Rinke, M. L., Chen, A. R., Bundy, D. G., Colantuoni, E., Fratino, L., Drucis, K. M., . . . Miller, M. R. (2012). Implementation of a central line maintenance care bundle in hospitalized pediatric oncology patients. Pediatrics, 130, e996–e1004.

To investigate whether a multidisciplinary, best practice central line maintenance care bundle reduces central line-associated blood stream infection (CLABSI) rates in hospitalized pediatric oncology patients and to further delineate the epidemiology of CLABSIs in this population.

The organization joined an effort to improve quality, focusing on CLABSI elimination through the implementation of best practice central line care bundles. The care bundle used was based on relevant Centers for Disease Control and Prevention (CDC) guidelines, including daily site assessment and dressings based on CDC recommendations; procedures for cap, tubing, dressing, and needle changes; catheter site care; and catheter hub, cap, and tubing care. Education on the Children’s Hospital Association (CHA) central line care bundle of reduction of line entries, aseptic entries into the line, and aseptic procedures when changing line components was performed. Nursing self-practice audits were performed prospectively, with a one day per week random nursing shift sampling for all patients with central lines. Targeted interventions were performed to improve compliance, including staff feedback of CLABSI rates, discussion in daily rounds, and mini root cause analysis in cases of CLABSI development. Ongoing individual and group education was performed based on the findings.

• Thirty patients (64% male, 36% female) were included.
• There were 14,059 central line days.
• Average age was 10.5 years.
• Key disease characteristics were hematologic and solid tumors and bone marrow transplantation (BMT).

• Single site 
• Inpatient 
• University-affiliated pediatric hospital in Maryland

• Patients were undergoing the active antitumor treatment phase of care. 
• The study has clinical applicability for pediatrics.

This study was a prospective, interupted time series.

• Anonymous nursing self-practice audits were performed on a randomly chosen nursing shift, one day every week, as a sampling strategy for all unit patients with central lines. Nursing practice was only recorded as compliant with one of the bundle elements if every part of that bundle was documented as completed appropriately.
• The CLABSI rate was defined as CLABSIs per 1,000 central line days.

The unit experienced a 20% decrease in CLABSI rates after the implementation of the intervention (p = 0.58). Secondary analyses indicated that the second year of the intervention had a 64% decline in CLABSI rates below baseline (p = 0.091), suggesting that a long ramp-up period may be necessary to achieve effective change. At the end of 24 months of continuous improvement efforts, 35% of patients were not receiving all bundle elements.

Although the implementation of best practices for central line care to decrease CLABSIs is a viable intervention, the long time to significant results should be seriously considered ongoing education, and monitoring would be required, potentially increasing costs and decreasing staff interest in the intervention.

• Small sample size (<100 patients)
• Findings were not generalizable.
• It is unclear if the results from a single-institution study can be generalized to nontertiary care inpatient pediatric oncology units that do not care for a large number of BMT recipients.
• Strategies described here for improvement activities included some but not all of those strategies shown by evidence to be effective. Staff did not adhere to bundle care 35% of the time, but there is no information about the causes of the lack of adherence.
• Various patient types and types of central lines were included, with a varied risk of infection.
• The heterogeneity of the sample and lack of sufficient sample size for related subgroup analysis limited the ability to draw firm conclusions. 
• The relationship between bundle adherence and infection development were not fully discussed.

CLABSI prevention efforts focusing on central line maintenance are difficult, rely directly on front-line staff participation, and require patience for culture change but also have a profound effect on each nurse who has worked to prevent an infection from occurring.  Nurses need to be aware of the evidence regarding effective approaches to improve guideline adherence and performance of evidence-based practice and use known effective strategies.  Causes of nonadherence to guidelines need to be identified in order for ongoing improvement.  With bundle approaches, it might be useful to analyze which bundle items are truly critical to the outcome.