pediatrics
June 2015, VOLUME135 /ISSUE 6

# Is Zero Central Line–Associated Bloodstream Infection Rate Sustainable? A 5-Year Perspective

1. Carmina Erdei, MDa,
2. Linda L. McAvoy, RNa,
3. Munish Gupta, MDb,
4. Sunita Pereira, MDa, and
5. Elisabeth C. McGowan, MDc
1. aDivision of Neonatology, Department of Pediatrics (Neonatology), Floating Hospital for Children at Tufts Medical Center, Boston, Massachusetts;
2. bDepartment of Pediatrics (Neonatology), Beth Israel Deaconess Medical Center, Boston, Massachusetts; and
3. cDepartment of Pediatrics (Neonatology), Women and Infants’ Hospital, Providence, Rhode Island

## Abstract

BACKGROUND AND OBJECTIVE: Adoption and implementation of evidence-based measures for catheter care leads to reductions in central line–associated bloodstream infection (CLABSI) rates in the NICU. The purpose of this study is to evaluate whether this rate reduction is sustainable for at least 1 year and to identify key determinants of this sustainability at the NICU of the Floating Hospital for Children at Tufts Medical Center.

METHODS: We reviewed the incidence of CLABSIs in the NICU temporally to the implementation of new practice policies and procedures, from July 2008 to December 2013.

RESULTS: Adoption of standardized care practices, including bundles and checklists, was associated with a significant reduction of the CLABSI rate to zero for >370 consecutive days in our NICU in 2012. Overall, our CLABSI rates decreased from 4.1 per 1000 line days in 2009 (13 infections; 3163 line days) to 0.94 in 2013 (2 infections; 2115 line days), which represents a 77% reduction over a 5-year period. In the first quarter of 2013, there was a brief increase in CLABSI rate to 3.3 per 1000 line days; after a series of interventions, the CLABSI rate was maintained at zero for >600 days. Ongoing training, surveillance, and vigilance with catheter insertion and maintenance practices and improved documentation were identified as key drivers for success.

CONCLUSIONS: High-quality training, strict compliance with evidence-based guidelines, and thorough documentation is associated with significant reductions in CLABSIs. Mindful organizing may lead to a better understanding of what goes into a unit’s ability to handle peak demands and sustain extraordinary performance in the long-term.

It is well documented that bloodstream infections in the neonatal period have a significant impact on morbidity, length of stay, hospital costs, and mortality.16 Data from the Neonatal Research Network of the Eunice Kennedy Shriver National Institute of Child Health and Human Development and other studies show a strong association between neonatal infection, poor growth, and impaired long-term neurodevelopmental outcomes, especially in very preterm infants.712

Nosocomial infection, and specifically central line–associated bloodstream infection (CLABSI), is a leading cause of sepsis in the NICU.5,13 In recent years, multiple centers and statewide quality improvement (QI) initiatives have reported drastic reductions in NICU CLABSI rates by using central line (CL) bundles and checklists.1319

Despite these advances, maintaining a sustained CLABSI rate reduction is challenging. A multi-institutional NICU collaborative recently reported a 71% reduction in CLABSI rates during the intervention period,19 and follow-up data show that the reductions continued several months postintervention. Team development, family partnership, adoption of bundle elements, and strict reporting on line care have been shown to be critical to the long-term success of maintaining zero infection. Although many of these key elements noted by collaboratives can be easily translated to other institutions, there may be other more site-specific factors that drive sustained success for improvement.

In 2009, an increasing NICU CLABSI rate at the Floating Hospital for Children at Tufts Medical Center prompted our Neonatal QI committee to target CLABSI reductions as a key initiative. In conjunction with a hospital-wide multidisciplinary Pediatric Task Force, existing practices were reevaluated and new bundles of care were integrated. By 2010, our CLABSI rate was steadily decreasing, and in 2011, it was well below the reported National Healthcare Safety Network (NHSN) standard.20 Over the next 4 years, our CLABSI intervention practices were dynamic and rigorous, leading to sustained reductions in CLABSI rates.

