Improve the Risk of Central Line-Associated Bloodstream Infections with Central Line Dressing Changes through a Team Approach

Practice Problem: Central Line Associated Bloodstream Infections (CLABSI) are a preventable hospital acquired infection which contributes to patient morbidity, mortality and rising healthcare costs. PICOT: The PICOT question that guided this project was: In adult inpatients with central venous catheters, does the use of a two-person dressing change team, compared to a single person procedure, decrease the rate of central line associated bloodstream infections over the course of 8 weeks? Evidence: The prevention of CLABSI is most effective when multifaceted line maintenance bundles are implemented and adherence to these bundles nears 100% (Schreiber et al. 2018). Intervention: A two-person, evidence-based dressing change procedure was implemented for all central line dressing changes, known as the sterile buddy. The role of this additional bedside nurse was to assist the dressing change through an extra set of hands and to provide real-time sterile technique feedback to the primary nurse. Outcome: The intervention did not lead to a statistically significant change in the rate of CLABSI, however there was a reduction in the overall number of observed CLABSI compared to both the prior year and the 6 months preceding to the intervention. Conclusion: The implementation of a sterile buddy was an effective intervention that resulted in a decline in the total of CLABSI, and although not statistically significant, resulted in an estimated cost savings of $56,000 when compared to the year prior and an estimated cost savings of $112,000 when compared to the 6 months preceding the intervention. CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTION 3 Does a Sterile Buddy for Central Line Dressing Changes Reduce the Rate of Central LineAssociated Bloodstream Infections? Hospital-acquired conditions (HAC) are those that a patient develops while undergoing treatment in the hospital for another disorder and include both hospital acquired infections (HAI) and injuries. These conditions that cause harm to the patient, are classified under patient safety and adverse events, and are considered preventable with the application of current evidencebased practice (Agency for Healthcare Research and Quality, 2019). HAC result in increased cost during a patient’s hospital stay, as well as, in future healthcare encounters that may not have been necessary, prior to the onset of the HAC (Kandilov et al., 2014). Central line-associated bloodstream infection (CLABSI) is one of five HAIs which are reported to the Centers for Disease Control and Prevention’s National Healthcare Safety Network (Centers for Medicare & Medicaid Services, 2020). Current evidence-based practice supports the use of a CLABSI maintenance bundle with key components that include hand hygiene, cap and tubing changes every 72 hours, chlorhexidine skin antisepsis, and transparent dressing changes every 7 days (Agency for Healthcare Research and Quality, 2018c). Despite implementation of the evidencebased CLABSI maintenance bundle, CLABSI continues to be prevalent within the DNP practice site. The purpose of this project is to address the concern of CLABSI through an evidence-based, quality improvement project that proposes the implementation of a 2-nurse team that consists of a primary nurse and secondary nurse, or sterile buddy, for central line dressing changes. Significance of the Practice Problem CLABSIs are a significant burden to not only the healthcare system, but also to patients, as they contribute to thousands of deaths and billions of dollars in added costs to the United States healthcare system (Centers for Disease Control and Prevention, 2011b). When compared CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTION 4 to other HAIs such as, catheter-associated urinary tract infections, ventilator-associated pneumonia, and surgical site infections, CLABSIs are associated with the highest number of preventable deaths and have the highest cost impact (Umscheid et al., 2011). Annually in the United States, there are an estimated 41,000 CLABSI in hospitalized patients with an associated mortality rate of 10%-20% (Centers for Disease Control and Prevention, 2011b). Furthermore, there is an average prolonged hospitalization period of 7 days and an increase in medical costs of $28,000 or more per occurrence (Agency for Healthcare Research and Quality, 2018b). The average annual cost to Centers for Medicare & Medicaid Services (CMS) from CLABSI is $19,246,293.15 (Sankaran et al., 2020). In response to rising healthcare costs, CMS developed the Hospital-Acquired Condition Reduction Program, which penalizes facilities with rates of HACs in the 75 percentile, or worst performing quartile, by 1% each year (Centers for Medicare & Medicaid, 2019). This consequence has led to incentivizing healthcare facilities to make a change in how they prevent CLABSI and other HAIs. In addition to the challenges that healthcare facilities face with CLABSIs, patients are also affected at the individual level with symptoms consisting of fever, pain, and redness around the insertion site (Centers for Disease Control and Prevention, 2011a). Severe illness due to CLABSI may also occur with patients manifesting signs of sepsis such as hypotension, hemodynamic instability, lethargy, fatigue, and altered mental status, which can be alarming and distressing to the patient and their family members, especially if the clinical course has been complicated and perilous. Treatment of a CLABSI may include additional invasive procedures, testing, and up to 14 days of parenteral antibiotics, which all result in pain or discomfort to the patient (Haddadin et al., 2020). CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTION 5 The majority of CLABSI can be prevented with correct insertion, skin antisepsis, and adherence to evidence-based central line maintenance (Johns Hopkins Medicine, n.d.). The Centers for Disease Control and Prevention provides guidelines and tools for the healthcare community to follow, from the time of insertion through removal, to help decrease the rate of CLABSI (Centers for Disease Control & Prevention, 2011a). In order to improve the quality and safety of patient care, implementation of evidence-based clinical practice guidelines is crucial. However, adherence to clinical practice guidelines across hospitals in the United States varies with implementation rates between 20% and 100%. In addition to increasing awareness, focusing on changing practice patterns at the bedside through multifaceted and multidisciplinary interventions, is the most effective strategy to combat rates of CLABSI (The Joint Commission, 2012).


