Changing Disinfecting Cap Protocol: A CLABSI Reduction Initiative

Central Line-Associated Bloodstream Infections (CLABSIs) cause an increased risk of mortality and cost to patients and hospitals. Short-staffing, non-compliance, and inadequate training are all possible contributing factors to an increase in CLABSIs. Antiseptic barrier caps are a possible preventative measure impregnated with 70% isopropyl alcohol. These caps are meant to cover needleless injection ports and keep them clean and protected. There is evidence showing a reduction in CLABSIs with these caps. However, more research is needed. Local Problem:Throughout the United States, CLABSI rates have increased. The COVID-19 pandemic saw an increase of over 50% in CLABSIs. At the site where this project took place, CLABSI rates have increased by 75% in the last six years, from 21 to 28 infections. Methods: The project manager created a pre-survey to assess current practices and readiness for change. Then, an in-service was completed, where nurses were individually given a demonstration, explanation, and teach-back. Observations were made after implementation to assess compliance, and after three months of this implementation, a post-survey was distributed to assess usability and satisfaction. The practice implementation was described as taking off the disinfecting cap, scrubbing the hub of the needleless injection port for five to fifteen seconds, and then connecting any medication or infusion. Once the medication or infusion is completed, disconnect it and scrub the hub for five to fifteen seconds with a new alcohol swab. Once it has dried, a new disinfecting cap may be applied. Observations of drug administrations were completed to assess compliance. At the end of the project period, nurses were given a post- survey to evaluate current practice and assess for any change in practice and knowledge. Interventions: The survey questions were derived using the University of Utah's IV Standards Summation and Comprehensive Management of Intravenous Catheters policy. The observation checklists were totaled to count the number of correct administrations. Results: Out of 57 nurses who participated in the project, 38 (67%) completed the pre-initiation survey, and 32 (56%) completed the post-initiation survey. Twenty-eight drug administrations were observed, with six (21%) of them performed correctly per the new protocol. No CLABSIs occurred during the project period of four months. An average of 15% increase in correct answers was seen in the education portion of the surveys. Of the nurses who completed the initial survey, 71% (27) said this project might reduce CLABSIs. However, the procedure change was inadequately followed. Conclusion: Considering low compliance rates, it is uncertain if adding a five-to fifteen- second alcohol scrub time between disinfecting cap application and removal is beneficial. Overall knowledge regarding central line care increased, indicating that in-person, frequent education on central line care may be beneficial.

1 Changing Disinfecting Cap Protocol: A CLABSI Reduction Initiative Kelsey J. Watnes, Jason Argyl, John Nerges College of Nursing: The University of Utah NURS 7703: DNP Scholarly Project III 5/1/2024 . 2 Abstract Background: Central Line-Associated Bloodstream Infections (CLABSIs) cause an increased risk of mortality and cost to patients and hospitals. Short-staffing, non-compliance, and inadequate training are all possible contributing factors to an increase in CLABSIs. Antiseptic barrier caps are a possible preventative measure impregnated with 70% isopropyl alcohol. These caps are meant to cover needleless injection ports and keep them clean and protected. There is evidence showing a reduction in CLABSIs with these caps. However, more research is needed. Local Problem:Throughout the United States, CLABSI rates have increased. The COVID-19 pandemic saw an increase of over 50% in CLABSIs. At the site where this project took place, CLABSI rates have increased by 75% in the last six years, from 21 to 28 infections. Methods: The project manager created a pre-survey to assess current practices and readiness for change. Then, an in-service was completed, where nurses were individually given a demonstration, explanation, and teach-back. Observations were made after implementation to assess compliance, and after three months of this implementation, a post-survey was distributed to assess usability and satisfaction. The practice implementation was described as taking off the disinfecting cap, scrubbing the hub of the needleless injection port for five to fifteen seconds, and then connecting any medication or infusion. Once the medication or infusion is completed, disconnect it and scrub the hub for five to fifteen seconds with a new alcohol swab. Once it has dried, a new disinfecting cap may be applied. Observations of drug administrations were completed to assess compliance. At the end of the project period, nurses were given a postsurvey to evaluate current practice and assess for any change in practice and knowledge. 