Maintenance Bundle Research Articles

Preventing pediatric catheter-associated urinary tract infections utilizing urinary catheter Kamishibai cards (K-cards)

We instituted Kamishibai (K-card rounding) with the goals of improving indwelling urinary catheter maintenance bundle reliability and decreasing catheter-associated urinary tract infection (CAUTI) rates. In a free-standing children's hospital, we undertook a hospital-wide quality improvement project from January 2019 to June 2021 after developing a K-card based on our urinary catheter maintenance bundle. Auditors used K-cards to ask standardized questions during weekly rounds. Bundle reliability and CAUTI rates were analyzed prospectively. During the study period, 826 K-card audits were performed for 657 unique patients. While overall maintenance bundle reliability remained stable at 84%, there was a statistically significant improvement in reliability to the bundle element "medical discussion of need for the urinary catheter" from 88% to 94% (P=.01). The hospital-wide CAUTI rate significantly decreased (incidence rate ratio, 0.38; 95% CI, 0.15-0.93; P=.04). Hospital-wide urinary catheter K-card rounding facilitated standardized data collection, discussion of reliability and real-time feedback to nurses. Maintenance bundle reliability remained stable after implementation, accompanied by a significant decrease in the CAUTI rate. Implementation of hospital-wide urinary catheter K-card rounding was associated with reduction in CAUTI rates. The project demonstrated likelihood of reproducibility with support of a multidisciplinary team.

The effect of an intervention bundle to prevent central venous catheter-related bloodstream infection in a national programme in the Netherlands

Central venous catheters (CVCs) can lead to central line-related bloodstream infections (CRBSIs). A six-item bundle was introduced in 2009 to prevent CRBSI in Dutch hospitals. This study aimed to determine the impact of an intervention bundle on CRBSI risk. Data were obtained from hospitals participating in the national CRBSI surveillance between 2009 and 2019. Bundle compliance was evaluated as a total ('overall') bundle (all six items) and as an insertion bundle (four items) and a maintenance bundle (two daily checks). We estimated the impact of the overall and partial bundles, using multi-level Cox regression. Of the 66 hospitals in the CRBSI surveillance 56 (84.8%) recorded annual bundle (non)compliance for >80% of the CVCs, for one to nine years. In these 56 hospitals CRBSI incidence decreased from 4.0 to 1.6/1000 CVC days. In the intensive care units (ICUs), compliance was not associated with CRBSI risk (hazard ratio (HR) for the overall, insertion and maintenance bundle were 1.14 (95% confidence interval 0.80-1.64), 1.05 (0.56-1.95) and 1.13 (0.79-1.62)), respectively. Outside the ICU the non-significant association of compliance with the overall bundle (HR 1.36 (0.96-1.93)) resulted from opposite effects of the insertion bundle, associated with decreased risk (HR 0.50 (0.30-0.85)) and the maintenance bundle, associated with increased risk (HR 1.68 (1.19-2.36)). Following a national programme to introduce an intervention bundle, CRBSI incidence decreased significantly. In the ICU, bundle compliance was not associated with CRBSI risk, but outside the ICU improved compliance with the insertion bundle resulted in a decreased CRBSI risk.

Reducing Central-Line-Associated Bloodstream Infections (CLABSI): An Improvement Project in a Specialized Tertiary Hospital.

Central-line-associated bloodstream infections (CLABSI) are preventable hospital-acquired infections that harm and prolong a patient's hospital stay and increase unnecessary hospital expenditure. In collaboration with infection control and hospital epidemiology, the quality management department initiated a performance improvement project to address 144 CLABSI events in 2017. The performance improvement project team used brainstorming to create change ideas presented in a driver diagram. The team then applied plan-do-study-act (PDSA) cycles to implement and monitor the improvements. Finally, the team applied a bundle of interventions that included the following: (a) policies and procedures for central line insertion, maintenance and removal processes standardization, (b) physicians training for line insertion by simulation, (c) an awareness campaign that included recognizing healthcare workers and enhancing patient engagement, (d) performing root cause analysis for the CLABSI events, and (e) automation of central line insertion, and (f) maintenance bundles documentation in the hospital information system. The CLABSI rate per 1000 patient days dropped from 1.5 per 1000 device days to 1.03 per 1000 device days. In addition, CLABSI events reduction was 24% by 2018. Then further reduction of 15% occurred by the end of 2019. Thus, the overall decrease in CLABSI events was 35% from the baseline number of events (i.e., 144 events) in 2017. Another achievement of the project is that 10 units reported zero CLABSI events in 2018 and 2019, of which four units had a high central line utilization rate, more than 40%. The implemented interventions effectively reduced the CLABSI events in the hospital. The project team will continue implementing more interventions with monitoring, aiming to achieve zero CLABSIs over time in all the hospital units.

