Efforts to improve education, increase auditing, standardize procedures and adopt an interdisciplinary approach have led to improved outcomes for hospital-acquired infections (HAIs). Measurable progress has been made in reducing CAUTIs (catheter-associated urinary tract infections) and CLABSIs (central line-associated bloodstream infections). Both are among the leading causes of hospital-acquired infections.
CAUTI outcomes
The number of CAUTIs has steadily declined since 2021, during which there were 75 cases systemwide, says Maninder (Mandy) Jasdhaul, MSN, RN, ACNS-BC, a clinical nurse specialist at UCLA Santa Monica Medical Center and a mentor on the Evidence-Based Practice Council.
Jasdhaul, along with Geronimo (Gerry) v, MSN, RN, CWOCN, a clinical nurse manager, facilitates a monthly Improving Patient Outcomes class, which nurses must attend once a year. She highlights some of the measures that have been effective in reducing CAUTIs:
Introduced an interdisciplinary mini-root-cause analysis for CAUTI events that includes physicians. Currently, there is 78% involvement from physicians
Built additional features into the system that require physicians to select the appropriate indications to ensure unnecessary catheters are not added to the patient; there is a 3%-to-7% increased risk of infection for each day a Foley catheter stays in place
- Improved hygiene to ensure patients with a catheter get perineal care and Foley care during every shift
- Increased the number of nurses inserting the Foley catheter to two
- Created a report to track the number of Foley catheters, Foley catheter days, and compliance with perineal and Foley care
- Worked with unit leadership on infection-prevention/quality-improvement projects
- Collaborated with IT, physicians and infectious disease experts to drive meaningful changes in catheter care
- Improved dialogue between nurses and physicians, empowering nurses to advocate for their patients
| Year | CAUTIs | CAUTI Rate | CAUTI SIR | % IMPROVEMENT |
|---|---|---|---|---|
| FY2021 | 75 | 2.02 | 1.31 | 18% |
| FY2022 | 56 | 1.52 | 0.98 | -58% |
| FY2023 | 53 | 1.50 | .097 | -2% |
| FY2024 | 42 | 1.15 | .076 | -23% |
Source: Maninder (Mandy) Jasdhaul
CLABSI outcomes
There has also been a reduction in CLABSI events, most notably in two units: 5 Merle Norman (5MN) Pavilion Intermediate Care Unit at UCLA Santa Monica Medical Center and 5 West, an acute pediatric medical/surgical unit within UCLA Mattel Children’s Hospital.
“It is a definite priority for our hospital to identify when there’s a CLABSI,” says Susan Polka, MSN, RN, CNS, CCRN, a clinical nurse specialist and subject-matter expert in preventing central line infections. “We work with our infection prevention department on each CLABSI event to address opportunities to prevent further infections, and to identify trends we’re seeing. We do this on both a systemwide and unit level.”
Education and monitoring
After a year of no central line infections, 5MN saw an increase in 2022 and 2023. At the beginning of the 2023 fiscal year, efforts around education and monitoring were reinvigorated, led by Claire Dauis, RN, a staff nurse on the unit, and Mary Lawanson-Nichols, MSN, RN, CNS, NP, CCRN, a clinical nurse specialist for the unit. Literature was reviewed and shared with colleagues through huddle messages and educational signage. Dauis was also instrumental in a project called Stop the Bleeding Lines, which researched, trialed and implemented two products that would help control bleeding around catheter insertion sites.
“That’s important because bodily fluids found around the insertion site can increase infection,” Polka explains. “And some studies have shown that the more times you change a dressing — the more you expose the site — the greater the risk of infection.”
“The product trial resulted in a decrease in the total number of dressing changes,” Polka says. After a successful trial, 5MN implemented two products for all patients with central line site bleeding. They are now being tested in other patient populations, with the potential for systemwide incorporation.
Additional work included:
- Daily rounding and visualizing central line sites
- Collaboration with physicians to assess the need to send blood cultures from peripheral lines rather than central lines
- Ensuring dialysis nurses are following proper protocols for dressing changes of dialysis catheters
5MN has now been CLABSI-free for more than a year.
Auditing high-risk patients
The 5 West unit at Mattel saw similar success with its CLABSI-reduction efforts. Patterned after processes started in the pediatric ICU and modified to fit criteria in 5West, the unit began ADM (active daily management) audits in winter 2022 — surveying the highest-risk patients for dressing changes and central line care.
High-risk criteria included:
- High stool, urine, emesis output; frequent dressing changes; immunocompromised patients requiring TPA; patients refusing care; patients with frequent readmissions; patients with a history of CLABSI; and behavioral risk factors
For those patients, prevention measures included:
- Hypervigilance with bundle compliance and automatic inclusion in ADM rounds
- Daily discussions of the need for the line highlighted in IDR rounds – MD involvement in discussion of need regarding removal and replacement&
- >A core group of RNs complete CVC line audits by assessing, visualizing and monitoring central line dressing status
- Consistently coach bedside RNs with dressing changes as needed and note gaps of care that indicate the need for further education or follow-up by the leadership team
- This core group also takes the lead in escalating to the MD team with discussions regarding line necessity or concerns
- CNMs track all high-risk patients three times a week
“We’ve worked with the entire interdisciplinary team, which includes physicians, infection-prevention specialists, respiratory therapists and environmental services, to ensure that we’re doing all the right things,” says Grace Sund, MSN, RN, CPNP, CPHON, CNS, a clinical nurse specialist in pediatrics.
The hard work paid off: 5West had seven consecutive CLABSI-free months. In May, unit leaders presented their work at the annual Solutions for Patient Safety Conference. “I think that it’s really good to get some national recognition for the hard work this unit’s been doing,” Sund says.
Polka agrees. “I think pediatrics has done an amazing job identifying the increase in central line infections, working with interdisciplinary teams, and doing focused interventions. Their experience shows that it can really make an impact on patient safety.”
