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Practice Problem: Patients in the hospital are 36.6% more likely to die after a diagnosis of a Central Line-Associated Bloodstream Infection (CLABSI) (Chovanec et al., 2021). The purpose of this evidence-based practice implementation is to reduce CLABSI rates in the Neurological ICU (Neuro ICU) at a private medical center through use of a CLABSI prevention bundle checklist each shift. PICOT: In the adult neuro-ICU (P), how does implementing a CLABSI prevention bundle checklist each shift (I), compared to current practice (C), affect CLABSI rates (O) within eight weeks (T)? Evidence: Evidence-based research supports that if clinical staff completed each part of the CLABSI bundle, remained informed, and used an interdisciplinary team approach there would be a lower risk of CLABSI. Intervention : The intervention for the project was to have the Neuro ICU staff nurses complete a CLABSI bundle checklist a the change of each shift for patients with a central line. The staff completed an educational lesson on CLABSI and completing each competent of the CLABSI bundle checklist. Outcome: 100% of nurses received education on CLABSI and CLABSI bundles. 100% of patients with central lines receive a documented CLABSI bundle checklist and there was a decreased CLABSI infections from 1.28% to 0%. Conclusion: This evidence-based practice implementation aimed to reduce the Neuro ICU's CLABSI rate through the CLABSI preventive bundle checklist at each shift. Going forward the best practice recommendations for reducing CLABSI rates include using CLABSI packages, informed staff, and an interdisciplinary team approach.


Reducing Central Venous Infections
Patients in the hospital are 36.6% more likely to die after a diagnosis of a Central Line-Associated Bloodstream Infection (CLABSI) (Chovanec et al., 2021). Central venous catheters (CVC) are beneficial for clinical staff to provide various treatments and interventions for patient care. For critically ill patients in the intensive care unit (ICU), CVC insertion is a customary practice (Kolikof et al., 2020). Unfortunately, if CVCs are not cared for effectively, the results can be deadly. CLABSI is caused when a CVC line becomes infected. Since having CVCs are common in the hospital and the risk associated with CLABSI could be deathly, it is necessary to ensure that all infection prevention methods are followed.
The negative impacts of CLABSI have made healthcare facilities prioritize infection control practices to reduce CLABSI rates (Haddadin et al., 2020). CVCs are flexible, thin catheters that advanced clinicians place through a large vein that leads to an area above the heart (Kolikof et al., 2020). Although there are national guidelines to prevent CLABSI infections, healthcare facilities and patients struggle with CLABSI diagnoses. Previous research on CLABSI prevention in the ICU shows that facilities utilize CVC bundle care to reduce CLABSI rates (Jusino-Leon et al., 2019). Research studies have shown that CVC bundles using chlorhexidine skin preparations, avoiding the femoral area, completing line changes, performing hand hygiene, and checking the CVC line are ways to reduce CLABSI (Johnson, 2018;Kolikof et al., 2020;Lee et al., 2018;Mattox, 2017). The purpose of this evidence-based practice implementation is to reduce CLABSI rates in the Neurological ICU (Neuro ICU) at a private medical center through use of a CLABSI prevention bundle checklist each shift.

Causes of CLABSI
One cause of CLABSI is by bacteria on a patient's skin that migrates from the surface of the catheter to the outer skin layer and into the intravascular space (Haddadin et al., 2020. CLABSI can also be caused by pathogens on a patient's CVC hub usually from a clinician's hands or equipment that enters a patient's bloodstream. In addition, CLABSI can form from a contaminated skin site, such as dirty skin before CVC insertion or a dirty CVC dressing. Grampositive pathogens are the most common causes for CLABSI, followed by gram negatives and Candida species. There are tunneled and non-tunnels catheters associated with CLABSI. Most CLABSI diagnoses occur with non-tunneled catheters.