Does a Sterile Buddy for Central Line Dressing Changes Reduce the Rate of Central Line-Associated Bloodstream Infections?
Hospital-acquired conditions (HAC) are those that a patient develops while undergoing treatment in the hospital for another disorder and include both hospital acquired infections (HAI) and injuries. These conditions that cause harm to the patient, are classified under patient safety and adverse events, and are considered preventable with the application of current evidencebased practice (Agency for Healthcare Research and Quality, 2019). HAC result in increased cost during a patient's hospital stay, as well as, in future healthcare encounters that may not have been necessary, prior to the onset of the HAC (Kandilov et al., 2014). Central line-associated bloodstream infection (CLABSI) is one of five HAIs which are reported to the Centers for Disease Control and Prevention's National Healthcare Safety Network (Centers for Medicare & Medicaid Services, 2020). Current evidence-based practice supports the use of a CLABSI maintenance bundle with key components that include hand hygiene, cap and tubing changes every 72 hours, chlorhexidine skin antisepsis, and transparent dressing changes every 7 days (Agency for Healthcare Research and Quality, 2018c). Despite implementation of the evidencebased CLABSI maintenance bundle, CLABSI continues to be prevalent within the DNP practice site. The purpose of this project is to address the concern of CLABSI through an evidence-based, quality improvement project that proposes the implementation of a 2-nurse team that consists of a primary nurse and secondary nurse, or sterile buddy, for central line dressing changes.

Significance of the Practice Problem
CLABSIs are a significant burden to not only the healthcare system, but also to patients, as they contribute to thousands of deaths and billions of dollars in added costs to the United States healthcare system (Centers for Disease Control and Prevention, 2011b). When compared to other HAIs such as, catheter-associated urinary tract infections, ventilator-associated pneumonia, and surgical site infections, CLABSIs are associated with the highest number of preventable deaths and have the highest cost impact (Umscheid et al., 2011). Annually in the United States, there are an estimated 41,000 CLABSI in hospitalized patients with an associated mortality rate of 10%-20% (Centers for Disease Control and Prevention, 2011b). Furthermore, there is an average prolonged hospitalization period of 7 days and an increase in medical costs of $28,000 or more per occurrence (Agency for Healthcare Research and Quality, 2018b). The average annual cost to Centers for Medicare & Medicaid Services (CMS) from CLABSI is $19,246,293.15 (Sankaran et al., 2020). In response to rising healthcare costs, CMS developed the Hospital-Acquired Condition Reduction Program, which penalizes facilities with rates of HACs in the 75 th percentile, or worst performing quartile, by 1% each year (Centers for Medicare & Medicaid, 2019). This consequence has led to incentivizing healthcare facilities to make a change in how they prevent CLABSI and other HAIs.
In addition to the challenges that healthcare facilities face with CLABSIs, patients are also affected at the individual level with symptoms consisting of fever, pain, and redness around the insertion site (Centers for Disease Control and Prevention, 2011a). Severe illness due to CLABSI may also occur with patients manifesting signs of sepsis such as hypotension, hemodynamic instability, lethargy, fatigue, and altered mental status, which can be alarming and distressing to the patient and their family members, especially if the clinical course has been complicated and perilous. Treatment of a CLABSI may include additional invasive procedures, testing, and up to 14 days of parenteral antibiotics, which all result in pain or discomfort to the patient (Haddadin et al., 2020).
The majority of CLABSI can be prevented with correct insertion, skin antisepsis, and adherence to evidence-based central line maintenance (Johns Hopkins Medicine, n.d.). The Centers for Disease Control and Prevention provides guidelines and tools for the healthcare community to follow, from the time of insertion through removal, to help decrease the rate of CLABSI (Centers for Disease Control & Prevention, 2011a). In order to improve the quality and safety of patient care, implementation of evidence-based clinical practice guidelines is crucial.
However, adherence to clinical practice guidelines across hospitals in the United States varies with implementation rates between 20% and 100%. In addition to increasing awareness, focusing on changing practice patterns at the bedside through multifaceted and multidisciplinary interventions, is the most effective strategy to combat rates of CLABSI (The Joint Commission, 2012).

