Open Access
01.12.2025 | Cardiology/CT Surgery (K Gist, Section Editor)
Reducing Central Line-Associated Bloodstream Infections in a Pediatric CICU: A Review
verfasst von:
Anna Milam, Lauren Ballard, Guy Beck, Denielle Bischoff, Katie Bruns, Amanda Ozolins, David S. Cooper, Jennifer N. Craven, Amanda Glenn, Katja M. Gist
Hospital acquired infection (HAI) prevention has been a top priority for healthcare professionals to ensure patient safety. Central line-associated bloodstream infections (CLABSIs) account for over half of all HAIs and are associated with increased morbidity, including prolonged hospital length of stay, mortality, and higher hospital costs. This review briefly discusses the burden of CLABSIs in a pediatric cardiac intensive care unit (CICU) and highlights our approach to current evidence-based practice interventions to aid in CLABSI reduction.
Recent Findings
Pediatric CICU patients are at an increased CLABSI risk due to their critical status, frequent use of central lines for prolonged periods, limited access availability for placement, and length of hospital stay. Literature has shown that consistent and reliable performance of evidence-based practice interventions can aid in the overall reduction of CLABSIs in various patient populations. Performing these interventions can maintain low CLABSI rates among this patient population. Using rapid Plan-Do-Study-Act cycles beginning in early 2022, we implemented several interventions, including multidisciplinary leadership rounds, a risk identification tool to reduce high CLABSI rates at our institution. In our center, we have demonstrated benefit from interventions described herein.
Summary
Reducing CLABSI occurrences in pediatric CICU patients can improve patient outcomes, enhance patient safety, and reduce per capita costs to both the patient and institution. Dissemination of reliable evidence-based interventions in this patient population can further be adopted in other institutions to reduce CLABSIs.
Hinweise
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Introduction
Central line-associated bloodstream infections (CLABSIs) are a type of hospital-acquired infection (HAI) that occur within a central vascular device, including peripherally inserted central catheters (PICC), umbilical venous catheters (UVC) and central venous catheters (CVC) in situ. Patients with congenital or acquired heart disease admitted to the cardiac intensive care unit (CICU) are at high risk for developing a CLABSI due to their critical status, prolonged need for central access, limited venous access availability for placement, and length of hospital stay [1, 2]. An estimated 65–70% of all CLABSIs are preventable [3]. CLABSI’s also account for up to 60% of all HAIs and are a major source of morbidity, mortality, and increased hospital costs in hospitalized patients [2, 4]. Adopting evidence-based practice interventions and maintaining adequate compliance with these interventions can reduce overall CLABSI incidence [5]. Common evidence-based practice interventions include patient bathing guidelines with chlorhexidine gluconate (CHG), routine line and cap changes, environmental wipe-downs, and the use of trained personnel for line management and CLABSI prevention. This review will summarize and discuss current CLABSI interventions in the CICU at a pediatric institution and highlight the importance of maintaining compliance with standards to further reduce CLABSIs.
Background
The Center for Disease Control and Prevention (CDC) defines CLABSI as an infection that enters the bloodstream through a central line [6]. A central line is used to administer medications, fluids, and nutrition and to collect blood for routine testing. A central line differs from a peripheral IV in that it provides access to a major vein that is close to the heart and can remain in place long-term, thus increasing the likelihood for it to be a source of infection. The CDC and The Joint Commission provide specific definitions and criteria for a CLABSI as well as a toolkit for a variety of topics including risk factors and pathogenesis [7, 8]. Regardless of the type of CLABSI, it is important for healthcare professionals to recognize those at risk and identify standardized, evidence-based practices to reduce or eliminate the threat.
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Institutions have utilized the Institute for Healthcare Improvement (IHI) Plan-Do-Study-Act (PDSA) cycle process for improvement [9]. While other improvement processes exist, we utilized PDSA cycles to test interventions to reduce CLABSI in our unit. The 2022 CDC HAI progress report showed an overall reduction in CLABSIs among hospitalized patients [8]. The ICU’s saw the largest reduction in CLABSI events of 21% [8]. The burden of each CLABSI event has the potential to increase the cost to the hospital from $22,000—$100,000 per case, depending on the severity of the infection and the treatment required. The total annual cost of CLABSI in the United States is estimated to exceed more than $1 billion [10]. The impact of CLABSIs on the pediatric healthcare system is also not trivial, where costs are reported to be increased by $55,000 [2, 11]. Thus, reducing CLABSI is not only essential to reduce costs to patients and the health care system.
Orozco-Santana et al. recently reported on methods to reduce CLABSI events in an adult CICU at a single institution [12]. This institution, like many, implemented multiple interventions with key stakeholder buy-in and reported on maintaining zero CLASBSI events for over 365 days. Other adult institutions have reported similar reductions with multi-disciplinary interventions [13]. Gauntt et al. not only reported a substantial reduction in CLABSI events in a pediatric CICU over a 3-year period but central line days were also decreased [11].
