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International Journal of Science and Healthcare Research
Vol.7; Issue: 2; April-June 2022
Website: ijshr.com
Original Research Article ISSN: 2455-7587
International Journal of Science and Healthcare Research (www.ijshr.com) 404
Vol.7; Issue: 2; April-June 2022
Impact of Training on Central Line Associated
Blood Stream Infection Maintenance Bundle on
Central Line Associated Blood Stream Infection
Rates - A Retro-prospective Study in a Selected
Hospital, Hyderabad
Sumathi Ardhalapudi1, Dr. Ratna Mani2, Pravalitha.K3, Satyamma. B4,
Dr. Prathiba5, Usha Prabhakar6, NagaSireesha7, Bhagya Lakshmi8,
Maryline Flinsi 9, Dr. N. Balakrishna10
Infection Control Nurse1, Head of Microbiology2, Infection Control Nurse3, Infection Control Nurse4,
Microbiologist5, Chief Nursing Officer6, Nursing Superintendent7, Nursing Quality Coordinator8,
Principal Apollo School of Nursing-Delhi9, HOD- Department of Statistics10,
Hyderabad, India
Corresponding Author: Sumathi Ardhalapudi
DOI: https://doi.org/10.52403/ijshr.20220457
ABSTRACT
Background: Central line-associated
bloodstream infections (CLABSI) are a very
common cause of healthcare-associated
infections (HAI). CLABSIs will not only
increase mortality and morbidity but also
increases length of stay (LOS) and financial
burden to ICU patients. Infection control
practices play a major role in preventing
CLABSI. Research indicates that quality
improvement initiatives have helped in reducing
CLABSI rates. CLABSI rates have been
successfully reduced in ICU settings however,
there is still significant variability in practice
due to poor adherence to evidence-based
CLABSI maintenance bundle components.
However, nurses frequently struggle to follow
evidence-based preventive practices, thus it is
necessary to understand better the behavioral
influences on implementing CLABSI prevention
measures. Additionally, it has been emphasized
that implementation studies must consider or
quantify the potential impact on CLABSI rates.
Before taking up the study, we have noticed
increase in CLABSI rates for 1month Period, for
which the Retrospective data was collected and
analyzed to understand the gaps to implement
CLABSI maintenance bundle components.
Therefore, this study helped us identifying gaps
in maintenance bundle and observed infections
rates before and after study
Aim: To evaluate the effect of central line (CL)
bundle compliance on central line-associated
bloodstream infections (CLABSIs)
To evaluate the knowledge and practices of
physicians and nurses working in all ICUs and
wards regarding the components of central line
maintenance bundles (ref table I)
Design: Used a retro prospective study, to
reduce the CLABSI rates and to increase
awareness on maintenance bundle components
in intensive care units (ICU) and wards. we have
initiated a structured training program to all
nurses and doctors. Two tools were prepared.
one is to assess the knowledge of nurses and
doctors working in ICUs and wards on
CLABSI. The second tool consists of
components related to central line maintenance
bundle to evaluate the effectiveness in reducing
incidence of CLABSI. A total 489 Registered
nurses and 10 intensivists and 15 ward doctors
were included in the current study. Phase I was
the pre-interventional period during this period
audits were conducted, we observed lacunae in
implementing CLABSI Maintenance bundle.
Phase II was the intervention period lasting for 2
Sumathi Ardhalapudi et.al. Impact of training on central line associated blood stream infection maintenance
bundle on central line associated blood stream infection rates - a retro prospective study in a selected hospital,
Hyderabad.
International Journal of Science and Healthcare Research (www.ijshr.com) 405
Vol.7; Issue: 2; April-June 2022
month, during this period, the entire nursing
staff and doctors working in ICUs and Wards
underwent a continuous teaching and training.
Phase III was the post-intervention period- In
this period questionnaire was given in
September and again in December. This was to
check for the impact of training on knowledge
and awareness level which will further lead
better implementation of the practices. Observed
CLABSI rate reduced from17.2. to 6.8 per 1000
central line days.