Diagnosis of CLABSI
Lowering the rate of CLABSI in healthcare is significant because of the mortality rates with critically ill patients and the cost associated with each infection. Regulating bodies such as the Joint Commission can utilize CLABSI rates to determine infection concerns at a facility (The Joint Commission, 2012). CLABSI diagnosis occurs within 48 hours after insertion and is confirmed with positive blood cultures (Haddadin et al., 2020). Those CLABSI results for a positive blood culture after 48 hours can be the cause of poor central line maintenance or an infection from another source in the body. The health care provider first assesses for signs and symptoms of CLABSI. For example, a patient requires further evaluation if they are experiencing symptoms such as fever, tachycardia, signs of sepsis, discharge from the CVC insertion site, and a CVC dressing site that is warm or swollen. If the patient has any of these symptoms, then a blood culture is completed. When the blood cultures are positive for a pathogen, a CLABSI diagnosis is validated.

Impacts of CLABSI
In the Neuro ICU, patients have CVC lines for hemodynamic monitoring, nutrition, medication administration, attaining labs, and other various reasons (Mattox, 2017 (CMS, 2021).

CLABSI Rates
In the United States, CLABSI rates in the ICU are approximately 0.8 cases per 100 CVC line days (Haddadin et al., 2020). The Antibiotic Resistance and Patient Safety Portal (n.d.) shows that Georgia's CLABSI rate is 7% lower than the national baseline. However, in the project site, CLABSI rates for fiscal year 2020 in the Neuro ICU are 1.28%. States that have laws for reporting CLABSI have lower CLABSI rates than states that do not (Liu et al., 2017).

PICOT Question
In the adult neuro-ICU (P), how does implementing a CLABSI prevention bundle checklist each shift (I), compared to current practice (C), affect CLABSI rates (O) within eight weeks (T)?

Population
The population of the adult ICU has a wide variety of patients and diagnoses. Patients in the ICU are more likely to have central lines than other areas in the hospital (Jock et al., 2016).
The diagnosis usually in the neuro ICU includes patients with traumatic brain injury, cerebrovascular diseases, epilepsy, and other neurological diseases and deficits (Hilz et al., 2019). Due to the greater chance of having patients with central lines, it is more efficient to monitor CLABSI rates in the ICU.

Intervention
Evidence-based practices show that utilizing bundles as an intervention is beneficial for reducing CLABSI rates (Jusino-Leon et al., 2019). Before implementing the project, the outcomes manager completed a CLABSI checklist for each central line. The vascular access team rounded on each central line and completed needed dressing changes and the bedside nurses would document and monitor the central lines. The intervention included the CLABSI bundle checklist at each shift and how it affects patient care with a central line. The intervention puts the responsibility of central line rounding onto the bedside nurse at shift change through the CLABSI bundle checklist. Each facility has variations to its CLABSI prevention bundle such as dressing change dates or terminal cleaning of rooms. Evidence-based research supports that if clinical staff completed each part of the CLABSI bundle, there is a lower risk of CLABSI (Reynolds et al., 2021).

Comparison
Comparing patients who have a CLABSI bundle checklist for each shift versus patients who do not have a CLABSI bundle checklist determines if the checklist decreased CLABSI infections. When completing chart audits, if a step is not noted, it is assumed that the patient did not receive the standard CVC line care.

Outcome
The desired outcome is that all patients with central lines receive a documented CLABSI bundle checklist and that there are decreased CLABSI cases. The outcome was measured through chart audits and lab results. The lab is a key component because CLABSI results come from positive blood cultures. Chart audits entail verifying how many patients have a central line and a documented checklist for each shift.

Time
The timing was within an eight-week period. CLABSI occurs within 48 hours of central line insertion (Haddadin et al., 2020). The nursing staff assessed the CVC line using the CVC bundle daily. Each time the nurses evaluate the CVC line, they checked if the line met the criteria for removal. The daily process took place on multiple patients and monitored the success or failure of the intervention.