Catheter-related complications in onco-hematologic children: A retrospective clinical study on 227 central venous access devices.

The use of central venous access devices (CVADs) is of paramount importance to safely deliver antiblastic and support therapies in children with cancer. Though, in pediatric patients, as much as in adults, CVADs are potentially associated with severe complications which may result in unscheduled interruption of therapy, hospitalization, increased morbidity/mortality, and increased cost of care. We have reviewed retrospectively our experience with CVADs in children with solid tumors and hematologic diseases, with the purpose of verifying if the adoption of well-defined insertion and maintenance bundles might be effective in reducing catheter-related complications, and in particular catheter-related thrombosis. A total of 227 CVADs were analyzed: 175 peripherally inserted central catheters (PICCs), 50 centrally inserted central catheters (CICCs), and 2 femorally inserted central catheters. All CVADs were non-valved, non-cuffed power injectable polyurethane catheters; 81% were tunneled. Median dwelling time of CVADs was 172 days, for a total number of 39,044 catheter days. A very low incidence of both symptomatic catheter-related thrombosis (0.9%) and catheter-related blood stream infection (0.56 episodes per 1000 catheter days) was found. Unscheduled removal or guidewire replacement because of mechanic complications occurred in 15.7% of CVADs. There was no difference in terms of complications between PICCs and CICCs or between tunneled and non-tunneled catheters. Our experience with CVADs in oncologic and hematologic children suggests that catheter-related complications may be minimized by the adoption of appropriate insertion and maintenance bundles.

The Central HAC Team: Advancing the Culture of Safety Through Practice Observations.

Background: At SickKids, central line-associated blood stream infections (CLABSIs) remain one of the most prevalent hospital acquired conditions. Despite implementation of evidence-based prevention bundles, adherence remains a challenge and obtaining reliable bundle adherence data is complex. An innovative approach to address gaps in practice was developed. Objectives: A centralized hospital acquired conditions team consisting of nurse leaders was created to improve bundle adherence and data reliability. The team partners with local leadership to reinforce the CLABSI maintenance bundle organization wide. The team completes observations, provides just-in-time feedback to nurses, and obtains reliable bundle adherence data. Methods: The team developed a defined model to complete observations: identify, coordinate, observe, feedback, document, and collaborate. Feedback is provided using error prevention strategies. Observations are electronically documented and visualized in real-time to trend results. The team identifies data-driven opportunities to inform priorities. Results: Since September 2018, the team has completed nearly 1500 practice observations with an observed 45% CLABSI reduction and a statistically significant centerline shift (Fig. 1). To evaluate team effectiveness, 118 nurses completed a survey. Seventy-eight percent of respondents agreed feedback was clear and 59% felt it helped improve their practice. Bundle adherence data comparing the team to local unit observers remains variable; however, education of local champions is improving reliability. Conclusions/Implications: The centralized approach for providing just-in-time feedback is an effective method to promote evidence-based practice and drive CLABSI maintenance bundle adherence. This method improves understanding of common failure modes to target improvements. Preliminary evaluation highlights how the team impacts safety culture and improves patient outcomes through practice observations.Fig. 1.: The Hospital for Sick Children Statistical Process Control Chart displaying hospital CLABSI rate comparative to the Solutions for Patient Safety network from August 2018 to February 2022. CLABSIs = central line-associated blood stream infections.

CLABSI Reduction Strategy: Utilizing Weekly Rounds with an Interdisciplinary Team.

