Inpatient Pediatric Oncology Research Articles

Feasibility, efficacy, and safety of animal-assisted activities with visiting dogs in inpatient pediatric oncology.

Childhood cancer entails a heavy burden for patients and their families. Recent advances in overall survival rates have increasingly brought long-term quality of life into focus. Animal-assisted activities (AAAs) have long been hypothesized to alleviate the burden on pediatric patients and their peers in the hospital setting. However, their use in inpatient pediatric oncology has been a sensitive issue mainly due to the fear of infections, resulting in a lack of studies. This study presents data on the feasibility, safety, and efficacy of AAAs from a single German center. Between 2018 and 2022, 60 patients (median age = 10.3years) diagnosed with malignancy and undergoing treatment were visited by an intervention dog (total visits = 100). Patients were screened for infections as per hospital policy, with additional microbiological testing performed based on symptoms. The dog was screened for human pathogens and zoonoses. Microbial data and hospitalizations were analyzed from twomonths prior to the first visit until twomonths after the last visit. Acceptance of being in the hospital, both with and without planned animal-assisted interventions and pre- and post-intervention state stress, were measured using a validated visual analogue scale (0-10). Patients benefited from AAAs, showing increased acceptance of being in the hospital (median: 7.25 vs. 4.50, P < 0.001) and decreased median state stress ratings one hour after the visit compared to one hour before the visit (1.00 vs. 4.25, P < 0.001). The intervention did not result in an increased number of infections or unplanned hospitalizations, and no zoonoses were detected. All microbial screening tests of the dog were negative. AAAs with visiting dogs in inpatient pediatric oncology are feasible and safe. Although they hold promise for enhancing patients' well-being, further prospective studies are needed. Supplementary file2 (MP4 240076KB).

Investigating the safety and feasibility of osteopathic manipulative medicine in hospitalized children and adolescent young adults with cancer.

Children and adolescents young adults (AYAs) undergoing treatment for oncologic diagnoses are frequently hospitalized and experience unwanted therapy-induced side effects that diminish quality of life. Osteopathic manipulative treatment (OMT) is a medical intervention that utilizes manual techniques to diagnose and treat body structures. Few studies have investigated the implementation of OMT in the pediatric oncology outpatient setting. To date, no studies have investigated the safety and feasibility of OMT in the pediatric oncology inpatient setting. The objective of this study is to investigate the safety and feasibility of OMT in the pediatric oncology inpatient setting. This is a prospective, single-institution pilot study evaluating children and AYAs aged≥2 years to≤30 years with a diagnosis of cancer hospitalized at Riley Hospital for Children (RH) from September 2022 to July 2023. Approval was obtained from the Indiana University Institutional Review Board (IRB). Patients were evaluated daily with a history and physical examination as part of routine inpatient management. Patients who reported chemotherapy side effects commonly encountered and managed in the inpatient setting, such as pain, headache, neuropathy, constipation, or nausea, were offered OMT. Patients provided written informed consent/assent prior to receiving OMT. OMT was provided by trained osteopathic medical students under the supervision of a board-certified osteopathic physician and included techniques commonly taught in first- and second-year osteopathic medical school curricula. Safety was assessed by a validated pain (FACES) scale immediately pre/post-OMT and by adverse event grading per Common Terminology Criteria for Adverse Events (CTCAE) 24 h post-OMT. All data were summarized utilizing descriptive statistics. A total of 11 patients were screened for eligibility. All patients met the eligibility criteria and were enrolled in the study. The majority of patients were male (n=7, 63.6 %) with a median age of 18.2 years at time of enrollment (range, 10.2-29.8 years). Patients had a variety of hematologic malignancies including B-cell acute lymphoblastic leukemia (ALL) (n=5, 45.5 %), T-cell ALL (n=1, 9.1 %), acute myeloid leukemia (AML) (n=2, 18.2 %), non-Hodgkin's lymphoma (n=2, 18.2 %), and Hodgkin's lymphoma (n=1, 9.1 %). All patients were actively undergoing cancer-directed therapy at the time of enrollment. There were 40 unique reasons for OMT reported and treated across 37 encounters, including musculoskeletal pain (n=23, 57.5 %), edema (n=7, 17.5 %), headache (n=5, 12.5 %), peripheral neuropathy (n=2, 5.0 %), constipation (n=2, 5.0 %), and epigastric pain not otherwise specified (n=1, 2.5 %). Validated FACES pain scores were reported in 27 encounters. Of the 10 encounters for which FACES pain scores were not reported, 8 encounters addressed lower extremity edema, 1 encounter addressed peripheral neuropathy, and 1 encounter addressed constipation. The total time of OMT was documented for 33 of the 37 encounters and averaged 9.8 min (range, 3-20 min). Hospitalized children and AYAs with cancer received OMT safely with decreased pain in their reported somatic dysfunction(s). These findings support further investigation into the safety, feasibility, and efficacy of implementing OMT in the pediatric oncology inpatient setting and to a broader inpatient pediatric oncology population.

