Running head: CONTINUOUS QUALITY IMPROVEMENT PROJECT 1

Continuous Quality Improvement Project

Sherri White
King University
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Continuous Quality Improvement Project

The adjective continuous indicates something is perpetual, nonstop, endless, infinite, and

constant. The noun quality evokes thoughts of excellence, value, superiority, and significance.

Improvement is also a noun that refers to refinement, enhancement or changing for the better.

Combining these three specific words, continuous quality improvement (CQI) should mean

quality is perpetual and seeking to improve quality would mean we never stop looking for the

best way to perform an action or a procedure. In healthcare, nurses are key drivers of continuous

quality improvement due to their persistent desire to achieve quality outcomes through critically

thinking and applying the nursing process of assessment, diagnosis, planning, implementation

and evaluating their patients.

Nursing leaders seek to identify and mitigate opportunities for performance improvement

using standard methods for identification, notification and problem solving. They promote a

culture of continuous improvement that often leads to sustained results across the continuum of

specialties. Quality improvement is accomplished when optimal performance standards are used

as opportunities to standardize practice methods that reduces practice variability and optimizes

patient outcomes. Finkelman (2018) states, “quality improvement program staff develop a

comprehensive quality improvement plan that relates to current standards and benchmarks,

performance appraisal, interprofessional assessment and improvement and specific health care

organization continuous quality improvement needs” (p. 313, ¶ 2).

Inpatient hospital units are benchmarked to meet quality metrics within their organization

to ensure collectively the organization is meeting regulatory requirements for reimbursement as

well as maintaining quality standards that protect the patient. Empirical outcomes is indicative

of improved patient outcomes based on quality initiatives and “evidence of the quality measures

through nurse-sensitive indicators” (Roussel, Thomas, & Harris, 2016. P. 215, ¶ 2). Examples in
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practice would be excellent patient discharge education, falls prevention initiatives, pressure

injury prevention initiatives, central line-associated blood stream infection (CLABSI)

preventions and pain control and prevention. The National Healthcare Safety Network (NHSN)

is a division of the Centers for Disease Control (CDC) that requires all acute care hospitals to

report CLABSIs and associated patient days and central line days (denominator data) for

infections that occur from all patient units meeting the NHSN definition for adult medical,

surgical, or combined medical/surgical areas (CDC, 2020, pp. 1-2).

CQI Question

Among Hematology/Oncology/Bone Marrow Transplant patients on the

Myelosuppression/Stem Cell Transplant Unit, how does attending a CLABSI

Education Blitz for standardization of practice for all staff compared to not

attending a CLABSI Education Blitz to standardize practice affect the ability to

reduce CLABSI rates to zero for two consecutive months?

Patients experiencing myelosuppression that develop a CLABSI have a higher incidence

of fatality due to the loss of their immune systems ability to respond to infectious disease. These

patients have either received chemotherapy which has temporarily depleted their immune

systems ability to fight infection, or the nature of their blood born cancer is affecting the

production of mature white blood cells also preventing the immune system response to infectious

pathogens.

Fiscal year (FY2020) quality tracking of hospital acquired infections (HAI) indicated an

increased incidence of CLABSI for patients admitted to the Myelosuppression/Stem Cell

Transplant Unit service area. The number of infections exceed those of previous years and the

benchmarking goal set for the unit. There were eleven CLABSI and eighteen central line-
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associated mucosal barrier infections (CLAMBI) which combined for a total of twenty-nine line

infections. CLAMBI are intestinal organisms and are not reportable to NHSN, however they are

preventable with meticulous mouth care as well as identifying mucosal wounds on admission or

during the hospitalization that have the potential to be a source for infection.

The increased incidence prompted our unit leadership to collaborate with infection

prevention to prepare an action plan to improve practice by auditing the individual practice of

each registered nurse and ensure all staff were adhering to the recommendations of completing

documentation of chlorhexidine bathing every twenty-four hours, reviewing the need for the line,

sterile dressing dated appropriately and intact, scrubbing the hub fifteen seconds when accessing

and using alcohol impregnated caps on the tubing luerlocks below the pump.

Stakeholders and Team

The main stakeholders are the patients and their family members. We are entrusted with

their care to ensure it is completed safely and of the highest quality. The institutional risk and

safety board monitors all hospital units for practice standards and infection rates. As the

manager of this service area, I review each incident with our infection prevention specialist to

determine if the infection would have been inevitable or preventable by following the evidence-

based practice care guidelines of the maintenance practice bundle determined by the CDC.

