Enhanced central venous catheter bundle for pediatric parenteral-dependent intestinal failure

doi:10.1016/j.ajic.2018.04.209

American Journal of Infection Control

Volume 46, Issue 11, November 2018, Pages 1284-1289

https://doi.org/10.1016/j.ajic.2018.04.209 Get rights and content

Highlights

•
CLABSI occurs frequently among high-risk pediatric patients with intestinal failure.
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An enhanced bundle for CVC care can reduce CLABSI for high-risk pediatric patients.
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Through a QI initiative, PN-dependent pediatric patients have 85% less CLABSI.
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Engagement of staff and leadership early in the planning is critical to success.

Background

Central line–associated bloodstream infections (CLABSIs) cause substantial morbidity and increase antimicrobial use and length of stay among hospitalized children in the United States. CLABSI occurs more frequently among high-risk pediatric patients, such as those with intestinal failure (IF) who are parenteral nutrition (PN) dependent. Following an increase in CLABSI rates, a quality improvement (QI) initiative was implemented.

Methods

Using QI methodology, an enhanced central venous catheter (CVC) maintenance bundle was developed and implemented on 2 units for pediatric PN-dependent patients with IF. CLABSI rates were prospectively monitored pre- and postimplementation, and bundle element adherence was monitored. Enhanced bundle elements included chlorhexidine-impregnated patch, daily bathing, ethanol locks, 2 nurses for CVC care in a distraction-free zone, peripheral laboratory draws, bundling routine laboratory tests, and PN administration set changes every 24 hours.

Results

Adherence to enhanced bundle elements increased to >90% over 3 months. CLABSI rates averaged 1.41 per 1,000 central line days preimplementation compared with 0.40 per 1,000 device days postimplementation (P = .003), an 85% absolute reduction in CLABSI rates over 12 months.

Conclusions

Patients with IF are at an increased risk for CLABSI. Enhanced CVC maintenance bundles that specifically target prevention practices in this population may be beneficial.

Section snippets

Study design and population

In response to an unusual increase in CLABSI rates, with most children diagnosed with CLABSI in July 2015 noted to have either IF or esophageal atresia or leak, a quality improvement (QI) project was developed using plan do study act (PDSA) methodology. Initial RCAs conducted by unit-based infection prevention and control liaisons did not reveal any systems issues within individual units; however, variation in practice existed across the enterprise with CVC care. The infection prevention and

Enhanced bundle implementation

A convenience sample of 355 audits were analyzed postintervention from February 2016-February 2017. Preintervention enhanced bundle compliance ranged from 56%-97% across all enhanced bundle elements following the education period in January 2016. Significant improvement in compliance was demonstrated over time. Monthly audits indicated that staff nurses were adherent to bundle elements. It took about 3 months to reach >90% compliance with enhanced bundle elements. The 2-nurse technique for IV

Discussion

The burden of CLABSI remains a problem in high-risk populations such as pediatric PN-dependent patients with IF. In this QI initiative, an enhanced CVC maintenance bundle was developed and reduced the overall CLABSI rate by 85%, when adjusting for time trends. The pediatric IF population is thought to be at particularly high risk for developing CLABSI because of their dependence on long-term CVCs for PN and because of the potential for pathogen translocation across the intestinal wall leading

Conclusions

This QI initiative suggests that an enhanced CVC maintenance bundle can reduce CLABSI in the PN-dependent IF population. In the PN-dependent population, CLABSIs may be preventable and not always related to intestinal translocation. Engagement and support of staff, stakeholders, and leadership early in the planning stage were critical to the success of this initiative. Future work will explore whether key components of the enhanced CVC maintenance bundle may be broadly applicable to other

Acknowledgments

We thank the Surgical Programs 10S & 10E care teams including nurses, clinical assistants, nurse practitioners, child life, phlebotomists, pharmacy, the center for intestinal rehabilitation team, and the home PN team for their ongoing support throughout the quality improvement initiative.

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Cited by (17)

