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Abstract
Background Premature and sick neonates in the neonatal intensive care unit (NICU) are in need of central lines placing them at high risk of contracting a central line-associated bloodstream infection (CLABSI). CLABSI extends length of stay to 10–14 days post negative cultures and increases morbidity, use of multiple antibiotics, mortality and hospital cost. To reduce CLABSI rate at the American University of Beirut Medical Center NICU, the National Collaborative Perinatal Neonatal Network developed a quality improvement project to reduce CLABSI rate by 50% over a 1-year period and to sustain reduced CLABSI rate.
Methods Central line insertion and maintenance bundles were implemented for all infants admitted to the NICU necessitating central lines placement. Bundles included hand washing, wearing protective material and sterile drapes during central lines insertion and maintenance.
Results CLABSI rate decreased by 76% from 4.82 (6 infections; 1244 catheter days) to 1.09 (2 infection; 1830 catheter days) per 1000 CL days after 1 year. Following the bundles’ success in reducing CLABSI rate, they were incorporated permanently to NICU standard procedure and bundle checklists were added to the medical sheets. CLABSI rate was maintained at 1.15 per 1000 CL days during the second year. It then decreased to 0.66 per 1000 CL days in the third year before reaching zero in the fourth year. In total, zero CLABSI rate was sustained for 23 consecutive months.
Conclusion Reducing CLABSI rate is necessary to improving newborn quality of care and outcome. Our bundles were successful in drastically reducing and sustaining a low CLABSI rate. It was even successful in achieving a zero CLABSI unit for 2 years.
- Infection control
- Quality improvement
- Paediatrics
Data availability statement
Data are available upon reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Infections increase the risk of morbidity, mortality, medical costs and hospital length of stay in neonatal intensive care unit (NICU).
Previous studies have shown significant reduction in central line-associated bloodstream infection (CLABSI) rates among adult, paediatric and NICU patients after introduction of central line insertion and maintenance bundles.
WHAT THIS STUDY ADDS
Implementation and incorporation of central line insertion and maintenance bundles into standard care can achieve a zero CLABSI rate.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
The central line insertion and maintenance bundles can serve as a model to standardise central line practice in Lebanese NICUs.
Introduction
Neonates admitted to intensive care units (ICUs) are prone to nosocomial infections leading to increased morbidities and complications. Central line-associated bloodstream infections (CLABSIs) are one of the most common nosocomial infections in the neonatal ICU (NICU).1 Although central line catheters are a vital part of management of severe illnesses as they provide venous access to critically ill patients by minimising frequent exposures to painful heel pricks and venipuncture procedures, they can lead to the development of infections in patients in critical care areas.2 These infections increase the risk of severe motor deficit and neurodevelopment impairment among very low-birth-weight preterm infants.3 4 It also extends hospital length of stay, increases medical costs and it is a leading cause of mortality among very preterm infants.5 6 Awareness of the burden of these infections has been rising in the last two decades while healthcare workers strive to find a reliable approach that can spare newborns life-threatening complications.7
To prevent CLABSIs, broad practice changes and quality improvement (QI) interventions are necessary. The cornerstone of these activities are central line bundles, which are evidence-based practices used together to improve patient outcomes.8–11 Implementation of central-line bundles can reduce the incidence of CLABSIs in ICUs worldwide and would decrease cost of care based on the reduction of ICU stay.10 A recent systematic review and meta-analysis on the effectiveness of insertion and maintenance bundles in preventing CLABSI revealed significant reduction in CLABSI rates among adult, paediatric and neonatal patients admitted to ICUs. Among the 75 studied NICUs, the average CLABSI rate decreased by 69% from 8.4 to 2.6 per 1000 catheter days.10 Another NICU-specific systematic review and meta-analysis of 24 eligible studies showed a 60% reduction in CLABSI following the introduction of care bundles.11
Low-and-middle-income countries (LMICs) are at a high risk for the development of central line infections due to poor basic infection control practices and limited resources. A review of the literature on CLABSIs in limited resource settings showed CLABSI rates ranging from 2.6 to 60.0 per 1000 central line days among NICUs.12–14
Lebanon, a developing country in the Middle East, has no national standardised policies for hospital care in the NICUs. Moreover, national data on CLABSIs is lacking in most centres except for some private hospitals. The American University of Beirut Medical Center (AUBMC) is a tertiary medical care centre located in Beirut, the capital of Lebanon. As a regional perinatal centre with an active referral network and high-risk delivery service, it has a level IV NICU that cares for extremely premature newborns and provides surgical repair of complex congenital or acquired conditions.