Result: Knowledge assessment- Comparison
data between June 2021 and September 2021
mean knowledge score significantly higher in
September (9.1) than June (6.4) .similarly,
December (9.9) score significantly higher than
June and September to determine the difference
between the mean of various observations in the
pre and post intervention period with 95%
confidence interval, the difference in the
knowledge level and CLABSI rate in the pre
and post intervention period was found
significant(p<0.001) .During this 6 months
period(July 2021 to December 2021) there were
a total of 1120 patients on central lines, for all
the patients line care was observed after
implementation of structured training
programme. The rate of CLABSI significantly
declined from 17.2 per 1000 catheter days to
6.8 per 1000 catheter days.
Conclusion: This study clearly indicated that
the educational interventions in structured
formats are imperative when imparting trainings
in Infection control practices and should be
implemented frequently to bridge the gap
between knowledge and practice. With the
dynamics of infection control and the challenges
faced in its implementation continuing this type
of trainings will ensure all use evidence-based
interventions.
Recommendations: Continues Training
program should be carried out for nurses and
doctors related to implementation of CLABSI
Bundle.
Key words: CLABSI, Catheter hub care, Hand
hygiene, Training, Maintenance bundle,
Teaching, Implementing, Structured program
INTRODUCTION
Central venous catheters (CVCs) are the
most important devices used in ICU patients
and they enable the administration of
medications, fluids and blood products
directly to the central venous system as well
as hemodynamic monitoring [1]. Although
they are extremely necessary tools, CVCs
can expose critically ill patients to the risk
of central line-associated bloodstream
infections. In conjunction with the
increasing use of central venous catheters
(CVC) among critically ill patients, the
occurrence of central line-associated
bloodstream infections (CLABSI) is
increasing. Recent studies have shown that
this serious complication could result in
increasing mortality, morbidity and hospital
stay [2],CLABSI is one of the common and
preventable Health care associated
infections (HAIs) [3] . Despite the fact that
CLABSIs are largely preventable [4]
.CLABSI occur due to breaches in sterile
technique while insertion of the catheter or
during maintenance of the catheter [5].
Physicians and nurses are responsible for
the insertion and maintenance of central
lines. Reducing CLABSI incidence will not
only improve patient outcome but also
reduce ALOS in ICU. Efforts to reduce and
eliminate such infections over the past years
have been successful by applying evidence-
based guidelines.
Several studies have shown reduction of
CLABSI rates after the utilization of central
line insertion and maintenance bundle [6] .
that simple interventions such as hand
hygiene, maximal sterile barriers during
catheter insertion, Chlorhexidine skin
disinfection, optimal catheter site selection,
scrub the hub practices and daily review of
line necessity with prompt removal of
unnecessary lines can decrease the risk of
CLABSIs. These studies showed that the
staff was aware of the bundles, but they
lacked adherence and application to these
practices [7].
Several educational interventions such as
training program have been organized with
the aim to reduce CLABSI rates. The
present systematic review examines the
impact of educational interventions on
Sumathi Ardhalapudi et.al. Impact of training on central line associated blood stream infection maintenance
bundle on central line associated blood stream infection rates - a retro prospective study in a selected hospital,
Hyderabad.
International Journal of Science and Healthcare Research (www.ijshr.com) 406
Vol.7; Issue: 2; April-June 2022
CLABSI rates in ICUs and wards [8]. The
association between effectiveness and
several characteristics of educational
programs on maintenance bundle was
discussed. We relied that educational
interventions will have a positive effect on
the prevention of CLABSI rates.
METHODS
This is a retro prospective study done in our
institute which is a 450 bedded hospital out
of which 115 are ICU beds. Baseline data
was collected retrospectively for one month
and was found that CLABSI rate was high
and then central line improvement team was
formed consisting of Infection control
officer (ICO), microbiologist and infection
control nurses. Any issues related to central
lines (CL) were escalated to this team like
presence of femoral line, unused lines, not
following aseptic precautions while
handling lines. Study continued for 6
months prospectively from July to
December 2021.
