Improving the central venous access devices maintenance process to reduce associated infections in paediatrics: evaluation of a practical, multi-faceted quality-improvement initiative
Tricia Kleidon A B , Abby Illing A , Gerry Fogarty A , Rachel Edwards A , Jane Tomlinson A and Amanda Ullman B C D
+ Author Affiliations
- Author Affiliations
A Lady Cilento Children’s Hospital, South Brisbane, Qld 4101, Australia.
B NHMRC Centre of Research Excellence in Nursing, Centre of Health Practice Innovation, Menzies Health Institute Queensland, Nathan, Qld 4111, Australia.
C School of Nursing and Midwifery, Griffith University, Nathan, Qld 4111, Australia.
D Corresponding author. Email: a.ullman@griffith.edu.au
Healthcare Infection 20(2) 46-53 https://doi.org/10.1071/HI14038
Submitted: 17 November 2014 Accepted: 22 December 2014 Published: 18 March 2015
Abstract
Introduction: Central venous access devices (CVADs) provide essential and reliable vascular access, but infection is a common and serious complication with paediatric patients. CVAD bundles have been demonstrated to effectively reduce central line-associated bloodstream infections (CLABSI), but primarily during CVAD insertion. Another emerging strategy to encourage best practice is the use of a dedicated CVAD trolley for maintenance.
Methods: A quality-improvement initiative was undertaken to improve CVAD maintenance and to evaluate the effectiveness of the chosen interventions at the Royal Children’s Hospital, Brisbane. Nursing staff from four wards within the hospital elected to participate and the wards were allocated to receive either Intervention A (CVAD maintenance bundle only) or Intervention B (CVAD maintenance bundle and dedicated CVAD trolley). Effectiveness of the interventions was evaluated by: (i) rate of CLABSI per 1000 catheter-days; and (ii) audits of clinician compliance with evidence-based CVAD maintenance strategies.
Results: During the initiative, the hospital-wide CLABSI rate decreased from 9.07 to 1.05 episodes per 1000 catheter-days (P = 0.01). The rate of CLABSI in Intervention A wards reduced from 7.6 to 2.2 episodes per 1000 catheter-days (P < 0.001) and in Intervention B wards reduced from 8.0 to 0.5 episodes per 1000 catheter-days (P < 0.001). Hospital-wide audits of clinician compliance increased from 11.9% to 35% (P = 0.001) in the Intervention A wards and to 83% (P < 0.001) in the Intervention B wards.
Conclusion: Implementation of CVAD maintenance bundles and a dedicated CVAD trolley successfully reduced CLABSI and improved audited compliance to evidence-based practices within our tertiary paediatric hospital.
References
[1] Cook LS. Choosing the right intravenous catheter. Home Healthc Nurse 2007; 25 523–31.| Choosing the right intravenous catheter.Crossref | GoogleScholarGoogle Scholar | 17828007PubMed |
[2] Maki DG, Ringer M. Risk factors for infusion-related phlebitis with small peripheral venous catheters: a randomized controlled trial. Ann Intern Med 1991; 114 845–54.
| Risk factors for infusion-related phlebitis with small peripheral venous catheters: a randomized controlled trial.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK3M7ps12qsw%3D%3D&md5=d4aa1133578b3055af50dfac96bd49b2CAS | 2014945PubMed |
[3] Cowl CT, Weinstock JV, Al-Jurf A, Ephgrave K, Murray JA, Dillon K. Complications and cost associated with parenteral nutrition delivered to hospitalized patients through either subclavian or peripherally-inserted central catheters. Clin Nutr 2000; 19 237–43.
| Complications and cost associated with parenteral nutrition delivered to hospitalized patients through either subclavian or peripherally-inserted central catheters.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BD3cXmvVWntLk%3D&md5=fd3acf02e7b19373c6d5cc3cd6e2725cCAS | 10952794PubMed |
[4] Lim MY, Al-Kali A, Ashrani AA, Begna KH, Elliott M, Hogan WJ, Hook CC, Kaufmann SH, Letendre L, Litzow MR, Patnaik MS, Pardanani A, Tefferi A, Wolanskyj AP, Grill DE, Pruthi RK. Comparison of complication rates of Hickman catheters versus peripherally inserted central catheters in patients with acute myeloid leukemia undergoing induction chemotherapy. Leuk Lymphoma 2013; 54 1263–7.
