Beyond the Bundle: Decreasing Central Catheter–Associated Bloodstream Infections

Central line [catheter]–associated blood stream infections (CLABSIs) continue to pose a major challenge to health care professionals in all health care settings. In pediatrics, CLABSI is the most common hospital-acquired condition, increasing health care costs (up to $55 000 per event), length of stay (up to 19 additional days), and morbidity and mortality rates (up to 37%).1–3 Existing guidelines and recommendations for a bundled approach to CLABSI prevention show improvement in infection rates when bundle compliance is at least 95%.4 Despite bundle development and implementation, pediatric CLABSI rates across the country remain elevated above targeted thresholds, suggesting there are additional risk factors not being addressed within the bundles.4,5 When our hospital system evaluated CLABSI trends, it was observed that some patient populations had persistently higher rates of infection. Currently, CLABSI bundles are not stratified based on unique patient and catheter characteristics, requiring further investigation.In our hospital system, high-risk pediatric populations were identified based on the separate patient care unit the patient was admitted on and included patients with congenital heart disease (CHD) specifically in the pediatric cardiac intensive care unit (PCICU), those with hematologic and oncologic diagnoses specifically on the pediatric hematology/oncology unit, and patients with short bowel syndrome (SBS) specifically on a pediatric medical unit. Risk factors for each patient population were identified, and each of these hospital units developed a high-risk protocol aimed at CLABSI reduction within their specific unit. The aim of the project was to reduce CLABSI rates for each population, targeting an overall children’s hospital CLABSI rate reduction of 25% by the end of fiscal year 2023. This article describes each of the high-risk populations and each unit’s targeted interventions designed to decrease CLABSI rates.The children’s hospital uses an infection prevention bundle developed through Solutions for Patient Safety, with a focus on Kamishibai cards as a method for peer-to-peer feedback, standardization, and data collection.6 Bundle elements include intentional interdisciplinary discussions focused on the catheter’s purpose, usage, issues, and plan for removal; dressing assessment and change; appropriate catheter access; end cap, tubing, and dressing change procedures; and if the patient received their daily bath and chlorhexidine gluconate (CHG) treatment. In addition, all units perform daily quality rounding, monitoring bundle compliance and reporting data with a monthly formal review of process data. Weekly interdisciplinary catheter rounds are also performed that include unit nursing leadership, a nurse specialist, a pediatric physician and/or medical director, a pediatric surgeon, the charge nurse, and the patient’s bedside nurse. Interdisciplinary rounds focus on removal of catheters when no longer indicated, blood culturing stewardship, CHG treatment compliance, and other patient-specific CLABSI risk factors. Patient-focused risk assessments were added to the daily and weekly rounding processes for the 3 high-risk pediatric populations.Patients with CHD were identified as a high-risk population in the pediatric intensive care unit (PCICU) for a variety of factors, including unique vasculature limiting anatomical sites for central venous catheter placement; altered tissue perfusion and hypoxia; longer length of hospitalization for those waiting on transplant and those with nonoperable diseases; and critical status that may include pulmonary bypass, extracorporeal membrane oxygenation, ventricular assist devices, delayed sternal closure, continuous medication infusions requiring a longer central venous catheter dwell time, and accessing the central venous catheter multiple times daily for blood draws, medications, electrolyte replacements, blood products, and total parenteral nutrition.5–8 The presence of gastrostomy tubes also increases the risk of a CLABSI due to potential leakage and colonization of tubes.5–8 An interdisciplinary team led by unit nursing leadership and including the medical director, nurse specialist, pharmacist, cardiac surgeon, anesthesiologist, and critical care practitioners determined interventions specifically targeting the unique risks identified for patients with CHD. These interventions included early removal of central venous catheters, catheter maintenance and accessing practices, and blood culturing stewardship.Patients with CHD regularly require a stable access device for long-term continuous infusions that support cardiac function, which often leads the care team to search for more appropriate long-term solutions (6 weeks or longer) to intravenous (IV) access than a typical peripheral IV. Such options include a central venous catheter (CVC), a peripherally inserted central catheter (PICC), a tunneled long-term central venous access catheter, or a totally implanted device.7 Two specific interventions related to central access dwell times for this population were developed.Added to the daily and weekly interdisciplinary rounds, each catheter was assessed for current dwell time, use of tissue plasminogen activator (tPA) to address clotting and catheter issues, such as occlusions, sluggish flow, or other compromise. A daily electronic report was developed identifying all catheters that received tPA within the previous 24 hours. If the patient received more than one dose of tPA, the catheter was evaluated for early removal and/or replacement. All catheters in place more than 30 days were evaluated for potential early removal, central catheter holiday, and/or replacement. All compromised catheters, such as those with occluded lumens or breakage, were immediately assessed for removal and replacement if warranted.When reviewing historical CLABSI data within the PCICU, small PICC lines (2.6 Fr) were identified as having a higher rate of CLABSI in the CHD population. These double lumen PICCs were often placed prior to surgery or within days postoperatively. One lumen was used as the continuous infusion port, often delivering vasopressors, and the second lumen was used for intermittent medications and