Presentation at an evidence-based practice conference describing research that confirmed the central line bundle data as a measure of a healthcare intervention

1. Confirmation of the Validity of the
Central-line Bundle as a Measure
of a Healthcare Intervention
Heather M. Gilmartin PhD, NP, CIC
Post-doctoral Nurse Fellow
Denver/Seattle Center of Innovation – Department of Veterans Affairs
Karen Sousa, PhD, RN, FAAN
Professor and Associate Dean of Research and Extramural Affairs
University of Colorado, Anschutz
College of Nursing
Disclaimer: The contents of this presentation do not represent the views of the
Department of Veterans Affairs or the United States Government.

2. Objectives
1. Define the central line (CL) bundle and
the influence of organizational context on
healthcare interventions and outcomes
2. Discuss the methods to test and confirm
the CL bundle as a latent variable model

3. What is a Central-line (CL)?
• Long, thin tube placed
in a vein that ends near
your heart
• Fluids, medications,
blood products,
monitoring, lab draws
• Used for critical
patients or those who
require long-term
medications

4. Central-line Associated Bloodstream
Infections (CLABSIs)
• The risk of CLABSIs in intensive care units
are high (Klevens et al., 2007)
– 31,000 estimated deaths per year
– $18,000 mean attributable cost per CLABSI
• Extended hospitalization
• Greater risk for other complications
• Loss of trust in healthcare system

5. IHI CL Bundle
 Perform hand hygiene prior to catheter insertion
 Use maximum sterile barrier precautions during
insertion
 Use alcoholic chlorhexidine (CHG) antiseptic for
skin preparation
 Avoid use of femoral vein when possible
 Assess need for CL daily, remove nonessential
catheters
http://www.ihi.org/resources/Pages/Changes/ImplementtheCentralLineBundle.aspx

6. CL Bundle Program
• Michigan Keystone Project:
– 66% reduction in CLABSIs for participating
ICUs (Pronovost et al., 2006)
– Reductions maintained 10 years after initial
study (Pronovost et al., 2015)
• Findings replicated in multiple settings
• Standard of practice for intensive care
units (Marschall et al., 2014)

7. Intervention Outcome
CL Bundle = Zero CLABSIs

8. Reality Check
Organizations report programs are hard to
fully implement and sustain
(Dixon-Woods et al., 2011)
“Popular accounts of CL bundle program have
often been simplistic and partial, perpetuating
the myth that the program’s achievements
can be traced to a “simple checklist” rather
than a complex social intervention” (Bosk et al., 2009)

9. Clinical Example
• Mr. Jones requires a CL for medication and cardiac
monitoring
• Ideal situation:
– Surgical team present and all equipment at bedside
– ICU nurse available to assist/monitor procedure
– Hand hygiene performed
– All staff don gloves/gown/mask/hat/eye protection
– Patient prepped with barrier precautions and CHG
– All others in room wearing a mask
– Subclavian vein is chosen
– Time out performed
– Line placed successfully

10. Equipment not
standardized and
easy to access
Nurses not
included in
rounds
“Check the box”
culture
RN not
comfortable
speaking up
Maximum barrier
precautions viewed
as ridiculous
Little
accountability to
safety processes
No policy
No training
What are the Challenges?
No belief in
“Time Out”

11. Organizational Context
• Organizational culture:
– Perceived values and roles
• Organizational climate:
– Practices and procedures
• Work environment:
– Teamwork, leadership, communication, resources
• Structural characteristics:
– Hospital size, teaching status, level of technology

12. Understanding how and why programs work, not
simply whether they work,
is crucial
(Dixon-Woods et al., 2011)
Intervention Outcome
Context

13. Learning Objective #2
• Discuss the methods to test and confirm
the CL bundle as a latent variable model
Intervention Outcome
Context

14. Methods
Sample:
• Prevention of Nosocomial Infection and Cost-effectiveness-
Refined (PNICER) Study (Stone et al., 2014)
• 614 U.S. hospitals reporting to NHSN
Methods:
• Secondary analysis using latent variable modeling
• Sample randomly split for exploration/confirmation
Variables:
• CL bundle = healthcare intervention
• CLABSI = outcome
• Context = work environment + climate instruments

15. Factor Analysis
• Multivariate statistical procedure
• Tests how well measured variables represent
the number of constructs
• Exploratory Factor Analysis:
– Data explored for number of factors to represent the
data
• Confirmatory Factor Analysis:
– Number of factors specified
– Confirms or rejects the theory