Introduction: Central line-associated bloodstream infections (CLABSIs) in pediatric ICU patients lead to a wide variety of adverse outcomes, including increased mortality and morbidity, longer length of stay in the hospital, and greater healthcare costs.1 Pediatric cardiac ICU patients are at a significantly higher risk for these healthcare-associated infections because of an increase in risk factors, such as congenital anomalies, presence of surgical wounds, compromised immune function post cardiopulmonary bypass, and the presence of multiple invasive medical devices.2 After noting an increase in the pediatric cardiac ICU CLABSI rate, an interdisciplinary team was formed to approach the problem. Objectives: The primary aim was to decrease the pediatric cardiac ICU’s CLABSI rate by 25% in 8 months by engaging an interdisciplinary team with identifying and addressing CLABSI maintenance bundle concerns in real time on the unit. Methods: An interdisciplinary team with representatives from nursing, unit leadership, intensive care physicians, infection prevention, nurse practitioners, vascular access team, and quality improvement utilized initial Plan-Do-Study-Act (PDSA) cycles to develop a rounding tool that identified threats to the CLABSI prevention bundle with patient-specific interventions to consider implementing. Weekly interdisciplinary rounds were then conducted on all central lines. Additional PDSA cycles focused on addressing unit-specific gaps in education and increasing awareness of best practices for central line care and maintenance. These included addition and delineation of space to separate clean and dirty supplies, hygiene supplementations to the care bundle, eRecord handoff updates, and both in-person and online educational offerings. Results: Preliminary data suggested a decrease in CLABSI rate during the initial 4-month intervention period (Fig. 1). The focus on central line care has also led to more consistent and robust observations for bundle compliance. In 2021, zero CLABSIs were noted for the initial 4 months after intervention contributing to a unit record of 243 days CLABSI-free. We would like to call attention to 2 points in Figure 1. Point two represents the initiation of weekly interdisciplinary CLABSI rounds. Point three represents 2 premature infants, atypical for unit census, on extracorporeal membrane oxygenation with hemodialysis catheters that required off-label use of Prismaflex. Conclusions: Engagement of a microsystem’s interdisciplinary team to focus efforts on identifying and addressing real-time concerns to central lines has led to a short-term decrease in CLABSI rate. Sustaining this decrease in CLABSIs will require continual reassessment of the effectiveness of strategies utilized. Additional PDSA interventions as a result of the weekly rounds are being investigated, including the use of antimicrobial sheets for high-risk patients, the creation of unit-specific prepackaged sterile central line dressing kits, and transitioning from alcohol to chlorohexidine scrubs for hub accessing.Fig

Meso-level factors fostering or hindering the implementation of age-related HR practices in firms

PurposeThis paper aims to examine two types of age-related human resources (HR) practices, i.e. age-specific and age-inclusive HR practices and firm-level (meso-level) factors that foster or hinder the implementation of these two types of practices.Design/methodology/approachBased on a cross-case analysis of four firms across industries in Thailand, a developing country, the empirical evidence draws on semi-structured interviews with the top managers, HR managers and aging employees of four firms; field visits; nonparticipant observations; and a review of archival documents and Web-based reports and resources.FindingsThis paper proposes that age-specific HR practices primarily include those HR practices under the regulation HR bundle and some HR practices under the maintenance and recovery HR bundles. Additionally, the factors fostering the implementation of age-specific HR practices in firms include group corporate culture, nonunionism within the workplace, paternalistic leaders, a focus on the development of internal labor markets within firms and the need for tacit knowledge transfer from aging employees to younger-generation employees, whereas the factors hindering the implementation of age-specific HR practices in firms include age biases within firms. Moreover, age-inclusive HR practices primarily include HR practices under the development HR bundle and some HR practices under the maintenance and recovery HR bundles. Additionally, the factors fostering the implementation of age-inclusive HR practices in firms include the procedural justice climate, the transition from a family ownership structure to a professional ownership structure and result-/output-based corporate culture, whereas the factors hindering the implementation of age-inclusive HR practices in firms include experience-/seniority-based corporate culture. In fact, some of the meso-level factors that foster or hinder the implementation of age-specific and age-inclusive HR practices tend to be influenced by the national institutional and cultural contexts of the developing country where firms that implement such HR practices are located.Originality/valueThis paper aims to fill the research gap by examining both age-specific and age-inclusive HR practices. Additionally, this paper analyzes the factors fostering or hindering the implementation of these two dimensions of age-related HR practices across firms by using a case study of firms in Thailand, a developing country. To date, most studies in this area have focused on one of these dimensions, while comparisons between different HR dimensions are rather scarce. Finally, this paper contributes to the prior literature on strategic HR and comparative institutional perspective on HR strategies and practices as proposed by Batt and Banerjee (2012) and Batt and Hermans (2012) that future research should go beyond the meso-level (organizational) context. In this regard, some of the factors that foster or hinder the implementation of age-specific and age-inclusive HR practices tend to be influenced by the national institutional and cultural contexts of the developing country of Thailand.