PICOT Question
In adult inpatients with central venous catheters, does the use of a two-person dressing change team, compared to a single person procedure, decrease the rate of central line associated bloodstream infections over the course of 8 weeks? The population consisted of adult inpatients with central venous catheters who were hospitalized in the cardiovascular intensive care unit (CVICU), either prior to or following cardiothoracic or vascular surgical procedures, or following acute cardiovascular decompensation requiring continuous respiratory and/or circulatory support. The patients were adults, greater than 18 years of age, and had a number of diagnoses including heart failure, coronary artery disease, peripheral artery disease, myocardial infarction, cardiogenic shock, valvular dysfunction, and cardiac arrest.
The intervention, as described by Wilder et al. (2016), utilized two nurses to perform the routine central line dressing change with the primary nurse performing the dressing change and the second nurse, or sterile buddy, assisting and functioning as a sterility monitor by stabilizing the catheter, completing a central line bundle checklist, and providing feedback. The usual care for a central line dressing change was for the primary nurse to perform the dressing change independently every Wednesday, or when soiled. Through implementing this method, yet maintaining the set day and time of dressing changes already established, Wilder et al. (2016) reported a 92% improvement in the rate of CLABSI, from 3.9 per 1000 line days to 0.3 per 1000 line days. The primary expected outcomes of this project were a diminution in the total number of CLABSI, calculated by adding up the total number of CLABSI during the implementation period, and rate of CLABSI as defined by the number of CLABSI divided by the number of central line days, multiplied by 1000 (Centers for Disease Control and Prevention, 2020). The raw number total of CLABSI differs from the CLABSI rate because it includes all CLABSI for the unit, including the extracorporeal life support and ventricular assisted device patients, who are excluded from the report to the National Healthcare Safety Network (Centers for Disease Control and Prevention, 2021). The implementation took place over a period of 8 weeks and comparisons were made to the same 8 weeks in the year prior to the implementation, as well as, the 4 months leading up to the implementation. Due to the substantial increase in CLABSI in the CVICU, there was significant buy-in from stakeholders and a sense of urgency for the completion of this project.

