Investigating the Implementation of a Complex Intervention to Reduce Central Line-Associated Bloodstream Infections on the Neonatal Intensive Care Unit

Abstract

Neonatal central line-associated bloodstream infections (CLABSIs) are associated with increased mortality, prolonged hospitalisation, and increased healthcare costs. Over the past decade, global incidences have ranged from zero to 21.8 CLABSIs per 1000 central line days, with inter-centre variations despite adjusting for case mix. Whilst complex interventions such as care bundles may reduce neonatal CLABSIs by 60%, there is heterogeneity in bundled elements and in the
magnitude of effect size. It is often unclear if it is the bundle, the implementation process, or a combination of both, that results in CLABSI reductions. In addition, it is now well known that what works in one setting cannot always be directly transferred to another. Therefore, understanding
what works, how it works, and in what settings, is important in order to improve the translation of evidence into practice.

This thesis aimed to investigate the implementation of a care bundle aimed at reducing CLABSIs in a UK neonatal intensive care unit (NICU). A sequential, mixed-methods approach was taken, using a focused-case ethnography design that was underpinned by Normalisation Process Theory. A systematic review with meta-analysis was undertaken o identify the evidence for CLABSI care bundles in the NICU and informed data collection. Normalization MeAsure Development (NoMAD) surveys, observations of practice with retrospective interviews and semi-structured interviews were used to investigate implementation.CLABSI rates were prospectively collected, with bundle adherence data collected retrospectively. Quantitative data were analysed using descriptive statistics, with thematic analysis used to inductively analyse qualitative data.

The results of this study found that whilst CLABSI rates reduced by 28% from 2015 to 2018 this was not sustained in 2019, despite apparent increases in bundle adherence. However, this study revealed there was only partial bundle implementation, with minimal changes in NoMAD construct scores between survey two and three. Influences across individual, team and organisational levels moderated bundle adoption, with features of the local context such as social norms and professional cultures sometimes undermining implementation efforts. Ultimately, there were challenges relating to reinforcement and endorsement of the bundle. Recommendations to improve
bundle adoption include improving reinforcement, building in accountability and improving knowledge management.

This is the first study to investigate the implementation of a care bundle to reduce CLABSIs on the NICU. Understanding the mechanisms by which an intervention works (or not) in specific contexts is important to optimise the delivery of evidence-based care.

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Identifiers

ORCID for Vicky Payne: orcid.org/0000-0002-3436-2806

ORCID for Jacqui Prieto: orcid.org/0000-0002-5524-6775

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