Impact of Training on Central Line Associated Blood Stream Infection Maintenance Bundle on Central Line Associated Blood Stream Infection Rates - A Retro-prospective Study in a Selected Hospital, Hyderabad

Background: Central line-associated bloodstream infections (CLABSI) are a very common cause of healthcare-associated infections (HAI). CLABSIs will not only increase mortality and morbidity but also increases length of stay (LOS) and financial burden to ICU patients. Infection control practices play a major role in preventing CLABSI. Research indicates that quality improvement initiatives have helped in reducing CLABSI rates. CLABSI rates have been successfully reduced in ICU settings however, there is still significant variability in practice due to poor adherence to evidence-based CLABSI maintenance bundle components. However, nurses frequently struggle to follow evidence-based preventive practices, thus it is necessary to understand better the behavioral influences on implementing CLABSI prevention measures. Additionally, it has been emphasized that implementation studies must consider or quantify the potential impact on CLABSI rates. Before taking up the study, we have noticed increase in CLABSI rates for 1month Period, for which the Retrospective data was collected and analyzed to understand the gaps to implement CLABSI maintenance bundle components. Therefore, this study helped us identifying gaps in maintenance bundle and observed infections rates before and after study Aim: To evaluate the effect of central line (CL) bundle compliance on central line-associated bloodstream infections (CLABSIs) To evaluate the knowledge and practices of physicians and nurses working in all ICUs and wards regarding the components of central line maintenance bundles (ref table I) Design: Used a retro prospective study, to reduce the CLABSI rates and to increase awareness on maintenance bundle components in intensive care units (ICU) and wards. we have initiated a structured training program to all nurses and doctors. Two tools were prepared. one is to assess the knowledge of nurses and doctors working in ICUs and wards on CLABSI. The second tool consists of components related to central line maintenance bundle to evaluate the effectiveness in reducing incidence of CLABSI. A total 489 Registered nurses and 10 intensivists and 15 ward doctors were included in the current study. Phase I was the pre-interventional period during this period audits were conducted, we observed lacunae in implementing CLABSI Maintenance bundle. Phase II was the intervention period lasting for 2 month, during this period, the entire nursing staff and doctors working in ICUs and Wards underwent a continuous teaching and training. Phase III was the post-intervention period- In this period questionnaire was given in September and again in December. This was to check for the impact of training on knowledge and awareness level which will further lead better implementation of the practices. Observed CLABSI rate reduced from17.2. to 6.8 per 1000 central line days. Result: Knowledge assessment- Comparison data between June 2021 and September 2021 mean knowledge score significantly higher in September (9.1) than June (6.4) .similarly, December (9.9) score significantly higher than June and September to determine the difference between the mean of various observations in the pre and post intervention period with 95% confidence interval, the difference in the knowledge level and CLABSI rate in the pre and post intervention period was found significant(p<0.001) .During this 6 months period(July 2021 to December 2021) there were a total of 1120 patients on central lines, for all the patients line care was observed after implementation of structured training programme. The rate of CLABSI significantly declined from 17.2 per 1000 catheter days to 6.8 per 1000 catheter days. Conclusion: This study clearly indicated that the educational interventions in structured formats are imperative when imparting trainings in Infection control practices and should be implemented frequently to bridge the gap between knowledge and practice. With the dynamics of infection control and the challenges faced in its implementation continuing this type of trainings will ensure all use evidence-based interventions. Recommendations: Continues Training program should be carried out for nurses and doctors related to implementation of CLABSI Bundle. Keywords: CLABSI, Catheter hub care, Hand hygiene, Training, Maintenance bundle, Teaching, Implementing, Structured program.

Implementation of Evidence-based Maintenance Bundles to Reduce Central Line-Associated Bloodstream Infection (CLABSI) and Catheter-Associated Urinary Tract Infection (CAUTI) Rates

