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A Simulation-Based Education Program for Nurses Reduces Central Line-Associated Bloodstream Infection

Nov 09, 2015

By Shira Klapper, Senior Writer/Editor

An intervention that used a task simulator to educate 25 nurses on the use, care, and maintenance of central venous catheters (CVCs), reduced the rate of central-line associated bloodstream infections (CLABSI) in an adult inpatient hematology–oncology unit at the University of Vermont Medical Center. The use of CVCs is associated with a risk of developing CLABSI—and patients with cancer, whose care often requires CVCs, are at an increased risk for this infection due to side effects of chemotherapy, mainly, a lowered immune system and neutropenia. The study was reported in the article, “Reducing Oncology Unit Central Line-Associated Bloodstream Infections: Initial Results of a Simulation-Based Educational Intervention,” published online, ahead of print, in the Journal of Oncology Practice (JOP).

The study’s first author, Jenna Page, MSN, RN, OCN, said the study’s findings are good news for patients.  “We saw a drop in infections, which is a big deal for a population of immuno-compromised patients with cancer. Going forward, we hope to continue seeing these benefits by making sure that all our practices are standardized and that we’re staying up to date as policies and best practices change.”

Few CLABSI interventions have focused on maintenance care carried out by nurses

The study was designed to address a gap in CVC interventions and educational programs: Many quality improvement initiatives have focused on the moment that doctors insert the line into patients, but fewer studies have focused on the tasks nurses carry out after the line is inserted.

“A previous study we did showed that we can decrease CLABSI rates in our unit through a simulation-based education program, so we knew there was a benefit in standardized training,” said study coauthor Ted A. James, MD, MS. “What was unique about this study is that we took the same model of a simulation-based education program but applied it to the nursing side. We know how to put lines in so they don’t get infected, but once they’re in, and sometimes they’re in for quite a long while, there are other opportunities for things to go awry.”

Identifying educational gaps in knowledge of central line care

In designing the study, a team consisting of a nurse educator, an assistant nurse manager, nine staff nurses, and an infection prevention consultant performed a retrospective review of hospital records to determine the frequency of CLABSI for the six months before the start of the intervention. The team also reviewed the medical centers’ policies on CVC care and met with an infection control specialist, who helped devise explain a definition of CLABSI.  

In the next step, the team devised a 31-question multiple choice pretest designed to identify gaps in nurses’ knowledge regarding standards of care for CVCs. Based on the gaps identified in the pretest, the team created a two-part educational series, which was carried out over six months. During this six-month period, nurses individually met with the nurse educator and used a training simulator to practice several care tasks, including identifying and caring for central lines, using a heparin flush, drawing labs, and changing dressings.

Reduced CLABSI rates

The intervention was associated with an increase in nurses’ knowledge about CVC care: On the pre-test, which was administered before the educational series, nurses scored an average of 74.3%, while on the post-test, the score jumped to 91.2%, a 16.9% improvement. The rate of CLABSIs on the oncology unit before and after the intervention was another indication that nurses were standardizing their skills in caring for CVCs and adhering to best practices: During the six months before the intervention, the CLABSI rate was 5.86 per 1,000 patient line–days; during the six months of the intervention, the rate decreased to 3.45, and during the six months after the intervention, the rate dipped to 3.43. After introducing a visual audit tool in the seventh month after the intervention, the rate of CLABSIs went down even further, to 1.42, a rate significantly lower than before the intervention.

Dr. James stated that a unique aspect of this study is its multi-modality approach. “Jenna and the implementation team focused on administrative policies, they focused on standardizing protocols in terms of nursing practice, and they incorporated a structured education framework to identify and correct any deficiencies in practice,” said Dr. James. “In addition, the study has a longitudinal monitoring component where we’re tracking data and carrying out audits to see if people are maintaining their competencies.”


Jenna Page, MSN, RN, OCN, is the Assistant Nurse Manager on the Hematology/Oncology unit at the University of Vermont Medical Center.

Ted A. James, MD, MS, is a Surgical Oncologist and the Medical Director of Clinical Simulation at University of Vermont. He is also a Professor of Surgery at University of Vermont College of Medicine. He has been an ASCO member since 2009 and is a participant in the 2015-2016 Leadership Development Program.

Implementation team nurses include: Kristen Gray, Ann Adsem, Shannon Albrecht, Kelly Carpenter, Kelly  Cueman Sargent, and Julie Hart.


Abstract of the original JOP article.

PDF of the original JOP article.


Page J, Tremblay M, Nicholas C, et al. Reducing oncology unit central line–associated bloodstream infections: initial results of a simulation-based educational intervention. J Oncol Pract. Epub 2015 Oct 6.

The Exclusive Coverage series on ASCO.org highlights selected research from JCO and JOP with additional perspective provided by the lead or corresponding author.

@ 2014 American Society of Clinical Oncology

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