INITIATION OF A ROBUST CLABSI BUNDLE: ONE NICU’S JOURNEY TO ZERO HARM

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INTRODUCTION

The Neonatal Intensive Care Unit (NICU) consists of one of the most vulnerable patient populations within the healthcare system. For patients with extremely low birthweights and immature immune systems, infection prevention continues to be a challenge for those care providers even with the best of intentions in mind. Like most institutions, the prevention of central line associated blood stream infections (CLABSI) has become a priority from a cost and patient safety perspective.

Preterm or sick infants depend on central lines to provide nutrition and medication for several weeks and sometimes months after birth. Umbilical catheters and peripherally inserted central catheters (PICC) are widely utilized in this population and require special care. Antiseptic solutions, adhesive use, and venous depletion have become problematic in small babies creating chemical burns, adhesive trauma, and disruptions in skin integrity. The utilization of small catheters has led to an increased risk of thrombus formation and line occlusions. With all the forementioned complications, a zero CLABSI rate seems daunting and incredibly challenging.

Just like any other journey, creating a CLABSI bundle has twists, turns, unexpected paths, and inevitably you reach the destination to zero. So, you must ask the question, “What’s the secret to a successful trip?”

WHAT IS IN YOUR CLABSI BUNDLE?

Many institutions assess the need for robust bundle solutions based on data. We ask ourselves, “do we really have a problem?” or state, “we have a low CLABSI rate.” Shifting the focus to prevention of harm is imperative. One of the bestkept secrets is this pivot of culture. This culture shift ensures everyone is responsible for the line no matter the role they play on the healthcare team.

In our institution, we succeeded in obtaining a ZERO CLABSI rate in the NICU for more than a year. This did not come without challenges. We started with low hanging fruit. Designated line carts were stocked with supplies for changing fluids and dressings. Custom preassembled IV sets were created to avoid piecing fluid tubing together for uncomplicated fluid changes. A custom dressing change kit was also created. Each intervention aims to avoid the risk of touch contamination.

We standardized our dressing change and insertion process and created a PICC team within the NICU comprised of a specific group of neonatal nurses and nurse practitioners. This team inserts lines, changes dressings, discontinues lines, and handles all line and dressing complications. Research shows that having a specialized team is one strategy to decrease the risk of line infections and complications.

All insertions, tubing changes, and dressing changes are observed and audited. This process is the new normal and has been cultivated by our culture of safety. Nursing leadership rounds on every central line several times a week utilizing bedside K-cards. During each shift, bedside team rounds discuss line necessity and line entries. CHG (Chlorhexidine gluconate) bathing is performed on older babies to help decrease the risk of infections.

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INITIATION OF A ROBUST CLABSI BUNDLE, CONTINUED FROM PREVIOUS PAGE

The creation of a CLABSI roadmap with all bundle elements was implemented and then incorporated in an electronic format for easier data collection. Bedside nursing staff are responsible for attesting these elements each shift. Our accountability equals reliability in CLABSI prevention.

Although we made significant improvements to the bundle, we revisited the most basic elements of any infection prevention strategy. We implemented UV light boxes for sanitizing cell phones, badges, pens, and watches for all staff and visitors. We re-educated staff on the importance of hand hygiene and placed important signs near sinks to help visitors and other staff maintain compliance.

New products incorporated in our bundle elements were the use of tissue adhesive at insertion sites of all vascular access devices, CHG pledgets instead of alcohol for scrubbing needleless connectors prior to line entries, and alcohol-based port protecting caps. Having these pieces stocked and readily available to staff made them more likely to be used appropriately.

We developed and utilized educational pamphlets to partner with parents and caregivers of babies with central lines. The focus for this education is on infection prevention, comfort, hand hygiene, and complications. In our journey we joined the Solutions for Patient Safety which gave us valuable resources and connections with other institutions. Assessing our feeding protocols and making changes to advance feedings in a timely manner meant fewer line days for most of our patients.

THE SECRET TO A SUCCESSFUL JOURNEY

A change in culture with a focus on safety and harm prevention continues to be the key to our success as each intervention builds upon the next. Deep diving into central line infection cases and learning from each one must be a priority. Holding staff accountable with processes and procedures creates this culture shift. Remembering to pivot from “we can’t” to “how can we, despite our circumstances” opens the door to a multitude of possibilities. We have a motto in our children’s hospital, “Keeping 1 child safe means you’re a hero, keeping 100s of children safe means you’re a hero at Carilion Children’s.” 9