Choi, S. W., Chang, L., Hanauer, D. A., Shaffer-Hartman, J., Teitelbaum, D., Lewis, I., . . . Niedner, M. F. (2013). Rapid reduction of central line infections in hospitalized pediatric oncology patients through simple quality improvement methods. Pediatric Blood and Cancer, 60, 262–269.

To investigate the effects of the implementation of a central line catheter care bundle on infection rates.

A working group comprised of physicians specializing in pediatric hematology-oncology, infectious diseases, anesthesiology, and surgery, as well as infection-control professionals, a phlebotomy service leader, and several nursing leaders, was formed to focus on improvement in central line-associated blood stream infection (CLABSI) rates. Team members were educated in quality improvement for a four-month period and developed techniques to improve the safety culture, identify best practices for insertion and line maintenance, and disseminate information to clinical care providers. A catheter care bundle was implemented, including proper hand hygiene, dressing change frequency, skin cleansing with chlorhexidine, tubing changes at least every 96 hours, chlorhexidine used for bathing, and standards for central line entry. Pre- and postimplementation data were analyzed at six months from the beginning of the effort and at 17 months.

• One hundred thirty patients were included.
• One hundred two CLABSI events occurred.  
• All participants were pediatric patients with cancer; some had undergone hematopoietic cell transplantation (HCT).

• Single site 
• Inpatient
• Michigan

This was a descriptive observational study.

• Nurse self-report of bundle care compliance
• CLABSI rate (calculated as events by number of patient days)
• Agency for Healthcare Research & Quality (AHRQ) patient safety culture survey
• CLABSI identification according to National Healthcare Safety Network (NHSN) methods

Self-reported adherence to catheter bundle care was more than 90% in most areas.  Lowest compliance areas were bathing practices and “all or none” (compliance with everything) areas in the first six months.  These both improved to more than 85% at 17 months. The preintervention CLABSI rate was 5.55% in patients undergoing bone marrow transplantation (BMT) and 1.81% in non-BMT patients. Postintervention CLABSI rates were 2.96% in BMT patients and 1.04% in non-BMT patients (p < 0.04). Patient safety culture survey results reflected improvement; however, sample sizes were small with low response rates, and comparisons were not statistically significant.

Findings showed that the institutional initiative used here was effective in reducing CLABSI rates.

• Measurement validity/reliability was questionable.
• CLABSI calculation did not use catheter patient days as the denominator, which influenced the results. 
• Self-reported compliance may not be accurate. 
• Specific implementation, dissemination, monitoring, and feedback methods were not described.

Comprehensive institutional initiatives can improve quality of care. Catheter care bundle implementation was effective in reducing overall CLABSI rates as measured here. Results showed that it took time to achieve improvement in compliance with all aspects of catheter care.