Investigating the implementation of a complex intervention to reduce central line-associated bloodstream infections in the Neonatal Intensive Care Unit, using Normalisation Process Theory

Background Translating evidence into practice has been notoriously difficult within the field of infection prevention and control (IPC). Care bundles- a form of complex intervention with multiple interacting components, may reduce neonatal CLABSIs by 60%. However, it may be unclear if it is the bundle, the implementation process, or a combination of both, that results in CLABSI reductions. Therefore, understanding what works, how it works, and in what settings, is important to improve the translation of evidence into practice. The aim of this study was to investigate the implementation of a care bundle aimed at reducing CLABSIs in a UK neonatal intensive care unit (NICU). Methods A mixed-methods, focused ethnography design underpinned by Normalisation Process Theory. Normalization MeAsure Development (NoMAD) surveys, observations of practice with retrospective, dyadic think aloud interviews, and semi-structured interviews were used to investigate implementation. CLABSI rates and bundle adherence rates were collected. Data analysis used descriptive statistics and thematic analysis. Results The introduction of a care bundle into a tertiary UK NICU did not result in sustained reductions in CLABSIs, despite apparent increases in bundle adherence. There was only partial bundle implementation, with minimal changes in survey scores and influences across individual, team and organisational levels moderating bundle adoption. Local organisational culture sometimes undermined 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 collective knowledge management. Conclusions The introduction of a care bundle into a tertiary UK NICU did not result in sustained reductions in CLABSIs, which is one of few negative studies. Understanding the mechanisms by which an intervention works (or not) in specific contexts is important to optimise the delivery of evidence-based care.