The Infection Control and Prevention Program (ICPP) at AUBMC reported CLABSI rate in the NICU to be equal to 6.8 per 1000 central line days during the period between 1 July 2011 and 30 June 2012. To reduce CLABSI rate and subsequently reduce neonatal morbidities and mortality, length of stay and cost in the NICU, the plan–do–study–act cycles was used to develop a QI project.15 We expected that implementing insertion and maintenance bundles that have shown successful impact on CLABSI rates reduction would help reduce our rates. This QI project aims to develop a central line insertion and maintenance bundle to reduce the risk of CLABSI by 50% after 1 year of implementation and to sustain reduced CLABSI rate.
Methods
Bundles
The central line insertion and maintenance bundles were developed based on the five evidence-based elements recommended by the Centers for Disease Control and Prevention (CDC) and identified as having the greatest effect on the rate of catheter-related bloodstream infection in acute care hospitals.16 The five elements consist of hand hygiene, maximal barrier precautions, skin preparation, optimal site selection and daily assessment of central line necessity with early removal of unnecessary lines.16 The developed checklists, which aim to ensure staff adherence to infection control practices, were adapted to our NICU based on types of catheters and antiseptic agents used in our NICU. The components of each bundle are described in table 1.
Central line insertion and maintenance bundle components
Definitions
Online supplemental appendix 1 reports CDC definitions used in this QI project.17 The neonatologist along with a team from the ICPP classified the CLABSIs according to the CDC National Health and Safety Network’s criteria.17
Supplemental material
The QI project consisted of three phases: a training and trial phase, 1-year QI implementation phase and the post 1-year intervention phase.
Phase 1: training and 1-month trial phase
Training of study personnel, consisting of nurses and medical doctors, started in January 2014. Prior to the implementation of the intervention, personnel were required to complete two mandatory online courses: the CDC’s ‘CLABSI’18 and Duke Health’s ‘Insertion of Central Venous Catheters’.19 20 The courses were followed by a training session given by the neonatology research fellow coordinating the study. The educational session included definition of CLABSI, preventive measures and explanation of project bundles, procedures and forms. Online supplemental appendix 2 explains the medical staff roles and associated forms that were filled for each project procedure. Several open discussion sessions were scheduled allowing study personnel to share their questions and concerns about the new implemented protocol.
One-month trial period was implemented starting on 1 April 2014. During this period, daily auditing on the proper insertion and maintenance procedures in the NICU were conducted by the neonatology research fellow. Several inconsistencies were noted such as wearing clean gloves instead of sterile ones during handling of central lines especially during line maintenance, improper central line dressing change, and incorrect filling of the insertion and maintenance checklists. To address these inconsistencies, one-on-one counselling was done to discuss the non-compliance. Weekly staff meetings were also set to discuss the occurred non-compliances. The meetings allowed the staff to raise questions and subsequently resolve any remaining misunderstandings on the insertion and maintenance bundles. Following the 1-month trial period, the checklists and forms were revised and modified based on feedback from the nursing and medical staff.
Phase 2: 1-year QI implementation phase
The 1-year period study officially started on 1 May 2014. The insertion and maintenance data collection medical forms were integrated into NICU medical records and collection of central line data started from each new central line inserted as of 1 May 2014. For every inserted and maintained central line: information sheets, insertion and maintenance checklists were filled as standard procedure. Anonymous auditing was implemented whereby three nurses unknown to the NICU staff and to each other were responsible for reporting non-compliance done by medical staff to the NICU head manager, who would report it to the study coordinator. The latter would then report to the neonatology research fellow who would discuss the non-compliance with the individuals involved. This phase extended until 30 April 2015.
