Results

Participation

A total of nine States participated in the quality improvement initiative (CO, FL, HI, MA, MI, NC, NJ, SC, WI) with a total of 100 units (Figure 1), 98 percent of which were matched to their 2010 AHA annual survey.  The majority of participating units were located in general medical/surgical hospitals (96 percent) although some were located in children’s general medical/surgical facilities (4 percent).  All hospitals had 100 or more beds with the majority of participating facilities having 500 or more beds (47 percent).  Additionally, the majority of participating hospitals were teaching facilities (76 percent), had Level III obstetric units (78 percent), and were in metropolitan settings (70 percent).  On average, hospitals had 26 neonatal ICU beds (minimum, 0; maximum, 105) and 13 neonatal intermediate care beds (minimum, 0; maximum 68).

Central Lines

Central lines were classified as: peripherally inserted central catheter (PICC), umbilical artery catheter (UAC), umbilical venous catheter (UVC), Broviac (a surgically placed, tunneled central venous catheter), or "other" (all other percutaneously placed central lines). To date, 17,212 central lines have been placed (Table 2) with 16,067 of these lines having both insertion and removal dates. Lines are more frequently missing removal dates later in the project than earlier in the project (of missing line removal dates, 29.4 percent occur in August compared to 3.6 percent in January), illustrating the "real time" nature of the database system.

Table 2. Central lines placed by type

Catheter Type	N (%)
Other	185 (1.1)
Broviac	577 (3.4)
UAC	4,270 (24.8)
UVC	5,397 (31.4)
PICC	6,783 (39.4)

Approximately 90 percent of central lines were new (8 percent placed outside the unit; 2 percent were repairs or replacements of an existing line).  Of the new lines placed, the procedures followed during placement can be found in Table 3.  Most frequently, skin was prepped using povidone iodine (41.9 percent) followed by chlorhexidine (39.9 percent).  Other skin preps such as alcohol (2.7 percent), sterile water (0.34 percent) or combinations of techniques (e.g. chlorhexidine and alcohol) were infrequently used accounting for approximately 15 percent of skin preparations.  No skin prep was noted for approximately 1 percent of patients.

Table 3. Procedures followed for 15,404 new lines placed

Procedures Followed	Without Prompt	With Prompt	Not Done
Unit Timeout Procedure Followed	95.8%	1.1%	3.1%
Inserter Performed Hand Hygiene	98.8%	0.2%	1.0%
Wore Sterile Barrier Precautions	98.3%	0.5%	1.2%
Covered With Drapes	98.6%	0.2%	1.1%

Infections

To date, 166 infections have been reported. Most patients with a positive infection also had a secondary culture noted as being obtained at the time of the initial culture (59.6 percent).  The types of catheters in use among patients with infections can be found in Table 4.  Patients with PICC lines had the greatest number of infections overall (50.6 percent); however, as a proportion of lines placed to date, infections were most frequently found among patients with Broviac (18/577 or 3.1 percent) followed by PICC lines (84/6,783 or 1.2 percent).

Table 4. Types of catheters in use among patients with infections*

Catheter Type	N (%)
PICC	84 (50.6)
UVC	21 (12.7)
Broviac	18 (10.8)
UAC, UVC	13 (7.8)
PICC, UAC	10 (6.0)
Missing	8 (4.8)
UAC	4 (2.4)
Broviac, Other	2 (1.2)
UAC, UVC, Other	2 (1.2)
PICC, Broviac	1 (0.6)
PICC, Other	1 (0.6)
PICC, UVC	1 (0.6)
UAC, Broviac	1 (0.6)

*Classification of "Other" includes all other percutaneously placed central lines. Eight infections had no catheter type noted.

Maintenance

As of August 31, 2012, 127,578 line maintenance notes have been entered representing 8,427 unique patients. The majority of patients were noted as having feedings <120 cc/k/d (87.6 percent). During multidisciplinary rounding, lines are typically assessed as necessary (90.3 percent) with 2.8 percent considered unnecessary (for 6.7 percent of lines it was unknown if the line was necessary). When lines were accessed, procedures followed can be found in Table 5.  On shifts when tubing was changed (n=52,077), clean gloves were used without prompting 99.7 percent of the time.

Table 5. Procedures followed when accessing lines (n=102,029)

Procedures Followed	Without Prompt	With Prompt	Not Done
Glove Before Access	96.4%	0.3%	3.4%
Hand Hygiene Prior to Gloving	98.7%	0.2%	1.0%
Hub/Connector Cleaned for 15 Seconds	99.3%	0.2%	0.5%
Air Dry Completely*	99.0%	0.2%	0.8%

*When lines were accessed, cleaning was not noted in 0.8 percent of instances.

Team Check-Up Tool

The number of unit teams submitting Team Check-Up Tool data per month has varied from 75 to 38 units over 8 months of data currently available (January—August 2012). Within the Knowledge/Skills section all questions have shown improvement over time. Five out of the six questions in the Attitudes/Beliefs section have shown improvement since baseline. Results for "A junior staff member feels comfortable to question a more senior staff member who is not following the maintenance bundle," showed initial improvement but in the last two reporting months, results dropped below baseline levels. Finally, three out of the five Resources section questions showed improvement with one question remaining fairly stable over time ("Data collection has not been a burden") and one question showing a drop below baseline levels in the last data collection period ("Unit leadership is stable, i.e. low turnover"). The highest scoring questions in each of the categories can be found in Table 6.

Table 6. Highest scoring questions in each of the three NCLABSI team check-up tool domains

Domain	Highest Rated Question
Knowledge/Skills	Five randomly selected staff (nurses, physicians, etc.) in our unit can list at least three maintenance interventions
Attitudes/Beliefs	We have had good buy-in from physician staff in this unit
Resource	Our NCLABSI team meets minimally once a month

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