3 Interventions: The survey questions were derived using the University of Utah’s IV Standards Summation and Comprehensive Management of Intravenous Catheters policy. The observation checklists were totaled to count the number of correct administrations. Results: Out of 57 nurses who participated in the project, 38 (67%) completed the pre-initiation survey, and 32 (56%) completed the post-initiation survey. Twenty-eight drug administrations were observed, with six (21%) of them performed correctly per the new protocol. No CLABSIs occurred during the project period of four months. An average of 15% increase in correct answers was seen in the education portion of the surveys. Of the nurses who completed the initial survey, 71% (27) said this project might reduce CLABSIs. However, the procedure change was inadequately followed. Conclusion: Considering low compliance rates, it is uncertain if adding a five—to fifteensecond alcohol scrub time between disinfecting cap application and removal is beneficial. Overall knowledge regarding central line care increased, indicating that in-person, frequent education on central line care may be beneficial. Keywords Central line care, antiseptic barrier cap, CLABSI, infection control, alcohol scrub 4 Changing Disinfecting Cap Protocol: A CLABSI Reduction Initiative Problem Description Central line-associated bloodstream infection (CLABSI) rates have increased 75% at the project site in the last six years. Specifically, in 2016, the project site had 21 CLABSIs in all inpatient locations (Utah Department of Health [UDH], 2016). In comparison, in 2020, there were 28 reported CLABSIs (Utah Department of Health, 2020). Preventative measures were introduced in 2019; however, additional measures are necessary. CurosTM caps, a brand of antiseptic barrier caps, were introduced within this timeframe and did not prevent this increase. During the COVID-19 pandemic, CLABSIs increased by over 50% (Fakih et al., 2021). The United States quadrupled its rates of CLABSIs between 2019 and 2020, and in Utah alone, during 2020, there were 109 CLABSIs (Thomas et al., 2022). This increase could be partly attributed to short-staffing, as nurse-to-patient ratios can predict CLABSI rates (Chovanec et al., 2021; Aloush & Alsaraireh, 2018). CLABSIs cause an increased risk of mortality by about 36.6%, an increased length of hospital stay by two days, and a 37% increased chance of readmission (Chovanec et al., 2021). A further concern involves increased resource strain and cost to hospitals (Haddadin et al., 2022). In Utah, the cost per episode of CLABSI ranges from $3,700 to $39,000 (Thomas et al., 2022). With 28 CLABSIs, this could cost an institution an average of $597,800 annually. A further concern involves non-compliance regarding the appropriate use of needleless connectors and the consistency of healthcare staff following policies and procedures. Most concerning, one observation study of 3,402 drug administrations demonstrated that 0% were done per protocol to prevent CLABSIs (Oliveira et al., 2018). Inadequate training could also be a factor in the shortfall of infection prevention, as inconsistencies in healthcare professional training can 5 increase CLABSI risk (Snyder et al., 2021). Short staffing leads to barriers in infection prevention, i.e., not restarting a Foley insertion after breaking the sterile field (Aloush & Alsaraireh, 2018; Chovanec et al., 2021). Available Knowledge Antiseptic barrier caps are impregnated with 70% isopropyl alcohol and are intended to be screwed onto needleless injection ports to keep them clean and protected. Evidence shows varied improvement in CLABSI rates with disinfecting caps, with some studies showing no improvement (Cruz-Aguilar et al., 2021) and others showing a reduction (Barton, 2019; Gillis et al., 2022; Tejada et al., 2022). More randomized controlled trials are needed to understand and confirm any benefits of disinfecting caps (Barton, 2019; Gillis et al., 2022). There is evidence that if antiseptic barrier caps are appropriately implemented, there may not be a need for additional time for an alcohol wipe scrub (Fillman et al., 2023). Historically, alcohol wipes have shown a reduction in CLABSI rates (O’Grady, 2017). Additionally, current Centers for Disease Control and Prevention (CDC) guidelines recommend accessing a needleless