Preventing pediatric catheter-associated urinary tract infections utilizing urinary catheter Kamishibai cards (K-cards).

BACKGROUND: We instituted Kamishibai (K-card rounding) with the goals of improving indwelling urinary catheter maintenance bundle reliability and decreasing catheter-associated urinary tract infection (CAUTI) rates. METHOD: In a free-standing children's hospital, we undertook a hospital-wide quality improvement project from January 2019 to June 2021 after developing a K-card based on our urinary catheter maintenance bundle. Auditors used K-cards to ask standardized questions during weekly rounds. Bundle reliability and CAUTI rates were analyzed prospectively. RESULTS: During the study period, 826 K-card audits were performed for 657 unique patients. While overall maintenance bundle reliability remained stable at 84%, there was a statistically significant improvement in reliability to the bundle element "medical discussion of need for the urinary catheter" from 88% to 94% (P = .01). The hospital-wide CAUTI rate significantly decreased (incidence rate ratio, 0.38; 95% CI, 0.15-0.93; P = .04). DISCUSSION: Hospital-wide urinary catheter K-card rounding facilitated standardized data collection, discussion of reliability and real-time feedback to nurses. Maintenance bundle reliability remained stable after implementation, accompanied by a significant decrease in the CAUTI rate. CONCLUSIONS: Implementation of hospital-wide urinary catheter K-card rounding was associated with reduction in CAUTI rates. The project demonstrated likelihood of reproducibility with support of a multidisciplinary team.

Stewardship Intervention to Optimize Central Venous Catheter Utilization in Critically Ill Children.

We aimed to describe utilization and indication(s) for long-term central venous catheters (CVCs) in a pediatric intensive care unit (PICU) and identify potential strategies to decrease CVC utilization. METHODS: We conducted a single-center prospective quality improvement initiative at a 30-bed PICU in a large, freestanding, academic children's hospital. We created an electronic report to identify patients with an indwelling CVC for 7 days and older (defined as long term). We discussed the ongoing need for each long-term CVC with PICU clinicians at weekly interdisciplinary structured "CVC stewardship rounds." We then made recommendations around expedited removal of CVCs. We conducted multiple Plan-Do-Study-Act cycles to categorize CVC indications, identify modifiable factors, and educate PICU clinicians. We hypothesized that CVC stewardship rounds would decrease long-term CVC utilization in our PICU. RESULTS: From October 2016 to September 2017, 607 long-term CVCs were eligible for the stewardship intervention. Compared to the preintervention period, we recorded a significant increase in peripherally inserted central catheters and a decrease in nontunneled CVCs (P < 0.001). Most patients had single- or double-lumen CVCs in both the preintervention and intervention periods (86% and 91%, respectively). The utilization of overall long-term CVC devices, and those with modifiable indications, decreased during the intervention period. CONCLUSIONS: A single-center QI intervention focused on PICU CVC stewardship was associated with a decrease in CVC utilization.

Expanding Hospital Capacity during the COVID-19 Pandemic: The Family Voice Matters.

During the initial COVID-19 response, this children's hospital reduced its inpatient capacity by 52 beds with double rooms' conversion to single patient occupancy, causing significant capacity constraints. To solve this challenge, the family perspective was engaged to safely redouble patient rooms and expand capacity as clinical activity increased during the COVID-19 response. METHODS: The team conducted qualitative descriptive interviews with parents of children undergoing congenital heart surgery admitted to the inpatient cardiac unit in a 404-bed free-standing children's hospital. A 2-week pilot study utilizing patient-specific inclusion criteria, newly developed patient room guidelines, universal masking, physical distancing, and inpatient room enhancements with parent COVID-19 testing was conducted. RESULTS: Interviews were conducted [pre (n = 7) and post (n = 6)] regarding patient room redoubling. Participants perceived utilization of double rooms as safe with increased protection, including universal masking, physical distancing, room enhancements, and increased bathroom cleaning. However, some families verbalized anxiety regarding visitation restriction to one parent at a time at the bedside. Additional concerns were voiced around the timing of communication about the need to be placed in a double room. In response, visitation increased to 2 parents at bedside and communication of utilization of double rooms was included in preoperative preparations postpilot. Inclusion criteria were expanded to patients of all ages and included full use of shared in-room bathrooms by parents and patients. CONCLUSIONS: Parents perceived patient room redoubling as safe and family centered. Findings from the pilot study were used to scale broad utilization and increase access to care across the institution.

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.

Enhanced central venous catheter bundle for pediatric parenteral-dependent intestinal failure.

BACKGROUND: Central line-associated bloodstream infections (CLABSIs) cause substantial morbidity and increase antimicrobial use and length of stay among hospitalized children in the United States. CLABSI occurs more frequently among high-risk pediatric patients, such as those with intestinal failure (IF) who are parenteral nutrition (PN) dependent. Following an increase in CLABSI rates, a quality improvement (QI) initiative was implemented. METHODS: Using QI methodology, an enhanced central venous catheter (CVC) maintenance bundle was developed and implemented on 2 units for pediatric PN-dependent patients with IF. CLABSI rates were prospectively monitored pre- and postimplementation, and bundle element adherence was monitored. Enhanced bundle elements included chlorhexidine-impregnated patch, daily bathing, ethanol locks, 2 nurses for CVC care in a distraction-free zone, peripheral laboratory draws, bundling routine laboratory tests, and PN administration set changes every 24 hours. RESULTS: Adherence to enhanced bundle elements increased to >90% over 3 months. CLABSI rates averaged 1.41 per 1,000 central line days preimplementation compared with 0.40 per 1,000 device days postimplementation (P = .003), an 85% absolute reduction in CLABSI rates over 12 months. CONCLUSIONS: Patients with IF are at an increased risk for CLABSI. Enhanced CVC maintenance bundles that specifically target prevention practices in this population may be beneficial.