The specific aim of this improvement project was to sustain a zero CLABSI rate for a minimum of 1 year and to identify the key factors that contributed to this sustained reduction. We demonstrate that strict compliance with documentation and compliance tools, rigorous adherence to bundles, and ongoing vigilance and staff training in our unit were associated with sustained CLABSI rate reductions.

## Methods

### Ethical Issues

The Institutional Review Board at Tufts Medical Center deemed this activity of QI nonpatient subject research and therefore exempt from institutional review board oversight.

### Setting

The NICU at the Floating Hospital for Children at Tufts Medical Center is a level IIIc NICU21 and a tertiary referral center that cares yearly for >500 infants with critical medical and surgical conditions who were born at either Tufts Medical Center or affiliated community sites.

### Definitions

For the purpose of this report, the term CL includes the following: peripherally inserted central catheters (PICCs), umbilical vessel catheters, and surgical CLs. In accordance with the NHSN, a CLABSI is defined as a bloodstream infection occurring with a CL in place or within 48 hours of a CL being removed, in the absence of another identifiable source of infection.22 A bloodstream infection is defined as a laboratory-confirmed positive blood culture. When feasible, 2 sets of blood cultures from 2 different sites are obtained per NICU Infection Control policy (2 peripheral blood cultures of 2 bottles per culture if infant has a PICC line; 1 peripheral and 1 central blood culture of 2 bottles per culture if infant has a umbilical artery catheter, umbilical venous catheter, or Broviac catheter). Each suspected case of CLABSI is reviewed by the Infection Control Department and the institutional CLABSI Task Force, which includes the NICU nursing clinical leader. Particular attention is given to situations in which the diagnosis of a CL infection is unclear, such as a blood culture growing an organism often thought be a contaminant (eg, coagulase-negative Staphylococcus). After the review process, a definitive diagnosis is made by the Infection Control Department based on a composite of clinical, laboratory, and microbiological data.

### Measures

Our primary outcome measure consisted of Infection Control Department–confirmed CLABSIs and CLABSI rates per 1000 CL days. Possible CLABSIs were identified by the medical team led by an attending neonatologist, based on clinical picture, as well as laboratory-confirmed positive blood cultures. The Infection Control Department and NICU CLABSI Task Force reviewed all suspected CLABSI cases independently, and final determination was made by the Infection Control Department.

Process measures involved close, regular monitoring of compliance with CLABSI bundle elements, as well as with documentation. Compliance with insertion and maintenance checklists was monitored weekly. Hand hygiene compliance was monitored via anonymous audits performed monthly at a minimum.

### Planning Key Interventions

Since 2008, our NICU QI Committee and the institutional Infection Control Department have been prospectively maintaining a CLABSI database. Root cause analyses (RCAs), including fishbone diagrams, were used to identify opportunities for improvement. After careful review of the data, refinements were made to policies and procedures by the NICU Clinical Skills Committee when it was believed to be indicated. During a 5-year period (July 2008 to December 2013), we conducted and implemented multiple safety programs and QI measures while closely monitoring CLABSI rates. These initiatives are detailed in chronological order in Table 1. Key components were creation of a NICU-specific QI CL team; refining line insertion and maintenance practices in compliance with a NICU-specific CLABSI bundle; revision of documentation and auditing processes; encouraging a multidisciplinary decision-making process; staff education and training in accordance with best practices guidelines; and interinstitutional collaboration.

TABLE 1

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

### Analysis

We used statistical process control charts generated with QI Macros software to evaluate for statistically significant changes. A u control chart was used to depict quarterly CLABSI rates (infection per 1000 line days),23 and a g control chart was used to evaluate time intervals between occurrences.23 A rolling average chart with timing of key initiatives is presented, as this model reduces some excessive variability often seen with rare events.

