What Was Done?
Identification of Problem
Central line-associated bloodstream infections (CLABSIs) are a potentially preventable cause of morbidity and mortality; and treatment of CLABSI is associated with increased health care costs. Risk factors for development of CLABSI are multifactorial and include: extended length of stay, patients' acuity, immune-compromised conditions, surgery, and central line maintenance procedures. To assess how an organization is performing with regard to CLABSI, the National Healthcare Safety Network's (NHSN) standardized infection ratio (SIR) can be used. SIR is a statistic that compares the number of healthcare-associated infections (HAIs) observed at a hospital to the predicted number of infections. The predicted number is based on national baseline data and is risk-adjusted to account for factors like the severity of patients being treated at the hospital. The SIR is calculated by dividing the number of observed HAIs by the number of predicted HAIs. CMS (Centers for Medicare and Medicaid Services’) and Leapfrog both use the NHSN SIR (National Healthcare Safety Network, Standardized Infection Ratio) in their calculations for scoring. CLABISs are one of 15 hospital acquired conditions (HAC) that are used to calculate and rank hospitals. CMS then reduces the payments of hospitals with a Total HAC Score greater than the 75th percentile of all total HAC Scores (the worst-performing quartile) by 1 percent.
At UAMS our SIR for 2023 was 1.364, with a total SIR for all inpatient units of 1.028, where SIR > 1.0 indicates that more HAI were observed than predicted. This represents an actual number of CLABSIs for CMS reportable units of 32, and 52 over all inpatient units. For the financial year 2025, our UAMS target has been calculated based on an expected SIR of 0.5, which would mean a target of 31 CLABSIs over all inpatient units, and ideally less. We therefore need to achieve a 50% reduction in CLABSIs.
There are already local Interventions underway to address this issue. For example, since July 2023, our infection prevention team through central line audits have been tracking central lines placement and maintenance. Sixteen percent of all central lines were deemed to be difficult to care for: 41% of those difficult to care for lines were due to placement factors (location, insertion, suturing, etc.). Key to improving the rate of CLABSI at UAMS is education to address the indications, placement and care of these lines.
Specific Aims to Solve It
Our aim is to implement low cost, sustainable tabletop simulation-based UAMS-specific educational program for all individuals who place central lines, in addition to those healthcare professionals who participate in this process. This work therefore impacts all patients with a central line and all providers who place or care for them. We also seek to educate the educators by training faculty to teach in a standardized way that addresses the issues contributing to our excess CLABSI. The overarching aim is to reduce local CLABSI rates in our patients through a simulation educational tool that can be tailored for any institution, with subject matter adaption determined by local root cause analysis and needs assessment.
How Simulation Is Part of the Solution
Based on local problem identification, general and targeted needs assessment we have developed a simulation education program for learners involved in central line placement and care. The Interprofessional learners include ICU nurses, ICU APRNs, internal medicine faculty and residents, anesthesia faculty and residents and general surgery faculty and residents. The volume of learners is high and, with any Interprofessional simulation education, disruption to clinical care should be minimized. With this in mind we have created a low cost, tabletop simulation that is delivered by Interprofessional faculty at the point of clinical care (in seminar rooms on the ICUs).
General and targeted needs assessment revealed five key areas on root cause analysis that contributed most to local CLABSI rates. These were – inappropriate indication/length of indwelling – issues with blood culture procedures and technique – issues with central line site care – issues with aseptic technique and –miscellaneous issues (including body habitus, body hair, line bleeding/oozing, immunocompromised patients).
Learning objectives were developed, to align with the root causes identified, by an Interprofessional educator team comprising of nurses, quality officers, surgeons, anesthesiologists, and a surgical simulation educator.
Educational strategies were discussed, aligned with the identified need for low cost, accessible simulation that could be delivered quickly and at the point of clinical care in order to cause least disruption to clinical services as Interprofessional learner teams participated.
Tabletop simulations have been traditionally used to stimulate critical thinking, decision making and teamwork in a variety of scenarios such as large-scale disasters, and infrequent system wide organizational issues. Tabletop simulations addressing central line education have not been described in the published literature however were identified by our team as a feasible, accessible way to provide education with the goal of reducing CLABSI infection rates as quickly as possible through education on current policies and targeted to current issues.
The tabletop simulation involves a simulated “central line ward round”. The Interprofessional learner groups (maximum 5-6 learners) participate in the simulation, led by a trained faculty member, in the ICU in which they all work together. The session begins with a brief in which the rationale for the education is described, the expectations for the session set and the learning objectives discussed. The learners then progress through five stations simulating five stops on the central line ward round. Each station has a clinical scenario based around one of the five issues contributing to CLABSI locally as per root cause analysis. The stations have a range of teaching modalities and include clinical scenarios with discussion points, clinical scenarios with skills practice (e.g., taking blood cultures peripherally and from a central line, central line care), and, for the miscellaneous station, a jeopardy style game board station. Upon completion of the central line ward round, the debrief is led by a trained facilitator and learners asked to reflect upon their actions, and teamwork.
What Is the Intended Outcome?
The intended outcome is to reduce local CLABSI rates. Learner evaluation of the event is completed on the day of the tabletop simulation and again six months after completion. The survey involves utilization of the Interprofessional Collaborative Competencies Attainment Survey (ICCAS) before and after the learning event, and the utility of the education to their daily clinical practice. The local, robust methods of data collection regarding CLABSI incidence will allow correlation of CLABSI rates with learner progression through the tabletop simulation and establish efficacy of the program.
How Is Hospital Leadership Engaged and/or Notified?
Throughout all stages of the development of this activity, the educational team has engaged with hospital leadership. For example, the regular organizational quality improvement meetings (QUEST) discuss issues and updates related to the local CLABSI rates. The CLABSI educational sub-committee also meets regularly to discuss and implement educational initiatives targeted at reducing CLABSI rates. Members of hospital leadership are present and involved in these committees.
This educational initiative has leadership support as it is directly aligned with the strategic mission of UAMS, Vision 2029, which emphasizes patient safety, interprofessional education and active learning.
Specifically, Dr Thea Rosenbaum is involved and actively engaged in all of these endeavors. She is an active member of this educational planning team for the tabletop simulation, and key sponsor of the event. Dr. Rosenbaum is a board-certified anesthesiologist and Professor of Anesthesiology at UAMS. She currently serves as a Chief Clinical Transformation Officer (CCTO) of UAMS Health and is a member of the UAMS Health executive team. Dr. Rosenbaum continues to serve as an Associate Chief Clinical Officer for Patient Safety and as a clinical anesthesiologist. As CCTO, she is responsible for driving care model redesign strategies for UAMS Health, encompassing all aspects of clinical quality, patient safety, clinical effectiveness, and efficiency. She develops strategic initiatives to support clinical excellence, expansion of the clinical footprint and enhance the population health of the state. In addition, she leads organization-wide initiatives to achieve the safest, highest quality, and most cost-efficient levels of patient care.