Optimizing Duration of Empiric Management of Suspected Central Line-Associated Bloodstream Infections in Pediatric Patients with Intestinal Failure
2020, Journal of Pediatrics
Citation Excerpt :
Although there were no significant differences in ethanol lock use between patients with positive and negative cultures in this study, the data do not include patients who did not have episodes of suspected CLABSI. Inpatient measures to minimize CLABSI in patients with intestinal failure also have been reported, some of which could potentially be adapted for outpatients.32-35 It is notable that there were several patients with multiple admissions to exclude CLABSI, 1 patient having 12 episodes.
To assess whether a 24-hour length of hospitalization and empiric antibiotic therapy to exclude central line-associated bloodstream infection (CLABSI) in children with intestinal failure is potentially as safe as 48 hours, which is the duration most commonly used but not evidence based.
A prospective single-institution observational cohort study was conducted among pediatric patients with intestinal failure from July 1, 2015, through June 30, 2018, to identify episodes of suspected CLABSI. The primary end point was time from blood sampling to positive blood culture. Secondary end points included presenting symptoms, laboratory test results, responses to a parent/legal guardian-completed symptom survey, length of inpatient stay, costs, and charges.
Seventy-three patients with intestinal failure receiving nutritional support via central venous catheters enrolled; 35 were hospitalized with suspected CLABSI at least once during the study. There were 49 positive blood cultures confirming CLABSI in 128 episodes (38%). The median time from blood sampling to positive culture was 11.1 hours. The probability of a blood culture becoming positive after 24 hours was 2.3%. Elevated C-reactive protein and neutrophil predominance in white blood cell count were associated with positive blood cultures. Estimated cost savings by transitioning from a 48-hour to a 24-hour admission to rule-out CLABSI was $4639 per admission.
A 24-hour duration of empiric management to exclude CLABSI may be appropriate for patients with negative blood cultures and no clinically concerning signs. A multi-institutional study would more robustly differentiate patients safe for discharge after 24 hours from those who warrant longer empiric treatment.
Clinical outcomes in pediatric intestinal failure: A meta-analysis and meta-regression
2019, American Journal of Clinical Nutrition
Intestinal failure (IF) is associated with significant morbidity and mortality, yet specific parameters that determine medium- and long-term outcomes remain ill defined.
The aim of this study was to determine the long-term outcomes in childhood IF and identify patient characteristics associated with clinical endpoints.
MEDLINE and EMBASE were searched for cohorts of >10 pediatric-onset IF patients with >12 mo follow-up. Random-effects meta-analysis and meta-regression weighted by follow-up duration were used to calculate clinical outcome rates and patient factors associated with outcomes. Primary outcome was mortality rate; secondary outcomes included neurodevelopmental status, transplantation, IF-associated liver disease (IFALD), enteral autonomy, and sepsis.
In total, 175 cohorts (9318 patients and 34,549 y follow-up) were included in the meta-analysis. Overall mortality was 5.2% per y (95% CI: 4.3, 6.0) and was associated with sepsis and IFALD on meta-regression. Mortality rate improved with time from 5.9% per y pre-2000 to 4.5% per y post-2005. Sepsis rate was also predictive of IFALD and liver failure. Enteral autonomy was associated with small bowel length but not presence of ileo-cecal valve. There was a relative lack of data on neurodevelopmental outcomes.
Sepsis is the primary modifiable factor associated with mortality and liver failure, whereas enteral autonomy correlates with small-bowel length. No clear parameters have been identified that accurately predict neurodevelopmental outcomes, and hence further research is needed. Together, our findings are helpful for parental counseling and resource planning, and support targeting reduction in sepsis.
Central venous catheters: Indications, techniques, and complications
2019, Seminars in Pediatric Surgery
Citation Excerpt :
One single-institution retrospective series suggested reduced infectious complications in neonates when CVCs were placed in the operating room rather than the neonatal intensive care unit.73 It is worth noting that minimizing unnecessary access to central lines appears to reduce CRBSI/CLABSI risk, and CVC care ‘bundles’ incorporating these various practices have demonstrated decreased rates of infectious complications.73–76 Thrombosis is a natural consequence of having foreign material within a vessel and is mediated by endothelial activation.
Central venous catheters (CVC) are commonplace in the management of critically ill patients and serve a variety of purposes. Venous access is important for the administration of fluid and medications as well as blood procurement needed for lab analyses. However, not every critically ill patient requires a CVC. This article highlights the key considerations, pitfalls and evidence-based practices regarding the use pediatric central venous catheters.
Central venous catheter bundle adherence: Kamishibai card (K-card) rounding for central-line-associated bloodstream infection (CLABSI) prevention
2020, Infection Control and Hospital Epidemiology
Implementation of Supportive Care Program to Decrease CLABSI in a Middle East Pediatric Hematology and Oncology Inpatient Unit
2023, Journal of Pediatric Hematology/Oncology Nursing
Risk factors forvessel catheter associated infection in children with intestinal failure: a scoping review
2023, Chinese Journal of Practical Nursing

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: Conflicts of interest: None to report.

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Major ArticleEnhanced central venous catheter bundle for pediatric parenteral-dependent intestinal failure

Highlights

Background

Methods

Results

Conclusions

Section snippets

Study design and population

Enhanced bundle implementation

Discussion

Conclusions

Acknowledgments

Am J Infect Control

J Pediatr Surg

Am J Infect Control

Attributable cost and length of stay for central line-associated bloodstream infections

Pediatrics

How-to guide: prevent central line-associated bloodstream infections (CLABSI)

Do no harm prevent central line-associated bloodstream

Preventing central line–associated bloodstream infections: a global challenge, a global perspective

Decreasing central line-associated bloodstream infections in the non-ICU population

J Nurs Care Qual

Central catheter-associated bloodstream infection reduction with ethanol lock prophylaxis in pediatric intestinal failure: broadening quality improvement initiatives from hospital to home

JAMA Pediatr

Central line-associated bloodstream infections in neonates with gastrointestinal conditions: developing a candidate definition for mucosal barrier injury bloodstream infections

Infect Control Hosp Epidemiol

Major Article
Enhanced central venous catheter bundle for pediatric parenteral-dependent intestinal failure