Background In 2021, an increase in central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI) rates was observed at an academic medical center. CLABSI and CAUTI have a significant impact on patient outcomes including mortality, length of stay, and healthcare costs. Reduction of CLABSI and CAUTI incidence can be achieved through implementation of standardized, evidence-based maintenance bundles for central lines and foley catheters. Methods A multidisciplinary team began meeting weekly in July 2021 to review CLABSI and CAUTI rates, insertion and maintenance practices, product utilization, and education initiatives. Standardized central line and foley catheter maintenance bundles were developed based on current infection prevention evidence-based guidelines. In August 2021, the maintenance bundles were implemented on every unit and education was provided to nursing unit leaders and staff by the infection prevention department. The maintenance bundles are maintained through daily audits by nursing unit leaders and weekly validation audits by the infection prevention department. Observations from the weekly validation audits are documented and reviewed on a weekly basis by the multidisciplinary team and influence ongoing education topics. Results Between August and November 2021, a 4% reduction in CLABSI rate (2.2 per 1,000 device days) and a 19% reduction in CAUTI rate (2.9 per 1,000 device days) was observed compared to the baseline period. The central line maintenance bundle compliance increased by 21% from August to November with a maximum monthly compliance of 84%. The foley catheter maintenance bundle compliance increased by 23% with a maximum monthly compliance of 79% during the same time period. Conclusions A standardized, evidence-based maintenance bundle for central lines and foley catheters contributes to the reduction of CLABSI and CAUTI rates. Continuous monitoring and validation of the maintenance bundles provides guidance, accountability, and feedback for staff and highlights issues and trends that can be addressed through education. In 2021, an increase in central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI) rates was observed at an academic medical center. CLABSI and CAUTI have a significant impact on patient outcomes including mortality, length of stay, and healthcare costs. Reduction of CLABSI and CAUTI incidence can be achieved through implementation of standardized, evidence-based maintenance bundles for central lines and foley catheters. A multidisciplinary team began meeting weekly in July 2021 to review CLABSI and CAUTI rates, insertion and maintenance practices, product utilization, and education initiatives. Standardized central line and foley catheter maintenance bundles were developed based on current infection prevention evidence-based guidelines. In August 2021, the maintenance bundles were implemented on every unit and education was provided to nursing unit leaders and staff by the infection prevention department. The maintenance bundles are maintained through daily audits by nursing unit leaders and weekly validation audits by the infection prevention department. Observations from the weekly validation audits are documented and reviewed on a weekly basis by the multidisciplinary team and influence ongoing education topics. Between August and November 2021, a 4% reduction in CLABSI rate (2.2 per 1,000 device days) and a 19% reduction in CAUTI rate (2.9 per 1,000 device days) was observed compared to the baseline period. The central line maintenance bundle compliance increased by 21% from August to November with a maximum monthly compliance of 84%. The foley catheter maintenance bundle compliance increased by 23% with a maximum monthly compliance of 79% during the same time period. A standardized, evidence-based maintenance bundle for central lines and foley catheters contributes to the reduction of CLABSI and CAUTI rates. Continuous monitoring and validation of the maintenance bundles provides guidance, accountability, and feedback for staff and highlights issues and trends that can be addressed through education.

A Quality Improvement Initiative to Increase Central Line Maintenance Bundle Compliance through Nursing-led Rounds

Introduction:Improvements in maintenance bundle compliance around central line-associated bloodstream infections (CLABSIs) lack standardization. The objective was to implement a formalized nursing-led rounding process, Rounds for Influence, with a goal of 12 rounds/wk on each inpatient unit and Ambulatory Infusion Center, achieving > 90% maintenance bundle compliance.Methods:Nurses served as peer “influencers” to perform rounds. The CLABSI prevention team created three comprehensive rounding tools (line access, dressing change/port needle insertion, and cap change) on a digital platform. The team designed these tools to assess clinical competence for maintenance bundle components and implemented nine plan-do-study-act cycles throughout the study period.Results:Influencers completed 191 rounds after the first month of implementation, resulting in a 264.2% increase from the baseline of 52.5 rounds per month. Over the 2.5 years postimplementation, rounds resulted in 7836 total observations. Maintenance bundle compliance decreased from 86.9% (centerline value from November 2017 to September 2018) to 40.8% after the first month of implementation. Compliance increased iteratively (two separate centerline shifts) to a current centerline value of 87.1%. The CLABSI 12-month cumulative standardized infection ratio (SIR) was 0.9 in November 2017 and dropped to 0.53 in June 2021.Conclusion:Implementing a formalized nursing-led rounding process led to increased maintenance bundle compliance, decreased CLABSI SIR, and is an integral part of nursing practice. Given this success, there is interest from other hospital-acquired condition improvement teams in applying this rounding practice to their improvement work.

Adherence to central venous catheter maintenance bundle in an intensive care unit.

To check adherence to the Central Venous Catheter maintenance bundle in an Intensive Care Unit, after an educational intervention to the professionals who provide care to patients using this catheter. Descriptive-exploratory study, carried out in two stages: stage 1 - educational intervention and stage 2 - verification/observation of adherence. Data were organized in the Microsoft Excel® and analyzed through the Stata®. Sixty three workers participated in stage 1 and 44 in stage 2. The sample consisted of 64 observation opportunities. Among the domains observed, the recording of indication of permanence had an 8% compliance rate; aseptic technique in catheter handling, 3%; maintenance of the infusion system, 15%; and care with the central venous catheter dressing, 17%. The domains represent unwanted care according to the Positivity Index for assessing the quality of care. The findings show the need for discussions, training, and investments in constant strategies for the prevention of primary bloodstream infections related to the central venous catheter.