| Comparison of complication rates of Hickman catheters versus peripherally inserted central catheters in patients with acute myeloid leukemia undergoing induction chemotherapy.Crossref | GoogleScholarGoogle Scholar | 23088670PubMed |
[5] Napalkov P, Felici DM, Chu LK, Jacobs JR, Begelman SM. Incidence of catheter-related complications in patients with central venous or hemodialysis catheters: a health care claims database analysis. BMC Cardiovasc Disord 2013; 13 86
| Incidence of catheter-related complications in patients with central venous or hemodialysis catheters: a health care claims database analysis.Crossref | GoogleScholarGoogle Scholar | 24131509PubMed |
[6] Ng F, Mastoroudes H, Paul E, Davies N, Tibballs J, Hochhauser D, Mayer A, Begent R, Meyer T. A comparison of Hickman line- and Port-a-Cath-associated complications in patients with solid tumours undergoing chemotherapy. Clin Oncol 2007; 19 551–6.
| A comparison of Hickman line- and Port-a-Cath-associated complications in patients with solid tumours undergoing chemotherapy.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD2svls1Giuw%3D%3D&md5=fabf8f7fb2adcb84284c414c76e47fa3CAS |
[7] Turcotte S, Dube S, Beauchamp G. Peripherally inserted CVCs are not superior to CVCs in the acute care of surgical patients on the ward. World J Surg 2006; 30 1605–19.
| Peripherally inserted CVCs are not superior to CVCs in the acute care of surgical patients on the ward.Crossref | GoogleScholarGoogle Scholar | 16865322PubMed |
[8] Marschall J, Leone C, Jones M, Nihill D, Fraser VJ, Warren DK. Catheter associated bloodstream infections in general medical patients outside the intensive care unit: a surveillance study. Infect Control Hosp Epidemiol 2007; 28 905–9.
| Catheter associated bloodstream infections in general medical patients outside the intensive care unit: a surveillance study.Crossref | GoogleScholarGoogle Scholar | 17620235PubMed |
[9] Mermel LA. Prevention of intravascular catheter-related infections. Ann Intern Med 2000; 132 391–402.
| Prevention of intravascular catheter-related infections.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3c7ktlSlsA%3D%3D&md5=dd8a2b5d54cdd1fd91236f9399ca2825CAS | 10691590PubMed |
[10] Pittet D, Tarara D, Wenzel RP. Nosocomial bloodstream infection in critically ill patients. Excess length of stay, extra costs and attributable mortality. JAMA 1994; 271 1598–601.
| Nosocomial bloodstream infection in critically ill patients. Excess length of stay, extra costs and attributable mortality.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK2c3jvVOlsw%3D%3D&md5=e8d28753f5bc93d97d1aecd0a492854fCAS | 8182812PubMed |
[11] O’Grady N, Alexander M, Burns L, Dellinger E, Garland J, Heard SO, Lipsett PA, Masur H, Mermel LA, Pearson ML, Raad II, Randolph AG, Rupp ME, Saint S, Healthcare Infection Control Practices Advisory Committee (HICPAC) (Appendix 1). Summary of recommendations: guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis 2011; 52 1087–99.
| Summary of recommendations: guidelines for the prevention of intravascular catheter-related infections.Crossref | GoogleScholarGoogle Scholar | 21467014PubMed |
[12] Infusion Nurses Society Infusion Nursing Standards of Practice. J Infus Nurs 2006; 29 S1
| 16429002PubMed |
[13] Loveday HP, Wilson JA, Pratt RJ, Golsorkhi M, Tingle A, Bak A, Browne J, Prieto J, Wilcox M., UK Department of Health epic3: National Evidence-based guidelines for preventing healthcare-associated infections. J Hosp Infect 2014; 86 S1–70.
| epic3: National Evidence-based guidelines for preventing healthcare-associated infections.Crossref | GoogleScholarGoogle Scholar | 24330862PubMed |
[14] Intravenous Nursing New Zealand Inc. Infusion Therapy Standards of Practice. New Zealand: IVNNZ Inc.; 2012. Available from: http://www.ivnnz.co.nz/about-ivnnz-inc./Infusion-Standards-of-Practice [Verified March 2015]
[15] Koletzko B, Goulet O, Hunt J, Krohn K, Shamir R. Guidelines on Paediatric Parenteral Nutrition of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), Supported by the European Society of Paediatric Research (ESPR). J Pediatr Gastroenterol Nutr 2005; 41 S1–4.
| Guidelines on Paediatric Parenteral Nutrition of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), Supported by the European Society of Paediatric Research (ESPR).Crossref | GoogleScholarGoogle Scholar | 16254497PubMed |
[16] Royal College of Nursing. Standards for Infusion Therapy The RCN IV Therapy Forum. London: Royal College of Nursing; 2010.