injection port after scrubbing with an appropriate antiseptic, including 70% isopropyl alcohol (O’Grady, 2017). Using disinfecting caps and alcohol wipes has no additional unaccounted cost for hospitals (Gillis et al., 2022; O’Connell et al., 2021). Some patient populations are at greater risk for CLABSIs and may develop worse effects from these infections (Baier et al., 2020; McGrath et al., 2023). Risk factors for CLABSIs include anemia, thrombocytopenia, and older age (Baier et al., 2020). Systemic bias and racism may also play a factor in CLABSI risk (McGrath et al., 2023; Stimpson et al., 2022). Patients who are Black or whose primary language is not English are at a higher risk for CLABSIs 6 (Stimpson et al., 2022), with Black patients almost twice as likely to obtain a CLABSI than the overall population (McGrath et al., 2023). Rational This project used the Johns Hopkins Nursing Evidenced-Based Practice (JHNEBP) model as a powerful problem-solving approach to clinical decision-making in conducting this quality improvement (QI) initiative. The JHNEBP model is comprised of three steps: 1) practice question, 2) evidence, and 3) translation (Dang et al., 2022). The practice question narrows down the focus for improvement and the surrounding circumstances that may involve this problem (Dang et al., 2022). The evidence portion is essential to explain the reasoning behind the project (Dang et al., 2022). Finally, the translation helps gather information gathered throughout the project and put it together to answer the practice question (Dang et al., 2022). The JHNEBP model disseminates information for the project to be completed systematically and is scholastically relevant (Dang et al., 2022). The practice question for this project is: For patients in an acute setting with a central line placed, does using a five to fifteen-second 70% alcohol port scrub time before and after antiseptic barrier cap placement reduce CLABSI rates? Based on this question, the literature was searched, critically appraised, and synthesized using 22 high-quality articles published within the past five years. The evidence was translated into an evidence-based practice project implemented over three months. During this time, if barriers arose, the Plan-Study-Do-Act (PDSA) cycle was used to meld them back into the practice question to see what evidence could be gathered to make rapid cycle changes. 7 Specific Aims The purpose of this Doctor of Nursing (DNP) QI project is to assess current practices for the prevention of CLABSIs and develop and implement a practice change based on evidence to improve the cleaning practices of central lines by implementing cleaning practices in between the usage of antiseptic barrier caps. Methods Context This project occurred in an acute care medical/surgical unit in a large Level 1 trauma center in the Intermountain West. This 38-bed unit cares for mainly solid organ transplant recipients with an average of nine central lines on any given day (this includes dialysis catheters, which were not included in this QI project). This unit has specific policies and procedures for caring for immunocompromised patients. A consideration for this project is the increased rate of CLABSIs in the black population and those whose primary language is not English (McGrath et al., 2023; Stimpson et al., 2022). The population of Salt Lake City, where this QI project takes place, as of 2022, includes 2.7% black or African American alone, 6.1% two or more races, and 23.6% who speak a language other than English at home (United States Census Bureau, 2022). Intervention(s) The project manager consulted with the infection preventionist for the unit in this project, the unit manager, and the unit educator. The stakeholders discussed and identified barriers to implementation. Previous practices were explored, and data regarding CLABSIs in the unit was gathered. Phase two of this project was creating a survey to assess current care practices in the unit and expectations regarding how effective the project would be. This survey also contained a quiz 8 regarding central line care. Participants completed a survey regarding current practice and knowledge (Appendix A). Each RN on the unit received an in-service that included a demonstration, explanation, and teach-back. This in-service was a short presentation given individually to each nurse that included demonstration. After the in-service, the RNs were asked to complete the survey to the best of their ability. The project manager created a poster board with current information regarding the evidence backing the project and information on the practice implementation. The practice implementation was described as taking off the