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Preventing Infections in the PICU

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Preventing Infections in the PICU

Nurses in American Family Children's Hospital's pediatric intensive care unitMadison, Wisconsin - What's a CLA-BSI?

Though the acronym may suggest the name of a distant galaxy in the latest Star Wars trilogy, CLA-BSI is taken very seriously by health care professionals because they pose threats to patient health and can cost hospitals thousands of dollars.

In response, American Family Children's Hospital's pediatric intensive care unit (PICU) has instituted a protocol that has reduced CLA-BSI - central line associated blood stream infections - and likely decreased the time very sick patients spend in the hospital. National statistics also suggest the initiative may have saved lives.

Central lines, which deliver medicine, IV fluids or blood products to patients via tubes inserted through the skin to a major vein leading to the heart, are common for PICU patients. Certified nurse specialist Deb Soetenga, who co-leads the Children's Hospital's CLA-BSI prevention committee with Dr. Tom Brazelton, estimates that half of all PICU patients require central lines. The threat of CLA-BSI is real and such infections are no small thing.

"Central line infections carry the highest mortality rate amongst the hospital-acquired infections," Soetenga says, citing the Centers for Disease Control (CDC). "They also increase your length of stay in the hospital. CLA-BSI makes patients feel horrible, and it's very costly (for the host hospitals)."

So what is the best way to prevent CLA-BSI? In a study published in a February 2010 issue of Pediatrics, a group of Johns Hopkins researchers looked at 29 PICUs in the United States to answer that question. Their conclusion recommended implementation of a consistent, repeatable series of steps designed to eliminate infections.

"The main drivers for further reducing pediatric CLA-BSI rates seem to be issues that surround daily maintenance care for central lines, an attribute of bedside nursing care and practice," the study concludes, pointing to a 43 percent CLA-BSI reduction in hospitals that followed a central line maintenance protocol.

In 2006 The National Association of Children's Hospitals and Related Institutions (NACHRI) began developing such a protocol. The NACHRI maintenance bundle identified standard interventions that decrease infections. It's more pragmatic than revolutionary, and includes instruction on when to change dressings surrounding central lines, having nurses wear masks when changing dressings, and creating central line kits that have all of the equipment needed for dressing changes.

Soetenga set about implementing the NACHRI maintenance bundle, which meant replacing old habits and disciplines with new.

"It was changing systems," she says. "It seems like a simple thing, but we were changing a mindset. That's the challenge."

A challenge the PICU staff eagerly embraced, because "everybody here cares about their patients and want the best possible care," Soetenga says.

Nurses were introduced to the mechanics of the NACHRI bundle via online computer-based trainings, employee orientations and, most effectively, peer-to-peer education. Two PICU nurses, Krista Walser and Kathy Taddy, became CLA-BSI "champions" - experts on the maintenance bundles - and shared their knowledge with their nursing colleagues. The changes included decreasing the number of times a central is opened and accessed, using one pair of sterile gloves to remove a dressing and a fresh pair to put on a new dressing, and making sure IV tubings were changed at scheduled times.

"Peer-to-peer feedback is so valuable," Soetenga says. "When a fellow nurse says, 'That dressing really needs to be changed, and I'll help you do it,' it made a huge difference."

The CLA-BSI champions took on the added responsibility of auditing central lines and making sure their peers adhered to the bundle, further reinforcing the importance of the protocol.

Walser, a nurse care team leader in the PICU, credits attendance at a national NACHRI conference in Dallas, during which she "learned a lot and was inspired by the stories that were presented by other hospitals," with catalyzing momentum for the process changes.

Walser took it upon herself to demonstrate to each member of her unit the proper way to change central line tubing, and came up with the idea of a line cart that not only had all of the supplies needed for changing the IV tubings of central lines but also featured a sterile environment for tube changes.

"The cart can be rolled right outside the patient's room, where it would ease the process of this task," Walser says. "The nursing staff uses it on a daily basis and it is very helpful in promoting our CLA-BSI initiative in the PICU."

Use of the NACHRI maintenance bundle has also encouraged collaboration within and amongst hospital units. The CLA-BSI committee partnered with UW Health's pharmacy department to study the effect of changing many of the IV solutions and IV tubing every 72 hours instead of every 48 hours, which would decrease the risk of contamination. The study revealed no difference in bacteria in the lines and saved money, as well. The practice is now standard operating procedure.

CLA-BSI prevention has extended to the operating room, as well, as anesthesiologists now use alcohol- impregnated caps when accessing central lines during surgical procedures. These caps cover access ports, keeping them free of infectious microbes, so anesthesiologists don't have to scrub every time they access the central line during surgery, saving them time they can't afford to spare.

"It's a very collaborative project, because the central line is touched by so many different people," Soetenga says.

The improvement in the PICU is quantifiable. The PICU staff has followed an insertion bundle when placing a central line and the maintenance bundle when accessing the line since November 2013 and went 354 days without a CLA-BSI.

"We were disappointed," Soetenga says, "because we really wanted to make it a full year."

Since that October 2014 infection the PICU has been CLA-BSI-free, a string of more than 200 days.

"The nurses and the health care providers in the PICU have developed what we call a 'reverence for the line,' Soetenga says. "It's part of their practice now, and it makes a huge difference."

Date Published: 05/04/2015