Determining infection prevention staffing needs for the pediatric ambulatory and procedural care setting.

BACKGROUND: Recent analyses suggest that existing infection preventionist (IP) staffing ratios do not reflect the scope of institutional needs after accounting for complexity and non-inpatient locations. We sought to determine the current IP staffing level required to address the complexity and scope of our pediatric ambulatory and procedural operations. METHODS: This needs assessment was adapted from previous analyses by Bartles et al (2018). We surveyed IPs covering ambulatory/procedural locations regarding clinical complexity indicators and estimated hours per week spent engaged in IP activities. The reported hours were used to calculate total IP hours per week and associated full-time equivalents (FTEs). RESULTS: Half (118/237) of surveyed locations/services reported at least 1 complexity indicator, while nearly 9% (21/237) reported 3 or more complexity indicators. IPs spent 181.0 h/wk focused on ambulatory/procedural locations, equating to 4.5 FTEs. DISCUSSION: Infection prevention and control leadership used these findings to successfully add 4 IP FTEs to the department. These FTEs will allow increased ambulatory/procedural IP support, improved regulatory readiness, and increased quality improvement initiatives. CONCLUSIONS: Assessing the complexity and scope of pediatric ambulatory/procedural locations can be a valuable tool for (1) advocating for overall IP staffing increases at a system level and (2) determining the distribution of IP time and resources in such locations.

Central venous catheter bundle adherence: Kamishibai card (K-card) rounding for central-line-associated bloodstream infection (CLABSI) prevention.

OBJECTIVE: To institute facility-wide Kamishibai card (K-card) rounding for central venous catheter (CVC) maintenance bundle education and adherence and to evaluate its impact on bundle reliability and central-line-associated bloodstream infection (CLABSI) rates. DESIGN: Quality improvement project. SETTING: Inpatient units at a large, academic freestanding children's hospital. PARTICIPANTS: Data for inpatients with a CVC in place for ≥1 day between November 1, 2017 and October 31, 2018 were included. INTERVENTION: A K-card was developed based on 7 core elements in our CVC maintenance bundle. During monthly audits, auditors used the K-cards to ask bedside nurses standardized questions and to conduct medical record documentation reviews in real time. Adherence to every bundle element was required for the audit to be considered "adherent." We recorded bundle reliability prospectively, and we compared reliability and CLABSI rates at baseline and 1 year after the intervention. RESULTS: During the study period, 2,321 K-card audits were performed for 1,051 unique patients. Overall maintenance bundle reliability increased significantly from 43% at baseline to 78% at 12 months after implementation (P < .001). The hospital-wide CLABSI rate decreased from 1.35 during the 12-month baseline period to 1.17 during the 12-month intervention period, but the change was not statistically significant (incidence rate ratio [IRR], 0.87; 95% confidence interval [CI], 0.60-1.24; P = .41). CONCLUSIONS: Hospital-wide CVC K-card rounding facilitated standardized data collection, discussion of reliability, and real-time feedback to nurses. Maintenance bundle reliability increased after implementation, accompanied by a nonsignificant decrease in the CLABSI rate.

A family empowerment strategy is associated with increased healthcare worker hand hygiene in a resource-limited setting.

BACKGROUND: Guidelines recommend empowering patients and families to remind healthcare workers (HCWs) to perform hand hygiene (HH). The effectiveness of empowerment tools for patients and their families in Southeast Asia is unknown. METHODS: We performed a prospective study in a pediatric intensive care unit (PICU) of a Vietnamese pediatric referral hospital. With family and HCW input, we developed a visual tool for families to prompt HCW HH. We used direct observation to collect baseline HH data. We then enrolled families to receive the visual tool and education on its use while continuing prospective collection of HH data. Multivariable logistic regression was used to identify independent predictors of HH in baseline and implementation periods. RESULTS: In total, 2,014 baseline and 2,498 implementation-period HH opportunities were observed. During the implementation period, 73 families were enrolled. Overall, HCW HH was 46% preimplementation, which increased to 73% in the implementation period (P < .001). The lowest HH adherence in both periods occurred after HCW contact with patient surroundings: 16% at baseline increased to 24% after implementation. In multivariable analyses, the odds of HCW HH during the implementation period were significantly higher than baseline (adjusted odds ratio [aOR], 2.94; 95% confidence interval [CI], 2.54-3.41; P < .001) after adjusting for observation room, HCW type, time of observation (weekday business hours vs evening or weekend), and HH moment. CONCLUSIONS: The introduction of a visual empowerment tool was associated with significant improvement in HH adherence among HCWs in a Vietnamese PICU. Future research should explore acceptability and barriers to use of similar tools in low- and middle-income settings.

Facilitators and barriers to a family empowerment strategy to improve healthcare worker hand hygiene in a resource-limited setting.

