Prevention of Central Venous Catheter-Associated Bloodstream Infections in Pediatric Intensive Care Units: A Performance Improvement Collaborative

University of Washington School of Medicine, Division of Pediatric Critical Care, Seattle Children's Hospital, Seattle, WA 98105, USA.
Infection Control and Hospital Epidemiology (Impact Factor: 4.18). 08/2009; 30(7):645-51. DOI: 10.1086/598341
Source: PubMed


The goal of this effort was to reduce central venous catheter (CVC)-associated bloodstream infections (BSIs) in pediatric intensive care unit (ICU) patients by means of a multicenter evidence-based intervention.
An observational study was conducted in 26 freestanding children's hospitals with pediatric or cardiac ICUs that joined a Child Health Corporation of America collaborative. CVC-associated BSI protocols were implemented using a collaborative process that included catheter insertion and maintenance bundles, daily review of CVC necessity, and daily goals. The primary goal was either a 50% reduction in the CVC-associated BSI rate or a rate of 1.5 CVC-associated BSIs per 1,000 CVC-days in each ICU at the end of a 9-month improvement period. A 12-month sustain period followed the initial improvement period, with the primary goal of maintaining the improvements achieved.
The collaborative median CVC-associated BSI rate decreased from 6.3 CVC-associated BSIs per 1,000 CVC-days at the start of the collaborative to 4.3 CVC-associated BSIs per 1,000 CVC-days at the end of the collaborative. Sixty-five percent of all participants documented a decrease in their CVC-associated BSI rate. Sixty-nine CVC-associated BSIs were prevented across all teams, with an estimated cost avoidance of $2.9 million. Hospitals were able to sustain their improvements during a 12-month sustain period and prevent another 198 infections.
We conclude that our collaborative quality improvement project demonstrated that significant reduction in CVC-associated BSI rates and related costs can be realized by means of evidence-based prevention interventions, enhanced communication among caregivers, standardization of CVC insertion and maintenance processes, enhanced measurement, and empowerment of team members to enforce adherence to best practices.