Improving Chemotherapy Administration on an Inpatient Pediatric Oncology Unit Through Implementation of EMR Chemotherapy Communication Order

Improving Chemotherapy Administration on an Inpatient Pediatric Oncology Unit Through Implementation of EMR Chemotherapy Communication Order

A Randomized Controlled Trial of Animal-assisted Activities for Pediatric Oncology Patients: Psychosocial and Microbial Outcomes

Evidence about the effectiveness and safety of dog visits in pediatric oncology is limited. We conducted a randomized controlled trial (n=26) of dog visits versus usual care among pediatric oncology inpatients. Psychological functioning and microbial load from hand wash samples were evaluated. Parental anxiety was a secondary outcome. We did not observe a difference in the adjusted mean present functioning score (-3.0; 95% confidence interval [CI], -12.4 to 6.4). The difference in microbial load on intervention versus control hands was -0.04 (95% CI, -0.60 to 0.52) log10 CFU/mL, with an upper 95% CI limit below the prespecified noninferiority margin. Anxiety was lower in parents of intervention versus control patients. We did not detect an effect of dog visits on functioning; however, our study was underpowered by low recruitment. Visits improved parental anxiety. With hand sanitization, visits did not increase hand microbial levels. Clinicaltrials.gov NCT03471221.

Decreasing Skin Breakdown Around Central Lines in Patients Receiving Thiotepa Prior to Bone Marrow Transplantation.

Skin breakdown occurring around central line dressings increases the risk for infection and bacteremia in all patients. The risk is magnified when experienced in pediatric patients receiving marrow-ablative therapy. A staff nurse on an inpatient pediatric oncology and bone marrow transplant unit noted an increased incidence of skin breakdown around central line dressings in patients receiving Thiotepa prior to bone marrow transplantation. Although there is a wealth of information surrounding routine care of central venous access devices, there is little evidence surrounding care with impaired skin integrity. A staff nurse turned to expert opinion and consensus revealed the use of nonocclusive dressings for central lines. A new protocol for changing central line dressings was developed to decrease the rate of skin breakdown. The protocol utilized gauze and a self-adherent wrap instead of tape to secure central lines. Bone marrow transplant staff nurses were educated prior to the practice change, and compliance was monitored through observation and review of documentation in the electronic medical record. A retrospective chart review compared the rate of skin breakdown and central line associated blood stream infections pre- and postpractice change. The overall percentage of skin breakdown surrounding central lines was reduced by over 80%.

Molecular Epidemiology and Genetic Relatedness of Clostridioides difficile Isolates in Pediatric Oncology and Transplant Patients Using Whole Genome Sequencing.

The incidence of Clostridioides difficile infection (CDI) has been rising among hospitalized children, with poor understanding of genomic variability of C. difficile isolates in this population. This was a retrospective cohort study of CDI in inpatient and outpatient pediatric oncology and cell transplant patients (POTPs) in 2016 and 2017. CDI cases were identified by positive C. difficile toxin polymerase chain reaction tests. Retrieved residual stool specimens were cultured anaerobically and toxin-producing C. difficile isolates underwent whole genome sequencing (WGS) followed by core genome multilocus sequence typing. Plausible time and location epidemiologic links among the closely related strains were evaluated to identify potential transmission events. Among 226 CDI episodes in 157 patients, 202 stool samples were cultured and had positive cytotoxicity tests. Sequencing identified 33 different strain types in 162 (80%) isolates. Thirty-nine (28%) patients had multiple episodes of CDI, and 31 clusters of related isolates were identified, 15 (47%) of which involved exclusively multiple specimens from the same patient. For the 16 clusters involving multiple patients, epidemiologic investigation revealed only 2 (12.5%) clusters with potential transmission events. WGS identified a highly diverse group of C. difficile isolates among POTPs with CDI. Although WGS identified clusters of closely related isolates in multiple patients, epidemiologic investigation of shared inpatient exposures identified potential transmission in only 2 clusters. Clostridioides difficile transmission was uncommon in this population. More than 70% of new CDI reinfections in POTPs are actually recurrences caused by a previous CDI strain.

