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An oncology nursing initiative at Duke Cancer Institute was associated with a 40% reduction in central line-associated bloodstream infections across participating units, including nearly a 70% reduction on a hematologic malignancy unit, without introducing a new product or clinical process.
The nursing-led effort instead returned to the basics of central line infection prevention, combining revamped central line rounds, standardized audits, real-time feedback, and short weekly education sessions built around practices already in the health system’s CLABSI prevention bundle.
For CNS Week, Nurse Approved is highlighting clinical nurse specialists whose work demonstrates how the role can influence patient care from the bedside to the health system level. For Jenipher Mathys, MS, APRN-CNS, AGCNS-BC, an oncology clinical nurse specialist at Duke Cancer Institute, that meant examining why established infection-prevention practices didn’t always translate consistently into everyday care.
“First of all, I want to highlight that one of the coolest parts of this project was that our teams achieved these results without introducing a new product or process,” Mathys said. “We re-adjusted how we operationalized central line rounds and presented micro-learnings based on existing policy, best practices, the existing CLABSI bundle, and explained the why behind the elements of our CLABSI bundle. This was truly a ‘back to the basics’ project.”
Rising CLABSI Rates Pointed to Gaps in Practice
The project began after CLABSI rates increased across nearly all of the oncology units.
As the team investigated, Mathys said they identified knowledge gaps surrounding practices such as chlorhexidine gluconate, or CHG, treatment baths and inconsistencies in central line care. Staff turnover was one factor. Although an established CLABSI prevention bundle was in place, some nurses were not familiar with every component or why each mattered.
The team also found communication gaps between disciplines.
In one case, a patient had been taken off dialysis, and nephrology recommended removing the temporary dialysis line. Days passed without the line being removed.
During scheduled rounds, a charge nurse reviewing central lines identified the issue. The team escalated the concern to providers, and the line was removed. The nurse was subsequently nominated for a Good Catch award.
The recommendation had been documented, Mathys said, but the need for removal had not been escalated to Interventional Radiology.
“It was just a simple oversight that could have had a huge impact on the patient, given his immunocompromised state and risk for infection,” Mathys said. “We knew we needed to do something to increase intentionality and focus on our patients with central lines.”
Nurses Knew to Scrub for 15 Seconds. They Averaged Seven.
Rather than add another major responsibility to nurses’ shifts, the project focused on making existing central line practices more deliberate.
Bedside nurses and nurse managers participated in revamped central line rounds. They provided brief reports on patients’ lines, including why each patient had a line and how it was being used during the admission. Those conversations could expose gaps in the prevention bundle or nurses’ knowledge and, in some cases, help reduce unnecessary line use and access.
Observing care firsthand revealed another problem.
Nurses knew they were supposed to “scrub the hub” for 15 seconds before accessing a central line. When the team observed the practice, however, nurses averaged about seven seconds, Mathys said.
“If I have to guess as to why this is happening, I think they’re counting double time. 15 seconds is a really long time, when you really get into doing something like scrubbing the hub,” she said.
The team also observed breaks in sterile technique while nurses accessed ports. Work to address access and re-access practices continues as what Mathys describes as a second phase of the initiative.
The finding highlighted a key quality improvement challenge: knowing the correct practice does not necessarily mean it is performed consistently during everyday patient care.
Five-Minute Lessons Put the “Why” Back Into Infection Prevention
Education became another component of the intervention.
Two members of the project team rounded each week with a “CLABSI snack cart,” providing five-minute micro-learning sessions followed by time for questions. The multidisciplinary team included Mathys, the hematologic malignancy and cellular therapy CNS, a quality and safety nurse, two oncology inpatient education supervisors, and the oncology infection preventionist.
The team scheduled education and central line rounds during historically less busy periods to minimize disruptions and increase participation.
One lesson focused on the rationale behind CHG treatment baths. Nurses learned about evidence supporting CHG use in oncology patients, along with its safety and efficacy for superficial burns, wounds, and stage 1 and 2 pressure injuries.
Much of that information was new to the nursing staff, Mathys said.
“It showcased, to the project team, that nurses sometimes do things because they’re told to do them and they aren’t always given all the information up front as to why this is important,” she said. “In healthcare, sometimes I think we forget to include the ‘why’ with an initiative.”
A Snack Cart Helped Turn Education Into Engagement
The team also introduced friendly competition between units based on measures within nursing’s control, including audit data and participation in the weekly micro-learning sessions. A traveling trophy went to the highest-performing unit each month.
The snacks accompanying the education sessions proved surprisingly effective at generating interest. By about the third week, Mathys said nurses would see the cart coming down the hallway and tell the team not to begin until they could join. Staff began requesting particular snacks and looking for them the following week.
Mathys joked that the team had “Pavlov-ed” the nurses into expecting snacks whenever they heard a cart coming down the hall.
But she believes the response represented something more important.
“In all seriousness, it wasn’t just about the snacks; I believe it was that the nurses felt seen and appreciated and weren’t just told to do something new, but were given the space to learn and question,” Mathys said. “That made the difference.”
CLABSI Rate Fell From 1.71 to 1.01
The project team began meeting in August and September to identify gaps, review the literature and develop the intervention. After presenting the plan to nursing leaders, the initiative ran from October through April, followed by three months of post-intervention monitoring.
At the end of the fiscal year, the CLABSI rate was 1.01, down from 1.71 the previous fiscal year, according to Mathys.
She said the reduction translated into more than $700,000 in institutional cost avoidance and an estimated reduction of approximately 112 to 140 days in patient length of stay based on current literature.
One participating unit is also approaching 500 days without a CLABSI.
Mathys said that the unit already had the lowest CLABSI rate among the oncology units when the initiative began. She credits its sustained performance largely to its culture.
“They hold each other accountable and are always eager to learn new things and adapt their practice to the evidence,” she said.
The unit opened two years ago and has yet to record a catheter-associated urinary tract infection, according to Mathys, and has exceeded its metrics for all healthcare-associated infections during the past two fiscal years.
“Sustaining any positive quality metric starts with a culture of curiosity and positivity, in my opinion,” she said.
What the Project Shows About the CNS Role
The initiative also demonstrates how a clinical nurse specialist can connect what happens during an individual nursing task with broader patient-safety goals.
Mathys describes CNSs as “clinical unicorns” because they can work at both the bedside and system level.
“We bring perspectives to the table that are sometimes missed or overlooked because we view things at both the micro- and the macro- level,” she said. “The CNS is a master collaborator, ensuring all voices are heard and valued.”
That reach allows Mathys to move between clinical care and organizational priorities.
“One of the best parts of my job is that in a single day I can go from the bedside to the boardroom and back again,” she said. “We seamlessly meld system-level priorities with bedside nurse and patient priorities. Having that kind of reach within a healthcare system is rare. Being able to view the system in such a capacity is unique to the role of the CNS.”
For nurses, the project offers a reminder that improving patient safety does not always require adding another product, policy, or task. Sometimes the opportunity is already embedded in existing practice: ensuring nurses understand why an intervention matters, observing how care is actually delivered at the bedside, and giving staff a meaningful role in improving it.
