High-risk Patients, High-risk Infections
How a NICU and bone marrow unit drove CLABSIs to zero
If there is a worst-case scenario in infection control, it likely involves a life-threatening infection spreading in a vulnerable patient population. They don’t get much more vulnerable than babies in a neonatal ICU, or adults undergoing bone marrow transplant. With their frail immune systems compromised, central line-associated bloodstream infections (CLABSIs) pose a serious threat warranting an immediate infection control response.
What follows is a portrait of two units that rose to the challenge, as described by IPs in presentations recently in Portland at the annual APIC conference. They included a NICU and a bone marrow unit that adopted and carefully reinforced measures to drive CLABSIs down to zero for prolonged periods.
In fact, the success of the CLABSI prevention effort in the NICU is exemplified by the need to continuously change the posters heralding the time period since the last infection.
“We used to have posters with days without a CLABSI; then we went to weeks without a CLABSI, and now we list months without a CLABSI,” said Robin Neale, MS, MT (ASCP) SM, CIC, FAPIC, director of infection prevention at the Care New England Health System in East Greenwich, RI.
As part of that system, Women & Infants Hospital houses an 80-bed NICU, one of the largest in the country. Over the past six years, through a collaborative effort of all the NICU staff, the unit has reduced the CLABSI standardized infection ratio from 1.2 to 0.20, a statistically significant improvement that has been sustained for three years, Neale reported.1
In human terms, the infants infected decreased from 12 to 2 annually, Neale said. She credits a knowledgeable and inclusive team of physicians, nurses, laboratorians, and nutritionists who collaborated to create a bundle for central line insertion and maintenance that includes the following key steps:
Insertion bundle
- Insert lines only when clearly indicated;
- clean hands;
- mask, cap, gown, sterile gloves for insertion;
- Chlorhexidine (CHG) for skin antisepsis.
Maintenance Bundle
- Clean hands;
- scrub the hub;
- sterile two-person tubing changing;
- CHG for skin cleaning at dressing change;
- remove the line as soon as no longer needed.
Without the bundle interventions, the previous rate of bloodstream infections would have taken a severe toll. Neale estimates that 42 babies would have experienced a CLABSI between January 2013 and June 2016. Instead, there were 10 infections during this timeframe. Thus, some 32 infections were prevented, and based on CLABSI mortality rates, between four and eight lives were saved. Neale and colleagues estimate $537,600 was saved by preventable infections over the 3.5-year period.
“Give staff feedback on performance and celebrate success,” she recommended. “At one point, we went 54 weeks [without a CLABSI]; another time, we went 51 weeks. In a NICU our size, that is a huge accomplishment for our staff. It’s really a tribute to what the staff is doing at the bedside, so we make sure that we celebrate with pizza lunches or cake. You need to have unwavering support from physician and nurse leaders. If they are not engaged, it’s hard to do anything. We all know that as IPs.”
Bad to the Bone
Turning to the bone marrow transplant unit (BMTU), alarms went off when the CLABSI rate went up to 3.44% in June 2015 and continued to be elevated through October 2015.2
“We all know that central line infections are among the most common we get in the hospital, and bone marrow transplant patients are really the most high-risk patients in our hospital because of their immunocompromised clinical state,” said Marissa McMeen, MPH, MLS, (ASCP), CIC, an infection preventionist at Thomas Jefferson University hospital in Philadelphia. “We wanted to make sure that we had a plan in place. We created a comprehensive action plan that focused on increasing staffing engagement and awareness of the problem.”
The plan included re-education for evidence-based CLABSI prevention strategies and mandatory, demonstrated central line care competencies that allowed for immediate follow-up and “teaching moments.”
“To empower staff and promote ownership, we began to foster an environment of transparency by regularly sharing metrics with the team and celebrating successes,” said Jessica Radicke, BSN, RN, OCN, the BMTU administrative charge nurse. “Unit signage was moved to highly visible staff areas. Days since last infection were posted and updated weekly. The unit celebrated infection control week to promote staff education.”
One of the activities was a scrub-the-hub challenge, in which invisible lotion was coated on the catheter hub and staff tried to scrub it off.
“Afterward, we used a black light and the areas that weren’t scrubbed were illuminated,” Radicke said. “So, it allowed for immediate teaching points. The nurses could see the different areas that they were missing. We also used it for handwashing. The staff really enjoyed it — it was a fun activity that they were able to participate in.”
In addition, unit leadership purchased a “chest” mannequin with central line areas clearly delineated for staff practice and education. Mandatory competencies were established, and ultimately, central line care on patients was limited to the staff that demonstrated the most skill on the dummy.
“‘Return demonstrations’ were key because it allowed for time to observe the staff and really see if they were making any mistakes, and allow for education right then and there,” Radicke said.
Each Monday, the critical care technicians completed central line dressing changes. Leadership adjusted staffing levels to allow a four-hour overlap in ancillary coverage to allow the techs appropriate time to change these dressings and pay close attention to the small details. The hospital also bought new dressing kits. “Super users” were again identified, and then watched the staff complete return demonstrations.
“The unit staff completed the team steps program facilitated by the patient safety department, and were further supported and empowered to speak up for patient safety,” Radicke said. “Speak up” programs typically empower anyone involved in a procedure to call attention to a break in protocol.
“As they became more engaged, they embraced the ‘speak up’ program more, which then fostered a culture of safety,” she said.
The CLABSI rate from June through October 2015 was 3.26% (five infections/1,532 line days) compared to the rate from November through June 2016 of 0.0% (zero infections/1,707 line days).
“Since the safety plan was implemented the unit has sustained zero CLABSIs, and a culture of safety pervades the unit,” McMeen said.
Future steps for the Thomas Jefferson BMTU include:
- Development of room auditing process and auditing tool.
- Annual return demonstration of central line dressing changes will be required by the CCTs.
- Weekly unit broadcast email highlighting infection rates.
- Sharing of best practices among among peers.
- A secure high importance alert email will be sent to all staff when a CLABSI is suspected.
- Development of a standardized way to draw blood cultures from central lines.
REFERENCES
- Robin Neale, CLABSI Prevention: Baby Bundle in an 80-Bed NICU Session 2308. APIC 44th Annual Educational Conference. Portland, OR: June 14-16.
- McMeen M, Radicke, J, Miller C. Bone Marrow Transplant Unit Embraces Culture Change to Meet and Sustain Unprecedented Central Line-associated Bloodstream Infection Rates. Oral abstract 1203. APIC 44th Annual Educational Conference. Portland, OR: June 14-16.
If there is a worst-case scenario in infection control, it likely involves a life-threatening infection spreading in a vulnerable patient population. They don’t get much more vulnerable than babies in a neonatal ICU, or adults undergoing bone marrow transplant. With their frail immune systems compromised, central line-associated bloodstream infections (CLABSIs) pose a serious threat warranting an immediate infection control response.
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