Evidence-Based Practice Framework & Change Theory
The Johns Hopkins Evidence-Based Practice (JHEBP) framework was used for the project. The JHEBP framework uses a problem-solving approach in three phases: practice question, evidence, translation (PET) and 20 steps (Dang et al., 2022). The first two phases were completed prior to implementing the project. The first phase of JHEBP for the project was identifying the clinical question using a PICOT format. An interdisciplinary team was assembled, along with meetings scheduled to address the question. The second phase involved gathering evidence. The researcher gathered evidence from internal sources of the project site for current data and external sources by completing a literature review. Using the JHEBP framework, the researcher appraised as either Level I, II, III, IV, or V (by strength) and rated either A (high quality) or B (good quality). In the third phase, the researcher shared information with the stakeholders and created an action plan. After creating the action plan, the plan was implemented, and the outcomes evaluated. In the end, the stakeholders received a report with the project's findings.
The foundation of the implementation plan for CLABSI prevention used Lewin's change theory. Lewin's change theory uses three steps: unfreezing, moving, and freezing as the concepts to change a person's behavior in the desired direction (Lewin, 1951). Lewin's change theory of unfreezing-moving-freezing can be used to make changes in a unit by implementing a CLABSI prevention bundle checklist each shift. Lewin's change theory incorporates an interdisciplinary team. The goal is to unfreeze the everyday occurrences in the Neuro ICU related to CVC care and education. That step includes education for all the staff members involved with CVC care.
Education includes reviewing each action item on the CLABSI prevention bedside checklist and its importance. Next is the moving step; the employees worked with an interdisciplinary team to achieve the desired outcome of CVC care and follow-up. This step includes the staff starting to use the bundle. Last was refreezing the new behavior in the Neuro ICU. Freezing was when each nurse used the CLABSI prevention checklist at shift change consistently.

Evidence Search Strategy
The evidence search strategy utilized for reduction of CLABSI in the Neuro ICU included the use of several databases. These included the use of the University of Saint Augustine's library for the CINAL Complete database, OVID Emcare database, and the Joanna Briggs Institute (JBI) database. The research included Boolean operators such as "AND" and "OR." The keywords included: CLABSI, ICU, central line, and bundle. Next, inclusion criteria included (CLABSI) AND (ICU) AND (central line) and (bundle). Interchangeable words included "CLABSI" and "central line bloodstream infection," "ICU" and "intensive care unit" and "critical care unit," "central line" and "CVC," and "bundle" and "checklist." Last, exclusion criteria included searching for information within the last five years (2018)(2019)(2020)(2021)(2022), full text only documents, removing duplicates, academic journals, English language, and geography for the USA. Further limiters were placed on articles that were only abstracts and articles that were specific to a population under 18 years old.

Evidence Search Results
A literature review was completed for the project. Many articles discuss CLABSI infections. The literature review with eligible publications used for the project is reflected in the PRISMA diagram (Appendix G).
The evidence search resulted in 308 articles. The initial search included (CLABSI) AND (ICU) AND (central line) AND (bundle). When applying the limiting factors such as full text, within the last five years (2018-2022), academic journals, English language, and geography for the USA, there were a remaining 17 articles available. Duplicate results were eliminated, and after further assessments of the articles, six remaining articles were left that were used in the project for core research (Appendix A and Appendix B). The preliminary review removed results that did not include the intensive care unit for adults, 18 and older and released results that did not have intensive care unit CVC placement. Other articles that were not in the primary search offered excellent information regarding CLABSI infections were included in the reviews.
Using the Johns Hopkins Nursing Evidence-Based practice quality grading system, it was essential to identify the level of quality of the articles used for the research based on the final six articles. There were one Level I article, three Level II articles, and two Level V articles. All the articles were of high quality.

Themes with Practice Recommendations
Through a literature review, themes were recognized from practice recommendations to reduce CLABSI rates in the ICU. The practice recommendation to reduce CLABSI rates included using CLABSI bundles, having informed clinical staff, and implementing an interdisciplinary team approach. The studies in Appendix A and Appendix B support that using CLABSI bundles reduces CLABSI rates in the ICU setting.

Population
The articles in Appendix A and Appendix B were conducted in an ICU setting. In the intensive care unit (ICU), CVC insertion is common (Kolikof et al., 2020). In the Neuro ICU, patients usually have neurological diseases that can have focal neurological such as traumatic brain injury, cerebrovascular diseases, and epilepsy (Bharadwaj et al., 2022;Hilz et al., 2019).
Patients in the ICU are more likely to have a CVC than other areas in the hospital (Jock et al., 2016). Invasive hemodynamic monitoring usually occurs in the ICU setting using a CVC line (Haddadin et al., 2020;Mattox, 2017).