CurosTM cap, scrubbing the hub of the needleless injection port for five to fifteen seconds, and then connecting any medication or infusion. Once the medication or infusion is completed, disconnect it and scrub the hub for five to fifteen seconds with a new alcohol swab. Once it has dried, a new CurosTM cap may be applied. Part three of this project involved implementing the practice change. Dialysis catheters were not included in this project as they have a different cleaning process. The project manager set up a poster board for reference, including the information given during the in-service and evidence to support the project. The project team provided information from the surveys and rationales to the staff. Observation checklists were given to charge nurses and orient RNs to audit medication administrations done by RNs on the unit. These checklists went over the expected steps in the proecedure for medication administration and could be marked as observed or notobserved (Appendix C). The completed checklists were returned to the project lead. The author compiled the data in part four. After three months of the implementation change, the checklists were gathered, and data was extracted. Nurses were also given a postsurvey to evaluate current practice with multiple-choice questions and “select all that apply” 9 questions. This information was put together to see if there was a change in correct answers from pre-implementation to after, as well as to evaluate for self-perception of practice change. Study of the Intervention(s) This QI project used the surveys to compare the gains in knowledge by examining correct answers from the pre-survey to correct answers from the post-survey (Appendix A and B). The project lead analyzed all data from these surveys. Observation checklists were utilized to assess compliance with implementation change. If compliance was low, barriers were assessed during project implementation, and the project was altered to increase compliance. Measures The surveys were developed using the University of Utah’s IV Standards Summation and Comprehensive Management of Intravenous Catheters policy (University of Utah, 2023). Questions about central line maintenance were derived directly from a section in this policy. These surveys were mainly multiple-choice, with two select all that apply questions (Appendix A and Appendix B). The question answers were compared from the pre- and post-surveys by the number of correct answers. The observation checklists were totaled to understand how many medication administrations were done correctly according to the new protocol. Analysis The project manager compared the number of correct answers from the first and second surveys. In this way, it was better understood if the first survey’s correct answers were due to recent learning or if there was accuracy in the knowledge gained. The observation checklists do not require a statistical tool to gain inference on current practice. Instead, the checklists were marked as either completed or not-completed. The checklists were only deemed ompleted if every step was followed. However, consideration should be made of the possible interference in 10 results from those observed being aware of their observation. This potentially caused an inflated amount of correct drug administrations. Ethical Considerations This QI project was deemed exempt from University of Utah institutional review board review. No patient information was obtained during this project. The project author shared findings and data with unit leadership and DNP faculty to mitigate a possible conflict of interest. No other conflicts of interest were present. Results Out of 57 nurses who participated in the project, 38 (67%) completed the pre-initiation survey, and 32 (56%) completed the post-initiation survey. These RNs were primarily white women in their 20s with a bachelor’s degree (Table 1). In the current knowledge assessment portion of the survey, 42% of the participants answered one question correctly, and less than 40% of the participants answered every other question correctly (Table 2). All participants (100%) answered that CLABSIs are preventable, while 71% believed this project would help reduce CLABSIs. During education on this project, nurses voiced concern over added time to their daily routines, causing added stress. Twenty-eight drug administrations were observed, with six (21%) of them performed correctly per the new protocol. Four standards were measured to ensure correct administration: 1) disinfecting cap present before administration or 70% isopropyl alcohol used to clean needleless injection port for 20 seconds; 2) remove the cap after disinfection and use a a 70% isopropyl