When the infection rates became excessive, we formed a team to further review our unit’s

practice. The team is comprised of an infection prevention specialist, the unit quality

improvement analyst, the unit quality and safety representative, the clinical staff leader, the unit

education specialist, two staff nurse representatives that attend the vascular access committee

meetings, one executive nursing leader, the medical director and the unit manager. Initially the

team met weekly and the frequency increased to bi-weekly to perform audits and see where the
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practice barriers were occurring. Twenty-five patients were interviewed weekly for four weeks

and their CHG bathing documentation reviewed for compliance as the main stakeholders for this

CQI.

Evidence

Reviewing the evidence began with a search of the Cumulative Index to Nursing and

Allied Health Literature (CINAHL) and PubMed for peer reviewed and reliable information.

Team members were instructed to locate two evidence based articles with specificity for stem

cell transplant populations. The evidence revealed “hospital-acquired bloodstream infections

(HABI), including CLABSI are associated with increased morbidity, mortality, length of hospital

stay and cost” (Musuuza, et al., 2019, p. 2, ¶ 1). Patients receiving hematopoietic stem cell

transplant (HSCT) and those with hematologic malignancies are especially at risk for CLABSI

due to immunosuppression and the presence of a central line. Musuuza, et al., (2019) conducted

a meta-analysis which concluded that patient bathing daily with chlorhexidine gluconate (CHG)

significantly reduces the incidence of HABI, including CLABSI. CHG is a topical antiseptic that

“binds to the negatively charged bacterial cell wall, altering the bacterial cell osmotic

equilibrium” (Raulji, Clay, Velasco, & Yu, 2015, p. 316, ¶ 2). According to Milstone, Passaretti,

& Perl, (2008), “chlorhexidine has residual activity on the skin that helps to prevent rapid

regrowth of skin organisms and enhances the duration of skin antisepsis” (p, 276, ¶ 1).

Most randomized clinical trials conducted utilizing CHG bathing have focused on the

Intensive Care Unit (ICU) setting; few have included the HSCT or hematology population. ICU

patients are typically bedbound, requiring a daily bed bath by staff. In this population, two

percent CHG impregnated cloths are a sensible product to reduce the risk of CLABSI. However,

the HSCT and hematology population are quite different from ICU patients. Many of the HSCT
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patients are independent or require only minimal assistance with their activities of daily living.

To decrease the risk of CLABSI for these patients, the Myelosuppression/Stem Cell Transplant

Unit requires a four-step process: shower with traditional soap and water, application of CHG

two percent impregnated cloths, and changing into clean cloths and clean linens. This is a

multistep process which increases the likelihood of staff missing a step or patient non-

compliance.

While auditing for patient compliance, the data revealed patients were frequently refusing

the CHG application due to the “sticky feeling” it leaves on their skin. It also must completely

dry prior to the patient redressing, and they complain they get chilled while waiting for the CHG

to dry. The research also revealed another type of CHG foam cleanser, Hibiclens which is four

percent CHG content and can be used in the shower, reducing the steps required with the cloths.

Briere and Chapman (n. d.), conducted a quality improvement project on the HSCT and

leukemia unit at University Hospital at Syracuse University New York (SUNY) Upstate Medical

Center University. During the first eight months, patients were instructed to shower with regular

soap, then apply CHG cloths. Poor patient compliance was noted with this process. During the

last two months of the pilot program, patients were switched to using four percent CHG foam

cleanser. Patient compliance increased, and there was a significant reduction in cost associated

with the price difference of the cloths and the foam cleanser. Patients tolerated the stronger

concentration of the CHG with no significant skin complications. Additionally, the stem cell

transplant unit at Michigan Medicine also realized a decrease in CLABSI rates after

implementing a CLABSI prevention bundle. The bundle includes: weekly central line audits by

leadership, utilizing new end caps that do not allow blood to become trapped after blood draws,

and using antimicrobial caps on all luerlocks below the infusion pump [CITATION Har19 \l 1033 ].
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Audits of sterile dressing changes on the Myelosuppression/Stem Cell Transplant Unit

revealed there is some variance of practice among staff which prompted the project team to

develop a step by step check off sheet to perform sterile dressing changes. This tool will be used

to focus teaching at mandatory CLABSI Blitz education sessions for staff registered nurses in

August and September.

Recommendations

CLABSIs rates of the Myelosuppression/Stem Cell Transplant Unit cause life threatening

complications to the patients necessitating significant practice change. I have often heard it said

to continue doing the same thing expecting different results is the definition of insanity. In order

to decrease the number of CLABSI on the unit, the collaboration of the team proposed additional

action plan elements to reduce infections.