Questionnaire was prepared based on CDC
guidelines for CLABSI prevention and was
distributed to doctors and nurses in ICU and
wards from 1 July2021 to 5th July 2021. On
analysis it was found that HCWs had
knowledge on CLABSI bundle and
prevention but during audit major findings
were noncompliance to Hand hygiene and
scrub the hub. The study was conducted in
three phases.
Phase I was the pre-interventional period
done in the month of June. In this period
CLABSI rate was high which was captured
by continuous audits on maintenance bundle
components and active surveillance of
CLABSI cases among ICUs and wards.
CDC NHSN guidelines were followed for
calculating CLABSI rates. Overall bundle
compliance was 79% for the month of June
Table 1 explains the CLABSI maintenance bundle each component compliance percentage during pre intervention period (June).
Table -1
S.no
Components
Pre Intervention %
1
6 steps of hand hygiene
65
2
Dressing is changed as per protocol (7 days and when its dirty)
88
3
2% Chlorhexidine used during dressing change changed in aseptic manner
85
4
Condition of dressing (Good, Not dump,loosened,soiled)
80
5
Scrub the hub before each access
65
6
Flush the line before and after (Tubing’s clear of blood and drugs)
88
7
Daily review of line necessity, with prompt removal of unnecessary lines
80
Phase II was the intervention period lasting
from July 21 to August 21.
Questions were prepared based on CDC
/NHSN guidelines Jan 2021. Objective
questions were prepared and test was
conducted to 489 Registered nurses and 10
intensivists and 15 ward doctors Training
programme was created by ICT. Education
material was taken from WHO 2009
guidelines for hand hygiene and CDC
NHSN and guidelines on CLBSI bundles
Jan 2021 and IHI guidelines on central line
2021.
During this period, the entire nursing staff
and doctors working in ICUs and Wards
underwent a continuous teaching and
training course. Department wise bed side
training was conducted by ICT on
maintenance bundle and class room sessions
were conducted.
The training included educational teaching
in the form of lectures and training as
practical demonstration on hand hygiene.
Alcohol disinfection of the scrub “before
and after” each access was emphasized. In
house Online HAI tracking sheet was
introduced. Ward line team was formed and
justification for femoral line usage (more
than 5 days in place) to be documented by
primary team, one on one discussions with
primary consultant for early removal of
central lines, daily visit by ICNs those who
Sumathi Ardhalapudi et.al. Impact of training on central line associated blood stream infection maintenance
bundle on central line associated blood stream infection rates - a retro prospective study in a selected hospital,
Hyderabad.
International Journal of Science and Healthcare Research (www.ijshr.com) 407
Vol.7; Issue: 2; April-June 2022
were on central lines and Continuous
surveillance of CLABSI cases was
monitored by the ICNs as per the standard
protocol of CDC/NHSN for all the patients
admitted to the ICUs and wards.
Phase III was the post-intervention period
conducted from September 2021 to
December 2021. After completion of
training, we selected two link nurses from
each department to monitor the compliance
of hand hygiene practices and central-line
hub care by the healthcare workers.
Repeat questionnaire was given to the
trained staff to see for improvement in
awareness of CLABSLI bundles. (Once in
September and once in December 2021).
Simultaneously, data was collected on
CLABSI rates, Patient days, central-line
days, and, compliance with maintenance
bundles.
The CLABSI rate and device utilization
ratios per 1,000 patient days were calculated
using the following formulas:
CLABSI Rate
Total number of CLABSI/Total number of
central-line catheter day’s × 1000
Device Utilization Ratio (DUR)
Number of central-line catheter days/Total
number of patient days
RESULTS
A total 489 Registered nurses and 10
intensivists and 15 ward doctors were
included in the current study. Knowledge
assessment was done by using structured
questionnaire.
