This initiative’s purpose was to reduce the catheter line-associated blood infection incidence rate (CLABSI) in the medical intensive care unit (MICU) to zero and maintain that rate by utilizing the best practice advisory (BPA) alert feature located in Epic, the institution’s EMR.

The 12-bed MICU of our urban full-service teaching hospital had 808 central line days for the first 5 months of 2021. During this time, the CLABSI incidence rate was elevated at a monthly average of 9.1.

Nursing informatics/quality brainstormed solutions to reduce the CLABSI incidence rate. We decided to utilize our pre-existing central venous line (CVL) maintenance order set and Epic’s clinical decision support systems (CDSS). We focused on prevention as the primary way to reduce the incidence rate. We developed the CVL maintenance order set from evidence-based practice (EBP) guidelines. This set contains orders that supports proper CVL flush protocols and various dressings, including CHG dressings for preventing infection.

The team observed that CVL maintenance orders were not always in place after central line insertion. Therefore, we leveraged BPAs, alerts that display when triggered by an action. They are a form of CDSS located within Epic. Our novel approach was to have the BPA trigger immediately after the documented placement of a CVL. Medical center information technology (MCIT) worked with Epic technical services to implement a programming solution that allowed for the following process: The provider signs the note, which triggers: 1) the CVL insertion order being added automatically and 2) the BPA alerts the provider to place the CVL maintenance order set.

After creating the BPA, testing involved monitoring its triggers for the right action and role. Go-live was on May 19, 2021. We used tools available in Epic to evaluate the BPA after implementation. The BPA fired in the MICU for 28 unique patients during the evaluative period (June –September). Of those 28 unique patients, 20 (71%) of the times, the provider placed a maintenance order; 7(25%), the provider chose the acknowledgement reason indicating that they placed the order outside of the BPA; and in 1 (4%) case the provider indicated they would place the order in the BPA, but no order was found. Our outcome measurement was the CLABSI incidence rate in the MICU. The rate dropped to zero from June through September 2021. The MICU had 235 central line days during this period.

Combining EBP and CDSS contributed to a significantly reduced CLABSI incidence rate in the MICU. To be effective, a CDSS alert should display for the user that has the most ability to act on it. Our innovative approach involved designing the BPA to fire when the provider signs the procedure note, right after physically placing the central line, which allowed informatics to target the alert to maximize its value. We suggest reviewing other BPAs (or similar CDSS tools in your EMR) that may also benefit from changing their triggering method.

Robert Kozlenko MSN Ed, RN-BC

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