## Results

The CLABSI rate in our NICU was 4.1 per 1000 line days in 2009 (13 infections per 3163 line days), 2.5 per 1000 line days in 2010 (7 infections per 2800 line days), 0.36 per 1000 line days in 2011 (1 infection per 2702 line days), 1.16 per 1000 line days in 2012 (3 infections per 2580 line days), and 0.94 per 1000 line days in 2013 (2 infections per 2115 line days). This is a 77% reduction over a 5-year period. Figure 1 (u chart) represents quarterly CLABSI rates. The mean CLABSI rate in our NICU from July 2008 to December 2013 was 2.2 infections per 1000 line days. A statistically significant reduction was seen from 2011 to 2013, as rates were below the mean for 8 consecutive quarters (from Q1 of 2011 through Q4 of 2012). In addition, rates were >1 SD below the mean for 3 consecutive quarters in 2013, and this reduction was maintained into 2014.

FIGURE 1

CLABSI rates by quarter in the NICU at Tufts Medical Center: u chart for umbilical lines and CLs. The central solid line represents the internal mean CLABSI rate at Tufts from July 2008 to December 2013, and the dotted horizontal lines are upper and lower control limits.

Figure 2 (g chart) demonstrates that days between CLABSIs were beginning to increase in 2010. By 2011, we experienced 373 CLABSI-free days, and in 2013 to 2014, our unit had 601 CLABSI-free days. Both of these time periods are >3 SDs above the mean, indicating a statistically significant increase in days between infections.

FIGURE 2

Days between CLABSIs in the NICU at Tufts Medical Center: g chart for umbilical lines and CLs. The solid horizontal line represents the mean number of days between infections, and the dotted horizontal lines are upper control limits, or the first, second, and third SDs above the mean.

Figure 3 shows the reduction in CLABSI rates over a 5-year period in relation to initiatives and interventions. Our CLABSI rate, which is shown as a rolling average, is compared with the pooled mean CLABSI rate for level III NICUs from the NHSN.20 The NHSN rate is not a rolling average but an absolute yearly rate, so direct comparison should be made with caution. Nonetheless, by the end of 2011, our rate dropped well below the NHSN published standard.20 We noted a rise in rate in 2013, with a cluster of 3 CLABSIs occurring in a 3-month period. This resulted in a brief increase in CLABSI rate to 3.3 per 1000 line days at the beginning of 2013. It was temporally associated with the retirement of the lead PICC line inserter, as well as decreased compliance with completion of daily maintenance checklists. After targeted interventions, our CLABSI rate was reduced again to zero, and it was sustained at zero for 601 days.

FIGURE 3

CLABSI rates in the NICU at Tufts Medical Center: 12-month rolling average chart. Data reflect all CL days and CLABSIs (dotted line). Comparison is NSHN pooled mean CLABSI rate for level III NICUs; data taken from NHSN publications available in Benneyan.23

Audits of insertion checklist and maintenance checklist completion (Fig 4) revealed 78% to 100% compliance, with mean compliance rates of 97% and 91%, respectively. Hand hygiene audits showed compliance between 73% and 100%.

FIGURE 4

Compliance with insertion (thin line) and maintenance (thick line) checklist completion between December 2011 and December 2013. Data obtained from the Neonatal Catheter Associated Bloodstream Infection multistate perinatal collaborative.

## Discussion

Very low rates of CLABSI are achievable1319; however, maintaining a zero CLABSI rate continues to be challenging. Multidisciplinary collaboration and rigorous application of evidence-based practices and interventions in our NICU were associated with a significant reduction in CLABSI infection rate over a 5-year period, with 2 extended periods (373 and 601 days) of zero infections.

In 2009, our QI CLABSI team integrated RCAs, evidence-based initiatives, and action plans as shown in Table 1. Interventions were formulated and built into practice at multiple levels. We incorporated standardization of CL insertion and maintenance practices, including sterile changing of CL tubing, bundling of blood draws to decrease number of breaks into a sterile line, optimization of hand-washing practices, staff education, timely removal of nonessential CLs, documentation of line care, and multidisciplinary collaboration. Recognizing that improvement is a dynamic process, we also built in regular auditing of implemented strategies and vigilance for variations or changes in care processes.