777. Implementation of Antimicrobial Impregnated Catheters to Reduce Central Line Associated Bloodstream Infections (CLABSI) in a Pediatric Setting

BackgroundAntimicrobial impregnated catheters (AIC) are one strategy to prevent CLABSI with existing data for central lines required for short duration, however, the strength of evidence, particularly for children, is lacking. Recent 3-year CLABSI data at our institution show 60 (51%) infections occurred in central lines within 8 weeks of insertion, suggesting an opportunity for evaluation of an intervention targeting this time frame. We implemented AIC to evaluate their effectiveness in reducing CLABSI standardized infection ratio (SIR) in patients requiring central venous access for less than 8 weeks. We also monitored for complications (malfunction, line exchange, fungal infection).MethodsA stepped wedge observational design was used to implement Minocycline + Rifampin impregnated catheters in a rolling fashion across the institution. Children > 3kg were eligible if admitted to a participating unit and required central venous access through a peripherally inserted central catheter (PICC), non-tunneled catheter, or tunneled non-cuffed femoral catheter for < 8 weeks. Units, prioritized based on CLABSI SIR, were added to the intervention monthly until AIC were used throughout the institution. A multidisciplinary team (infectious diseases and infection control experts, CLABSI leaders, unit-based physicians and nurses, proceduralists, supply chain) met weekly to facilitate implementation, assess for CLABSI and monitor for complications.Figure 1. Study design. This figure describes the stepped wedge study design where units were phased into the invention on a rolling monthly basis allowing for comparison between and within units. The shaded boxes represent time periods when units were using antimicrobial impregnated catheters and the white boxes represent time periods when units were using standard non-impregnated catheters.ResultsAIC were systematically implemented over a 7-month period. The institution’s CLABSI SIR decreased from 0.80 to 0.59 during this timeframe. There were no NHSH defined CLABSI in patients with an AIC during the intervention. Obstacles included shortage of catheters due to supply chain disruption, adjustment of technique for line insertion and cracked/broken lines. Infections and complications were reviewed by the multidisciplinary team and compared to historical rates with non-impregnated lines. This figure shows the institution’s rolling 12-month SIR during the intervention period.ConclusionCLABSI SIR decreased at our institution during the intervention period. While many efforts likely led to this reduction (optimizing maintenance bundle, unit based CLABSI initiatives), we believe the use of AIC contributed to this improvement. There were no pediatric-specific safety events identified during implementation.Disclosures Ravi Jhaveri, MD, AstraZeneca (Consultant)Dynavax (Consultant)Elsevier (Other Financial or Material Support, Editorial stipend as Co-EiC, Clinical Therapeutics)Hologic (Consultant)Seqirus (Consultant)

The Compliance of Healthcare Providers to Care Bundles in a Tertiary Hospital in Riyadh Region

This study aimed to describe the compliance rate of healthcare providers to care bundles in a tertiary hospital in Riyadh Region. The overall compliance rate of hand hygiene was low (less than 80%). The overall compliance rates of urinary catheter bundle, central line insertion bundle, and central line maintenance bundle were high (more than 95 %). The compliance rate to SSI bundle, ventilator bundle, safe injection practice, and using personal protective equipment was high. It is important to increase the compliance rate of the care bundles elements to 95 percent or greater, particularly the compliance to hand hygiene to improve patient care.

Reducing central line-associated bloodstream infection in contaminated central venous catheters: case studies of a pediatric contamination guideline

Healthcare organizations have prioritized patient safety and quality improvement efforts to reduce central line-associated bloodstream infections (CLABSIs). Implementation of central venous catheter (CVC) insertion and maintenance bundles have significantly reduced infection rates. Nevertheless, CLABSIs continue to be a significant cause of mortality and morbidity in hospitals, and further efforts are necessary to improve CVC care practices. A hospital-wide committee at a tertiary care pediatric hospital identified gaps in our CVC maintenance practices resulting from CVC contamination events from a patient's body fluids. A lack of published literature on the topic resulted in the need to create an institutional clinical practice guideline (CPG) to develop guidance to mitigate potential CLASBIs from CVC contamination. Utilization of the CVC CPG in all inpatient units and other reduction strategies resulted in a steady decline in our CLABSI rates, particularly in those related to CVC contamination events. Case reports illustrate the effectiveness of the CPG.