OBJECTIVES: The World Health Organization recommends empowering patients/families to remind healthcare workers (HCWs) to perform hand hygiene (HH). We sought to understand acceptability of a family empowerment strategy in a Vietnamese pediatric intensive care unit (PICU). METHODS: With end-user input, we designed a tool to help families in a PICU in Vietnam to remind HCWs to perform HH. We conducted 3 preliminary focus group discussions (FGDs) with patients' family members (n = 8), physicians (n = 9), and nurses (n = 8) to understand acceptability of preliminary tools, attitudes towards HH and barriers to HH. Tools were then modified and implemented in a 5-week intervention study. We then conducted 3 more FGDs with families (n = 7), physicians (n = 7), and nurses (n = 8). Discussions were analyzed using qualitative directed content analysis. Families who used the tool were asked to complete written surveys. FINDINGS: Both family members and HCWs felt that HCWs had a responsibility to perform HH. Barriers to performing HH were identified, including forgetfulness and time constraints. Family members felt shy reminding HCWs to perform HH. However, the HH reminder tool was acceptable, and some felt it could overcome barriers to reminding HCWs to perform HH. HCWs felt embarrassed when reminded to perform HH, but felt that the reminder was useful. Nearly all (99%) survey respondents felt that family members should speak up if they noticed HCWs omitting HH. CONCLUSIONS: A tool given to families to remind HCWs to perform HH was largely acceptable in a pediatric ICU in Vietnam. Perceived benefits of improving HH were felt to surmount barriers to tool use.

Safety of Biweekly Chlorhexidine Gluconate Bathing in Infants 36 To 48 Weeks' Postmenstrual Age.

BACKGROUND: Little evidence supports use of chlorhexidine gluconate (CHG) baths to reduce health care-associated infections, including central catheter-associated bloodstream infections in infants less than 2 months old. OBJECTIVE: To describe the safety of biweekly CHG baths in infants less than 2 months old by measuring blood levels of CHG, liver and renal function, skin reactions, and adverse events. METHODS: Study participants received twice-weekly 2% CHG baths, weekly blood tests, and twice-daily skin assessments. Adverse events were monitored. RESULTS: Ten infants 36 to 48 weeks' postmenstrual age with central venous catheters admitted to the neonatal or cardiac intensive care unit were enrolled before the study was closed by the Food and Drug Administration. The 9 patients contributing data had 83 CHG exposures; 31 CHG levels were analyzed. All patients had evidence of CHG absorption. Seven patients had CHG levels of 100 ng/mL or greater. Findings did not support accumulation of CHG but did show evidence of higher absorption than previously reported. Results of liver and renal function studies remained within reference limits. No patient had any adverse events, including skin reactions. CONCLUSIONS: Although no adverse events were observed, our patients had evidence of CHG absorption. The effects of this absorption remain unknown. More research is needed to determine safe blood levels of CHG in infants less than 2 months of age.

It's in Your Hands: An Educational Initiative to Improve Parent/Family Hand Hygiene Compliance.

BACKGROUND: Health care-associated infections contribute to increased morbidity and mortality, increased resource use, higher costs, and extended hospitalizations. Proper hand hygiene (HH) is essential to health care-associated infection prevention. Low compliance among parents in our neonatal intensive care unit (NICU) was identified and prompted development of an HH initiative. OBJECTIVE: The objective of this quality improvement project was to improve parent HH practices with the ultimate goal of achieving 100% compliance with parent HH. METHODS: Between December 2011 and November 2014, our NICU Infection Prevention Committee developed and implemented the parent/family HH initiative entitled "It's in Your Hands" and created learning materials based on the World Health Organization and Centers for Disease Control and Prevention recommendations. Materials included information sheets, posters, stickers, and checklists. Audits, based on the World Health Organization's Five Moments for Hand Hygiene, were performed several times per week to monitor compliance. RESULTS: Before the intervention, only 71% (n = 1143) of all observed parents and family members performed proper HH. After the intervention, proper HH increased to 89% (n = 939). An average compliance of 89% was maintained throughout the intervention phase. DISCUSSION: This initiative led to sustained improvements in HH compliance among NICU parents. It has empowered parents to speak up and request proper HH from health care providers when interacting with their child. This initiative has been adopted as a hospital-wide standard of care.

Health care failure mode and effect analysis to reduce NICU line-associated bloodstream infections.

OBJECTIVE: Central line-associated bloodstream infections (CLABSIs) in NICU result in increased mortality, morbidity, and length of stay. Our NICU experienced an increase in the number of CLABSIs over a 2-year period. We sought to reduce risks for CLABSIs using health care failure mode and effect analysis (HFMEA) by analyzing central line insertion, maintenance, and removal practices. METHODS: A multidisciplinary team was assembled that included clinicians from nursing, neonatology, surgery, infection prevention, pharmacy, and quality management. Between March and October 2011, the team completed the HFMEA process and implemented action plans that included reeducation, practice changes, auditing, and outcome measures. RESULTS: The HFMEA identified 5 common failure modes that contribute to the development of CLABSIs. These included contamination, suboptimal environment of care, improper documentation and evaluation of central venous catheter dressing integrity, issues with equipment and suppliers, and lack of knowledge. Since implementing the appropriate action plans, the NICU has experienced a significant decrease in CLABSIs from 2.6 to 0.8 CLABSIs per 1000 line days. CONCLUSIONS: The process of HFMEA helped reduce the CLABSI rate and reinforce the culture of continuous quality improvement and safety in the NICU.