Table -2 shows the Rates before structured
training program (June-2021) and Rates
after implementation of structured training
program and maintenance bundle awareness
(July 2021-December 2021) this study was
conducted for 6 months. During this period
we collected data on how many patients on
central lines and central line days from
ICUs and wards. Audits done on CLABSI
maintenance bundle in the wards and ICUs
and compared the CLABSI rates.
Table -2
Rates before structured
training program (June-2021)
Rates after implementation of structured training program and
Maintenance bundle awareness (July 2021-December 2021)
Infection control parameters
Jun-21
Jul-21
Aug-21
Sep-21
Oct-21
Nov-21
Dec-21
Central line patients
350
283
186
192
162
150
147
Central line days
1890
1173
811
756
776
628
709
CLABSI Trend in DD
17.2
14.1
16.1
10.4
6.1
0
6.8
CLBSI Bundle Maintenance
compliance
79%
85%
88%
91%
95%
97%
99%
In phase I CLBSI rate was 17.2 and bundle
compliance was 79%, in phase II that is
during training period bundle compliance
was around 85% and CLBSI rate reduced to
16.1% and in phase III bundle compliance
rate increased to 99% and rate reduced to
6.8.
Table 3 shows the Socio demographic data
Questionnaire was distributed to 514 health
care workers in ICU and wards out of which
94.2 % were female, 5.8% were males.
Experience wise less than 1 year 31.1%,1-2
years 26.3%,2-3 years 17.1%,3-5years
15.2%,>5 years 10.3%.
Majority of the participants were B.SC
nursing (75.9%), GNM nursing were
(19.1%) and MBBS (5.1%). Majority of
participants were working as a staff nurse
(95%) and remaining 5% were doctors.
Number of participants from ward were
54.3% and ICU were 45.7
Sumathi Ardhalapudi et.al. Impact of training on central line associated blood stream infection maintenance
bundle on central line associated blood stream infection rates - a retro prospective study in a selected hospital,
Hyderabad.
International Journal of Science and Healthcare Research (www.ijshr.com) 408
Vol.7; Issue: 2; April-June 2022
Table-3
Assessing the knowledge of health care workers by demographic General characteristic of study population
Variables
Categories
%
Education
GNM
19.1
BSC
75.9
MBBS
5.1
Area
Ward
54.3
ICU
45.7
Gender
Male
5.8
Female
94.2
Experience
<1
31.1
1y-2y
26.3
2y-3y
17.1
3y-5y
15.2
>5
10.3
Table –4 shows Variations in superscripts indicate significance of mean differences across
experience groups ,<1 year 159 staff,1-3 years 224 staff,>3 years 131 staff total assessment
done for 514 , it’s a significant difference in experience wise knowledge >3 years experience
staff have good knowledge than <1 year and 1-3years staff.
Table-4 Mean ± SD values of knowledge assessment by experience at baseline
Experience
N
Knowledge
F'
P Value
<1
159
a5.0 ± 0.16
1y-3y
224
b7.0 ± 0.13
1804.3
0
>3
131
c7.2 ±0.66
Total
514
6.4 ± 1.01
Table –5 Shows that in Pre intervention period ICU Staff had 70% knowledge and ward staff
had 59% knowledge, in post intervention period observed that ICU staff had 100%
knowledge and ward staff had 98% knowledge. ICU staff had good knowledge when
compared to ward staff.
Table-6 Demonstrates the knowledge level done three times during study period. In
September 2021 mean knowledge score was significantly higher (9.1) than in June (6.4)
similarly December score (9.9) significantly higher than June and September.