Evidence-Based Practice Framework & Change Theory
The ideal evidence-based practice (EBP) model is the Johns Hopkins EBP (JHEBP) model which consists of three interrelated components: inquiry, practice, and learning (Dang & Dearholt, 2017). Inquiry is the first step and includes members of the nursing staff and healthcare team, questioning whether the best evidence and practice is being used for the management or prevention of a specific problem. Next is practice and involves three steps: practice question, evidence, and translation (PET). The PET process is a systematic approach that involves solving the practice question, finding the best evidence, and translating that evidence into practice, and is a continuous process that leads to the third component, learning. The cycle of practice and learning continues and can lead to a new EBP process that starts over with inquiry or can progress forward into best practice application and practice improvements.
In the first step, nursing staff were verbalizing frustration with the difficulty of central line dressing changes and the increase in observed CLABSI for their unit. The next step starts the PET process. First is considering what aspect of the dressing change may be correlated to rising CLABSI rates in the institution, and what evidence must be gathered in order to find a solution to the problem. Second is finding the best evidence and conducting a thorough review of the literature. The third step involves translating and creating a change in practice that results in improved patient outcomes through planning, implementing, and evaluating the practice change.
Throughout the PET process, there may often be new information, thoughts, and ideas that lead to more questions, yielding the start of the JHEBP model. This aspect of the model is learning, which is the informal process of adopting knowledge by applying it in practice and creating a behavioral change and thus influencing practice (Dang & Dearholt, 2017). The end result is the identification and creation of best practices which leads to quality improvements.
The change theory that best fits the project is described by John Kotter and involves eight steps (Kotter, n.d.). First, create a sense of urgency by addressing a problem that is a part of the current culture and has led to adverse patient outcomes (Small et al., 2016). Second, the formation of a diverse team that has the ability and the willingness to create and support change.
Third is creating a strategic vision which motivates people to take action (Kotter, n.d.). Fourth is communicating the vision through education. The fifth step is to empower others to act on the strategic vision and promote buy-in on the unit and organizational level (Small et al., 2016).
Sixth is to create small wins so that members of the team can see their progress or positive change from the intervention. Seventh is to build on the change in order make it more streamlined and to increase its practicality for nursing staff to complete, which increases adherence and the potential for change. The eighth step is to institutionalize the change by making it the new norm and promoting nursing education to promote sustainability.
Utilizing Kotter as the change theory for this project is the best fit because of the nature of the problem. CLABSIs are preventable conditions that occur from the breakdown in the central line bundle. Creating a sense of urgency to address CLABSI is crucial, especially as rates are rising and the policy at the DNP practice site already includes the implementation of the central line bundle for insertion and maintenance. The success of this project needed the willingness of key stakeholders to drive the change, and the creation of a great team, or guiding coalition. Kotter (n.d.) states the buy-in from the stakeholders and the team is the linchpin of the entire model as it allows for accountability and diversity and involves team members that are committed to the change initiative. The intervention to address CLABSI in the DNP practice site asked nursing staff to devote more time and effort to their current practice.

Evidence Search Strategy
In order to identify potential solutions to climbing CLABSI rates, a literature search was performed that focused on evidence-based prevention strategies. There are many evidence-based interventions in the literature including the creation of central line dressing maintenance kits, implementation of daily maintenance bundles, promotion of skin antisepsis, creating checklists, and utilizing central line alternatives such as midline catheters or ultrasound guided peripheral IV lines. However, when discussing central line maintenance with the nursing staff, it was revealed that the central line dressing changes performed according to hospital policy and the dressing manufacturer's recommendation can be difficult to accomplish independently while still maintaining sterility. There is also considerable variability in how the nursing staff perform each dressing change in order to circumvent this difficulty.
A search of the literature was performed in three databases including CINAHL Complete, PubMed, and Google Scholar. The keywords for the search included "central line associated bloodstream infections or CLABSI", "prevention", "maintenance", "team or two person or 2 person". Additional criteria included limiting text to the English language, scholarly and peer reviewed journals and evidence published after 2015. The one initial exclusionary criterion was "hemodialysis", primarily because these patients leave the hospital with their line in place and CLABSI prevention in this population would require a different scope of interventions when compared to the hospitalized inpatient. Initially abstracts were reviewed for relevancy. For those abstracts which were unclear or appeared relevant, the full text articles were obtained and reviewed. Articles included in the evaluation were those that discussed the two-person dressing change performed by nursing staff for central line maintenance in an effort to decrease rates of CLABSI.

Evidence Search Results
As demonstrated by Moher et al. (2009)

in the Preferred Reporting Items for Systematic
Reviews and Meta-Analysis (PRISMA) flow diagram (Figure 1), the above database search yielded 1329 articles with three additional articles obtained during the review of each individual full text articles. After duplicates were removed, there were 1245 articles in which the abstracts were screened for relevancy and those that did not pertain to central line maintenance bundles or include a component of two person or team dressing changes were excluded. This resulted in 20 full text articles which were then reviewed for eligibility. Two additional articles were removed because once the full texts were obtained it was found that the abstracts belonged to conference presentations and not full peer-reviewed articles. This led to 18 full text articles which were read critically with 11 additional articles excluded primarily for the method or lack of detail behind the intervention. For example, there was one article that utilized a team of respiratory therapists instead of registered nurses and was thus excluded. This led to seven critically appraised and summarized articles, four primary research articles, and three systematic reviews which are described in Appendices A and B, respectively.
Utilizing the Johns Hopkins Nursing Evidence-Based Practice Model, the quality of the articles were A, or high, (n = 1) and B, or good, (n = 3), the evidence was appraised for level and quality (Dang & Dearholt, 2017). The primary research articles were level III (n = 1) and V (n = 3), which is presented in Appendix A. This level was primarily due to the fact that the articles were quality improvement projects or non-experimental in nature. The primary reason for the majority of the articles being considered as good quality was that the interventions were not conducted across multiple settings and focused primarily on one unit with a specific patient population. The results were consistent with the recommendations provided and there were clear aims and objectives for each project with a thorough review of the current scientific evidence included. In addition to the primary research articles, there were three systematic reviews and meta-analyses. Two of the three of these articles were level III with one being a level II but all were high quality, A. The primary rationale behind the evidence level of III was the lack of randomized controlled trials and inclusion of non-experimental quality improvement projects.
All three articles included meta-analyses and provided consistent and generalizable results that are based on a comprehensive literature review, which is presented in Appendix B.