alcohol pad was used to clean needleless injection port for 5-15 seconds; 3) needleless 11 injection port was never in contact with anything other than materials necessary for medication administration; and before reapplication of disinfecting cap, 4) the needleless injection port was scrubbed with 70% isopropyl alcohol for 5-15 seconds before reapplying disinfecting cap. The most common error was not scrubbing the needleless injection port after removing disinfecting caps, correct completion of this step of 29%. No CLABSIs occurred during the project period of four months. In the post-initiation survey, there were increases in base knowledge of central line care (Table 3). Thirty-two RNs answered this survey, showing a decline from the initial survey. In general, nurses had strong opinions on the change in practice. In the post-initiation survey, the RNs were asked for feedback on the project. One RN with seven years of experience wrote, “Get rid of Curos caps. I think they’ve become a crutch and an excuse to not scrub the needleless caps”. During the education period, I heard this sentiment from multiple nurses. Discussion Summary No CLABSIs occurred during the four months the project took place. During this time, compliance was low, with 21% of observed drug administrations performed correctly per the new protocol. The overall knowledge base increased, with an average of a 15% increase in the number of correct answers to the survey questions. This project saw adequate responses to the surveys, with about the same number of people responding. Almost all of the surveys were answered to completion, with only one question not being answered out of all of them. Interpretation It is difficult to understand if the increased alcohol scrub time had any benefit to the lack of CLABSIs due to the low compliance. There could be no increase in CLABSI rates because the 12 disinfecting caps are sufficient (Fillman et al., 2023). There are a few reasons that compliance was low. When this project took place, nine nurses left the unit; ten were hired. Hired nurses did not undergo the education that occurred at the beginning of this project and may not have been educated on the new protocol, which would also influence compliance (Snyder, 2021). One reason nurses noted they were not performing the extra alcohol scrub time was that they would forget to bring the alcohol wipes with them into rooms. This unit cannot stock alcohol wipes in rooms due to infection risks between patients. The main benefit of this project may lie in the increased knowledge of how to care for central lines. With increased knowledge of how to care for them, there should be an increase in appropriate care for the lines (Beaudry & ScottoDiMaso, 2020). Intermittent education and training on caring for central lines could be beneficial. This unit has an annual training that includes central line care, primarily focusing on dressing changes instead of day-to-day care. Limitations A limitation of this project is the possibility that some of the observations may be inaccurate because the nurses performing the drug administration were aware they were being observed. Awareness of the observation could lead to higher rates of correctly performing the administration. In order to counteract this limitation, the participants were often not told that they were being observed. The survey responses needed to be improved, with 38 (67%) responses to the first survey and 32 (56%) to the second. With two-thirds of the response rate in the first survey and a little over one-half in the second, it is uncertain how well this project was accepted in this setting. Survey responses were heavily encouraged, with the project lead discussing the surveys individually with all participants and giving them a QR code with the survey. 13 It is also uncertain if the same participants who responded to the first survey responded to the second, as identifiers were not used in either survey. Different survey participants impact the understanding of whether any knowledge increase has occurred. This project was located in a unit with a largely immunocompromised population. This makes the project likely generalizable to a larger population, as this population is more likely to obtain CLABSIs. Conclusions CLABSIs have increased at the project site in the last six years (Utah Department of Health, 2020). CLABSIs are costly to hospitals and patients, increase the risk of mortality, and cause an increased length of hospital stay (Chovanec et al., 2021). The hospital's short staffing is a possible cause of this (Chovanec et al., 2021; Aloush & Alsaraich, 2018). Another contributing factor could be non-compliance with policy and procedures