CLABSI Process Improvement
We identified CLABSI to be a significant problem in the CICU at Cincinnati Children’s Hospital Medical Center (CCHMC). Beginning in January 2022, we identified several processes annotated in the run chart (Fig. 1). In addition, the CLABSI rate is also summarized in Fig. 1 from 1/1/2020–2/1/2024. Herein, we describe the existing CLABSI standards and the trialed CICU-specific interventions at CCHMC for reducing CLABSI events. A Key Driver Diagram was used to keep track of our global aim, key drivers, and interventions, and these are displayed in Figs. 2a for fiscal year 2023 and Fig. 2b for fiscal year 2024.
Fig. 1
U chart summarizing the CLABSI Rate per 10,000 Line days. The chart is annotated with specific interventions over time
Fig. 2
Key driver diagram for fiscal year 2023 (A) and 2024 (B)
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Current CLABSI Prevention Standards
Hospital Standards
The hospital has several prevention standards that include routine line and cap changes (performed every four days), dressing changes (frequency varies based on gestational age and product to be used) [14], hourly line assessment by bedside nursing, daily bathing with chlorhexidine gluconate (CHG) [15], daily environmental wipe downs of frequently touched surfaces. Proper hand hygiene and sterility is to be maintained during all central line maintenance and care. The hospital prevention standards are summarized in Table 1. The hospital has CLABSI champions available as a resource for all patients, and there is a CLABSI team on every unit. CLABSI champions must take annual training classes to maintain competency and remain current on standard practices. All bedside nurses are encouraged to become a CLABSI champion. However, this does not result in a reduction in bedside shift assignments. In addition, annual education surrounding CLABSI prevention is required for all patient-facing staff.
Table 1
Current CLABSI interventions in a pediatric cardiac intensive care unit at a single institution
Current Intervention
Explanation
Usage of 3.15% chlorhexidine gluconate (CHG) with 70% isopropyl alcohol
Used for cleaning of all central lines and antisepsis of skin for insertion and maintenance
Used to identify high risk patients, create hyperawareness, and aid in central line-associated bloodstream infection (CLABSI) reduction
Environmental wipe downs
Done by bedside staff twice a day
Hand hygiene
Meticulous hand hygiene with either soap and water or hand sanitizer done for all central venous catheter (CVC) or peripherally inserted central catheter (PICC) care
Daily CHG bathing
All patients with a central line must receive daily CHG baths unless contraindicated:
- Contraindications include adjusted age < 48 weeks for premature infants or < 2 months for full term infants, sensitivity or allergy to CHG, or patients with irritated, red, non-intact skin or rash
Sterile technique using maximum barrier precautions
Maintain sterile field throughout entire procedure of central line insertion and maintenance, including dressing and line changes
Daily discussion of necessity of central line
Necessity and adequacy of access, line integrity issues, mitigation plans, and prompt removal/insertion discussed with bedside staff and providers to minimize risk
Hourly line assessment using Touch- Look- Compare (TLC) approach
Monitors and identifies issues with skin integrity, signs/symptoms of infection, or extravasation
Two person CVC/PICC dressing changes
Monitors for break in sterile technique, educates parents/caregivers, supports newer staff, and suggests ideas for securement and routing of lines
Routine dressing changes
-Change transparent dressing every 7 days except for patients < 2 months adjusted age
-If < 2 months adjusted age, dressings are changed PRN
-Change gauze dressing every 2 days
-Change dressing anytime if loose, soiled, visible blood, or if antimicrobial disc is swollen
IV Clear and Cova Clear usage
Used to prevent soiling of dressing and enhance prolongation of current dressing in place
Standardized line setup for IV fluid and medication delivery
Ensures standardized handling of catheter and all add on devices to reduce contamination
Change needless connector and continuous administration sets every 96 h
-Replace blood tubing within 4 h of initiation
-Replace lipid tubing every 24 h
-Change propofol infusion every 6 h if in a secondary container or every 12 h if in original manufacturer container
-Replace if suspected break/contamination
Place passive disinfection devices (PDD) on all open access sites
Limits areas of possible break of infection
Annual training of staff
Staff are required to perform annual dressing/cap/line changes to demonstrate competency and proficiency
CLABSI Rounders
Trained individuals scheduled for strict line assessment, infection prevention, coaching, and documentation
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CICU Specific CLABSI Standards
CICU CLABSI champions are charged with maintenance and troubleshooting of central line dressing and line issues. Annual education is required for all CLABSI champions with the intent to provide a refresher on best practices, discuss learnings and disseminate new interventions to aid in CLABSI reduction. A detailed description of interventions are discussed in detail in the following section.
Transparency in current trends and events are crucial for ongoing learning. Hospital acquired conditions are reviewed and discussed weekly at the CICU patient safety meeting. Following each CLABSI event, nurse champions, infection control and process improvement specialists perform a “deep dive” into details around the event, including parent interviews. After data is gathered, the team meets to discuss the review, and next steps on changing or improving existing processes. Specifics on diversity and equity around care are also discussed as part of the review process.