In 2011, our unit had only 1 CLABSI. This was followed by a 373-day CLABSI-free span, surpassing our 1-year zero CLABSI rate goal, and our year-end rate was well below the NHSN published standard.20 However, in early 2013, a cluster of CLABSIs was noted. RCA was performed and identified 2 potential contributing factors: retirement of our lead PICC inserter and a decrease in compliance with daily maintenance checklists to 80% (Fig 4). Having a heightened awareness of potential problems, also known as signal detection, is critical,24 and in our case, we had not adequately prepared for the retirement of our PICC line nurse. We quickly recognized the importance of not only skill maintenance but also expertise among all team members. In addition, we acknowledged the importance of checklist compliance as a validated and effective tool in the CLABSI reduction process.17,25,26 Thus, 3 areas of vulnerability were targeted:

1. Documentation

• Bedside maintenance checklists were revised to be more user friendly, be easier to read, and have more areas for nursing input.

• Use of maintenance checklists was transitioned from a QI data collection tool to part of the permanent medical record, with the goal of increasing compliance.

• Weekly multidisciplinary huddles were performed to reinforce the importance of daily documentation practices.

2. Auditing

• A hospital-wide CL audit tool (Table 2), focusing on catheter care practices and adherence to CLABSI bundle elements, was implemented.

• - This auditing tool was used weekly by our NICU clinical leader for all CLs.

• - Random CL audits were performed several times weekly during high-risk periods such as catheter dwell time >2 weeks,27 higher patient census, or higher unit acuity.

• Audit results of insertion and maintenance checklists, which were collected daily as part of a multistate collaborative, were shared with nursing staff.

• Anonymous hand hygiene audits, usually performed monthly, were increased in frequency during high patient census.

3. Staff education

• All NICU-specific CL inserters (5 team members) underwent refresher courses on optimal insertion procedures.

• CL dressing changes were standardized.

• CL Competency Training Initiative: one-on-one training of all NICU nurses was performed on updated CL practices, including competency of intravenous fluid tubing changing processes; sign-off on competency was required for all nursing staff.

TABLE 2

CL Maintenance Bundle Compliance Audit Form

We incorporated the above 3 areas into refining our team, teamwork, and team-training efforts. An underlying goal was to incorporate “mindful organizing,” which has been used to describe a joint behavioral effort to increase attention to every detail, anticipate errors before occurrence, and intervene promptly to prevent errors.24 Mindful organizing is applicable to any organization that is striving for high reliability,28 as it represents, in essence, the composite of a set of social processes in which people are committed to work for the benefit of others. A high level of motivation to help others by going beyond the requirements of an assignment, and experiencing emotional ambivalence by keeping an open mind to alternatives and asking for others’ advice, may constitute the foundation of the NICU as a high-reliability environment.

Staff observations and feedback were encouraged. Nurses became empowered to stop a procedure if nonadherence to policy or a breech in sterility was noted. They were encouraged to initiate a discussion of CL necessity during morning rounds. This verbal prompt, which was also incorporated as a key question in the bedside maintenance checklist, helped facilitate thoughtful decision-making by the team. A heightened awareness within the NICU that every action or decision may potentially increase the risk for a CLABSI underscored the need for constant vigilance. Building sustainable safe habits requires going beyond mere performance of a task, but requires understanding the significance of one’s actions and anticipating or responding promptly to problems. This guiding principle is imperative to high-reliability organizations, and we recognize that the science of behavior has much to offer in improving the science of medicine.29

We cannot overemphasize the value of hospital-wide support and multilevel collaboration. Our hospital administration supported nursing champions, who had dedicated protected time to work on CLABSI reduction initiatives. Neonatology fellows were encouraged to participate in conferences, webinars, and data collection as part of their QI scholarly activities. Hospital-wide recognition and celebration of the 1-year NICU CLABSI-free milestone fostered a sense of pride, mission, and value among the stakeholders. Recognition of CLABSI-free periods during staff nursing and physician meetings and celebration of successes with lunches or token gifts were used as positive reinforcers. Posting the number of days from the last infection on a centralized poster board in the NICU allowed caregivers, as well as families, to become powerful and informed team members. Emphasis was placed on shared responsibility and teamwork toward a common goal of a safe environment. Lapses at any level of care were regarded not as individual errors, but as opportunities for system improvements.