Themes with Practice Recommendations
The literature presented in Appendix A summarizes primary research articles that discuss the utilization of a two-person team to conduct central line dressing changes. The literature presented in Appendix B summarizes the systematic reviews and meta-analyses that discuss the utilization of bundles for central line maintenance to prevent CLABSI. There were several key themes that emerged from the literature review including adherence to central line maintenance bundles to reduce the rate of CLABSI, presence of three key categories that must be utilized in the bundle for effectiveness, and implementation of a central line maintenance bundle to reduce healthcare costs.

Central Line Maintenance Bundles to Reduce CLABSI
In an effort to decrease the rate of CLABSI, the implementation of multifaceted central line maintenance bundle and increased rates of adherence, resulted in risk reduction (Ista et al., 2016;Payne et al., 2018;Schreiber et al., 2018). Schreiber et al. (2018) reviewed literature for all reportable hospital acquired conditions and found that multifaceted bundles were most effective in the reduction of CLABSI rates. Ormsby et al. (2018) demonstrated that an enhanced central line maintenance bundle, and implementation of a two-person dressing change, was more effective at reducing CLABSI rates when compared to the basic maintenance bundle as described the by the Centers for Disease Control and Prevention. Ormsby et al. (2018) implementation led to an 85% reduction over a 12-month period of CLABSI. Dandoy et al.
(2015) added that improved system stress on the nursing staff by providing a second person for the central line dressing change, resulted in increased bundle compliance to 100%, daily hand hygiene improved to 75%, and CLABSI rates decreased to 0.39 per 1000-line days compared to 2.03 prior to the intervention.

Presence of Key Bundle Categories
Schreiber et al. (2018) and Ista et al. (2016) in systematic reviews found that bundle components vary across the literature, but there were three main categories present in each successful bundle. First was the use of education, where the nursing staff was educated on each aspect of the bundle and how to perform each portion correctly. Second was the use of audit and feedback where nursing staff were observed by peers and/or administration, feedback was provided on compliance, and changes in performance were made when indicated. Third was the utilization of daily checklists to remind nurses to utilize and document bundle adherence. dressing team performed the procedure and daily line checklist together, leading to a 92% reduction in CLABSI rates over three years and a decreased length of stay by 17.6 days.

Improved CLABSI Rates Decreases Costs
One of the themes that was present in the majority of the literature was the cost savings to the healthcare facility with a reduction in CLABSI through bundle implementation and adherence. Wilder et al. (2016) reported cost savings in terms of preventable infections with a reported savings of $327,238.34. While Ista et al. (2016) in a systematic review reported a median cost savings of $42,609 following bundle implementation.

Caveat
One caveat to report is that the majority of the research was conducted in the pediatric inpatient setting, however, the utilization of a two-person dressing change team was not specific to the pediatric population and did not contain pediatric specific care. For example, the utilization of the second nurse was not to provide moral support or hold a child in place while the primary nurse performed the dressing change. The literature supported the use of an additional nurse to function as a sterility monitor and an extra set of hands to assist with removal of the original dressing (Ormsby et al., 2018;Wilder et al., 2016). Ista et al., (2016) demonstrated that care bundle implementation in the maintenance of central lines was associated with a decline in CLABSI rates, regardless of the age of the population.

