Implementing a Central Line Maintenance Bundle to Reduce Hospital Acquired Central Line Associated Blood Stream Infections in General Pediatric Patients Outside the Intensive Care Unit

Background: Pediatric patients with central venous catheters (CVC) are at risk of developing central line associated bloodstream infections (CLABSI).   Data has shown that implementing a central line maintenance bundle (CLMB) improves care and results in substantially better outcomes.  The CLMB is considered standard of care and is recommended for all patients with CVCs.  Though the CLMB is widely recommended, compliance data is not readily available and no such data exists for pediatric patients outside of the ICU.

Objective: Determine the impact of a CLMB on the incidence of CLABIs in pediatric patients outside the ICU.

Methods: Children’s Memorial Hermann Hospital is a 240 bed tertiary care pediatric hospital with a 96 bed pediatric unit.  CLABSI surveillance began in the pediatric unit in 4/08. NHSN/CDC definitions have been used to identify CLABSIs.    All patients admitted to the pediatric unit were monitored for development of a CLABSI.  Audits of CLMB compliance were conducted weekly.  Line day data is available from 5/09 to 6/10 and CLABSI rates per 1000 line days were calculated for this time period.  CLMB compliance data is available for the entire surveillance period.  Quarterly data of total number of CLABSIs and rates were complied and compared with quarterly CLMB compliance.  The CLMB components included:  CVC dressing occlusiveness, assessment of insertion site, CVC dressing labeled with insertion date and last dressing change, CVC tubing labeled, and CVC hubs covered.  All patients on the pediatric unit with a CVC were audited weekly.  Overall CLMB compliance is defined as the total number of patients with all components of the CLMB compliant at time of audit divided by the total number of patients with CVCs.

Results: There were a total of 31 CLABSIs identified during the surveillance period (mean of 1 CLABSI per month, 3 per quarter).  The mean monthly overall CLMB compliance was 64% (range: 0-100%); the mean quarterly overall CLMB compliance was 62% (range: 30-91%).   Data demonstrated that over time CLABSI rates decreased with increasing CLMB compliance.  A total of 17 CLABSIs were identified during the period of which CLABSI rate data is available.  The mean monthly CLABSI rate was 2.3/1000 line days (range: 0.0-7.1/1000 line days).  The mean quarterly CLABSI rate was 2.5/1000 line days (range: 0.6–6.4/1000 line days).  Mean monthly overall CLMB compliance was 88% (range: 50-100%).  Likewise, the mean quarterly overall CLMB compliance was 88% (range: 68-91%).  Quarters 2 and 3 of 2009 had the lowest CLMB compliance and the highest CLABSI rates.  As the CLMB compliance increased in quarter 4 of 2009 and quarters 1 and 2 of 2010, there was a marked decrease in CLABSI rate.

Conclusions: Improving compliance with a CLMB was associated with a decreasing trend of CLABSI.  Such interventions should be implemented in the non-ICU as well as the ICU setting.