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A Protocol to Set Up Needle-Free Connector with Positive Displacement on Central Venous Catheter in Intensive Care Unit
Published on: July 13, 2019
Decreasing PICU catheter-associated bloodstream infections: NACHRI's quality transformation efforts
Marlene R Miller1, Michael Griswold, J Mitchell Harris
1MSc, Johns Hopkins University, Johns Hopkins Children's Center, CMSC 1-141, 600 N Wolfe St, Baltimore, MD 21287, USA. mmille21@jhmi.edu
Insights
Implementing comprehensive central venous catheter care bundles significantly reduced catheter-associated bloodstream infections (CA-BSIs) in pediatric intensive care units (PICUs). Daily maintenance bundle compliance was key to decreasing pediatric CA-BSI rates.
Area of Science:
- Pediatric critical care medicine
- Infectious disease prevention
- Quality improvement in healthcare
Background:
- Catheter-associated bloodstream infections (CA-BSIs) pose a significant threat in pediatric intensive care units (PICUs).
- Limited research exists on effective strategies to mitigate CA-BSIs in pediatric populations.
- Developing targeted catheter care practices is crucial for patient safety.
Purpose of the Study:
- To develop and evaluate effective catheter care practices aimed at reducing CA-BSIs in children.
- To assess the impact of standardized insertion and maintenance bundles on infection rates.
- To identify key components of catheter care that contribute to infection reduction.
Main Methods:
- A multi-institutional, interrupted time-series study involving 29 US PICUs.
- Intervention included two practice bundles: a pediatric-tailored insertion bundle and a CDC-based maintenance bundle.
- Quality improvement methods and teaching supported bundle adoption; CA-BSI rates and bundle compliance were tracked.
Main Results:
- A 43% reduction in average CA-BSI rates across participating PICUs (5.4 to 3.1 per 1000 central-line-days).
- High compliance rates achieved: 84% for insertion bundle and 82% for maintenance bundle.
- Maintenance bundle compliance was the sole significant predictor of reduced infection rates (RR: 0.41; P = .017).
Conclusions:
- Maximizing insertion bundle compliance alone is insufficient to eliminate CA-BSIs in pediatric ICUs.
- Daily central line maintenance care, as defined by the maintenance bundle, is critical for reducing pediatric CA-BSIs.
- Further research is needed to optimize the maintenance bundle for complete CA-BSI elimination in children.
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 catheter-care 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 < .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 < .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 maintenance-bundle compliance (RR: 0.41 [95% CI: 0.20-0.85]; P = .017).
Conclusions:
In contrast with adult ICU care, maximizing insertion-bundle 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.
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