Newly Developed Processes and Tools
Surveillance Tool
The CICU CLABSI leadership team developed a bedside tool to identify patients at greatest risk for a CLABSI. While not validated, this FLITES tool is specific for the CICU and is constantly being reevaluated for ways to capture patient-specific risk. The FLITES tool includes Frequency of dressing changes and line entries (for example, frequent laboratory draws, issues with the line requiring interventions, codes, emergent intubations), Line days since insertion, Immunocompromised patient (i.e. post heart transplant, known immune deficiency syndrome), tissue plasminogen activator (tPA) usage, External visible length (EVL) change, and Skin integrity. Details of this tool are summarized in Fig. 3. Facets of this tool are discussed on daily rounds with the entire care team, and it facilitates the identification of patients, which warrants increased surveillance outside of standard precautions on whom weekly rounding can be performed. Additionally, patients with two or more FLITES risk factors, are discussed in more detail amongst the care team and receive weekly mitigation plans to correct modifiable risk factors. Unit CLABSI rounders are responsible for assisting bedside staff in the proper documentation for standard CLABSI prevention measures. In addition, a collaborative approach, including the attending, nurse practitioner/fellow, bedside nurse, parent, and CLABSI rounders, is used to identify mitigation plans for CLABSI prevention in high-risk patients. One of the major challenges in the deployment of the FLITES tool for use during daily rounds is that it is kept by the CLABSI rounder, and that integration into the medical record has not been possible. Future work on integrating a dashboard-like feature that can be updated in real-time is currently ongoing.
Fig. 3
FLITES Tool for assessment of central venous lines in patients admitted to the cardiac intensive care unit at risk for a central line associated blood stream infection
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CLABSI Rounding
CLABSI rounding takes place daily by a trained CICU-dedicated CLABSI nurse. When possible, the CLABSI rounder has no patient assignment. Multidisciplinary leadership rounds are performed weekly, where high-risk patients identified by the FLITES tool are discussed, and individual patient assessments are performed. The multidisciplinary team includes a physician lead, nurse practitioner, nurse champion, nursing manager and director, infection control personnel, vascular access team staff, and a process improvement specialist. On-service attendings change weekly, and participate only if they have high-risk patients. Real-time discussions occur with the on-service attendings to develop mitigation plans that focus on timely central line removal when possible.
Other Interventions
Several other interventions have been trialed in the CICU. The “CLABSI Caddy” is a basket containing all the supplies needed for a dressing change in a single location. We identified in review of CLABSI events, that staff were frequently leaving the bedside with the line exposed to gather forgotten supplies. This caddy has simplified dressing changes, limiting an unnecessary duration of insertion site exposure to pathogens, and continues to be used.
Early during interventions, we trialed placement of a sterile barrier underneath the access point for administration of medications. The rationale for this was that many hubs sit on the bed and come into contact with surrounding frequently handled materials, which are a source of pathogens [16, 17] Unfortunately, this method resulted in poor compliance and the perception of inadequate protection per nursing, and its use was abandoned. We have since utilized procedure tables in each patient room that facilitate proper sterile technique and accessibility of all supplies.
Sequential scrubbing, an aseptic technique derived during access to needless connectors/hubs relies on a 5 s scrub and 5 s dry with each medication administration in a sequential fashion [11, 18, 19]. This process was described by Gaunt et al.:1. Scrub the catheter hub with cleaner for five seconds and allow to dry for five seconds. 2. Attach medication to the hub and give it according to hospital protocol. 3. Scrub the connection spot again with cleaner for five seconds and allow to dry for five seconds. 4. If no other medications are needed to be given, flush the line per hospital protocol and place an alcohol-impregnated cap on the end for completion. If additional medications exist, repeat steps 1–4 [11]. Sequential scrubbing using a 3.15% chlorhexidine gluconate (CHG) with 70% isopropyl alcohol swab resulted in a lower number of bacteria on needless connectors as compared to products that are only CHG or alcohol [20] and in a CICU with similar volume and complexity to CCHMC, has been shown to reduce CLABSI events with implementation of this technique [11]. The process itself, even in the absence of perfect technique, is thought to offer increased protection due to the sequential cleaning that takes place, as compared to traditional single-episode cleaning techniques given the colonization that is often present on catheter connectors [21]. Despite the national shortage of available products, we were able to trial this process. It is unclear whether there is staff buy-in of this process, and the overall satisfaction of this compared to the prior product utilized. Whether this process will result in a sustained reduction in our CLABSI rates remains to be seen.
In combination of these interventions for maintenance, surveillance surrounding infection prevention, and development of several PDSA cycles in need of change, the institution has maintained an average CLABSI rate of 0.5 per 1000-line days. The number of days between CLABSIs can also be prolonged through increased compliance with standards and maintaining enthusiasm to infection prevention among staff. The CICU has also reduced the total number of CLABSIs over several years, (Fig. 1) from 22 occurrences in fiscal year 2022 to 4 occurrences in fiscal year 2024.
Conclusions
Through standardization and development of interventions via PDSA cycles, we have successfully reduced CLABSI events in the CICU. Further work, including understanding the benefit of sequential scrubbing and maintaining our current rates are essential for success. Teamwork and collaboration are essential to improvement efforts. Whether the interventions performed in the CICU can be applied to other units remains to be seen.
Declarations
Competing Interests
The authors declare no competing interests.
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