Children’s Hospital & Medical Center CLA-BSI Prevention and You

Introduction Catheter line-associated bloodstream infections (CLA-BSI) are a significant source of morbidity, mortality and added medical costs to hospitalized adult and pediatric patients every year. Approximately 10% of CLABSIs will result in death due directly to the CLABSI and each CLABSI adds approximately $35,000 to a patient's hospital cost. CLABSIs are preventable and preventing CLABSIs is a top priority of Children's Hospital & Medical Center. Numerous strategies have been deployed to combat this problem. The backbone of eradication is Quality Improvement techniques to spread the correct practice of line insertion and maintenance bundles. Our goal is greater than 90% complete compliance. Current Numbers While we have made efforts to prevent CLABSIs for many years, our efforts began to bear fruit in 2009. At that time, the line infection rate in the PICU was 4.5 infections/1000 line days. We joined the Children's Hospital Association (CHA) CLABSI prevention collaborative which combined the knowledge of over 70 PICUs to apply insertion and maintenance bundles that were based on research in adults. The collaborative showed that correctly utilizing these bundles could decrease line infection rates by 50% in 1 year. We were able to achieve this as well. Since that time, with continued effort and some additions to those bundles, we have shown further progress in the PICU. In 2013, we achieved a rate of 0.5 infections/1000 line days and we recently had a streak of 306 days without an Infection. In the last few years, these bundles have been spread throughout the other units in the hospital. We also joined a similar CHA collaborative for Heme-Onc. Our current hospital-wide rate is 1.7 infections/1000 line days. We continue to have particular challenges with 2 patient populations: those receiving intensive chemotherapy regimens and those with short gut syndrome. Multiple children's hospitals throughout the country have been able to decrease their overall rates below 1 infection/1000 line days even though they also struggle with those populations, too. Current Policies Our policies are based on bundles that have been developed at a national level through the CHA and the CDC. The policies have been set as a group keeping in mind the current state of the research and the practicalities of carrying it out in our patient population. There are multiple strategies that we do not utilize because we feel that the science is questionable or the benefit may be too small. We are constantly re-evaluating these strategies. Line insertion: Anyone inserting a central line (temporary or permanent) is expected to utilize full barrier protection. This includes hat, mask, sterile gown and sterile gloves. In addition, a full-sized sheet should be employed to cover at least 90% of the bed. The insertion site should be scrubbed with CHG for 2 minutes if it is in a crease or 30 seconds if no crease. The CHG should be allowed to dry. After successful insertion, a Biopatch or Algidex patch should be placed on the insertion site, followed by a Tegaderm with at least a 1 inch border all the way around the site. These anti-bacterial patches are intended to decrease the skin flora load. We have shown that the use of the Biopatch decreased our infections from skin bacteria by over 50%. Iodine should not be used since it is relatively ineffective compared to CHG. In the event of an emergency, use your discretion as to how much of this protocol you can follow, but remember that the EZ-IO is available in all crash carts throughout the hospital. We suggest placing an IO to stabilize a patient in an emergent situation. Then, when the patient is stable, a central line can be placed using aseptic technique. If a line is placed under less than ideal circumstances, strongly consider replacing that line when the patient becomes stable. Every failure to follow aseptic technique increases the patient's risk of getting a line infection. Every practitioner who fails to follow aseptic technique places him/herself and our hospital outside the standards of care of the entire country.

Maintenance: Nursing policy governs day-to-day line care. Our current policy mandates that anytime a line is entered (to give medicines or draw labs), the hub will be scrubbed for 15 seconds with an alcohol prep and allowed to dry for 15 seconds. In addition, we use alcohol-impregnated "Dual Caps" to protect unused hubs. Even when one of these caps is in place, the hub must still be scrubbed. The insertion site is protected with a Biopatch or Algidex patch and a Tegaderm or similar occlusive dressing. The dressing is replaced no sooner than every 7 days unless it is coming loose or there is soiling/seepage from the insertion site. Whenever the line is uncovered or open, everyone in the room must wear a mask and the room door must be closed. Do not enter the room if the line is being opened or the dressing is being changed. The nurses will place a red "stop" sign on the door at these times. IV tubing is changed every 5 days unless drips are changed daily. If blood products are given, the tubing and the central line MicroClave caps (not to be confused with the DualCaps) are changed within 24 hours. Exogenous blood products increase the risk of line infections. Expectations As a licensed independent practitioner, you are a leader. People watch everything you do and adjust their behaviors accordingly. If you show that you take CLABSI prevention seriously, others will also take it seriously. If you show that you don't take it seriously, you are giving others permission to not take it seriously and this puts our patients at risk of harm. If you must enter a central line, you must scrub the hub for 15 seconds. If you see others entering the line, please take 15 seconds and make sure that they scrub the hub for 15 seconds. If they do so without prompting, please tell them that you appreciate the great job they are doing. Positive reinforcement is a powerful tool. If they do not, please gently remind them that our standard is a 15 second scrub. Please do not enter the room if a stop sign is in place - this means that the line is open or tubing is being changed. If you do not want the nurses to follow any particular part of the maintenance bundle, e.g., the patient has a true allergy to CHG, you must enter an order in EPIC. Please also list the reason for not following these proven practices. Be prepared to defend your action because we will contact you to discuss why you want to deviate from the standard of care. Whenever possible, change IV meds to oral. Whenever possible, decrease the lab burden (reduce the number of lab checks or consolidate lab draw times). Whenever possible, remove the line. On every rounds, you should ask about the condition of the line and whether the line can be discontinued. Just asking the questions has been shown to decrease line infections. Overall, please be supportive of the nurses. We are asking them to do a lot, and they are already stepping up to the challenge of providing meticulous central line care. Let's not allow line maintenance to become a thankless task. If you have questions about a particular strategy or if you hear of something that is being done at another hospital, we are more than happy to discuss it with you. We are willing to look into new strategies and have the wherewithal to do product research, value-analysis, and even small tests of change, aka, PDSAs. We have several going on right now. CLABSIs can be reduced. Other hospitals have done it. We have done it. Our goal is to have a consistent reduction in CLABSI rates. It is not easy but it is definitely worthwhile. Thank you for your effort. Sincerely, Andrew J. Macfadyen, MD for the CLABSI Prevention Workgroup MR Miller et al, Reducing PICU Central Line -Associated Blood stream Infections: 3-Year Results, Pediatrics, 2011; 128(5); e1077-1083 MR Miller, etal, Decreasing PICU Catheter-Associated Bloodstream Infections: NACHRI's Quality Transformation Efforts, Pediatrics 2010; 125; 206-213 NP O'Grady, et al, Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011, CDC