Evaluating Visual Cues to Improve Central Line Checklist Adherence: Challenges and Lessons Learned
BACKGROUND: Standardizing central line procedures with checklists has been shown to reduce central line-associated bloodstream infections (CLABSIs), which contribute to increased morbidity, mortality, healthcare costs, and prolonged hospital stays. A prior Plan-Do-Study-Act (PDSA) study at our institution resulted in the creation of a central line checklist to standardize bedside central line insertions. While initial adherence rates reached 92% with a paper-based checklist in one ICU, adherence declined following its integration into EPIC and expansion to four additional ICUs. Post-integration survey results indicated adherence had fallen to 57%. LOCAL PROBLEM: Checklist adherence rates of 57% highlighted a gap in consistent use, raising concerns about the checklist's ability to positively impact on infection prevention efforts. Behavioral and operational barriers, including procedural staff turnover, lack of automation in EPIC, and cognitive overload among nursing staff, were identified as significant contributors to reduced adherence. METHODS: This study was conducted across five adult ICUs in a teaching hospital using a PDSA framework. Participants included proceduralists (resident physicians, APPs, and faculty), registered nurses, and Unit-Based Educators (UBEs). Baseline adherence data was collected through surveys, which identified barriers such as difficulty accessing the checklist and lack of awareness. Literature reviews and UBE interviews informed the intervention design. INTERVENTION: To promote checklist use, visual cues in the form of three unique posters were created and reviewed by stakeholders for relevance. Posters were strategically placed in high-visibility areas across the ICUs to maximize exposure and encourage checklist utilization. RESULTS: Checklist adherence across five ICUs from October 2022 to mid-March 2023 was 47% (138/293), with variability between units. The multispecialty ICU had the highest adherence (56%), while the cardiovascular ICU had the lowest (32%). Adherence rates fluctuated over time, with the highest monthly adherence observed in February (53%) and the lowest in March (44%), though March data were incomplete. Two outcome measures were evaluated. CLABSI rates varied across units and months, increasing from 0.016 in October to 0.125 in March. Additionally, no statistically significant association was found between checklist completion and first-attempt success rates (p = 0.46). Survey responses showed that 15 of 21 respondents (71%) were aware of at least one poster, and 10 of 21 (48%) agreed or strongly agreed that the posters were effective reminders of the checklist process. Three respondents (14%) disagreed or strongly disagreed regarding poster effectiveness, while eight (38%) were neutral. The perception of psychological safety remained stable before and after the intervention. Nurse engagement in checklist completion varied by unit. Although usage of the recommended communication tool was reported, no direct conclusions could be drawn regarding its impact. CONCLUSION: Although the study did not achieve the 75% adherence target across all units, it provided valuable insights into barriers and opportunities for improvement. Future efforts should prioritize implementing a forced function within EPIC to ensure checklist completion during central line procedures, thereby reducing reliance on voluntary adherence and susceptibility to human error. Tailored education to address specific ICU needs and fostering a culture of safety and collaboration among multidisciplinary teams remain critical priorities. Additionally, retrospective chart reviews could be leveraged to provide more objective pre-intervention data to guide subsequent interventions and refine future strategies.
Catheter-Related Infections, Checklist, Guideline Adherence, Infection Control, Practice Guidelines as Topic, Quality Assurance, Health Care, Catheterization, Central Venous
University of Texas Southwestern Medical Center
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