It Takes A Village: Multidisciplinary Collaboration to Reduce Central Line-Associated Bloodstream Infections in a Neonatal Intensive Care Unit

Background:  Central line-associated bloodstream infections (CLABSI) are the most common form of healthcare-associated infections (HAI) among neonatal intensive care unit (NICU) patients.  They cause increases in morbidity and mortality, lead to poor neurologic development, and cost $12,000-$39,000 per episode.  A 551 licensed-bed urban community-teaching hospital with a trauma center and a Level III NICU noted an increase in CLABSI rates. Since partnerships have been shown to help quality improvement initiatives, Infection Prevention (IP) initiated a partnership with NICU personnel. 
Objective: The goal of this quality improvement initiative was to reduce neonatal CLABSI rates by partnering with NICU personnel.

Methods:   IP partnered with a newly appointed Clinical Director (Neonatologist) for the NICU and an experienced nurse trained to insert and care for peripherally inserted central lines. The Neonatologist was instrumental in focusing attention and resources on reducing CLABSI, while the nurse provided education. Both oversaw daily practices.  IP assisted with adapting the CLABSI bundle for neonates, monitored neonates in the unit for CLABSI, and spearheaded apparent cause analyses on all cases.  Centers for Disease Control and Prevention National Healthcare Safety Network definitions for CLABSI and methods for determining infection rates were used.  

In April 2009, the Neonatologist and nurse educated all NICU nurses and neonatologists.  Education emphasized closer adherence with maximum barrier precautions during insertion and care of the lines, changing intravenous fluids, tubings and connectors at the same time, cleaning ports with chlorhexidine, flushing lines every 8 hours, using at least a 10 mL syringe for flushes to prevent rupture of catheters, assigning 2 nurses to perform each dressing change, changing dressings at least weekly, notifying a neonatologist immediately when a line clots, not using new lines until placement is confirmed by x-ray and physician approval is given, and appropriately documenting the location, insertion dates, and care of the lines.  A parent information sheet on central lines was also created.
Results:  From November 1, 2008 through April 30, 2009, CLABSI rates ranged from 0-76.9 per 1000 patient days among infants with birth weights ≤ 750 g, and from 0-50 per 1000 patient days in neonates 751-1000 g.  There were no CLABSI in the other birth weight categories. From May 1, 2009 through October 31, 2009 there were no CLABSI in the NICU.  However, differences in CLABSI rates were not statistically-significant.

Conclusions:   The NICU has eliminated CLABSI for 7 months.  The most important factor may have been closer adherence to bundle.  Rates were noted to decrease even as the initiative was being undertaken amongst staff, suggesting that active engagement of personnel empowered adherence to bundle.