Decreasing PICU Catheter-Associated Bloodstream Infections: NACHRI's Quality Transformation Efforts

Abstract

WHAT'S KNOWN ON THIS SUBJECT:CA-BSIs are a significant source of morbidity, mortality, and added medical costs to hospitalized adult and pediatric patients. Despite these data, strategies for reducing health care complications such as pediatric CA-BSIs have received relatively little attention. WHAT THIS STUDY ADDS:In contrast with adult ICU care, maximizing insertion-bundle compliance alone cannot help PICUs to eliminate CA-BSIs. Instead, the main drivers for additional reductions in pediatric CA-BSI rates seem to be issues surrounding daily maintenance care for central lines.abstract OBJECTIVE: Despite the magnitude of the problem of catheter-associated bloodstream infections (CA-BSIs) in children, relatively little research has been performed to identify effective strategies to reduce these complications. In this study, we aimed to develop and evaluate effective cathetercare practices to reduce pediatric CA-BSIs. STUDY DESIGN AND METHODS:Our study was a multi-institutional, interrupted time-series design with historical control data and was conducted in 29 PICUs across the United States. Two central venous catheter-care practice bundles comprised our intervention: the insertion bundle of pediatric-tailored care elements derived from adult efforts and the maintenance bundle derived from the Centers for Disease Control and Prevention recommendations and expert pediatric clinician consensus. The bundles were deployed with quality-improvement teaching and methods to support their adoption by teams at the participating PICUs. The main outcome measures were the rate of CA-BSIs from January 2004 to September 2007 and compliance with each element of the insertion and maintenance bundles from October 2006 to September 2007. RESULTS:Average CA-BSI rates were reduced by 43% across 29 PICUs (5.4 vs 3.1 CA-BSIs per 1000 central-line-days; P Ͻ .0001). By September 2007, insertion-bundle compliance was 84% and maintenance-bundle compliance was 82%. Hierarchical regression modeling showed that the only significant predictor of an observed decrease in infection rates was the collective use of the insertion and maintenance bundles, as demonstrated by the relative rate (RR) and confidence intervals (CIs) (RR: 0.57 [95% CI: 0.45-0.74]; P Ͻ .0001). We used comparable modeling to assess the relative importance of the insertion versus maintenance bundles; the results showed that the only significant predictor of an infection-rate decrease was maintenancebundle compliance (RR: 0.41 [95% CI: 0.20 -0.85]; P ϭ .017). CONCLUSIONS:In contrast with adult ICU care, maximizing insertionbundle compliance alone cannot help PICUs to eliminate CA-BSIs. The main drivers for additional reductions in pediatric CA-BSI rates are issues that surround daily maintenance care for central lines, as defined in our maintenance bundle. Additional research is needed to define the optimal maintenance bundle that will facilitate elimination of CA-BSIs for children. Catheter-associated bloodstream infections (CA-BSIs) are a significant cause of morbidity, morta...

Effect of heparin and other factors associated with complications of peripherally inserted central venous catheters in neonates

“…However, the CA-BSI rate in the second epoch is similar to the rate reported in the pediatric intensive care units and NICUs that implemented 'CA-BSI-prevention bundles' as quality improvement initiatives. [18][19][20] We agree with Miller et al 18 that policies regarding insertion and maintenance of PICCs, together (1) non-central location of the catheter tip, (2) use of dual lumen catheter and (3) insertion into the cephalic vein. Centrally located PICC tips were associated with fewer complications in a report in which catheters ranging in size gauge from 2F to 5F were used in children.…”

Bacterial bloodstream infections in the allogeneic hematopoietic cell transplant patient: new considerations for a persistent nemesis

“…9 ( Figure 1) Currently, the NHSN defines primary BSIs in patients with a CVC as 'laboratory-confirmed bloodstream infection (LCBI)' and subcategorized as 'CLABSI' or 'MBI-LCBI '. 11 Inherent to this distinction is emerging evidence showing that improved CVC maintenance is effective at reducing CLABSI rates, [12][13][14] but not in preventing MBI-LCBIs. 15 CLABSI and MBI-LCBI are terms utilized by the NHSN for BSI surveillance.…”

Infection in pediatric interventional radiology

“…In one study, this decreased infection rates from 7.8/1,000 catheter days to 2.3/1,000 catheter days with an overall bundle compliance of 94% [43]. In a study performed in a pediatric ICU, there was a similar decrease in infections from 5.4 to 3.1/1,000 catheter days [44]; however, they determined that more improvement was due to compliance in daily care than during insertion [44].…”

“…In central venous catheters (CVC), the incidence of infection varies depending on [40 The definition of a catheter-related bloodstream infection (CR-BSI) is a positive blood culture from a peripheral vein, clinical manifestations of infection and no apparent source except the catheter [41]. Overall infection rates are 2.3-7.8/ 1,000 catheter days, although this may be an overestimation as infection from another unknown source may be [41][42][43][44][45]. ICU LOS may increase 14.6 days and total hospital LOS 21.1 d [43].…”