Phase 3: post 1-year intervention phase
During the post implementation phase, the impact of the QI project on CLABSI incidence in the NICU was assessed. A decision to maintain low CLABSI rate and reach zero rate was made and the developed bundles were incorporated into standard NICU care. Data from this phase is reported for a 3-year period from 1 May 2015 to 30 April 2018.
Retrospective data collection
To calculate an accurate baseline CLABSI rate, retrospective data collection of all central lines inserted 2 years prior to implementation of the study was conducted. Data collection was conducted by a neonatology research fellow though a review of medical records for all neonates admitted to the NICU from 1 January 2012 to 31 December 2012. The year 2012 was selected for retrospective data collection, since medical staff training on the importance of reducing CLABSI rates started in 2013 prior to implementation of CLABSI bundle and its respective education and training. For each reviewed CLABSI case, a BSI report was filled to allow for comparison of central line site and organisms isolated with the prospective CLABSI cases.
Statistical analysis
All statistical analysis were conducted using Statistical Package for Social Sciences program, V.23.0 for Windows. Analysis of variance was used to compare CLABSI rates and Device Utilization Ratio (DUR) before, during and after the intervention period. We used statistical process control charts generated to evaluate for statistically significant changes. A g-control chart was used to evaluate time intervals between occurrences. DUR graphs were generated to compare utilisation ratios among different phases of this study. A two-tailed p value of 0.05 was considered significant.
Patient and public involvement
It was not appropriate or possible to involve patients or the public in the design, or conduct, or reporting, or dissemination plans of our research.
Results
Retrospective data analysis revealed a high CLABSI rate of 4.82 cases per 1000 central line days in 2012. A total of 6 infections and 1244 central line days were reported over the 1-year period. Introduction of the Central line Insertion and Maintenance Bundles resulted in a 76% reduction of CLABSI rate to 1.09 cases per 1000 central line days after the occurrence of two CLABSI infections (1830 central line days) during the 1 year of project implementation. A reduced CLABSI rate was maintained during the post implementation period with an overall CLABSI rate of 0.66 per 1000 central line days (3 infections; 4552 central line days). Precisely, reduced CLABSI rate was maintained during the first year of post implementation phase at 1.15 per 1000 central line days (2 infections; 1745 central line days). The rate then decreased to 0.66 per 1000 central line days (1 infection; 1505 central line days) during the second year before achieving a zero CLABSI rate in the third year where no infection occurred over 1302 central line days. A detailed quarterly breakdown of CLABSI rates in the NICU is shown in figure 1.
Quarterly central line-associated bloodstream infection (CLABSI) rate pre, during and post quality improvement (QI) implementation.
The number of days between CLABSIs events are shown in online supplemental appendix 3. The numbers are represented through a g-chart, where the number of days begins to increase in 2014. By 2015, 341 CLABSI-free days were achieved. From 12 May 2016 to 30 April 2018, the unit had 713 CLABSI-free days. Both of these periods were statistically significant increase in days between infections with both number above the upper control limit (+3 SD). Overall, a zero CLABSI rate was achieved for almost 2 years from June 2016 to April 2018.
Table 2 reports CLABSI rate and DUR prior to, during and post 1-year QI implementation phase. Overall, the bundle decreased CLABSI rates despite an increase in DUR in the NICU. The average DUR reported in this QI increased from 0.22 pre implementation to 0.41 during the 1-year project implementation. DUR then decreased to an average of 0.36 during the post QI phase. Online supplemental appendix 4 represents the quarterly DUR variation before, during and post QI implementation.