obtaining laboratory specimens. As the patient’s clinical condition improved, the lumens were accessed less frequently, potentially allowing thrombus development at the tip of the catheter without intervention. Evidence is limited supporting the use of intermittent heparin or 0.9% sodium chloride in infants and children,9 therefore a keep-vein-open (KVO) algorithm was developed for use in small PICC catheters (Figure 1). If the lumen was accessed less than every 8 hours, a continuous infusion with 2 IU of heparin in 1 mL of 0.9% sodium chloride was ordered to run at a rate of 1-2 mL/h continuously.Patients with CHD often require frequent accessing of their central venous catheters for blood samples to monitor several laboratory values, including electrolytes, medication peaks and troughs, cardiac markers, and blood gases.7 Added to the weekly interdisciplinary rounding was a focus on the number of blood samples ordered and frequency and timing of the orders. Nursing was able to help condense the number of times the catheter was accessed for blood samples by consolidating laboratory tests to a standardized time (eg, if a trough was to be drawn for an antirejection medication, all other samples for laboratory analysis were collected at the same time). The medical team reduced the number of laboratory tests by decreasing the frequency of items such as a complete blood cell count and/or basic metabolic panel to once or twice weekly if there were no major concerns requiring trend analysis, such as kidney or liver function. This process involved a discussion with the interdisciplinary team for each patient, determining the best individualized plan.The children’s hospital already had a blood culture guideline and algorithm in place (Figure 2) that directed sterile blood culturing practices via peripheral venipuncture. Contamination rates may be increased when obtaining blood cultures directly from a central or peripheral catheter.10 In addition, indwelling catheters may have bacterial colonization, making the blood culture result unreliable in identifying a true bacteremia.10Often missed in the CHD population was the identification of other potential sources for infection when ordering blood cultures. In addition, there was an increase in blood cultures being drawn directly from the indwelling catheter because practitioner orders were not following the algorithm. Education was presented to the medical team on the pediatric blood culturing guideline and algorithm and included case reviews of missed opportunities for identification of additional potential infectious sources (ranging from missed wound cultures to missed imaging of the chest or abdomen). The pediatric infection control specialist reviewed the National Healthcare Safety Network guideline for reporting infections, including exclusion criteria for CLABSI. Documentation practices were amended to include the correct wording for suspicion of infection, with special interest in detailing early treatment for suspicion of necrotizing enterocolitis in infants.Simulation for sterile culturing was added to the annual nursing skills fair. The patient was presented to the bedside nurse with a possible infection and orders for a blood culture during the simulation. The nurse had to identify at least 1 other potential source of infection and then practice verbalizing this concern with a recommendation to the practitioner (eg, “This patient has a red wound with drainage, should we culture the wound as well?” Or, “This patient has had foul-smelling urine; should we obtain a urine culture as well?”). The second part of the simulation involved obtaining a sterile culture from the simulation mannequin while being observed for sterile practices, including donning sterile gloves and the transfer of the blood sample to the culture bottle.Quality rounding and bundle compliance were audited monthly using a run chart. Central venous catheter utilization rate per 1000 patient days and CLABSI rate per CVC days were analyzed monthly using control charts. Vizient and the National Database of Nursing Quality Indicators were referenced for benchmarking. In 2022, the PCICU had a standardized infection ratio of 0.88. CLABSI rates decreased to 0 for all of 2023, as the PCICU reached their first year of being CLABSI free. Central venous catheter utilization decreased from a consistent 0.92 to a sustained 0.81 per 1000 patient days (Figure 3). Weekly catheter rounding intervention has resulted in recognition and reduction of extraneous laboratory tests by 6% (Figure 4). In addition, 1% of CVCs were designated as ready for early removal.The pediatric hematology and oncology population often require long-term central catheter access for ongoing therapies. These patients are at a particularly high risk for CLABSI due to neutropenia, severe immunosuppression, and mucositis. Additional risk factors for this group include longer length of hospitalization for treatment; a longer central venous catheter dwell time for caustic medication administration over a longer period of time (patients are often discharged to the community with the central access device); the use of multiple central access devices at the same time, including large bore apheresis catheters; and accessing the central venous catheter multiple times daily for blood draws, medications, electrolyte replacements, blood product administration, and total parenteral nutrition.11 The presence of oral mucositis also leads to an increase in risk of CLABSI that may be deemed a mucosal barrier injury.11 A historical review of nursing care practices demonstrated a lack of key hygiene and oral care practices. These factors contribute to an increased risk for infection within this patient population; therefore, interventions aimed at reducing CVC and mucosal barrier infections were implemented. These interventions included hygiene bundles, enhancement of CVC maintenance protocols, and reinforced compliance through daily multidisciplinary care team review.A stable central access device is integral for the long-term (months to years) treatment plan of pediatric hematology/oncology patients. These devices are used for chemotherapy infusions, blood product transfusions, and blood sampling in the inpatient and ambulatory settings.12,13 Most of these patients are discharged