Medical Professional Publications

Reducing Central Line Infections in Neonates

(From the September 2015 Issue of PediatricsOnline)

Many infants in neonatal intensive care units (NICUs) need central venous lines to survive, but use of those lines carries a risk of central line-associated bloodstream infection (CLABSI). CLABSIs cause significant morbidity and mortality, so the very intervention that may save a neonate could also result in harm.

At least, that used to be the perception in NICUs. A recent study from Nationwide Children’s Hospital published in The Journal of Pediatrics, however, shows that even a network of neonatal nurseries spread across several hospitals can dramatically reduce CLABSIs and sustain the much lower rate for years.

“We used to think of these infections as the cost of doing business,” says Edward Shepherd, MD, section chief of Neonatology at Nationwide Children’s and lead author of the study. “We have very sick patients with central lines, and they get infections. Now we take that as a personal challenge.”

Nationwide Children’s has eight NICUs in six hospitals, representing at least five distinct nursing and support staff cultures. It is one of the largest neonatal intensive care programs in the United States. By late 2006, there was a quarterly mean rate of 6 CLABSIs per 1,000 catheter days in Nationwide Children’s NICUs. A multidisciplinary neonatal CLABSI reduction quality improvement team was created, with the goal of reducing the rate from 6 to 3 CLABSIs per 1,000 catheter days by the end of 2007.

The rate actually was reduced to 1.43 CLABSIs per 1,000 days by May 2007, and further reduced to 0.68 CLABSIs per 1,000 days by June 2008. The rate was maintained within control limits in every quarter except one through 2013, the end of the study period. CLABSIs were reduced by 89 percent overall. There was an average of 63 CLABSIs per year from 2003 through 2006, but just six in 2013.

The project team -- comprised of neonatologists, neonatal nurses, infectious disease specialists and epidemiology staff -- implemented approximately 30 different evidence-based measures over the course of six years to reduce the rate and keep it low. The largest reduction in rate came after the introduction of the following three measures:

  • Standardized chlorhexidine-ethanol skin antisepsis usage for all infants older than 2 months of age.
  • Chlorhexidine-impregnated disk usage at the peripherally-inserted central catheter site for infants ≥28 weeks gestation and ≥1,000 grams birth weight.
  • Bedside “huddles” among team members within 72 hours of a positive blood culture.

Also important was the creation of central line insertion and maintenance “bundles,” or standard procedures, with compliance determined by independent observers who watched every line insertion or act of maintenance, according to Dr. Shepherd. A renewed focus on hand-hygiene and the engagement of senior executive leadership at Nationwide Children’s played roles in the rate reduction as well.

“There has been earlier success in reducing these infections among adults and older children,” says Dr. Shepherd, who is also a faculty member at The Ohio State University College of Medicine. “What our study shows is that it can be done anywhere.” 

Reference:
Shepherd EG, Kelly TJ, Vinsel JA, Cunningham DJ, Keels E, Beauseau W, McClead RE Jr. Significant reduction of central-line associated bloodstream infections in a network of diverse neonatal nurseries.The Journal of Pediatrics. 2015 Jul;167(1):41-46.

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