[17] Australian New Zealand Intensive Care Society. Central Line Insertion and Maintenance Guideline. Melbourne; 2012.
[18] Infusion Nurses Society Infusion nursing standards of practice. J Infus Nurs 2011; 34 S16–7.
[19] Ullman AJ, Long DA, Rickard CM. Prevention of central venous catheter infections: a survey of paediatric ICU nurses’ knowledge and practice. Nurse Educ Today 2014; 34 202–7.
| Prevention of central venous catheter infections: a survey of paediatric ICU nurses’ knowledge and practice.Crossref | GoogleScholarGoogle Scholar | 24070818PubMed |
[20] Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, Milanovich S, Garrett-Mayer E, Winters BD, Rubin HR, Dorman T, Perl TM. Eliminating catheter-related bloodstream infections in the intenstive care unit. Crit Care Med 2004; 32 2014–20.
| Eliminating catheter-related bloodstream infections in the intenstive care unit.Crossref | GoogleScholarGoogle Scholar | 15483409PubMed |
[21] Pronovost PJ, Berenholtz SM, Goeschel C. Improving patient safety in intensive care units in Michigan. J Crit Care 2008; 23 207–21.
| Improving patient safety in intensive care units in Michigan.Crossref | GoogleScholarGoogle Scholar | 18538214PubMed |
[22] DePalo VA, McNicoll L, Cornell M, Rocha JM, Adams L, Pronovost PJ. The Rhode Island ICU collaborative: a model for reducing central line-associated bloodstream infection and ventilator associated pneumonia. Statewide. Qual Saf Health Care 2010; 19 555–61.
| The Rhode Island ICU collaborative: a model for reducing central line-associated bloodstream infection and ventilator associated pneumonia. Statewide.Crossref | GoogleScholarGoogle Scholar | 21127114PubMed |
[23] McLaws M, Jarvis W. Central line-associated bloodstream infection (CLABSI) rates: achieving the elusive goal of zero. Healthc Infect 2014; 19 39–41.
| Central line-associated bloodstream infection (CLABSI) rates: achieving the elusive goal of zero.Crossref | GoogleScholarGoogle Scholar |
[24] Burrell AR, McLaws M-L, Murgo M, Calabria E, Pantle AC, Herkes R. Aseptic insertion of central venous lines to reduce bacteraemia. Med J Aust 2011; 194 583–7.
| 21644871PubMed |
[25] Costello JM, Morrow DF, Graham DA, Potter-Bynoe G, Sandora TJ, Laussen PC. Systematic interventions to reduce central line-associated bloodstream infection rates in a pediatric cardiac intensive care unit. Pediatrics 2008; 121 915–23.
| Systematic interventions to reduce central line-associated bloodstream infection rates in a pediatric cardiac intensive care unit.Crossref | GoogleScholarGoogle Scholar | 18450894PubMed |
[26] Climo M, Diekema D, Warren DK, Herwaldt LA, Perl TM, Peterson L, Plaskett T, Price C, Sepkowitz K, Solomon S, Tokars J, Fraser VJ, Wong E. Prevalence of the use of central venous access devices within and outside of the intensive care unit: results of a survey among hospitals in the prevention epicentre program of the Centres for Disease Control and Prevention. Infect Control Hosp Epidemiol 2003; 24 942–5.
| Prevalence of the use of central venous access devices within and outside of the intensive care unit: results of a survey among hospitals in the prevention epicentre program of the Centres for Disease Control and Prevention.Crossref | GoogleScholarGoogle Scholar | 14700410PubMed |
[27] Zingg W, Imhof A, Maggiorini M, Stocker R, Keller E, Ruef C. Impact of a prevention strategy targeting hand hygiene and catheter care on the incidence of catheter-related bloodstream infections. Crit Care Med 2009; 37 2167–73, quiz 80.
| Impact of a prevention strategy targeting hand hygiene and catheter care on the incidence of catheter-related bloodstream infections.Crossref | GoogleScholarGoogle Scholar | 19487942PubMed |
[28] Sitges-Serra A, Pi-Suner T, Garces JM, Segura M. Pathogenesis and prevention of catheter-related septicemia. Am J Infect Control 1995; 23 310–6.
| Pathogenesis and prevention of catheter-related septicemia.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK287is1aquw%3D%3D&md5=8008c3698bf3e8060bf959674693327eCAS | 8585643PubMed |
[29] Melville S, Paulus S. Impact of a central venous line care bundle on rates of central line associated blood stream infection (CLABSI) in hospitalised children. J Infect Prevention. 2014; 15 139–41.
| Impact of a central venous line care bundle on rates of central line associated blood stream infection (CLABSI) in hospitalised children.Crossref | GoogleScholarGoogle Scholar |
[30] Miller-Hoover S. Pediatric central line: bundle implementation and outcomes. J Infus Nurs 2011; 34 36–48.
| Pediatric central line: bundle implementation and outcomes.Crossref | GoogleScholarGoogle Scholar | 21239950PubMed |
[31] Rowley S. Aseptic non-touch technique. Nurs Times 2001; 97 6–9.