Efficacy of oral cryotherapy versus chewing gum on mucositis in children receiving chemotherapy

Background Oral mucositis is considered one of the most common debilitating and serious complications of cancer treatment. Aim This study aimed to evaluate the effect of oral cryotherapy versus chewing gum on mucositis in children receiving chemotherapy. Patients and method A quasi-experimental design was conducted on a convenient sample of 90 children from both sex with cancer and undergoing chemotherapy, who attended the pediatric outpatient clinics and in-patient pediatric oncology department in Cancer Institute of South Egypt. The children were in the age range from 6 to 18 years, newly diagnosed with cancer and in the induction stage of chemotherapeutic protocol and had a healthy oral mucosa. Tools A structural interview questionnaire dealt with characteristics, clinical data of children, and oral assessment guide. Results More than half of children in the cryotherapy group and one-third of children in the chewing gum group had moderate mucositis compared with 83.3% of children in the control group who had severe mucositis during day 21. Conclusion Using oral cryotherapy with honey flavor and sugar-free gum lead to healthier oral mucosa and lower mucositis score compared with children using only the routine mouth care. Recommendations Provide in-services, up-to-date, regular training programs to improve nurses’ knowledge and practices regarding the use of flavored cryotherapy and chewing gum technique as routine care for children treated with chemotherapy.

Trainee-led Engagement of the Care Team Improves Application of an Institutional Blood Culture Clinical Decision Algorithm to Pediatric Oncology Inpatients: A Single-institution Quality Improvement Project.

Introduction:Meaningful engagement in quality improvement (QI) projects by trainees is often challenging. A fellow-led QI project aimed to improve adherence to a blood culture clinical decision algorithm and reduce unnecessary cultures in pediatric oncology inpatients.Methods:We visualized preintervention rates of blood cultures drawn on pediatric oncology inpatients using a control chart. Following the introduction of the algorithm to our division, an Ishikawa fishbone diagram of cause-and-effect identified two areas for improvement: prescriber education on the algorithm and targeted feedback on its use. We developed two interventions to support algorithm awareness and use: (1) bundled educational interventions and (2) targeted chart review and feedback. Fellows reviewed >750 blood culture episodes and adjudicated each as “adherent” or “nonadherent” to the algorithm. In addition, fellows provided direct feedback to prescribers regarding nonadherent episodes and discussed strategies for algorithm adherence.Results:Blood culture rates in preintervention, intervention, and follow-up periods were 33.35, 25.24, and 22.67 cultures/100 patient-days, respectively. The proportion of nonadherent culture episodes decreased from 47.14% to 11.11%. The use of the algorithm did not prolong the time to cultures drawn on patients with new fever. Seventy-five percent of fellows provided feedback to inpatient teams on algorithm use. Following this project, trainees reported feeling more qualified to apply QI principles to patient care.Conclusions:Implementation of a clinical decision algorithm reduced the rate of cultures drawn on pediatric oncology inpatients. Fellow-led education of the care team decreased the proportion of nonadherent culture episodes and provided active engagement in QI.

An End-of-Life Care Educational Series to Improve Staff Knowledge and Comfort Levels.

Nursing staff play a key role in enhancing a patient's quality of life during end of life; however, they perceive lack of knowledge to be the largest barrier in providing quality end-of-life (EOL) care. Literature suggests that implementation of palliative and EOL care education can improve nursing EOL care practices. In order to address the gap in nursing knowledge and comfort, a quasi-experimental study was conducted; this study included the implementation of a multimodal EOL care educational series on an inpatient pediatric hematology oncology floor over 6 months. Prior to implementation, nursing staff completed a survey to measure perceived knowledge and comfort level regarding EOL care. The series included didactic sessions, in-services, case studies, practice exercises, and interactive discussions led by an interprofessional team of nurses, child-life specialists, and social workers. Educational topics included EOL symptom management, child-life services, supportive care resources, COMFORT communication, and an End-of-Life Nursing Education Consortium course. Following the educational series, the survey was repeated. Results of the survey demonstrated an increase in nursing knowledge and comfort levels. Significant improvements were observed across several items including medication management of dyspnea (χ1,83 =5.1, P = .023), comfort with implementing interventions (χ1,93 = 3.9, P = .049), and knowledge of hospital resources (χ1,93 = 6.1, P = .014). These results suggest that while EOL education strategies can vary, a combination of learner engagement tactics can increase knowledge and comfort regarding EOL concepts and potentially positively impact nursing practice.

