Knowledge Based Approach to Solving CLABSIs in Patients Receiving Total Parenteral Nutrition...Improving Nursing Best Practice Through Direct Observation & Education

Background Total parental nutrition (TPN) administered via a central line has been identified as an independent risk factor for central line-associated bloodstream infection (CLABSI). Our institution experienced a large increase in CLABSI from 8 for December 2017- July 2018 to 15 for August 2018 - March 2019; SIR = 0.614 vs 1.270; p= 0.0958. Likewise, the percentage of CLABSI associated with TPN administration via peripherally inserted catheter (PICC) increased from zero to 60% (9/15). We propose there is a TPN set-up and maintenance knowledge deficit among nursing that is contributing to the increase in CLABSI. Methods An intervention was conducted from April to July 2019 to evaluate nursing knowledge and practice of TPN administration. A multidisciplinary group of infection prevention, nursing, pharmacy, and education rounded on xx of patients receiving TPN to conduct audits of best practice and provide real-time feedback as an educational intervention. In addition, a voluntary anonymous 12-question survey addressing TPN administration and central line care was distributed to nursing. Results 70 nurses participated in the intervention by completing the survey. 37% indicated awareness of proper TPN setup, 50% reported scrubbing the hub prior to connecting the patient, 71% were aware to stop TPN infusion if line became disconnected, 57% were aware of appropriate TPN indications, and 43% of direct observations included proper hand hygiene. 3 CLABSI have been identified April to October 2019 (SIR = 0.513); zero associated with TPN administration via PICC. Conclusions Many opportunities for improvement were discovered through direct observation. Our group utilized results from rounding and the knowledge assessment to tailor educational opportunities for all disciplines involved. Clinical lessons learned were incorporated into mandatory nursing competencies and six additional knowledge based sessions. Periodic audits to assess TPN practice combined with knowledge assessments may be needed to improve and sustain compliance with TPN administration standards of care.