G23(P) Development of a root cause analysis tool to investigate catheter associated blood stream infections (CABSI) in a tertiary neonatal unit

Abstract

Aims the Oliver Fisher Neonatal Unit has joined the ‘Matching Michigan’ initiative during 2011. As part of this work we implemented evidence based clinical care bundle for central line insertion and continued to monitor CABSI rates/1000 catheter days monthly. There was a noticeable reduction in CABSI rates from 2012–2014; however this reduction was not sustainable. We developed an RCA tool for CABSI surveillance which enabled measurement of the scope of the problem, identification of special cause variations which since then has driven improvements through changes in clinical practice where necessary. Methods the RCA tool contained 35 data fields which addressed the following five elements; line type, infant’s demographics, operator characteristics and line maintenance issues. The type of organisms identified on positive blood cultures were examined in all cases and sensitivity patterns checked. Recommendations and shared learning was provided at the end of the review. Results We have undertaken RCA reviews on nine infants with confirmed CABSI from Jan–April 2016. Their gestation ranged from 23–40 weeks. All infants were either in-born or ex-utero transfers. Early onset CABSI’s were found in 3/9 cases and late onset in 6/9 cases. We found that in 5/9 infants’ percutaneous Premicath Vygon® central line was present and in 4/9 cases CABSI was associated with UAC/UVC lines. Of the inborn infants, only 4 had a complete line insertion checklist. We identified several line related events which increased the likelihood of infection like extravasation of mal-positioned lines, re-dressing and re-positioning without antimicrobial cover. We have also noticed the emergence of Staphylococcus species resistant to Teicoplanin which is our second line antibiotic of choice in all cases. In some cases Teicoplanin was continued despite microbial resistance identified. Conclusion A CABSI RCA tool has been valuable in identifying factual sources of deviation in a tertiary neonatal setting. This tool maximised opportunities for learning and has resulted in the unit actively pursuing avenues to improve clinical practice.