Table-6 Mean ± SD values of knowledge assessment by time
S.no
N
Jun-21
Sep-21
Dec-21
Paired 't' value
p value
1
514
6.4± 1.01
9.1± 0.51
74.6
0.001
2
514
6.4± 1.01
9.9± 0.25
84.3
0.001
3
514
9.1± 0.51
9.9± 0.25
45.2
0.001
Statistical Analysis
Figure 1 shows the paired t-test was applied to determine the difference between the mean of
various observations in the pre and post intervention period with 95% confidence interval, the
difference in the knowledge level and CLABSI rate in the pre and post intervention period
was found significant(p<0.001)
Table -5 Mean ± SD values of knowledge assessment Different times and areas
Time
Area
N
Knowledge
t'value
p value
Jun-21
Ward
279
5.9± 1.13
14.77
0.001
ICU
235
7.0± 0.25
15.97
0.001
Sep-21
Ward
279
8.99± 0.5
4.2
0.001
ICU
235
9.18± 0.38
4.3
0.001
Dec-21
Ward
279
9.88± 0.3
5.7
0.001
ICU
235
10± 0.0
6.2
0.001
Sumathi Ardhalapudi et.al. Impact of training on central line associated blood stream infection maintenance
bundle on central line associated blood stream infection rates - a retro prospective study in a selected hospital,
Hyderabad.
International Journal of Science and Healthcare Research (www.ijshr.com) 409
Vol.7; Issue: 2; April-June 2022
Figure-1
Figure-2: During and Post interventions Audit Compliance
Figure 2 shows the significant improvement
in bundle compliance as Comparing the pre-
and post-intervention period as shown in
Table -1. Pre intervention period overall
bundle compliance was 79%. Figure 2
shows that audit compliance increased data
Sumathi Ardhalapudi et.al. Impact of training on central line associated blood stream infection maintenance
bundle on central line associated blood stream infection rates - a retro prospective study in a selected hospital,
Hyderabad.
International Journal of Science and Healthcare Research (www.ijshr.com) 410
Vol.7; Issue: 2; April-June 2022
from July to December 2021. It was found
that the knowledge and practice of hand
hygiene and scrub the hub practices had
been drastically increased and primary team
was involved in early removal of lines and
checking for line necessity .There was
significant decrease in the CLABSI rate.
DISCUSSION
The initiative remains very effective in
identifying the gaps in the knowledge as
well as easy to implement in routine
practice. In the current study, we realized
that important of central-line maintenance
bundle components such as the hand
hygiene practice and catheter hub cleaning
while accessing line and keeping the line for
prolonged period for easy access were
practiced more compared to other
components.
Hence, we emphasized to strengthen these
components and evaluated the role of
continuous teaching and training tool on
reduction of the CLABSI. This shows that
there was a definite gap in the knowledge
and practice toward the hand hygiene and
catheter hub care, and prompt removal of
line which led to increased CLABSI. In this
study, data related to DAI (Device
associated infections) collected and the
patients followed up after being shifted from
ICU to other patient care area(Wards). Our
study showed that small initiative helps to
find out the exact gaps in the knowledge and
implementation.
CONCLUSION
Our study highlighted the key strategies,
which were identified as neglected and
targeted for intervention. Continuous
teaching and training about why, when,
where and how breaches may happen and
identifying the opportunities for correcting
them improves the practices among the
nursing staff and doctors. Assessing the
awareness on infection control practices
gives a positive reinforcement for better
acceptance of the bundle practices.
Acknowledgement: None
Source of funding: None
Ethical approval: Approved
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Sumathi Ardhalapudi et.al. Impact of training on central line associated blood stream infection maintenance
bundle on central line associated blood stream infection rates - a retro prospective study in a selected hospital,
Hyderabad.
International Journal of Science and Healthcare Research (www.ijshr.com) 411
Vol.7; Issue: 2; April-June 2022
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How to cite this article: Sumathi Ardhalapudi,
Ratna Mani, Pravalitha. K. et.al. Impact of
training on central line associated blood stream
infection maintenance bundle on central line
associated blood stream infection rates - a retro
prospective study in a selected hospital,
Hyderabad. International Journal of Science &
Healthcare Research. 2022; 7(2): 404-411.
DOI: https://doi.org/10.52403/ijshr.20220457
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