Summary
The extensive literature review performed identified key themes. Of primary importance is that the use of central line maintenance bundles as described by the Agency for Healthcare Research and Quality are prevalent throughout the literature and adherence to central line maintenance bundles decreases the rate of CLABSI (Agency for Healthcare Research and Quality, 2018b; Ista et al., 2016;Payne et al., 2018;Schreiber et al., 2018). Facilities that observed rising or persistent rates of CLABSI, enhanced central line maintenance bundles using a two-person dressing change to provide real-time audit and feedback, physical assistance with the procedure has shown to improve rates of CLABSI and promote nursing adherence to the maintenance bundle (Dandoy et al., 2015;Ormsby et al., 2018;Wilder et al., 2016). The strength of this recommendation with the utilization of the JHEBP model, is level III due to the abundance of quality improvement projects reviewed and systematic reviews that contained high quality improvement projects; and due to the extensive application in a number of populations, settings, and breadth of background research included (Dang & Dearholt, 2017).

Setting, Stakeholders, and Systems Change
The implementation of a secondary nurse, or sterile buddy, for central line dressing changes was performed in the CVICU in a large academic medical center. The patients on the unit are primarily postoperative cardiovascular or cardiothoracic patients, who are recovering from procedures such as heart transplant, coronary artery bypass grafts, heart valve replacement, aortic aneurysm repair, and pulmonary embolism. In addition, some patients were recovering from a critical illness where they were hospitalized in the ICU following cardiac arrest, implantation of heart-assistance devices or temporary total artificial heart or other cardiovascular decompensation. These patients had multiple lines in place including central venous catheters, arterial lines, extracorporeal membrane oxygenation lines, and aortic balloon pumps that were crucial to survival. A CLABSI, in this population, has the potential to increase the following: hemodynamic instability, risk of decompensation, risk of mortality, length of stay in the hospital, and healthcare costs. These risks and concerns for patients and healthcare facilities create an urgency for interventions.
The need to address the rate of CLABSI in the organization was brought forth by the quality and safety team members who report rising rates across the organization. The rising rates were initially attributed to supply chain disturbance and extension of IV tubing changes from every 96 hours to every 7 days, with the management of the novel Coronavirus infection.
However, as the supply chain returned to baseline and the tubing changes returned to the recommended every 96 hours, the rates of CLABSI failed to return to rates consistent with the previous fiscal year, resulting in an opportunity for change in current practices. Key stakeholders identified included the nursing staff, patient care managers, CLABSI task force, quality and safety team, infection prevention and control, as well as, patients and their family.
The patient care manager for the CVICU was concerned about persistent CLABSI, and provided education to staff and encouraged staff to perform daily line checklists to address the unit's high CLABSI rates. Additionally, the CLABSI task force pursued opportunities and ideas for process change, to reduce rates of infection with updated evidence-based interventions that would promote the necessary change for improved CLABSI rates. In this project, sustainability was shown through the use of a sterile buddy, as this provided support for the organization's staffing model to effectively follow policy and strengthen compliance surrounding central line dressing changes. The CVICU nurses already conduct a daily central line checklist, and the primary nurse simply relies on an additional nurse to complete a certain aspect of the daily care routine, which is common in nursing practice, particularly in the ICU. The importance of interprofessional collaboration between the nurses and the patient care managers, regarding matters such as bedside procedures, quality and safety, and infection prevention and control is vital for ongoing education and compliance.
When conducting the SWOT analysis, shown in Figure 2, the primary strength was the current desire of the nursing staff and patient care manager to create change in the unit's CLABSI rates. The primary weakness, which was used as a strength, was the number of new nurses that came off orientation on this unit in the months immediately preceding and during the intervention implementation. The risk of the newer nurses becoming overwhelmed with functioning independently and missing crucial aspects of the central line bundle was circumvented by the opportunity to provide education and create a culture based on the goal of zero HAC, including CLABSI. The goal of this project was to create a system change at the micro and meso level. At the micro level, the day-to-day practice will change as the nursing staff utilize sterile buddies for the maintenance of their central lines, and potentially other sterile procedures, in order to prevent hospital acquired conditions. At the meso level, there would be a change in the unit, service line, and organizational policy to promote the use of the sterile buddy across the organization as a method to prevent HAC.