Use of CLABSI Bundle
Related literature states that the best method to decrease CLABSI is utilizing a CLABSI bundle (Johnson, 2018;Kolikof et al., 2020;Lee et al., 2018;Mattox, 2017). The research studies explained that using the Chlorhexidine skin preparation, avoiding the femoral area, completing line changes, hand hygiene, and review of CVC line are methods to decrease CLABSI. The Joint Commission has a CLABSI toolkit that offers a CVC maintenance bundle that the facility could use as a resource (Jusino-Leon et al., 2019).
Forty-three participating hospitals from 22 countries had central line bundles that included chlorhexidine, sterile barriers during insertion, subclavian or internal jugular vein over the femoral vein, hand hygiene, and daily review of the central line's needs (Devrim et al., 2022).
Prior to insertion, cleansing the skin with chlorhexidine prevents bacteria from the skin from entering the patient's intravascular space (Haddadin et al., 2020). Providers should avoid using the femoral area for CVC insertion because femoral catheters are associated with a higher risk of CLABSI infection. During the insertion of the CVC and at the time of the CVC dressing change, the provider completes their task in a sterile space wearing sterile gloves. After insertion, chlorhexidine baths help decrease bacteria on the patient's skin that may lead to infection (Haddadin et al., 2020). Cleaning the CVC hub is essential to decrease bacteria from migrating from the hub site to the patient's bloodstream, leading to CLABSI.
Knowledgeable staff is more inclined to follow the policies in place for interventions. Staff education includes understanding the patient consequences from a CLABSI infection, such as increased length of stay, healthcare cost, morbidity, and mortality (Reynolds et al., 2021). Jusino-Leon et al. (2019) stated that providers who follow evidence-based practice protocols effectively decrease CLABSI rate (Appendix D). However, there is no way to ensure that having a written hospital policy will result in employee compliance. Informed staff will be accountable for following the practices to reduce CLABSI.

Interdisciplinary Team Approach
Four studies supported that the interdisciplinary team's compliance determines decreasing CLABSI results (Gabbard et al., 2021;Haddadin et al., 2020;Jusino-Leon et al., 2019;Kolikof et al., 2021). The interdisciplinary team includes the medical doctor, registered nurse, laboratory specialist, and clinical nursing specialist. The registered nurse ensures that the medical doctor has everything they need prior to inserting the CVC line, and during the procedure, everything remains sterile and follows up with the CVC line (Kolikof et al., 2021). Nurses are also responsible for making sure the CVC dressing remains clean and that the medical doctors Overall, the studies support the practice recommendation to complete a CVC bundle checklist at the change of each shift. The studies state that CVC bundles that include chlorhexidine skin preparations, avoiding the femoral area, completing line changes, performing hand hygiene, and checking the CVC line are ways to reduce CLABSI (Johnson, 2018;Kolikof et al., 2020;Lee et al., 2018;Mattox, 2017).