home with a central access device, so any focused intervention for maintenance and infection reduction must be applicable to both the hospital and home setting. The interdisciplinary team identified hygiene practices as an intervention opportunity that could impact both settings.A hygiene bundle was developed that focused on maintaining infection prevention through proper hygiene. The bundle included a daily CHG treatment with CHG impregnated cloths for cleansing after a soap and water bath, daily linen changes, and twice-daily oral care. Daily CHG treatments decrease mutualistic organisms on the skin, decreasing infection risk.13 The use of a soft bristle toothbrush, twice daily, is the preferred method for oral care and most effective in removing debris.14 If patients had severe mucositis and could not perform twice-daily toothbrushing, alternative care was provided in the form of sodium bicarbonate rinses to reduce bacterial colonization. Sodium bicarbonate reduces the risk of bacteremia more thoroughly than CHG oral rinses.13,14 The bedside nurse reviewed the hygiene bundle with patients and families during each admission, highlighting the scientific rationale behind the practices. Later in this project, a cryotherapy protocol, focused on delivery of ice chips and frozen drinks during chemotherapy administration, was developed as a supplementary therapy to enhance oral mucosal integrity and further support the prevention of mucosal barrier injuries.15Documentation of CHG treatments was monitored to ensure compliance with daily hygiene. Historically, compliance with daily CHG treatment in our hospital did not meet the targeted goal of 90%. A hospital-wide practice of adding CHG treatments to the medication administration record was used to promote consistent performance of the treatments. This intervention was successful for pediatric hematology and oncology patients, as it enhanced use, increased accountability, streamlined the workflow, and thus increased compliance with daily CHG treatments.Observation of central venous catheter care showed evidence of breaks in sterility during accessing of the central venous catheter, which increases the risk of CLABSI. To address these concerns, the practice of a buddy system requiring 2 registered nurses to oversee all CVC sterile procedures was implemented on the pediatric hematology and oncology unit to support central catheter maintenance and sterility. This practice aimed to ensure adherence to infection control protocols by incorporating real-time accountability and an additional layer of verification. The sterile procedures covered under this initiative included dressing changes, end cap changes, and blood culture collection, all of which are critical moments for maintaining central catheter sterility. The buddy system not only reduced the likelihood of contamination but also fostered a culture of teamwork and meticulous attention to detail in central venous catheter maintenance.Communication between medical practitioners and nursing staff is integral to prevention of infection. Barriers to communication include nursing workload, patient ratios, timing of rounds, and awareness of rounds starting.16 To improve care coordination, communication, and identification of patients at risk for CLABSI, a process for multidisciplinary care team review was developed, called SAFE rounds (Figure 5). These rounds focused on key areas of patient care including safety, skin/hygiene, access, activity, family, and exit planning. During the rounds, the bedside nurse presented crucial information related to hygiene and access, such as compliance with CHG treatments, oral care, central catheter indications, concerns regarding the catheter, frequency of catheter access, and any pending blood cultures. Nurse leaders also reviewed daily compliance with the CLABSI bundle, including CHG treatment and oral care compliance, and discussed opportunities for improvement during the rounds. Additionally, efforts were made to increase caregiver and patient involvement, recognizing that their active participation was often critical in enhancing compliance with the hygiene and oral care bundles. This collaborative approach not only helped address clinical concerns in real time but also empowered families to play an integral role in infection prevention and care.The implementation of structured hygiene, oral care, and central venous catheter maintenance bundles reduced infection in pediatric hematology and oncology patients. Process measures showed that compliance with twice-daily toothbrushing, initially unmonitored, ranged from 31% to 60% after implementation, while CHG treatment compliance ranged from 88% to 98% (Figure 6), with a mean value of 93%, which exceeds the goal of 90%.Outcome measures revealed a CLABSI rate of 1.39 and a mucosal barrier injury rate of 0.52 per 1000 central catheter days following the intervention period. As of the end of 2024, the pediatric hematology/oncology unit was CLABSI-free for more than a year. The combination of these initiatives fostered adherence to best practices and improved care outcomes. Despite these positive changes, ongoing efforts are required to address areas of lower compliance, such as twice-daily toothbrushing, and sustained improvements in infection prevention. These findings emphasize the value of a multidisciplinary, data-driven approach to optimize care for this high-risk population.Pediatric patients with short bowel syndrome (SBS) and intestinal failure are heavily dependent on central venous catheter access for administration of long-term total parental nutrition. As many as 46% of hospitalizations for patients with SBS are due to central catheter infections that occur in the home setting.17 A historical review highlighted variations in practitioner ordering practices regarding antimicrobial and/or ethanol lock coverage and blood culture practices. These inconsistencies often led to confusion on preferred protocols for blood cultures and lock therapy among care providers during admissions, causing delays in blood culture collection and initiation of lock therapy. Additional risk factors for the SBS population included a history of CLABSI, poor home care practices, and damaged central venous catheters. 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