In addition to local hospital support, participation in multi-institutional collaboratives is associated with significant reductions in CLABSI rates.17,19,30 Collaboratives offer valuable opportunities for shared learning. During the 5-year period, we participated in the national Neonatal Catheter Associated Bloodstream Infection collaborative from 2011 to 2013.31 Similarly, since the beginning of 2013, we have been part of a large children’s hospital network, with the goal of sharing best practices toward achieving best outcomes. Conference calls, Web-based workshops, and group emails were all opportunities for cost-efficient, real-time learning and feedback.

The short- and long-term economic burdens of CLABSIs are substantial. A recent analysis estimated that each CLABSI episode independently increases length of hospitalization from 7 to 21 days.26 In a cost-effectiveness analysis that varied the cost of CLABSI between $5000 and$23 000 dollars, maximum barrier precautions resulted in estimated maximum cost savings from ∼$100 to$500 per line placed.32 We suggest that cost-benefit analysis of QI measures be studied locally and compared with the cost of prolonged hospitalization; teams can use this information to advocate for further support from the stakeholders. Additionally, costs are not limited to hospitals. As infection increases the risk of long-term neurodevelopmental impairment,712 the societal lifetime costs can be as high as $1 million per child.33 Limitations to this study are acknowledged. First, because CL insertion and maintenance bundles were implemented simultaneously, we have not differentiated which specific elements contributed the most to CLABSI reduction. However, sustained reduction occurred once we instituted regular audits of both bundles and hand hygiene audits. Other changes in clinical practice (such as reduction in line days due to introduction of strict feeding protocols, with discontinuation of central catheters when an enteral feeding volume of 100 mL/kg/day was reached) might have also affected outcome. Second, over the 5-year period, our data collection and monitoring system has varied. Upon joining multistate collaboratives and with the introduction of new measures and auditing tools, compliance was tracked more vigilantly. Third, we are comparing our rates with the published NHSN data as a benchmark, although it has been suggested that validation processes are needed to ensure accuracy of NHSN data.34 Of note, there were no changes in antibiotic prophylaxis and treatment protocols during the study period. Screening for methicillin-resistant Staphylococcus aureus was performed weekly throughout the study period. Fluconazole for fungal prophylaxis in infants with a birth weight <1 kg or born at gestational age <28 weeks has been unit policy since 2007. Future studies are needed to determine whether the CLABSI pattern we described in this report is generalizable to other NICUs. To date, there have been few published reports tracking NICU CLABSIs for such an extended period of time. There are multiple published quality reports focusing on specific interventions, with a pre- and postintervention comparison. A unique aspect of this study is that we present our data as a sequential, dynamic process of evidence-based benchmarks and best practices implementation as well as ongoing compliance auditing, with concomitant analysis of results, variations in practices, and changes instituted in real time. We have identified site-specific factors that we consider key drivers for our continued success. Incorporation of organizational behaviors such as collective mindfulness and strategies to improve teamwork in sustaining extraordinary performance in the NICU needs further study. ## Acknowledgments Tufts Medical Center Floating Hospital for Children NICU has collaborated on reduction of CL infections with the following: Neonatal Quality Improvement Collaborative of Massachusetts (NeoQIC), the Perinatal Quality Collaborative of North Carolina and American Hospital Association (AHA) National CABSI Prevention Initiative, and the Ohio Children’s Hospital Association. ## Footnotes • Accepted January 26, 2015. • Address correspondence to Carmina Erdei, MD, Floating Hospital for Children at Tufts Medical Center, Division on Newborn Medicine, 800 Washington St, Boston, MA 02111. E-mail: carmina.erdei{at}gmail.com • All authors contributed to the conceptualization of the study and analysis and interpretation of the data; Drs Erdei, Pereira, and McGowan and Ms McAvoy contributed to the design of the initial study and data collection; Dr Erdei drafted the initial manuscript and revised the manuscript; Dr Gupta critically reviewed the manuscript; Ms McAvoy and Drs Pereira and McGowan reviewed and revised the manuscript; and all authors approved the final manuscript as submitted. • FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. • FUNDING: A total stipend of$5000 was received and used for administrative purposes for participation in the Neonatal Catheter Associated Bloodstream Infection initiative during the period 2011 to 2013.

• POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.