Three specific practice changes initiated in June 2020 were dedicated tubing change and

dead end cap change days on Sundays and Thursdays. Hibiclens option for ambulatory patients

daily showering has also been offered. The Hibiclens is the same cost as the CHG clothes

already in use. The reduced use of CHG clothes offsets the cost of the Hibiclens. These

changes required staff education and adding Hibiclens to the supply room stock. To date this

change has resulted in a project win thus far of sixty plus days of zero infections on the unit.

The major project emphasis is the standardization of each person’s practice for dressing

changes and line maintenance to ensure all staff nurses practice is reflected the same to each

patient. Some patients that had longer length of stay time voiced they had noticed differences in

each person’s dressing change technique. The project focus is the CLABSI Blitz Practice

Standardization Education. This will require 1 hour after work or before work for groups of six

people. We have three practice manikins which will be shared by two staff members. There will
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be one leadership team member per session to certify each nurse on the standardized practice.

Cost will be one hour pay per staff member and the cost of the dressing change kits. Eighty-six

registered nurses average pay rate is $30 per one hour each, equals labor cost of $2580.00. The

eighty-six dressing change kits are $4 each for a total supply cost of $344.00. The total project

cost is $2924.00.

Action Plan

Change is difficult to maneuver for some staff members, and it is important for unit

leadership to plan and educate with any practice change. “Change involves nursing leaders’

continued awareness of all aspects of their nursing environment…nurse leaders use

communication, leadership and motivation theory to overcome resistance and gain support to

make the change work” (Roussel, Thomas, & Harris, 2016, p. 136, ¶ 1).

The Agency for Clinical Innovation (ACI) (2017) discusses Rogers’ Diffusion of

Innovations as an “influencing diffusion of new ideas through cultures, innovations,

communication channels, time and social systems” (p. 1, ¶ 1). Rogers change model is a five

step process of knowledge, persuasion, decision, implementation, and confirmation (ACI.Health,

2017). Using this model, staff education will be to instruct and persuade them of the benefits of

practice standardization for dressing changes and long term patient’s to see no variation of

practice between nurses. The practice change will be implemented by one hour training sessions

using teach back and competency check off to ensure staff understanding of the new technique.

The most revealing will be to have patient confirmation of standard practice and to continue the

number of zero days without a CLABSI.

Support and Resources

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The CLABSI Blitz Practice Standardization CQI project check off tool was developed to

use for each person to demonstrate this competency as a standardized process. These have been

distributed to all our nursing staff so each person will have the ability to study the sequential

steps for sterile dressing change. This should be familiar to most of the nursing staff, however,

the sequence of the steps is the difference in most individual’s practice. We further discovered

the nurse residency program does not teach using the alcohol swabs in the dressing change kits

and to only utilize the chlorhexidine applicators. The goal is to make it a unit standard to first

use the three alcohol swabs in the cleaning process as well as the chlorhexidine applicators using

friction to clean the site.

Nurse residents are new novel nurses in their first nursing job after receiving their nursing

license and one of the largest personnel sources for replacement of resigning staff. The

Myelosuppression/Stem Cell Transplant unit is onboarding nine new residents in late August.

Those new nurse residents will be taught this new requirement from the onset of their practice

and we are hopeful this will be the beginning of culture change for our unit.

Additionally, in anticipation of the upcoming scheduling process sign-in sheets for the

nursing staff to choose the date for the one hour in-service were posted. The in-services have

been promoted in the daily visual management board huddle and this has produced lots of

questions and excitement for the standardization process. The additional dressing change kits to

utilize for the teaching have been secured and the manikins have been reserved. The schedule

posted this week and we are set for each class and the leadership responsible to facilitate each

class.

We have coordinated with our infectious disease department to utilize their black light

and glowing gel to demonstrate to staff the places that are touched in the patient rooms when
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they enter. This will be a visual to them to ensure they are appropriately completing hand

hygiene just prior to accessing the patient’s central lines.

To ensure the additional hour of possible overtime would be permitted, I consulted with

our Associate Nursing Officer to obtain permission. She agreed this project is necessary for this

patient population and the timing was perfect with the new onboarding of nurse residents.

Implementation

Unfortunately, the in-services will begin after this class completes in August. The new

schedule begins on Sunday, August 30, 2020 with the first in-service scheduled on August 31,

2020. We are set and ready to teach the in-service sessions with six staff each, two times per day

for seven days over a two week period with the last class on Friday, September 11, 2020.

Evaluate Outcomes

The outcome objectives are:

 To ensure all staff are trained and documented by check-off of standard practice
 To hardwire standard maintenance practice of central lines including sterile dressing
change and access of lines
 To see a significant decrease in CLABSI on the Myelosuppression/Stem Cell
Transplant Unit
 To have the patients voice they do not see variation of practice from nurse to nurse
during their stay.