A Prospective Study of Family Engagement for Prevention of Central Line-associated Blood Stream Infections.

We sought to determine if a family-centered care (FCC) handout intervention designed to encourage family engagement (FE) in the prevention of central line-associated bloodstream infections (CLABSIs) would alter parental perceptions of FCC and improve staff compliance with CLABSI bundle components. A prospective quasiexperimental study of 121 legal guardians of children with a central venous catheter (CVC) admitted to the pediatric intensive care unit (PICU). Baseline (n = 59) and intervention (n = 62) groups of parents completed an 18-question online survey assessing basic CLABSI care practices and FCC principles. The intervention group received an FE handout before completing the survey with information about CLABSI prevention practices designed to encourage active participation in their child's CVC care. Independent sample t-tests found significant improvements in the intervention parents responses compared to the baseline group (no handout) on survey items assessing CLABSI knowledge (P < 0.001) and on parental perceptions of FCC in the domains of dignity and respect, information sharing, participation, and partnership (all with a P < 0.001). An improvement was observed in staff CLABSI maintenance bundle compliance in the postintervention period, increasing from 89% to 94%. Educating parents on CLABSI prevention strategies and encouraging family participation in CVC care was associated with improved parental perceptions of participation in their child's care, medical team's listening, attention, honesty, and explanation of treatment plans and was associated with an increase in staff compliance with CLABSI maintenance bundle practices.

Reducing late-onset neonatal sepsis in very low birthweight neonates with central lines in a low-and-middle-income country setting

BackgroundLate-onset neonatal sepsis (LONS) is a significant contributor to morbidity and mortality in very low birthweight (VLBW) neonates with indwelling central lines. Compliance to central line care bundles is suboptimal...

Inequities in CLABSI Rates in a Children’s Hospital by Race, Ethnicity, and Language Preference

Background: Systemic racism results in health inequities based on patient race, ethnicity, and language preference. Whether these inequities exist in pediatric central-line–associated bloodstream infections (CLABSIs) is unknown. Methods: This retrospective cohort study included patients with central lines hospitalized from October 2012 to June 2019 at our tertiary-care children’s hospital. Self-reported race, ethnicity, language preference, demographic, and clinical factors were extracted from the electronic health record. The primary outcome was non–mucosal barrier injury (non-MBI) CLABSI episodes as defined by the NHSN. CLABSI rates between groups were compared using χ2 tests and Cox proportional hazard regression. We adjusted for care unit, age, immunosuppressed status, diapered status, central-line type, line insertion within 7 days, daily CLABSI maintenance bundle compliance, number of blood draws and IV medication doses, and need for total parental nutrition, extracorporeal membrane oxygenation, and renal replacement therapy. In mid-2019, we engaged stakeholders in each care unit to describe preliminary findings and to identify and address potential drivers of observed inequities. Results: We included 337 non-MBI CLABSI events over 230,699 central-line days (CLDs). The overall non-MBI CLABSI rate during the study period was 1.46 per 1,000 CLDs. Unadjusted CLABSI rates for black or African American (henceforth, “black”), Hispanic, non-Hispanic white, and Asian (the 4 largest race or ethnicity groups by CLDs) patients were 2.74, 1.53, 1.42, 1.24 per 1,000 CLDs, respectively (P &lt; .001) (Table 1). Unadjusted CLABSI rates for patients with limited-English proficiency (LEP) and English-language preference were 1.98 and 1.38 per 1,000 CLDs, respectively (P = .014). After adjusting for covariates, the hazard ratio (HR) point estimate for CLABSI rate remained higher for black patients (HR, 1.50; 95% CI, 0.99–2.28) and patients with LEP (HR, 1.33; 95% CI, 0.87–2.05), compared to the reference group based on largest CLD. The differences in CLABSI rate by race or ethnicity and language were more pronounced in 2 of our 6 care units. Stakeholder engagement and analysis of hospital data revealed opportunities on those units for improved (1) interpreter utilization and (2) line maintenance observation practices by race/ethnicity and language preference (data not shown). These findings and CLABSI rates over time by race/ethnicity and language preference (Figures 1 and 2) were shared with frontline staff. Conclusions: In our children’s hospital, CLABSI rates differed based on patients’ self-reported race, ethnicity, and language preference, despite controlling for factors commonly associated with CLABSI. Identifying inequities in CLABSI rates and mitigating their determinants are both essential to the goal of achieving equitable care.Funding: NoDisclosures: None

Reduction of central line-associated bloodstream infections in a large acute care hospital in Midwest United States following implementation of a comprehensive central line insertion and maintenance bundle.

