( 48 , 87 ), the surviving sepsis campaign bundles (2/82, 2.4%) ( 64 , 82 ), interdisciplinary rounding/handover tools (2/82, 2.4%) ( 31 , 58 ), and “other” EBPs (7/82, 8.5%) ( 27 , 44 , 45 , 50 , 74 , 79 , 92 ).…”

“…Studies reported both clinical and implementation outcomes ( Supplemental Table 2 , http://links.lww.com/CCX/A457 ). Across all study designs, many reported only clinical outcomes (44/82, 53.6%) ( 22 , 34 , 36 – 38 , 40 , 41 , 43 – 50 , 52 , 54 – 56 , 60 – 66 , 68 , 70 , 72 , 75 , 77 – 81 , 83 , 85 , 87 , 88 , 90 – 94 ), while few reported solely implementation outcomes (15/82, 18.3%) ( 15 – 20 , 24 , 27 , 28 , 32 , 51 , 57 , 67 , 95 , 96 ), and some reported both clinical and implementation outcomes (22/82, 26.8%) ( 14 , 21 , 23 , 25 , 26 , 29 , 30 , 32 , 39 , 42 , 53 , 58 , 59 , 62 , 71 , 73 , 74 , 76 , 82 , 84 , 86 , 89 ). Primary clinical outcomes were most often linked to the EBP that was evaluated (e.g., VAP bundle implementation reported VAP rates), rather than solely surrogate metrics such as mortality or length of stay.…”

The most recent concepts for the management of bacterial and fungal infections in ICU

“…In the latter, both 0.5% and 1.0% alcohol chlorhexidine gluconate were superior to 10% aqueous povidone iodine for the prevention of intravascular catheter colonisation. In a high volume burn unit in the USA, a sustained reduction of central-line-associated bloodstream infection (CLABSI) rates from 15.5 per 1000 central-line days to zero over 3 years became feasible, with the implementation of a rigorous program translating research into practice including among others chlorhexidine bathing, chlorhexidine dressings and use of alcohol-impregnated caps [11].…”