Implementation Plan with Timeline and Budget
There were three main objectives for this project. First was a reduction in the rate of CLABSI over an 8 week period. Prior to implementation, the unit had a CLABSI two to four times per month. With the implementation of this project there was the ability to determine quickly if there was an impact on CLABSI. The second objective for this project was the utilization of the organizationally developed "WILDCARD", or central line checklist. The Wednesdays. If a dressing change was indicated outside of the weekly dressing change, the primary nurse utilized another nurse on the unit as their sterile buddy to complete the procedure, as described in Appendix F. In addition to the use of the sterile buddy intervention, signage was created for the unit, shown in Appendix G, and placed in common areas to serve as a reminder for the nursing staff to perform the CLABSI WILDCARD checklist, included in Appendix D.
Education was conducted utilizing a SurveyMonkey link which included a 3-minute educational video and 3 true/false questions, in addition, a final question in the survey provided an open text box for questions and comments. The link for the educational survey was rolled out 2 weeks prior to implementation. Every Wednesday emails were sent to remind staff of the intervention and to provide the link for the education and survey. Weekly rounds were made on day and night shifts to provide just-in-time educational refreshers and query nursing staff for any problems that may have been encountered when carrying out the intervention. Data was collected using the WILDCARD checklist at the end of each week with nursing staff documenting the dressing change and the use of a sterile buddy in the comment section.
The first role of the project manager was to create a budget for the implementation of the project, included in Table 1. The primary cost for the implementation of this project was the cost to perform the educational sessions during the implementation phase, which was performed by the project manager. Given that there are 170 nurses, the project manager created a brief informational video for the staff to watch and answer 3 true/false questions, which required about 5 minutes of time by the nursing staff. There was an additional 55 minutes allotted in the budget for bedside education with individual nurses regarding project implementation, providing responses to questions or concerns throughout the eight-week implementation period, as well as, reading the weekly project update emails. In addition, the project manager reviewed the adherence and progress of the intervention each week, addressed concerns by the staff during the implementation period, and provided updates throughout the implementation to empower nursing staff in an effort to continue to promote the reduction of CLABSI rates. The project manager functioned as a member of the interprofessional team, to support the nurses and other healthcare members in creating a positive change on the unit.

Results
All of the measures were collected utilizing a medical record review and WILDCARD data. The data was collected by the healthcare quality and safety team within the organization, and provided to the project manager as de-identified raw numbers. The data provided was raw numbers of total CLABSI, total central line days and calculated rate of CLABSI. The primary outcome measure was the rate of CLABSI which is defined as the rate of CLABSI per 1000 patient days. The remaining measures with their associated statistical tests are included in Appendix H. The data discussed in Appendix I was collected weekly and the number of CLABSI and daily central line checklist completion was calculated on a continuous manner by the clinical nurse specialist and stored in a HIPAA compliant manner according to the facility's policy.
Analysis was completed by the project manager, using Intellectus Statistics software through permission provided by the University of St. Augustine for Health Sciences. Data was collected for 8 weeks during the implementation period and compared to the last quarter of 2020 through the start of the intervention and the same 8 weeks in the year prior to the intervention.
The data collection tool used is presented in Appendix I.

CLABSI Rate Reduction
The rate of CLABSI during the implementation period was 0. As a result, a two-tailed one sample t-test was performed to examine whether the null hypothesis could be rejected, and that the CLABSI rate of 0 during implementation was a result of the intervention and not based on chance. A p-value of 0.05 determined statistical significance. When comparing the same 8 weeks in 2020 to the implementation period, a Shapiro-Wilk test was conducted to determine whether the 2020 data could have been produced by a normal distribution (Razali & Wah, 2011).
The results of the Shapiro-Wilk test were significant based on an alpha value of 0.05, W = 0.75, p < .001, indicating that the normality assumption was violated. When the Shapiro-Wilk test was completed for the time period from October 2020 to the start of the intervention, the results were not significant based on an alpha value of 0.05, W = 0.86, p = .271. The results of the Shapiro-Wilk test means that the likelihood that the rates were produced by a normal distribution could not be ruled out, thus the normality assumption was met. The results of the two-tailed sample ttest are presented in Table 1. Based on the p-values for both comparison periods the null hypothesis cannot be rejected.

Additional Measures
The main process measure was the rate of completion through the addition of a sterile buddy for central line dressing changes, as defined by the number of dressing changes documented in the WILDCARD being performed with or without a sterile buddy, divided by the number of times two people were used, times 100. The goal protocol adherence rate was 80% for the utilization of a sterile buddy in the documentation of the daily central line review. The average adherence rate for the intervention, or percent completion of central line dressing changes with a sterile buddy, was 83.6%.
If we assume that the average increase in cost per CLABSI was $28,000 based on data from the Agency for Healthcare Research and Quality (2018b). The estimated cost savings when compared to the same time frame in the prior year was $56,000 and $112,000 for the time period from October 2020 until the start of the intervention.

