QAPI 114 - Increasing Compliance with the Central Line Maintenance Bundle via Nurse Led Observations

Background: A suburban community hospital in Illinois identified an increase in central line bloodstream infections (CLABSI) in 2021. Review of each CLABSI demonstrated a need to enhance documentation and/or performance of central line maintenance for patients with central lines. The SAR CO-V-2 pandemic led to higher acuity patients and practice drift during the pandemic. Meticulous central line maintenance is proven to help prevent central line bloodstream infections.

Methods: Patients with central lines on the intensive care/step down unit were assessed from January 2022-July 2022. Compliance with central line maintenance bundle practices was documented in an electronic database. The data was evaluated with the premise that if it was not documented, it was not completed. The data revealed that the key drivers of low compliance with the maintenance bundle was documentation of the injection cap change, tubing change, and labeling the IV tubing. Interventions were developed to address the key drivers of low compliance, which included central line competency sign-off, nurse-led central line observations with real time coaching and implementation of a central line maintenance visual management board.

Results: Interventions increased documentation compliance with the central line maintenance bundle. Compared to the baseline period, compliance with cap change documentation increased by 110% and compliance with labeling the IV tubing increased by 37.5%. Compliance with tubing change documentation decreased by 12% during the intervention period. CLABSI occurrences on the unit during the intervention period decreased by 83% as compared to the baseline period.

Conclusions: Nursing engagement and ownership of process improvements were vital to the success of the project. Documentation review is important, but frequent nurse-led observations of central lines and real-time coaching of peers is the key to achieving desired behavior. Sharing data with staff is critical to success via a visual management board and adds transparency to the process.