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    • "confidence intervals 0.19–1.0)* 2+ Costello et al. (2008) PICU C Hand hygiene promotion, daily evaluation need for CVC removal, CVC insertion kid From 7.8 to 4.7 and to 2.3 per 1000 line-days 2- McKee et al. (2008) PICU D Proper insertion and nursing care, empower nurses to stop the insertion procedure if guidelines were not followed, using a checklist to ensure adherence to the guidelines, providing weekly performance feedback, promotion of hand hygiene, chlorhexedine skin preparation, From 5.2 to 3.0 per 1000 line-days* 2+ Jeffries et al. (2009) "
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    ABSTRACT: Central venous catheter-associated bloodstream infections in children are an increasingly recognized serious safety problem worldwide, but are often preventable. Central venous catheter bundles have proved effective to prevent such infections. Successful implementation requires changes in the hospital system as well as in healthcare professionals' behaviour. The aim of the study is to evaluate process and outcome of implementation of a state-of-the-art central venous catheter insertion and maintenance bundle in a large university children's hospital.Methods/ design: An interrupted time series design will be used; the study will encompass all children who need a central venous catheter. New state-of-the-art central venous catheter bundles will be developed. The Pronovost-model will guide the implementation process. We developed a tailored multifaceted implementation strategy consisting of reminders, feedback, management support, local opinion leaders, and education. Primary outcome measure is the number of catheter-associated infections per 1000 line-days. The process outcome is degree of adherence to use of these central venous catheter bundles is the secondary outcome. A cost-effectiveness analysis is part of the study. Outcomes will be monitored during three periods: baseline, pre-intervention, and post-intervention for over 48 months. This model-based implementation strategy will reveal the challenges of implementing a hospital-wide safety program. This work will add to the body of knowledge in the field of implementation. We postulate that healthcare workers' willingness to shift from providing habitual care to state-of-the-art care may reflect the need for consistent care improvement. Trial registration: Dutch trials registry, trial # 3635.Trial registration: Dutch trials registry (, trial # 3635.
    Full-text · Article · Oct 2013 · BMC Health Services Research
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    • "Krein et al. (2007), within their survey of 516 non-federally funded US adult ICUs, found an association between the use of CR-BSI prevention practices and a higher safety culture score and/or participation in an infection control collaboration. Other factors which have been suggested by literature to support evidence-based practice include the number of ICU beds, level of facility support for evidence-based practice, and metropolitan location (Jeffries et al., 2009; Morritt et al., 2006). "
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    ABSTRACT: Central venous catheters are important in the management of paediatric intensive care unit patients, but can have serious complications which worsen the patients' health, prolong hospital stays and increase the cost of care. Evidence-based recommendations for preventing catheter-related bloodstream infections are available, but it is unknown how widely these are known or practiced in the paediatric intensive care environment. To assess nursing knowledge of evidence based guidelines to prevent catheter-related bloodstream infections; the extent to which Australia and New Zealand paediatric intensive cares have adopted prevention practices; and to identify the factors that encouraged their adoption and improve nursing knowledge. Cross-sectional surveys using convenience sampling. Tertiary level paediatric intensive care units in Australia and New Zealand. Paediatric intensive care nursing staff and nurse managers. Between 2010 and 2011, the 'Paediatric Intensive Care Nurses' Knowledge of Evidence-Based Catheter-Related Bloodstream Infection Prevention Questionnaire' was distributed to paediatric intensive care nursing staff and the 'Catheter-Related Bloodstream Infection Prevention Practices Survey' was distributed to nurse managers to measure knowledge, practices and culture. The questionnaires were completed by 253 paediatric intensive care nurses (response rate: 34%). The mean total knowledge score was 5.5 (SD=1.4) out of a possible ten, with significant variation of total scores between paediatric intensive care sites (p=0.01). Other demographic characteristics were not significantly associated with variation in total knowledge scores. All nursing managers from Australian and New Zealand paediatric intensive care units participated in the survey (n=8; response rate: 100%). Wide practice variation was reported, with inconsistent adherence to recommendations. Safety culture was not significantly associated with mean knowledge scores per site. This study has identified that there is variation in the infection prevention approach and nurses' knowledge about catheter-related bloodstream infection prevention. The presence of an improved safety culture, years of paediatric intensive care experience and higher qualifications did not influence the nurses' uptake of recommendations, therefore further factors need to be explored in order to improve understanding and implementation of best practice.
    Full-text · Article · Sep 2013 · Nurse education today
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    • "Keywords central venous catheter, bloodstream infections, CVC-related BSIs, pediatric oncology topics such as epidemiology, microbiology, complications of CVC-related BSIs, and issues related to CVC care and maintenance (Aly et al., 2005; Institute for Healthcare Improvement [IHI], 2005, 2006; Jeffries et al., 2009; Krein et al., 2007; Pérez-Parra et al., 2010; Pronovost et al., 2006; Shuman et al., 2010; Wall et al., 2005). Despite the common use of CVCs in the 12 400 children diagnosed with cancer annually in the United States, few studies or reviews related to infection prevention strategies in this high-risk population have been conducted (Smith et al., 2010). "
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    ABSTRACT: Reducing or eliminating hospital acquired infections is a national quality of care priority. The majority of the 12,400 children diagnosed with cancer each year require long-term intravenous access to receive intensive and complex therapies. These children are at high risk for infection by nature of their disease and treatment, which often involves use of a central venous catheter (CVC). Throughout the nation, nurses assume frontline responsibility for safe, quality CVC care to minimize the risk of potentially life-threatening infections. Substantial financial and human costs are associated with CVC-related bloodstream infections, including prolonged hospital lengths of stay and increased care required to treat these infections. The purpose of this review of the literature is to summarize existing adult and pediatric data on CVC-related bloodstream infections and explore nursing models of CVC care that may improve pediatric oncology patient outcomes.
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