[32] Rowley S, Clare S. Improving standards of aseptic practice through an ANTT trust-wide implementation process: a matter of prioritisation and care. J Infect Prevention. 2009; 10 s18–23.
| Improving standards of aseptic practice through an ANTT trust-wide implementation process: a matter of prioritisation and care.Crossref | GoogleScholarGoogle Scholar |
[33] Hui S, Ng J, Santiano N, Schmidt H-M, Caldwell J, Ryan E, Maley M. Improving hand hygiene compliance: harnessing the effect of advertised auditing. Healthc Infect 2014; 19 108–13.
| Improving hand hygiene compliance: harnessing the effect of advertised auditing.Crossref | GoogleScholarGoogle Scholar |
[34] Centers for Disease Control and Prevention. National Healthcare Safety Network Device Associated Module: CLABSI. In Government USoA, ed. Atlanta; 2014: pp. 1–9.
[35] VICNISS Healthcare Associated Infection Surveillance Coordinating Centre. CDC/NHSN Surveillance Definition of Healthcare-Associated Infection and Criteria for Specific Types of Infections in the Acute Care Setting Melbourne, Victoria: Victorian Government; 2014.
[36] Dumyati G, Concannon C, van Wijngaarden E, Love T, Garman P, Pettis A, Greene L, El-Daher N, Farnsworth D, Quinlan G, Karr G, Ward L, Knab R, Shelly M. Sustained reduction of central line-associated bloodstream infections outside the intensive care unit with a multimodal intervention focusing on central line maintenance. Am J Infect Control 2014; 42 723–30.
| Sustained reduction of central line-associated bloodstream infections outside the intensive care unit with a multimodal intervention focusing on central line maintenance.Crossref | GoogleScholarGoogle Scholar | 24856587PubMed |
[37] National Health and Medical Research Council. The Australian Research Council, the Australian Vice-Chancellors’ Committee. National statement on ethical conduct in human research. Canberra; 2013.
[38] Wheeler D, Giaccone M, Hutchinson N, Haygood M, Bondurant P, Demmel K, Kotagal UR, Connelly B, Corcoran MS, Line K, Rich K, Schoettker PJ, Brilli RJ. A hospital-wide quality-improvement collaborative to reduce catheter associated bloodstream infections. Pediatrics 2011; 128 e995–1007.
| A hospital-wide quality-improvement collaborative to reduce catheter associated bloodstream infections.Crossref | GoogleScholarGoogle Scholar | 21930547PubMed |
[39] Seddon ME, Hocking CJ, Bryce EA, Hillman J, McCoubrie V. From ICU to hospital-wide: extending central line associated bacteraemia (CLAB) prevention. N Z Med J 2014; 127 60–71.
| 24929572PubMed |
[40] Cherry MG, Brown JM, Neal T, Shaw N. What features of educational interventions lead to competence in aseptic insertion and maintenance of CV catheters in acute care? BEME guide no. 15. Med Teach 2010; 32 198–218.
| What features of educational interventions lead to competence in aseptic insertion and maintenance of CV catheters in acute care? BEME guide no. 15.Crossref | GoogleScholarGoogle Scholar | 20218835PubMed |
[41] Pronovost PJ, Berenholtz SM, Goeschel C, Needham DM, Sexton JB, Thompson DA, Lubomski LH, Marsteller JA, Makary MA, Hunt E. Creating high reliability in health care organizations. Health Serv Res 2006; 41 1599–617.
| Creating high reliability in health care organizations.Crossref | GoogleScholarGoogle Scholar | 16898981PubMed |
[42] Pronovost P, Goeschel C, Colantuoni E, Watson S, Lubomski LH, Berenholtz SM, Thompson DA, Sinopoli DJ, Cosgrove S, Sexton JB, Marsteller JA, Hyzy RC, Welsh R, Posa P, Schumacher K, Needham D. Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: Observational study. BMJ 2010; 340 c309
| Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: Observational study.Crossref | GoogleScholarGoogle Scholar | 20133365PubMed |