Setting, Stakeholders, and Systems Changes
The project occurs at a 520-bed adult hospital in Georgia with a 20-bed Neuro ICU. It is the region's only level I trauma center, and the only one with a level IV neonatal intensive care unit. At most, the Neuro ICU could have 20 patients, each with the possibility of multiple CVCs.
There are uncertainties with the patient census in the Neuro ICU that would delay the project.
For example, there is the potential for the Neuro ICU to have no CVCs lines in place. The organization is associated with a research university. The organization's mission is to provide leadership and excellence in clinical care through student-centered comprehensive research. The mission aligns with infection control practices for reducing CLABSI rates.
The stakeholders include the Chief Nursing Officer, the Director of Adult Patient Care Services and Centralized Nursing Services, the Clinical Outcomes Manager, and the Neuro ICU staff nurses. These stakeholders were interested in improving patient outcomes and reducing costs by decreasing CLABSI in the Neuro ICU. The Neuro ICU is the hospital area that has CLABSI rates higher than the Georgia state average. The population for the project is patients in the Neuro ICU who have a CVC. A meeting with the stakeholders reviewed the current CLABSI rates, the current unit's practice, and the practice change of implementing evidence-based practice to reduce CLABSI rates. The stakeholders view the project to be beneficial because of the improved patient outcomes, reduced cost, and improved quality care.
The project was constrained to the Neuro ICU, making it a micro-level change. Evidencebased practice to address CLABSI in the Neuro ICU is at the micro-level through the support of the stakeholders and the interdisciplinary team. The project to implement a CLABSI checklist at shift change relies on the nursing staff's understanding of the negative impact of CLABSI on the patient and the healthcare facility. The checklist made the nurses more accountable for monitoring the CVC and advocating for their patients if there is a sign of infection.
A SWOT analysis reviewed the strengths, weaknesses, opportunities, and threats (Nelson & Staggers, 2018). The information gathered from the SWOT analysis (Appendix H) assists with implementing the project. The project's strength was that the facility is recognized as the top comprehensive stroke center in the area. Holding such a high distinction leads to a continuously growing population of patients that utilize the Neuro ICU. Another strength is the project team; the stakeholders and leaders in the organization are invested in supporting a project that focuses on infection control. The weakness of the project includes the high turnover of staff. Having different staff members that are not always core staff is an added variable of an education gap.
Another weakness is that the project was only implemented in one hospital area. An opportunity from the project is the potential to streamline the CLABSI checklist in the Cerner electric medical records system. The threat related to the project is the census of the population in the Neuro ICU that have a CVC. There is a potential that although the Neuro ICU has 20-beds, there may be no patient with a CVC on the unit. Another potential threat could be the resistance from the nursing staff for completing the checklist at the change of shift.

Implementation Plan with Timeline and Budget
The project identified how using a CLABSI checklist at the change of shift affected the CLABSI rate in the Neuro ICU within eight weeks of implementation. The Neuro ICU staff nurses utilized the CLABSI checklist (Appendix I) at each shift to ensure that each section was complete, and issues were be addressed during the shift. The checklist guides nurses to bring concerns to medical or management staff. There were three main goals for the project. Neuro ICU staff nurses had education training opportunities in huddles resulting in 100% of staff reviewing the CLABSI bundle checklist by week 1 (Appendix M). Neuro ICU staff nurses at each shift completed the CLABSI bundle checklist for each patient with a CVC at 100% by week 8 (Appendix L). By week eight, Neuro-ICU reduced the percentage of CLABSI diagnosis to below the 1.28% baseline in the Neuro ICU. The projects goals focus was to decrease the CLABSI rate in the Neuro ICU, whose rates are higher than the state of Georgia's average.

Unfreezing Step
The CLABSI education occurred the week of the project's start date during the huddle. This period is considered the unfreezing step from Lewin's change theory. Huddle is a beginning of the shift meeting between the nurses and the unit manager or charge nurse. In huddle information regarding the unit is reviewed and usually quick educational moments can take place. Huddles vary in time between five and twenty minutes. After all the nurses in the unit have received an education, there was regular reminders at each shift huddle, encouraging the use of the checklist tool at the bedside. In the huddle, the Clinical Outcomes manager and project leader had a CLABSI review document for the nurses to review (Appendix M). Due to the demanding schedule of the Clinical Outcomes manager and the clinical nurse specialist, the charge nurses for the unit ensured that the checklist tool was used during the change of shift.

Moving Step
The staff nurses for eight weeks initiated the project. This period is considered the moving step of Lewin's change theory. Data was collected from the checklist that was collected and the results received from the laboratory if there are positive blood cultures. Four weeks after the implementation there was a midway checkpoint to briefly assess the gathered data. All positive blood cultures were going to be tracked and identifying information from the checklist was going to be used. Every Friday there was a CLABSI checklist audit to ensure that staff nurses were completing the checklist. The SOS report generated by the project site was reviewed every Friday by the researcher if there is a positive blood culture for a patient with a CVC.

Freezing Step
At the end of eight weeks, this time was considered the freezing step of Lewin's change theory. By this time, all nurses were using the CLABSI checklist at the change of shift for all patients with a CVC and submitting the checklist to the Clinical Outcomes manager. The data was analyzed against the baseline data of the Neuro ICU, the CLABSI rate from the state, and the final CLABSI rate after eight weeks. After a comparison report on the project, the analysis was sent to the stakeholders. For the project, there was a minimal budget (Appendix K) of ten dollars used for printing the CLABSI checklist for nurses to use. There was no cost associated with creating the CLABSI checklist.