Comparison of CLABSI rate and DUR pre, during and post quality improvement implementation
Discussion
CLABSIs can be prevented by best-practice central line insertion and maintenance bundles including range of techniques such as aseptic insertion practices, daily assessment of catheter need and early discontinuation of central lines.21 The bundles, as predicted, were successful in decreasing CLABSI rates by 76% after 1 year despite an increase in central line utilisation ratio. Our results were in line with other studies in high-income countries and in LMICs, such as the QI project conducted in a private hospital in Lebanon, which significantly decreased CLABSI rate by 57.3% from 15 to 6.4 per 1000 central line days in the post intervention period.10 11 22–25 Similarly, a multicountry study conducted by Rosenthal et al in El Salvador, Mexico, Philippines and Tunisia where a CLABSI intervention decrease CLABSI rates by 55% from 21.4 to 9.7/1000 centreline days.26 On the other hand, our QI was able to achieve and sustain a CLABSI-free unit for 2 years, which is unique and to our knowledge has not been reported in the literature by other NICU interventions in LMICs.23 24
After assessing the bundles’ success in reducing CLABSI rate after the first year of implementation and its smooth integration into daily care practices, the insertion and maintenance checklists were incorporated permanently into the NICU medical charts. Staff education, optimisation of hand-hygiene practices, documentation of line care and timely removal of non-essential central lines became part of routine care. Additionally, staff observations and feedback were encouraged and the nurses were empowered to stop a procedure if non-adherence or breech of protocol was noted.
This was followed by a 341-day CLABSI-free span, almost reaching a 1-year zero CLABSI rate. However, in the second and third quarters of 2015, three CLABSIs events were noted. An investigation was conducted to identify the cause of the infections. The root cause analysis identified sporadic breaches in the CLABSI bundle during a period of high number of central line patients in the unit where more than two-thirds of neonates in the unit had central lines at that time. Accordingly, to improve compliance, staff was re-educated on the bundle and optimal hand-hygiene practices were reiterated. Moreover, continuous audits and regularly scheduled meetings were implemented to monitor and evaluate team progress and insure proper practice in the unit. On 13 May 2017, the unit achieved a full year with no CLABSI infections reaching a 1-year zero CLABSI rate. The hospital’s Chief of Staff and Head of Infection Control congratulated the NICU Medical Director and staff for their commended efforts. The 1-year zero CLABSI rate was celebrated in the unit through a staff gathering. The celebration promoted a sense of pride and ownership among all NICU staff.
Several limitations to this study are acknowledged. Since insertion and maintenance bundles were implemented simultaneously, we cannot assess which bundle contributed the most to CLABSI reduction. Moreover, the reduction of CLABSI incidence could be due to the gradual decrease in central line use in the 4 years of bundle implementation. Moreover, since medical staff education started prior to the introduction of the intervention, the reduction in CLABSI rates could have started in 2013 and continued to decline after the introduction of bundles in 2014.
Conclusion
The experience and success of the CLABSI insertion and maintenance bundles should be translated to other referral hospitals in Lebanon especially those facing high central line infection rates. The largest of whom are governmental hospitals, who have high patient loads in their NICU and could not afford the short-term and long-term economic and health repercussions of CLABSI infections. We plan to share our bundles and experience with the Ministry of Public Health to assess the feasibility of implementing this intervention in their governmental hospitals.
Data availability statement
Data are available upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
The institutional review board (IRB) at American University of Beirut Medical Center considered this project as a quality improvement project and exempted from IRB review and approval.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors AA, AO, TD, LC, NM, PN and KY contributed to the conception and design of the quality improvement project. AA, AO, TD, PN and KY contributed to the acquisition of data. AA analysed the data. AA, RH, AO, TD, CL, NM, PN and KY contributed to interpretation of data. AA, RH, PN and KY contributed to the drafting of the work. All Authors approved the final version to be published and agreed to be accountable for all aspects of the work. KY is the guarantor for this work.
Funding Establishment of the quality improvement (QI) was funded by March of Dimes Foundation (Award number 100296). Since then, it has been maintained as a standard practice of care in the neonatal intensive care unit.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.