Selected Policies and Procedures Initiated or Revised Between July 2008 and December 2013

TimelinePolicy or Procedure Description
August 2009CLABSI chart review by NICU staff
Designation of:
• Unit Champions
• dedicated nursing educator for CL practices
• NICU MD and RN clinical leaders
October 2009Reeducation on hand-washing procedures
January 2010Designated NICU CL cart
March 2010Trial of a designated triage and CL placement bed space
April–May 2010Establishment of a multidisciplinary, hospital-wide QI committee, the Pediatric Task Force, which included a NICU subgroup. Defined goals:
• critical assessment of current policies and procedures
• identifying areas of strengths and weaknesses
• initiation and formulation of a CLABSI bundle
July 2010Major revisions of the CLABSI bundle
• maximization of sterile barrier precautions during CL placement
• a unit pod closed off to nonessential personnel during CL placement to minimize traffic
• CL placement became a required 2-person procedure
August 2010Scrub the Hub: scrubbing the hub of the CL tubing system with alcohol for 15 s
Institution of daily assessment of need for CL during morning rounds
October 2010Training and reeducation of PICC line insertion team
• 5 pediatric RNs were trained in PICC line insertion
• 3 of the 5 RNs were NICU-specific
• all bedside NICU RNs completed a CL Competency: one-on-one, hands-on training for CL daily maintenance updated practices
• clinical practice change: removal of CL when total enteral fluids achieve a volume of 120 mL/kg/day
June 2011Focus on documentation; online insertion checklist to be completed by bedside RN
November 2011 to December 2013Joined a multistate perinatal quality collaborative
• goal to reduce CLABSI rates in the NICU by 75%
• focus on safety culture, refining documentation, and maximizing safe and effective practices
• introduction of a bedside maintenance checklist
August 2012Clinical practice change: prompt removal of umbilical lines by day of life 5, or day of life 7 at the latest in case of difficult access
January 2013Joined a children’s hospital network collaborative
February 2013Use of alcohol-impregnated port protectors
July 2013More frequent auditing of compliance with CLABSI bundle
• transition from monthly to weekly audits
May 2013• parent information packet with CL safe practices information for families
• informed consent obtained from parents by PICC nurses before placement of a nonemergent CL
January 2014Standardization of nutrition advancement per feeding protocols
April 2014Clinical practice changes:
• skin preparation: betadine use for infants with postmenstrual age <27 wks, clorhexidine use only for infants with postmenstrual age >27 wks for both PICC and umbilical lines
• dressing changes of surgical lines (ie, Broviac) to be done by PICC team RNs only