Results
The project aimed to evaluate CLABSI rates before and after implementing the CLABSI checklist. For the project, there were three main goals. The first goal was to have the neuro ICU staff nurses' complete education training in huddles with participation at 100% within the first week. In the huddle, the project leader and the Clinical Outcomes manager completed a CLABSI review document for the nurses to review (Appendix M). This goal was met with the staff reviewing the CLABSI bundle checklist by week one at 100%.
Nurses who completed the huddle signed their names, initialed, and dated, indicating that they reviewed the CLABSI checklist and implemented it each shift (Appendix L). The clinical outcomes manager confirmed this goal by examining the sign-in sheet from the huddles to ensure that all staff members participated. The signed list was compared to the nursing staff roster to ensure that each nurse participated in the huddle and CLABSI checklist tool.
The second goal was to have the neuro ICU staff nurses at each shift complete the CLABSI bundle checklist for each patient with a CVC at 100% by week eight. This goal was met at 100%. The oncoming nurses completed the CLABSI checklist each shift, and the form was given to the Clinical Outcomes manager to review daily. The clinical outcomes manager measured this goal through chart audits.
The final goal was to reduce the neuro-ICU CLABSI rate to below 1.28% in eight weeks.
The neuro-ICU accomplished this goal with a CLABSI rate of 0% during the eight-week implementation period. CLABSI rates are reported through the National Healthcare Safety Network (NHSN) (Bagchi et al., 2018). The validity of the CLABSI checklist tool is based on calculating the CLABSI rates (Appendix D), which is the number of CLABSI divided by the total catheter days and multiplied by 1000 (Pathak et al., 2018). Data collection to monitor CLABSI rates was through the hospital's SOS system that tracks patient information such as positive blood cultures. The CLABSI rates were calculated by reviewing the SOS system, which resulted in no CLABSI cases. The project did not put the patients at risk of harm, and the CLABSI checklist stayed securely with the clinical outcomes manager.

Impact
The project's purpose was to implement a CLABSI checklist to utilize at change of shift to decrease the CLABSI rate in the Neuro ICU. The project's outcome had a clinical impact on the care provided by nurses that went through each area of the checklist to ensure that patients' central lines were up to the standards of the hospital. The project reduced CLABSI infections from 1.28% to 0%.
The project impacted how nurses reported to one another when a patient had a central line. The current practice within the unit requires nurses to do bedside shift reports. The project made nurses highlight and utilize a checklist so that patients with a central line required a digital assessment between two nurses.
A few project limitations early on included a lack of enthusiasm from the nursing staff to utilize a checklist. The nursing staff felt the checklist was repetitive information already collected from the vascular access team within the hospital and the clinical outcomes manager.
Other limitations were associated with receiving data from the hospital that led to their FY 21 1.28 CLABSI percentage for the Neuro ICU. Another limitation of the project is related to the coronavirus pandemic. The hospital staff experienced staff shortages along with problems with their throughput. Essentially patients were placed in critical care areas that would not have genuinely qualified for critical care before the coronavirus.
It is speculated that due to the inappropriate bedding of medical intensive care unit patients within the Neuro ICU setting, the baseline results were much higher than what they would've been if it was not for the coronavirus pandemic. Medical intensive care unit patients within this facility have a history of higher CLABSI rates than patients that in the Neuro ICU.
Before starting the project, the hospital recognized that certain areas had higher infection rates than others. The vascular access team was created to support departments more to help the hospital achieve lower infection rates. Fortunately, upon the project completion, the implemented population had a zero rate for CLABSI.
In the future, the facility will not make it the nurse's responsibility to complete a CLABSI checklist. Instead, the project helped nurses understand the key components necessary to maintain a patient central line to the hospital standards. From now on, the hospital will continue utilizing its vascular access team to help keep central lines within its standards. Outside of the vascular access team, additional training will occur within the units so that nurses can know how to complete dressing changes for patients with a central line correctly in case the dressings are soiled.

Dissemination Plan
The project results were reviewed with the project preceptor. Next, the project was shared with the project site's nursing administration, nursing staff, unit managers, and the vascular access team. The results were presented through a printed report and a presentation.