16. Exploratory Factor Analysis
Item Component 1
Factor Loading
Hand Hygiene .950
Max Barrier .957
CHG .941
Optimal Site .898
Daily Check .823
Component Table Matrix
Explained variance 61.21%
Cronbach's alpha = .84

17. Confirmatory Factor Analysis
Es mator: WLSMV
Chi-sq (5) = 7.15
P <.21
RMSEA = .04
CFI = .99
Healthcare
Interven on
HH
MAX
CHG
OPS
DAILY
.95
.94
.99
.81
.61
.11
.12
.01
.35
.37
.89

18. Implications for Research
Intervention Outcome
Context

19. Implications for Practice
• The CL bundle is more than just a
checklist
• Contextual factors need to be considered
• Investigate your environment – what are
your barriers?

20. Future Research
• Expand theory to other health outcomes
– Other healthcare-associated infections
– Falls/pressure ulcers
– Medication errors
• Validation of existing contextual data sources
to diagnose a units readiness to implement a
new patient safety initiative
– Annual Organizational Culture Survey
– AHRQ Annual Patient Safety Culture Survey
– Nurse Satisfaction Survey

21. Acknowledgements
• The authors would like to thank Dr. Pat
Stone for use of the P-NICER data for
secondary analysis, and the Infection
Preventionists who responded to the
survey.
• Funding for the P-NICER study was
provided by the National Institute of
Nursing Research (R01NR010107).

22. References
• Bate, P. (2014). Context is everything. In J. R. Bamber (Ed.), Perspectives on context: A selection of essays considering the
role of context in successful quality improvement (pp. 1-30). London, England: Health Foundation.
• Bosk, C.L., Dixon-Woods, M., Goeschel, C. A., & Pronovost, P.J. (2009). Reality check for checklists. The Lancet,
374(9688), 444-445.
• Dixon-Woods, M., Bosk, C.L., Aveling, E.L., Goeschel, C.A., & Pronovost, P.J. (2011). Explaining Michigan: Developing an
ex post theory of a quality improvement program. Milbank Quarterly, 89(2), 167-205. doi:
http://dx.doi.org/10.1111/j.1468-0009.2011.00625.x
• Furuya, E.Y., Dick, A., Perencevich, E.N., Pogorzelska, M., Goldmann, D., & Stone, P. (2011). Central line bundle
implementation in US intensive care units and impact on bloodstream infections. PLoS ONE [Electronic Resource], 6(1),
1-6. doi: http://dx.doi.org/10.1371/journal.pone.0015452
• Klevens, R.M., Edwards, J.R., Richards, C.L., Horan, T., Gaynes, R.P., Pollock, D.A., & Cardo, D.M. (2002). Estimating
healthcare-associated infections and deaths in US hospitals, 2002. Public Health Reports, 122, 160-166.
• Marschall, J., Mermel, L.A., Fakih, M., Hadaway, L., Kallen, A., O'Grady, N.P., . . . Yokoe, D.S. (2014). Strategies to prevent
central line–associated bloodstream infections in acute care hospitals: 2014 pdate. Infection Control and Hospital
Epidemiology, 35(7), 753-771. doi: 10.1086/676533
• Mitchell, P.H., Ferketich, S. , Jennings, B.M., & Care, American Academy of Nursing Expert Panel on Quality Health.
(1998). Quality health outcomes model. Image - the Journal of Nursing Scholarship, 30(1), 43-46. doi:
http://dx.doi.org/10.1111/j.1547-5069.1998.tb01234.x
• Pronovost, P., Goeschel, C.A., Colantuoni, E., Watson, S., Lubomski, L.H., Berenholtz, S., . . . Needham, D. (2010).
Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: Observational study.
British Medical Journal, 340(c309), 1-6. doi: http://dx.doi.org/10.1136/bmj.c309
• Stone, P., Pogorzelska-Maziarz, M., Herzig, C.T., Weiner, L.M., Furuya, E.Y., Dick, A., & Larson, E. (2014). State of infection
prevention in US hospitals enrolled in the National Health and Safety Network. American Journal of Infection Control,
42(2), 94-99. doi: http://dx.doi.org/10.1016/j.ajic.2013.10.003

23. Thank you
Questions?