during drug administrations (Oliveria et al., 2018). Some patient populations are at higher risk for CLABSIs, such as immunocompromised and/or have anemia, thrombocytopenia, and older age (Baier et al., 2020). The project site is a solid organ transplant unit with specific policies and procedures for caring for immunocompromised patients. Antiseptic barrier caps are impregnated with 70% isopropyl alcohol and are intended to be screwed onto needleless injection ports to keep them clean and protected. Evidence shows reduced CLABSI rates with these disinfecting caps (Cruz-Aguilar et al., 2021). Further research is needed to fully understand the benefits of the caps (Gillis et al., 2022). This project involved adding a five to fifteen-second scrub time to needleless injection ports before and after disinfecting cap application. The JHNEBP model is a powerful problem-solving approach to clinical decision-making. The model was used to narrow down the focus for improvement, 14 explain the reasoning behind the project, and gather information throughout the project to answer the practice question. This project occurred in an acute care medical/surgical unit with a generally immunocompromised patient population. Phase one included consulting with the Infection Preventionist for the unit, who works directly with the infection prevention team in the hospital, the unit manager, and the unit educator, and gathering information and data relevant to CLABSIs on the unit. Phase two included creating a survey to assess current care practices and expectations, an in-service on the procedure change, and creating a poster board with information regarding the project. Phase three was the practice change and observing drug administrations. Lastly, phase four was a compilation and interpretation of data. Out of 57 nurses who participated in the project, 38 (67%) completed the pre-initiation survey, and 32 (56%) completed the post-initiation survey. Out of those who responded to the first survey, 100% (38) answered that CLABSIs are preventable, and 71% (27) believed this project would help reduce CLABSIs. Between the pre- and post-surveys, there was an increase in knowledge surrounding central line care. No new CLABSIs were found during the four-month project implementation period. Compliance was found to be low during the drug administration observations, with 21% (6) of them completed exactly per the new protocol. Of the nurses who completed the initial survey, 27 (71%) said this project might help reduce CLABSIs; however, the procedure change was inadequately followed. Due to the low compliance rates of this project, it is uncertain if there is any benefit to adding a five to fifteensecond alcohol scrub time between disinfecting cap application and removal. There was an increase in overall knowledge regarding central line care, which may show that in-person education on central line care may be beneficial. Increased CLABSIs may also be attributed to 15 frequent understaffing, which can lead to nurses not taking the proper precautions when it comes to central lines. It is uncertain at this time if the cause for low compliance was the frequent short staffing seen on the unit. 16 References Aloush, S. M., & Alsaraireh, F. A. (2018). Nurses’ compliance with Central Line Associated Blood Stream Infection Prevention Guidelines. 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Patient safety in nursing care during medication administration. Revista LatinoAmericana de Enfermagem, 26(0). https://doi.org/10.1590/1518-8345.2350.3017 Stimpson, M. D., Johnson, S. M., Wood, L. R., Bettinger, B., Sharek, P. J., Fryzlewicz, B., & Zerr, D. M. (2022). Confronting CLABSI disparities: The role of real variables, data transparency, and intentional process measurement in achieving equitable outcomes. Pediatric Quality & Safety, 7. https://doi.org/10.1097/pq9.0000000000000606 Snyder, R. L., White, K. A., Glowicz, J. B., Novosad, S. A., Soda, E. A., Hsu, S., Kuhar, D. T., & Cochran, R. L. (2021). Gaps in infection prevention practices for catheter-associated urinary tract infections and Central line-associated bloodstream infections as identified by the targeted assessment for prevention strategy. American Journal of Infection Control, 49(7), 874–878. https://doi.org/10.1016/j.ajic.2021.01.014 Tejada, S., Leal-dos-Santos, M., Peña-López, Y., Blot, S., Alp, E., & Rello, J. (2022). Antiseptic barrier caps in Central line-associated bloodstream infections: A systematic review and meta-analysis. European Journal of Internal Medicine, 99, 70–81. https://doi.org/10.1016/j.ejim.2022.01.040 19 Thomas, S., Clements, A., & Kammerman, J. (2022, March). Healthcare-associated infections in Utah . Healthcare associated infections in Utah. https://epi.health.utah.gov/wpcontent/uploads/2021/04/2019_HAI_Report.pdf University of Utah. IV Standards Summation and Comprehensive Management of Intravenous Catheters. Nursing clinical operations council. 