Lisa Truini-Pittman, RN, BSN, MPH, OCN
Linda Sullivan, RN
Kirsten Pedersen, RN, BSN, OCN
Tanaz Mistry, RN, BSN, OCN, NP
Jill Williams, RN, BSN, NP
(left to right) Lisa Truini-Pittman is quality and patient safety coordinator, Linda Sullivan is infection preventionist, Kirsten Pedersen is service line educator, Tanaz Mistry is assistant patient services manager, and Jill Williams is patient services manager at the Smilow Cancer Hospital at Yale-New Haven in New Haven, Connecticut.
Decreasing hospital associated infection rates including Central Line–Associated Bloodstream Infections (CLABSIs) is an issue of ongoing focus nationwide. CLABSIs increase patient morbidity, mortality, and length of stay and are estimated to add between $3700 and $39,000 to the cost of a hospitalization.
Evidence-based guidelines have resulted in substantial improvements in many clinical settings. However, institutions continue to struggle to reduce CLABSI rates in the hematology, oncology, and post–stem cell transplant patients for many clinical reasons. The uniqueness of the disease, its treatment with cytotoxic agents, resulting immunodeficiency, risk of mucosal barrier injury, and the duration of central venous catheter use all play a role in increasing the susceptibility in this population.
A multidisciplinary team from the Hematology Oncology and Medical Oncology units at Smilow Cancer Hospital at Yale-New Haven has worked tirelessly to monitor, implement changes, and measure the resulting levels of success. Initially, they engaged frontline staff in the initiatives, provided education, validated competency, tracked staff caring for patients who developed CLABSI, and involved patients in the monitoring of clinical practice. Improvement in the CLABSI rates was nominal.
The Yale-New Haven Hospital CLABSI Prevention Committee instituted a guideline restricting clinicians from drawing blood cultures from central venous access devices (CVADs). This guideline is based on strong evidence that blood cultures drawn from CVADs have higher contamination rates and higher false positive infection rates. In the Oncology Services, this posed a challenge. Traditionally, management of CVADs by the oncology team was directed by the published guidelines of the American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN). These guidelines recommended obtaining blood cultures from CVADs and peripherally.
Additionally, clinicians were concerned about patient discomfort and the quality of the patient experience. In fact, many clinicians informed patients that the CVADs would prevent them from having needle sticks for blood drawing.
In an effort to assist the two oncology units in the reduction of their CLABSI rates, an infectious disease physician and an infection preventionist, joined forces with the multidisciplinary team working on CLABSI reduction on these units. Discussions were held about the benefits and evidence behind the value of reducing blood cultures drawn from CVADs. Collaboratively, they developed a strategy to minimize the number of blood cultures drawn from CVADs. The end product was an algorithm that gave consideration to the clinicians’ concerns and minimized the number of central line cultures drawn.
Subsequently, the team implemented multiple rapid-fire interventions in its efforts to reduce CLABSI. A vein illuminator was purchased to assist nursing staff with obtaining peripheral blood cultures. Scripting was developed for clinicians to use to educate patients on the importance of obtaining blood cultures peripherally. Lastly, a CVAD blood drawing kit was customized and implemented along with a two-nurse process for drawing blood cultures from a CVAD. The two-person process was not continued, as it was not operationally sustainable. Introduction of these interventions was challenging for the clinical staff. However, staff demonstrated an eagerness to embrace changes that would result in both reduced CLABSI rates and better outcomes for their patients.
Prior to implementation of the algorithm and CVAD blood culture kit, the rate of blood cultures obtained from CVADS was 35.9% over 6 months, and the CLABSI rate was 3.4 infections/1000 device days. Following implementation, the percentage of cultures obtained from CVADs decreased to 20.3%, and the CLABSI rate decreased to 2.1 infections/1000 device days for the following 6 months. Hence, they achieved success in both reducing the number of blood cultures drawn from CVADs and in reducing their CLABSI rates.
Engagement of the patient and interdisciplinary team was critical to the success of this project. In 2014, these units demonstrated sustained success over the first three quarters. However, the fourth quarter of 2014 proved challenging and brought the team back to the conference table for additional strategizing on sustainability.
CLABSI prevention is a challenging national initiative. The patient with an oncology diagnosis is at high risk because of cancer’s unique biology and because of its unique treatment and toxicities. It will take ongoing efforts and vigilance to sustain successes in reducing CLABSI in this population. The teams of inpatient units NP 11 and 12, in collaboration with our Infection Control partners, will persevere with deliberate steps toward this goal.
Metzger KE, Rucker Y, Callaghan M, et al. The burden of mucosal barrier injury laboratory-confirmed bloodstream infection among hematology, oncology, and stem cell transplant patients. Infect Control Hosp Epidemiol. 2015;36(2):119-124.
Schiffer CA, Mangu PB, Camp-Sorrell D, et al. Central venous catheter care for the patient with cancer: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol. 2013;31(10):1357-1370.
Snyder SR, Favoretto AM, Baetz RA, et al. Effectiveness of practices to reduce blood culture contamination: a Laboratory Medicine Best Practices systematic review and meta-analysis. Clin Biochem. 2012;45(13-14):999-1011.