Creation of a chemotherapy-induced nausea/vomiting dashboard to improve outcomes for pediatric cancer patients.

Two of the most common acute side effects of chemotherapy are nausea and vomiting. Nausea and vomiting impact quality of life, nutritional status, and ability to tolerate further chemotherapy. Parents of pediatric oncology patients rank nausea as one of the most bothersome treatment-related symptoms. Utilizing Quality Improvement methodology, we developed a dashboard interface to facilitate extraction of data from the electronic medical record (EMR), which is presented via a visual display that summarizes the type of chemotherapy and antiemetic medications, use of as needed medications, and number of episodes of emesis. This dashboard interface allows for rapid and efficient identification of patients whose antiemetic regimen is mismatched for the emetogenicity of ordered chemotherapy, thus providing a timely opportunity to modify the antiemetic regimen based on published guidelines before administration of chemotherapy drugs. It also allows measurement of the effectiveness of the antiemetic regimen in terms of the number of break through emesis and the need for as needed medications. A novel CINV dashboard was created, which visually conveys complex information about antiemetics, chemotherapy emetogenicity, as needed medications, and breakthrough vomiting for inpatient pediatric oncology patients.

Clinical Simulation Training in Nurses Caring for Pediatric Oncology Patients

BackgroundGeneral nurses caring for pediatric oncology inpatients lack training and confidence to provide safe effective care. MethodsMajor components of pediatric oncology care were identified and a combined didactic and clinical simulation educational program was provided to 60 nurses caring for pediatric oncology inpatients in an urban academic hospital. ResultsExcellent response rate (96.7%, 58/60). Statistically significant improvement in nurses' self-efficacy six months after intervention on paired sample t-test and Wilcoxon signed rank tests in each care domain. ConclusionsThe didactic and clinical simulation program was effective for training nurses caring for pediatric oncology patients and can be used as a model for general nurses caring for vulnerable patient populations.

2368. Molecular Epidemiology of Clostridioides difficile Infections in Pediatric Oncology and Transplant Patients

BackgroundThe incidence of Clostridioides difficile infection (CDI) has been rising among children, both in the community and hospital setting. The genomic variability and molecular epidemiology of CDI in children, especially with cancer are poorly understood. We aim to evaluate the molecular epidemiology and relatedness of C. difficile isolates among inpatient and outpatient pediatric oncology and stem cell transplant patients (POTP) using whole-genome sequencing (WGS).MethodsThis was a retrospective cohort study of CDI in POTP in 2016. CDI cases were identified by electronic medical record search for positive C. difficile toxin PCR tests. Retrieved residual stool specimens were cultured anaerobically using pre-reduced CCMB-TAL broth (Anaerobe Systems, Inc.), toxin-producing C. difficile isolates were determined using a cell culture cytotoxicity assay with neutralization (TechLab, Inc.), and WGS was performed, followed by core genome MLST (cgMLST). Variability of the isolates was summarized by strain type (ST), and a minimum spanning tree was constructed, defining clusters of genomically related isolates as those with < 7 alleles difference. Plausible epidemiologic links among the closely related strains such as receiving care on the same inpatient unit on the same day or on the same unit but on different days within 8 weeks before CDI were evaluated to identify potential transmission events.ResultsAmong 141 CDI episodes in 89 patients; 103 stool samples were cultured, and 101 (98%) isolates were sequenced identifying 23 different strain types in 81 (80%) isolates. 34 (38%) patients had multiple episodes of CDI. 16 clusters of related isolates were identified (figure), 10 (62%) of which involved only multiple specimens from the same patient. For the 6 clusters involving multiple patients, epidemiologic investigation revealed only 2 (33%) potential transmission events.ConclusionWGS identified a highly diverse group of C. difficile isolates among POTP with CDI. Although WGS identified clusters of closely related isolates in multiple patients, epidemiologic investigation of shared inpatient exposures identified potential transmission in only two clusters. C. difficile transmission was uncommon. DisclosuresRandall Hayden, MD, Abbott Molecular: Advisory Board; Quidel: Advisory Board; Roche Diagnostics: Advisory Board.