2023. https://pulse.utah.edu/policies/Lists/Policies/DispForm.aspx?ID=2516 U.S Government. (2022). U.S. Census Bureau quickfacts: Salt Lake City City, Utah. United States Census Bureau. https://www.census.gov/quickfacts/fact/table/saltlakecitycityutah/PST045222 Utah department of health. (2016). Healthcare-associated infections in Utah 2016 annual report. 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National library of medicine. https://www.ncbi.nlm.nih.gov/books/NBK553048/ 20 Table 1 Socioeconomic Characteristics of Participants Characteristic Pre-initiation survey Post-initiation survey n % n % 20 or younger 0 0% 0 0% 21-30 22 58% 18 56% 31-40 6 16% 6 19% 41-50 4 11% 4 13% 51-60 6 16% 4 13% 61-70 0 0% 0 0% Male 6 16% 4 13% Female 32 84% 28 87% Non-binary 0 0% 0 0% Genderqueer 0 0% 0 0% Intersex 0 0% 0 0% Gender not 0 0% 0 0% 0 0% 0 0% Associates 10 26% 9 28% Bachelors 28 74% 23 72% Masters 0 0% 0 0% Doctoral 0 0% 0 0% Age Gender listed Prefer not to answer Highest degree completed 21 Employment status Full-time 36 97% 31 97% Part-time 1 3% 1 3% PRN or per 0 0% 0 0% 32 86% 28 88% 3 8% 3 9% 0 0% 0 Native American 0 0% 0 Asian 2 5% 1 3% Pacific Islander 0 0% 0 0% Other 0 0% 0 0% diem Race/ethnicity White/ Caucasian Hispanic/ Latino Black/ African American 22 Table 2 Central line care quiz Questions Possible answers How often should 1. When soiled dressings be changed on 2. Every 7 days central lines? (Select all 3. After 24 hours if gauze is present that apply) 4. After 48 hours if gauze is present 5. Every 5 days How often should 1. Every 4 days needleless injection ports 2. Every 7 days be changed? (select all 3. Every night that apply) 4. With TPN bag change 5. Before lab draws 6. After lab draws How long do you need to 1. 20 seconds scrub the catheter hub 2. 10 seconds with alcohol when 3. 5 seconds changing needleless 4. You do not need to scrub when changing injection caps? the needleless injection ports How often should you 1. Every 4 days change Curos caps? 2. Every time you remove one (Select all that apply) 3. With lab draws 4. With medication administrations 23 Do you believe that 1. Yes CLABSIs on this unit are 2. No preventable? 3. Unsure Do you think adding a 5- 1. Yes 15 second alcohol scrub 2. No time in between Curos 3. Unsure cap usage will help decrease the risk for CLABSIs? 24 Table 3 Comparison of correct answers on pre-initiation and post-initiation surveys Question Pre-initiation n correct Post-initiation % of total n correct answered How often should % of total answered 15 39% 19 60% 9 24% 8 25% 16 42% 21 66% dressings be changed on central lines? (Select all that apply) How often should needleless injection ports be changed? (select all that apply) How long do you need to scrub the catheter hub with alcohol when changing needleless injection caps? 25 How often should you change Curos caps? (Select all that apply) 4 11% 8 25% 26 Appendix A Pre-initiation Survey 1. What is your age? a. 20 or younger b. 21-30 c. 31-40 d. 41-50 e. 51-60 f. 61-70 2. What gender do you identify as? a. Male b. Female c. Non-binary d. Genderqueer e. Intersex f. A gender not listed here g. Prefer not to answer 3. What is the highest degree or level of school you have completed? a. Associates degree b. Bachelors degree c. Masters degree d. Doctoral degree 4. What is your current employment status? a. Full-time (0.75 FTE or above) 27 b. Part-time c. PRN or per diem 5. What race/ethnicity do you identify with? a. White/caucasian b. Hispanic/Latino c. Black / African American d. Native American e. Asian f. Pacific Islander g. Other 6. How often should dressings be changed on central lines? (Select all that apply) a. When soiled b. Every 7 days c. After 24 hours if gauze is present d. After 48 hours if gauze is present e. Every 5 days 7. How often should needleless injection ports be changed? (Select all that apply) a. Every 4 days b. Every 7 days c. Every night d. With TPN bag change e. Before lab draws f. After lab draws 28 8. How long do you need to scrub the catheter hub with alcohol when changing needleless injection caps? a. 20 seconds b. 10 seconds c. 5 seconds d. You do not need to scrub when changing the needleless injection caps 9. How often should you change Curos caps? (Select all that apply) a. Every 4 days b. Every time you remove one c. With lab draws d. With medication administrations 10. Do you believe that CLABSIs on this unit are preventable? a. Yes b. No c. Unsure 11. Do you think adding a 5-second alcohol scrub time in between Curos cap usage will help decrease the risk for CLABSIs? a. Yes b. No c. Unsure 29 Appendix B Post-initiation Survey 1. What is your age? a. 20 or younger b. 21-30 c. 31-40 d. 41-50 e. 51-60 f. 61-70 2. What gender do you identify as? a. Male b. Female c. Non-binary d. Genderqueer e. Intersex f. A gender not listed here g. Prefer not to answer 3. What is the highest degree or level of school you have completed? a. Associates degree b. Bachelors degree c. Masters degree d. Doctoral degree 4. What is your current employment status? 