Reduced Central Line Associated Bloodstream Infections in Pediatric Cardiac Patients

Purpose/Aims: To reduce the incidence of central line associated bloodstream infections (CLABSIs) in a 12 bed Cardiovascular Intensive Care Unit (CVICU).

Background: Our 238 bed children's hospital participated in a collaborative of 24 children's hospitals led by Children's Hospital Association (CHA) in 2005-2006 to reduce CLABSI through development of evidence-based catheter insertion and maintenance bundles. Adoption of these care bundles led to organization-wide and unit level reduction in CLABSI rates, from 1.2/1000 catheter days in FY 2011 to 0.6/1000 catheter days in FY 2012. However, 4 CLABSIs occurred in CVICU over an 8 week time period in Fall 2012. Root cause analysis of the individual events as well as the cluster of events revealed that prescribed care bundles were followed; however, there was an increased use of larger bore peripherally inserted central catheter (PICC) lines in infants undergoing cardiac surgery that were left in place for longer periods of time. Larger PICC lines allow lab draws and administration of blood products which resulted in more frequent line access and increased risk for CLABSI. Central line days increased from 1625 in FY 2011 to 2248 in FY 2014.

Methods: Staff received refresher education on PICC line dressing changes due to some inconsistent practices identified in root cause analysis. In late October 2012 the “hub scrub” agent for accessing any line hub was changed from 70% isopropyl alcohol pads to Chlorascrub® wipes (3.15% chlorhexadine (CHG) + 70% isopropyl alcohol). To ensure that this practice change was enacted, all alcohol prep pads were removed from the CVICU and replaced with Chlorascrub wipes. Although no literature demonstrates that either agent is superior, an easily implemented, rapid change was needed in the CVICU due to the cluster of infections. Some case reports describe a decrease in CLABSI after changing “hub scrub” agents, secondary to increased attention to the “hub scrub” procedure. In October 2013, daily bathing with CHG-impregnated bath cloths was also implemented in the CVICU as supported by clinical practice guidelines. Outcomes: Since October 2012, there have been no CLABSIs in the CVICU, despite increasing central line days (see Table 1). The CHG “hub scrub” procedure has been easily incorporated, after some initial concerns

about longer drying time for CHG compared to alcohol. CHG bathing has produced some    concerns about skin dryness, but no significant adverse effects have been seen.

Implications: Significant reduction of CLABSI is achievable, and the goal of zero seems less formidable following this evidence-based quality improvement project. Initial implementation of evidence-based practice bundles was effective in reducing CLABSI, but changes in practice required willingness to investigate and adopt new evidence-based strategies to meet changing needs. Root cause analysis is an effective method of identifying need for practice revision.