Central line-associated bloodstream infection (CLABSI) is a preventable medical condition that results in increased patient morbidity and mortality. We describe the impact of various quality improvement interventions on the incidence of CLABSI in an 848-bed community teaching hospital from 1 January 2013 to 31 December 2017. To reduce CLABSI rates after implementation of a comprehensive central line insertion and maintenance bundle. A comprehensive bundle of interventions was implemented incorporating the standard US Centers for Disease Control and Prevention bundle with additional measures such as root-cause analysis of all CLABSI cases, use of passive disinfection caps on vascular access ports, standardisation of weekly central venous catheter (CVC) site dressing changes, and use of antithrombotic and antimicrobial-coated CVCs with fewer lumens. A retrospective study evaluated CLABSI rates and time of CLABSI onset after CVC placement in both intensive care unit (ICU) and non-ICU settings. The annual number of CLABSI cases declined 68% (34 to 11 patients) from 2013 to 2017. There was a 30% decline in CVC days from years 2014 to 2017. Over the same period, CLABSI cases per 1000 CVC days decreased from 0.624 to 0.362: a 42% decline. Following the implementation of a comprehensive bundle of interventions for CVC insertion and maintenance, we found a reduction in rates of CLABSI.

Reducing Central Line-Associated Bloodstream Infection in Contaminated Central Venous Catheters: Case Studies of a Pediatric Contamination Guideline

Highlights Abstract Healthcare organizations have prioritized patient safety and quality improvement efforts to reduce central line-associated bloodstream infections (CLABSIs). Implementation of central venous catheter (CVC) insertion and maintenance bundles have significantly reduced infection rates. Nevertheless, CLABSIs continue to be a significant cause of mortality and morbidity in hospitals, and further efforts are necessary to improve CVC care practices. A hospital-wide committee at a tertiary care pediatric hospital identified gaps in our CVC maintenance practices resulting from CVC contamination events from a patient’s body fluids. A lack of published literature on the topic resulted in the need to create an institutional clinical practice guideline (CPG) to develop guidance to mitigate potential CLASBIs from CVC contamination. Utilization of the CVC CPG in all inpatient units and other reduction strategies resulted in a steady decline in our CLABSI rates, particularly in those related to CVC contamination events. Case reports illustrate the effectiveness of the CPG.

Quality Improvement Initiative to Reduce Intravenous Line-related Infiltration and Phlebitis Incidence in Pediatric Emergency Room.

Aim and objectiveTo reduce the incidence of infiltration and phlebitis by 50% over 2 months among children admitted to the emergency room (ER) of a tertiary care hospital.Materials and methodsThe study was conducted in the pediatric ER of a tertiary care hospital in North India. All children aged >28 days, receiving intravenous (IV) medication and/or fluids, were enrolled between June (2017) and September (2017). Existing practices of IV line insertion and maintenance were observed and recorded. The visual infusion phlebitis score and infiltration assessment scale were to grade the extent of two. The intervention classified as “IV line insertion and maintenance bundle” included the introduction of low-cost mobile sterile compartment trays, audit and feedback, organizational change, introduction of infection control nurse and quality improvement (QI) team formations were implement in different Plan-Do-Study-Act (PDSA) cycles. Reduction in the “incidence of phlebitis and infiltration” was outcome measures while “scores on checklist of IV line insertion and IV line maintenance and administration of drugs” were process measures.ResultThe process measures, for IV line insertion, maintenance and administration of drugs through IV line, revealed an increase in scores on the checklist. There was a significant decrease in the incidence of infiltration and phlebitis from 82.9 and 96.1% to 45 and 55%, respectively, postimplementation of all PDSA cycles.ConclusionMultifaceted QI IV line insertion and maintenance bundle reduced the incidence of infiltration and phlebitis. These interventions when integrated into daily work bundles along with continuous education and motivation help in sustaining the goal and attaining long-term success.How to cite this articleSingh N, Kalyan G, Kaur S, Jayashree M, Ghai S. Quality Improvement Initiative to Reduce Intravenous Line-related Infiltration and Phlebitis Incidence in Pediatric Emergency Room. Indian J Crit Care Med 2021;25(5):557–565.