Clinical Significance
Ultimately, the goal for evidence-based practice is to create clinical significance, which In order to continue to improve on the practice problem, there should be additional review of the data and the impact that the intervention had on the rate of CLABSI in the CVICU.
Prior to and during the implementation there was concern from the nursing staff that their current staffing levels did not support a two-person dressing change. Additionally, there were opinions that felt the use of two nurses for a commonly performed nursing procedure was not a good utilization of the available staff. In order to promote sustainability of this intervention over time, there needs to be more conversations with the nursing staff regarding the importance of CLABSI reduction on the unit and the role that the nurse plays in CLABSI prevention. Additionally, a secondary study could be completed which measures the amount of time spent on the two-person dressing change, compared to the single person dressing change to clearly illustrate the time requirements for each nursing team member. Illustrating the time difference may encourage continued participation and improve the longevity of the intervention.

Dissemination Plan
PowerPoint presentation during the weekly CLABSI meeting held by the quality and safety department, with the goal of creating a new policy to support the importance of the use of a sterile buddy for all central line dressing changes. The next step for dissemination was to present the project and results at the organization's nursing research day, which was in the form of a poster presentation. Key invitees included the primary stakeholders for this project, the director of cardiovascular nursing services, chief nursing officer, infection prevention manager, enterprise nursing operations director, and physician and advanced practice provider staff for the CVICU.
The primary journal for dissemination of the results from this evidence-based project will be the journal Critical Care Nurse published by the American Association of Critical-Care Nurses with a focus on clinical, relevant information regarding the care of critically and acutely ill patients. This journal is a great fit for dissemination of the results of this project because it is focused on tools that bedside nurses use daily to provide care for patients in the ICU. The first level of peer review will come from the preceptor for this project who is knowledgeable about the organization, cardiovascular intensive care, and understands the primary objectives of the project. Following each presentation described above there will also be opportunities to provide feedback, which will be used to tailor the final manuscript that will be submitted to the selected journal and regional meeting. The final step in the dissemination process will be submitting the completed project into the SOAR@USA repository. This step takes place after final approval of the manuscript is received from the University of St. Augustine faculty and includes uploading the manuscript and assigning keywords and subject categories to facilitate the search of the manuscript in the future.

Conclusion
Addressing rates of CLABSI is multidimensional and requires a team approach. The use of daily central line maintenance bundles has been demonstrated to decrease the rate of CLABSI    health record adjusted to allow for a co-sign area to document the two-person dressing change technique was performed X Create signage for unit bulletin board with contact information to empower members on the unit to act and participate fully in the project implementation X Compile background data X Educational sessions for project implementation with time for re-education and multiple sessions over two weeks X Project implementation period X X X X X Assess nursing performance following 1 week of implementation including problems with implementation, questions/concerns regarding adherence X Compile data for prior week findings, address nursing concerns, update bulletin board with general questions and successes to give nursing staff small wins or knowledge that they are creating positive change X X X X X Halfway point -assess nursing adherence and performance, provide update to stakeholders with outcomes to date, make changes if needed to streamline or increase practicality X Provide education refresher course for implementation to nursing staff based on identified needs/adherence to date X End of implementation phase X Thank you party/celebration for nursing staff Week 13 Week 15 X Data collection for raw data for primary outcome and other measures X X X Data analysis and evaluation of outcomes, measures X X Determine sustainability of project through budget reconciliation, nursing and administration feedback, project strengths, weaknesses and limitations X X Present key findings to stakeholders, nursing, administration and institutionalize change to make it the new norm X Arrange/schedule and present school of nursing research day presentation X Disseminate findings to University of St. Augustine X Completion of DNP X to dry without fanning or waving. The SB will monitor their technique and stop the procedure in case of potential site contamination.
5. New dressing application: Once the site is dry, the primary nurse will apply the new central line dressing. Once the dressing is adhered, the primary nurse and sterile buddy will clear their sterile field, remove their sterile gloves, and perform hand hygiene. The primary nurse will then label the dressing with the date, time, and their initials. The SB will then remind the primary nurse to document the dressing change in the electronic health record and co-sign the record to show the use of the two-person dressing change technique.