Optimizing symptom control in children and adolescents with cancer.

There is growing recognition of the degree to which symptoms negatively impact on children receiving cancer treatments. A recent study described that almost all inpatient pediatric oncology patients are experiencing at least one bothersome symptom and almost 60% are experiencing at least one severely bothersome symptom. Poor symptom control occurs because of challenges with communication of bothersome symptoms to clinicians, lack of clinical practice guidelines (CPGs) for most of these symptoms, and failure to administer preventative and therapeutic interventions known to be effective for symptom control. This article reviews approaches used to improve symptom control for children receiving cancer treatments. Areas addressed include systematic symptom screening and creation of CPGs for symptom management. Challenges with electronic health integration are also addressed. Several multi-symptom assessment scales have been developed but none have yet been used to directly influence patient management. The number of CPGs applicable to symptom control in pediatric oncology is increasing but remains small. Improving the creation of and adherence to CPGs for symptom management is an important priority. Finally, identifying ways that symptom management systems can be integrated into clinical work flows is essential; these will likely need to focus on electronic health records.

Back to Basics: CLABSI Reduction Through Implementation of an Oral Care and Hygiene Bundle.

Children with cancer often undergo treatments that render them severely immunocompromised. Side effects of treatment place them at risk for developing oral mucositis (OM), which can potentially lead to infection and bacteremia. Staff nurses on an inpatient pediatric oncology unit noted inconsistent daily oral hygiene practices despite assessing OM consistently. Basic oral hygiene can reduce the severity of OM, and evidence-based bundled care has shown to increase consistency of practice. Based on findings and recommendations from the literature, an oral care and hygiene bundle was developed. The oral care bundle included a soft bristled toothbrush, fluoride toothpaste, twice-daily brushing and sodium bicarbonate rinses, lip balm, and oral moisturizer. The hygiene component consisted of a daily bath or shower and daily linen changes. Education on the rationale and purpose for the use of an oral care and hygiene bundle was provided to the inpatient direct care staff prior to implementation on two inpatient oncology units. Audits were performed to measure the adherence of the oral care and hygiene bundle. Central line-associated bloodstream infections were measured in collaboration with the quality and infection prevention departments. Since the oral care and hygiene bundle was implemented, laboratory-confirmed bloodstream infection rates decreased from 1.05 to 0.54 per 1,000 catheter days, while mucosal barrier injury rates decreased from 2.98 to 1.27 per 1,000 catheter days.

Reducing Compassion Fatigue in Inpatient Pediatric Oncology Nurses.

To develop an evidence-based compassion fatigue program and evaluate its impact on nurse-reported burnout, secondary traumatic stress, and compassion satisfaction, as well as correlated factors of resilience and coping behaviors. The quality improvement pilot program was conducted with 59 nurses on a 20-bed subspecialty pediatric oncology unit at the St. Jude Children's Research Hospital in Memphis, Tennessee. Validated measures of compassion fatigue and satisfaction (Professional Quality of Life Scale V [ProQOLV]), coping (Brief COPE), and resilience (Connor-Davidson Resilience Scale-2) were evaluated preprogram and at two, four, and six months postprogram, with resilience and coping style measured at baseline and at six months postprogram. Secondary traumatic stress scores significantly improved from baseline to four months. Select coping characteristics were significantly correlated with ProQOLV subscale scores. Ongoing organizational support and intervention can reduce compassion fatigue and foster compassion satisfaction among pediatric oncology nurses.

Pediatric oncology and stem cell transplant patients with healthcare-associated Clostridium difficile infection were already colonized on admission.

A prospective cohort study was conducted over a three-year period in an inpatient pediatric oncology and stem cell transplant setting. Baseline stool samples were collected within three days of admission and were genotypically compared with clinically indicated samples submitted after three days of admission. A total of 175 patients were recruited with a total of 536 admissions. The adjusted prevalence of baseline toxigenic C. difficile colonization among admissions was 32.8%. Seventy-eight percent of positive admissions did not have history of CDI. Colonization with a toxigenic strain on admission was predictive of CDI (OR=28.6; 95% CI, 6.58-124.39; P<0.001). Nearly all clinical isolates (8/9) shared identical pulsed-field gel electrophoresis patterns with baseline isolates or were closely related (1/9). Only one of the 11 cases that were considered HA-CDI was potentially nosocomially acquired. The prevalence of colonization with toxigenic C. difficile in our cohort is high. Unfortunately, the current CDI surveillance definitions overestimate the incidence of HA-CDI in pediatric oncology and stem cell transplantation settings.