30 a. Full-time (0.75 FTE or above) b. Part-time c. PRN or per diem 5. What race/ethnicity do you identify with? a. White/Caucasian b. Hispanic/ Latino c. Black / African American d. Native American e. Asian f. Pacific Islander g. Other 6. How often should dressings be changed on central lines? (Select all that apply) a. When soiled b. Every 7 days c. After 24 hours if gauze is present d. After 48 hours if gauze is present e. Every 5 days 7. How often should needleless injection ports be changed? (Select all that apply) a. Every 4 days b. Every 7 days c. Every night d. With TPN bag change e. Before lab draws 31 f. After lab draws 8. How long do you need to scrub the catheter hub with alcohol when changing needleless injection ports? (Select all that apply) a. 20 seconds b. 10 seconds c. 5 seconds d. You do not need to scrub when changing the needleless injection caps 9. How often should you change Curos caps? (Select all that apply) a. Every 4 days b. Every time you remove one c. With lab draws d. With medication administrations 10. How often do you scrub the needleless injection port with alcohol before putting a Curos cap on? a. Always b. Most of the time c. Sometimes d. Rarely e. Never 11. How often do you scrub the needleless injection port after removing a Curos cap? a. Always b. Usually c. Sometimes 32 d. Rarely e. Never 12. How long are you scrubbing the needleless injection ports with alcohol after removal of a Curos cap or before application of one? a. 5 seconds b. 10 seconds c. 15 seconds d. 20 seconds e. Longer than 20 seconds f. N/A, I do not scrub the needleless injection ports with alcohol 13. Do you have any suggestions for improvement of compliance on scrubbing the needleless injection ports? 14. Do you have any comments or concerns regarding this quality improvement project? 33 Appendix C Observation Checklist 1. Curos cap present before administration? a. Yes b. No c. N/A 2. After Curos cap was removed, an alcohol prep pad was used to clean the needleless injection port for 5-15 seconds a. Yes b. No c. N/A 3. Needeless injection port was never in contact with something other than materials necessary for medication administration, Curos cap, or alcohol pad. a. Yes b. No 4. Before reapplication of Curos cap, needleless injection port was scrubbed with alcohol pad for 5-15 seconds a. Yes b. No c. N/A 5. Any additional comments or observations? 34 Appendix D Executive Summary Summary: CLABSIs have surged in the US, leading to higher mortality and costs. To combat this, a protocol was implemented involving extended scrub time with 70% isopropyl alcohol. Post-implementation, no CLABSIs were reported, but compliance was low. The COVID-19 pandemic worsened CLABSI rates by over 50%, prompting the exploration of antiseptic barrier caps, although more trials are needed for validation. Background: During the COVID-19 pandemic, CLABSIs increased by over 50%. Antiseptic barrier caps, infused with 70% isopropyl alcohol, are a new preventive measure designed to keep needleless injection ports clean and protected. Although data supports their use, more randomized controlled trials are necessary for validation. Intervention: Implemented in an acute care medical/surgical 38-bed unit at a Level 1 trauma center in the Intermountain West, the project aimed to improve central line care. Surveys, inservice sessions, and observations of drug administrations were conducted. The project was initiated due to observed soiling of needleless injection ports. Results: No CLABSIs occurred during the four-month implementation period. However, only 21% of observed drug administrations adhered to the new protocol. While there was an overall increase in central line care knowledge, some nurses criticized the reliance on Curos caps. Recommendation: There was not a high enough compliance rate for this project to understand if there was any benefit to CLABSI reduction. If alcohol swabs were more easily accessible, this may increase compliance, and this project could be repeated. Based on the data, there could be benefits from having more frequent central line education, which could also serve as CLABSI prevention. 35