Implementing the Central Venous Catheter Infection Prevention Bundle in the Emergency Department: Experiences Among Early Adopters - 14/02/14

Doi : 10.1016/j.annemergmed.2013.09.006

Christopher H. LeMaster, MD, MPH ^a,^b,^c,^⁎ , Nancy Hoffart, PhD, RN ^d, Tom Chafe, RN, BSN ^a, Ted Benzer, MD, PhD ^b,^e, Jeremiah D. Schuur, MD, MHS ^a,^e
^a Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
^b Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
^c David Geffen School of Medicine at UCLA, Department of Emergency Medicine, Los Angeles, CA
^d Alice Ramez Chagoury School of Nursing, Lebanese American University, Beirut, Lebanon
^e Harvard Medical School, Department of Medicine, Boston, MA

^∗Address for correspondence: Christopher H. LeMaster, MD, MPH.

Abstract

Study objective

Central line–associated bloodstream infections (CLABSI) cause preventable morbidity and mortality. Hospitals have reduced CLABSI by using a bundle of evidence-based infection prevention practices. Systems factors in the emergency department (ED) present unique barriers to bundle adoption, and no guidelines exist for bundle implementation. We aim to identify barriers and facilitators to central line bundle adoption in EDs.

Methods

We used a qualitative, grounded theory approach, enrolling 6 EDs that were early adopters of the central line bundle. We interviewed 49 administrators and staff (nurses and physicians) through 26 semistructured interviews and 3 focus groups of 6 to 8 individuals. Investigators read each transcript and then iteratively built and refined a set of themes that emerged from the data.

Results

Barriers to central line bundle adoption included high acuity, time constraints, staffing, space, ED culture, high ED volume and acuity, role ambiguity, and a lack of methods to track compliance and infection surveillance. Facilitators included champions, staff engagement, workflow redesign that includes a checklist and central line kit or cart, clear staff responsibilities, observer empowerment, and compliance and infection surveillance data.

Conclusion

The strategies for implementing and sustaining a central line infection prevention bundle in the ED are distinct from those of other clinical settings. Our findings describe the central line bundle workflow in the ED, staff motivations, and the critical systems factors that impede and foster its use. Knowledge of these systems factors should improve bundle adoption in the ED and thereby reduce hospital incidence of CLABSIs.

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Plan

Introduction

Background

Importance

Goals of This Investigation

Materials and Methods

Study Design

Setting and Selection of Participants

Methods of Measurement

Primary Data Analysis

Results

Limitations

Discussion

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	Supervising editors: Daniel A. Handel, MD, MPH; Judd E. Hollander, MD
	Author contributions: CHL and JDS conceived and designed the study and obtained research funding. NH and JDS supervised the development of a questionnaire, interviews, focus groups, and data analysis. CHL, TC, TB, and JDS undertook recruitment of participating centers and collected data. All authors analyzed the data. CHL drafted the article, and all authors contributed substantially to its revision. CHL managed the data, conducted the majority of this project as a resident at Harvard-Affiliated Emergency Medicine Residency Program, and then completed the analysis at UCLA. CHL takes responsibility for the paper as a whole.
	Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org/). The authors have stated that no such relationships exist. Dr. LeMaster and Dr. Schuur received support for the project by a Resident Research Grant from the Emergency Medicine Foundation. Dr. Schuur is supported by a grant (R18-HS020013) from the Agency for Healthcare Research and Quality.