Pilot Study of Therapy Dog Visits for Inpatient Youth With Cancer.

This study assessed the feasibility of studying animal-assisted activities (AAA) in inpatient pediatric oncology and collected preliminary data on potential benefits of AAA for this population. Patients at a large pediatric hospital were identified using electronic medical records and approached with physician approval. Patients completed surveys before and after a therapy dog visit in their private hospital room. Data on infections were ascertained by electronic medical record review. Provider surveys were placed in provider common areas and distributed through a link in an e-mail. We summarized resultsusing descriptive statistics and estimated mean changes in pre- and postintervention distress and conducted hypothesis tests using the paired t test. The study population (mean age = 12.9 years) consisted of 9 females and 10 males. Following the therapy dog visit, patients had lower distress and significant decreases in worry, tiredness, fear, sadness, and pain. Providers were generally supportive of the intervention. Eight patients developed infections during the 14 days after the dog visit but none could be clearly attributed to the therapy dog visit. The study's primary limitation was that there was no control group. However, results support the feasibility of and need for future studies on AAA in pediatric oncology.

Effect of a Clinical Pathway on Outcome of Children with Cancer Suffering from Neutropenia Undergoing Chemotherapy Treatment

The child suffering from neutropenia undergoing chemotherapy is demanding and requiring the integration of skills from numerous different specialties. These children often have prolonged hospitalizations, which may be marked by many complications. The aim of this study to design, implement and evaluate the effect of a clinical pathway for children with neutropenia undergoing chemotherapy.Quasi experimental research design was used. The study was carried out at Tanta Cancer Center Affiliated to the Ministry of Health. Out patient Clinic of Oncology and Inpatient Pediatric Oncology Department in Benha Children Hospital. 72 children with neutropenia undergoing chemotherapy was recruited for the study. Four tools were used for data collection, questionnaire sheet, Nutritional Assessment Sheets, Complication monitor sheet and follow pathway design for the study group. The result of the study revealed that there was no statistically significant difference between the study and control groups on admission but there was a statistically significant difference between the study and control groups after the implementation of the clinical pathway for the study group compared with the routine hospital policy care. Conclusion: Children with neutropenia undergoing chemotherapy to whom clinical pathway was applied fewer complications, less hospital stay and less readmission than those who received routine hospital care. Recommendations: Clinical pathway should be integrated into the routine nursing care for children with neutropenia undergoing chemotherapy.

Exercise interventions for patients with pediatric cancer during inpatient acute care: A systematic review of literature

Physical inactivity has been shown to exacerbate negative side effects experienced by pediatric patients undergoing cancer therapy. Exercise interventions are being created in response. This review summarizes current exercise intervention data in the inpatient pediatric oncology setting. Two independent reviewers collected literature from three databases, and analyzed data following the PRISMA statement for systematic reviews and meta-analyses. Ten studies were included, representing 204 patients. Good adherence, positive trends in health status, and no adverse events were noted. Common strategies included individual, supervised, combination training with adaptability to meet fluctuating patient abilities. We recommend that general physical activity programming be offered to pediatric oncology inpatients.

Using Practice-Based Evidence to Improve Supportive Care Practices to Reduce Central Line-Associated Bloodstream Infections in a Pediatric Oncology Unit [Formula: see text

Children with cancer are a subset of patients with central lines with distinct risk factors for infection including periods of prolonged neutropenia and compromised mucous membrane integrity. This article relates the implementation of principles of practice-based evidence to identify interventions in addition to best practice maintenance care bundles to reduce central line-associated bloodstream infections involving viridans group streptococci and coagulase-negative staphylococci on an inpatient pediatric oncology unit. Review of individual events combined with review of current clinical practice guided the development of structured protocols emphasizing routine oral care and general supportive cares. Key principles of the protocols emphasized a 1-2-3 mnemonic and included daily bathing, twice daily oral care, and out-of-bed activity 3 times daily. Poisson regression identified a significant main effect for time period for central line-associated bloodstream infection rates involving both viridans group streptococci and coagulase-negative staphylococci. Significant differences were present between the preintervention baseline and implementation of the supportive care protocols. Project outcomes demonstrate the added value of using principles of practice-based evidence to guide the development of interventions to improve clinical care when evidence-based sources are limited.