Audits will begin on Monday, September 14, 2020 and will continue until we have the

practice hardwired. Twenty-five audits weekly will be completed by unit leadership comprised

of five audits each by three clinical staff leaders and ten audits by the quality initiative analyst.

Audits will be input into our institutional audit system program with data tabulated weekly and

reported to staff and executive leadership. The compliance rate expectation is ninety percent or
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greater for documentation, and patient reports of no variance in practice. The CLABSI rate is

documented as last incident date by the infectious disease/quality and safety department.

Report to Stakeholders

The main stakeholders are the patients and their family members. This information is

posted on the visual management board for all who enter the unit to review. Additionally, when

auditing for compliance a conversation will be initiated with the patients that discusses how we

take ownership of their safety and the results verbalized. Our medical director, executive

leadership and risk and safety board will receive monthly, computer generated reports from the

institutional reporting system of the status of our units infection rates. The unit leadership will

be reviewing weekly with the quality and safety department as well as infection prevention to

ensure there is accountability. The unit staff will receive this data daily at the visual

management board for compliance rates and issues that may have been noted through the

previous week to ensure we maintain the greater than or equal to ninety percent compliance.

The desire is to compare FY20 total data month by month without these changes in place

and to show the changes in practice have reduced CLABSI and CLAMBI rates per month and

overall. There is already improvements being realized from both patient compliance and staff

compliance as well as zero infections for sixty plus days.

Next Step

The success of this project will be evaluated by the unit leadership who are invested in

the project achievement being positive. The institution is consistently reviewing quality and this

information will be disseminated through the nursing leadership board if the results show a

reduction in CLABSI. Successes are wins for the institution and as a magnet institution, positive

results are shared and praised as nursing accomplishments. The change in alcohol swab
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utilization during the sterile dressing change is already being discussed through our education

department and will be an area of change in the institutional teaching of new nurse residents.

Communicating the Findings

There are plans to present a poster to the Oncology Nursing Society convention if

successful. Our institution also has opportunities system wide to share successful team stories

quarterly at leadership assemblies. One of the clinical staff leaders and I are monitoring these

findings for possible publishing in a professional journal.

This team has the desire to build a culture of safety by reducing FY20 total infections of

twenty-nine including eleven CLABSI and eighteen CLAMBI. We began by chasing zero

infections for two months and achieved that goal as of July 31, 2020. We are now chasing zero

infections for ninety-days and will continue to build lofty goals as we continue to see successes.

We know there are requirements to hardwire practice and continuing to be vigilant with staff

huddles daily at the visual management board and sharing wins will be the course to build on the

momentum. Continuous quality improvement (CQI) is our goal and in so doing we realize

quality is perpetual and seeking to improve quality would mean we never stop looking for the

best way to perform an action or a procedure.

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References
ACI.Health. (2017). Current management theories and models - Everett Rogers. Retrieved from

Agency for Clinical Innovation:

https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0010/298756/Change_Manage

ment_Theories_and_Models_Everett_Rogers.pdf

Centers for Disease Control (CDC). (2019). Operational Guidance for Acute Care Hospitals to

Report Central Line-Associated Bloodstream Infection (CLABSI) Data to CDC's NHSN

for the Purpose of Fulfilling CMS Hospital Inpatient Quality Report (IQR) Requirements.

Retrieved from Centers for Disease Control (CDC):

https://www.cdc.gov/nhsn/pdfs/cms/Final-ACH-CLABSI-Guidance-508.pdf

Finkelman, A. (2018). Quality Improvement: A Guide for Integration in Nursing. Burlington:

Jones and Bartlett Learning, LLC.

Harding, C. (2019). Adult bone marrow transplant unit significantly prevents central line-

associated bloodstream infections. Biology of Blood and Marrow Transplantation, S246.

doi:10.1016/j.bbmt.2018.12.484

Musuuza, J., Guru, P., O'Horo, J., Bongiorno, C., Korobkin, M., Gangnon, R., & Safdar, N.

(2019). The impact of chlorhexidine bathing on hospital-acquired bloodstream infections:

A systematic review and meta-analysis. Biomed Central Infectious Diseases, 1-10.

doi:0.1186/s12879-019-4002-7

Raulji, C., Clay, K., Velasco, C., & Yu, L. (2015). Daily bathing with chlorhexidine and its

effectson nosocomial infection rates in pediatric oncology patients. Pediatric

Hematology and Oncology, 315-321. doi:10.3109/08880018.2015.1013588

Roussel, L., Thomas, P., & Harris, J. (2016). Management and Leadership for Nurse
Administrators. Burlington: Jones and Bartlett Learning
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