Sustaining Improvements in CLABSI Reduction in a Pediatric Cardiac Intensive Care Unit.

Central line-associated bloodstream infections (CLABSIs) are preventable events that increase morbidity and mortality. The objective of this quality project was to reduce the incidence of CLABSIs in a pediatric cardiothoracic intensive care unit. Methods: Institutional review of an unacceptably high rate of CLABSIs led to the implementation of 4 new interventions. These interventions included: the use of sequential cleaning between line accesses, Kamishibai card audits, central line utilization and entry audits, and proctored simulation of line access. Results: There was a reduction in CLABSI rate from 1.52 per 1,000 central line days in 2018 to 0.37 per 1,000 central line days in 2020 and 0.32 in 2021. Additionally, central line days per 100 patient days decreased from 77 to 70 days over the study period. The cardiothoracic intensive care unit went 389 days without a CLABSI from October 2020 to November 2021. Conclusions: Implementation of multiple interventions led to a successful reduction in the incidence of CLABSIs in our unit, with a sustained reduction over 1 year.

Elimination of hospital-acquired central line-associated bloodstream infection on a mixed-service pediatric unit.

INTRODUCTION: Hospital-acquired central line-associated bloodstream infections (CLABSI) are "never events" in U.S. healthcare. National efforts to improve CLABSI rates are ongoing. Efforts are important for all patients with a central venous catheter (CVC) and critical to children with intestinal failure (IF) who depend on long-term, daily use of a CVC and undergo extended hospitalizations. We describe outcomes of a multidisciplinary CLABSI elimination effort on a 24-bed medical-surgical unit caring for children with IF. METHODS: Unit CLABSI events from 1/9/2012 to 4/16/2020 were evaluated with multiple improvement interventions. We leveraged prospectively maintained clinical registries and National Healthcare Safety Network (NHSN) reporting data to extract patient and unit demographics, ethanol lock utilization, and unit CVC days. Interventions were developed utilizing expert consensus and CDC guidelines with active frontline staff engagement. Descriptive statistics and tests of non-parametric data were employed for analysis. RESULTS: Ninety-five patients with IF and 862 non-IF patients experienced a total of 1,629 admissions with 20,372 CVC days. Twelve hospital-acquired CLABSI events occurred during the study period, including 7 following NHSN definition change on 1/1/2015 (0.56 per 1,000 CVC days). After the last unit CLABSI on 12/5/2016, there were 7,117 CVC days through study conclusion. CONCLUSIONS: Described interventions with an enhanced culture of collaborative care profoundly improved hospital-acquired CLABSI occurrence. Success in a specific population translated to all other unit patients with a CVC. Findings suggest elimination is not the result of a single new product or practice, but also includes support and empowerment of those caring for the patient and their CVC.

Significant Reduction of Central-Line Associated Bloodstream Infections in a Network of Diverse Neonatal Nurseries.

OBJECTIVE: To describe a quality improvement (QI) initiative that was associated with a dramatic reduction in neonatal central-line associated bloodstream infection (CLABSI) rate in a diverse group of 8 intensive care nurseries (Neonatal Services). STUDY DESIGN: A quasi-experimental time series QI initiative using the model for improvement and evidenced-based interventions. RESULTS: The aggregate CLABSI rate for Nationwide Children's Hospital-associated Neonatal Services decreased from 6.0 CLABSI per 1000 catheter days to 1.43 CLABSI per 1000 catheter days in less than 2 years and has remained in control at 0.68 per 1000 catheter days for over 5 years. Each of 8 nurseries has had a 1 year or more CLABSI-free period, including the neonatal intensive care unit with the largest patient volume, acuity, and central line usage. Aggregate Neonatal Services has experienced 3 CLABSI-free quarters since 2007. Key success factors included: (1) engagement of senior executive leadership; (2) bedside "huddles" among clinical and epidemiology staffs conducted within 72 hours after a positive blood culture; (3) implementation of chlorhexidine antisepsis and the use of chlorhexidine-impregnated catheter site discs; and (4) and establishment of a dedicated team for percutaneously inserted central catheter insertion to serve units in which central lines are placed less frequently. CONCLUSIONS: Using the model for improvement and evidenced-based interventions, this QI project has been associated with reduction in the CLABSI rate by 89%, and over 430 CLABSIs likely have been avoided.

Necrotizing enterocolitis in neonates undergoing the hybrid approach to complex congenital heart disease.

OBJECTIVE: To investigate the prevalence of necrotizing enterocolitis (NEC) in neonates undergoing the Stage I hybrid procedure for palliation of complex congenital heart disease (CHD). Neonates undergoing the Norwood surgery for hypoplastic left-heart syndrome have the highest risk for NEC of all CHD patients. The hybrid procedure is another palliative option for hypoplastic left-heart syndrome, but NEC in neonates undergoing this procedure has not been reported. DESIGN: Retrospective chart review of 73 neonates who underwent the hybrid procedure for palliation of complex CHD. Demographic, perinatal, perioperative, clinical, and procedural data were collected. NEC was defined as modified Bell's Stage II and above. SETTING: The cardiothoracic and neonatal intensive care units in a large free-standing children's hospital. PATIENTS: All neonates who underwent the hybrid Stage I procedure for the palliation of complex CHD from April 2002 through April 2008. MEASUREMENTS AND MAIN RESULTS: Seventy-three neonates were reviewed and 11.0% (eight of 73) developed NEC. Of the patients with NEC, 37.5% (three of eight) died and two patients required abdominal surgery. Earlier gestational age (< 37 wks), lower maximum dose of prostaglandin infusion, and unexpected readmission to the intensive care unit were statistically associated with NEC (p = .009, 0.02, and 0.04, respectively). No other demographic, perinatal, perioperative, clinical, or procedural variables were associated with the development of NEC in this patient population, including enteral feeding regimens, umbilical artery catheters, inotrope use, and average oxygen saturation and diastolic blood pressure. CONCLUSIONS: The prevalence of NEC in patients undergoing the hybrid procedure is comparable to that reported for neonates undergoing the Norwood procedure. Earlier gestational age is a significant risk factor for NEC in patients who undergo the hybrid Stage I procedure. Multidisciplinary approaches to better understand abdominal complications and to develop feeding regimens in neonates undergoing the hybrid approach to complex CHD are needed to improve outcomes and decrease morbidities.