Clinical Nurse Specialist Children's Mercy Hospital Kansas City, Missouri, United States
Abstract: Complex cardiac patients may require extended dwell time of central lines for nutrition, medication administration, and lab studies, placing this population at risk for central line associated blood stream infections (CLABSI). A mixed intensive care unit (ICU) noted a trend of CLABSI events in patients with complex cardiac diagnoses and extended ICU stay. The purpose of this quality improvement (QI) work was to evaluate risk factors and identify targeted interventions, aimed at decreasing the overall incidence of CLABSI in the pediatric cardiac patient population. Continuous review and analysis of CLABSI events revealed a trend in a vulnerable and growing population of cardiac patients. More comprehensive data was collected weekly for two years on this subset of cardiac patients with intent to uncover common risk factors such as lower extremity lines (Figure 1) and mitigate the risk with targeted interventions. Criteria was established for the population as greater than a six-week ICU stay, less than three years of age, and without acutely critical interventions (e.g., delayed sternal closure, mechanical ventilation, frequent transfusions, hemodynamic instability) or surgical procedures within the previous two weeks. Weekly data collection included central line information (number, type, location, dwell time), dressing complications, functionality, utilization, migration, and insertion distance from the groin. Themes from the data were prioritized by a small multidisciplinary working group. Targeted interventions were then implemented based on data collection findings with small tests of change. Interventions implemented included a 3-person dressing change, multidisciplinary huddles for positive blood cultures, primary care nursing, individualized care plans (Figure 2), line clearance guidelines, and updated standards of practice for small lumen management. Perceived risk for the long-stay population were confirmed within the first five months of data collection with 56% of patients experiencing line migration and 30% with a CLABSI. The first two years of collecting data and trialing a variety of interventions saw a 33% decrease in CLABSI events for long-stay complex cardiac patients (figure 3). A larger decrease of 67% was noted in the following year, and by the fourth year, interventions evolved into routine practice for patients with lower extremity lines and an 89% decrease in CLABSI events was achieved. Understanding risk factors and trends in hospital-acquired conditions (HAC) such as CLABSI, allow for targeted interventions to the most vulnerable and affected population. Small tests of change led to a significant and sustained positive impact with a highly complex HAC. This method of implementation of change did not place an increased workload to staff, carry a significant educational burden, or create a recognizable cognitive load that a complete overhaul of practices is known to carry with efforts to improve complex issues in healthcare.
