Assistant Professor, Pediatrics UT Austin Dell Childrens Austin, Texas, United States
Abstract: Introduction Congenital heart disease (CHD) patients are at high risk for central line associated bloodstream infections (CLABSI), with deleterious effects on outcomes and resource utilization. Chlorhexidine gluconate (CHG)-impregnated dressings have decreased CLABSI rates in multiple critically ill populations, likely due to broader bacterial coverage compared to other antimicrobial foam devices (AMD). Guideline recommendations have lacked sufficient evidence to support use of CHG-impregnated dressings in the neonatal or pediatric population. A 2019 meta-analysis found the use of CHG-impregnated dressing to be beneficial in reducing CLABSI rates, however only two reviewed studies involved pediatric patients. In our Cardiac Care Unit (CCU), despite our standard care of AMDs with BioPatch, scheduled sterile dressing changes, and catheter maintenance bundles, a CLABSI rate of 2.17/1,000 central venous catheter (CVC) days was observed in 2021. This led to a nurse-driven QI initiative to evaluate the effect of CHG-impregnated dressings on CLABSI rate, utilizing an iterative plan-do-study-act (PDSA) approach.
Methods The project was implemented after an internal QI Committee review in the Dell Children’s CCU from January – June 2022. The primary outcome of interest was CLABSI rate. Secondary outcomes included complications related to the CHG-impregnated dressings such as incorrect application, skin site breakdown or catheter dislodgement. All CHD patients ≥ 2 months old with a CVC were included. In addition to provider and nurse education, a central vascular access device (CVAD) team was created to oversee proper CHG dressing application, ensuring a CVAD team member’s presence during every clinical shift to assist with CVC dressing changes . With the initial PDSA cycle, all patients > 2 months old received CHG impregnated dressings while those < 2 months continued to receive standard care. Descriptive univariate analysis was performed for comparison.
Results With the initial PDSA cycle, 117 central lines received CHG, 66 central lines received AMD. 3 CLABSIs were identified, all in the AMD cohort. For 2022, our CLABSI rate has been 1.4/1000 CVC days. Additionally, there were zero catheter complications related to CHG gel dressing use. Given these findings, the second PDSA cycle included all CCU patients with central lines that were at least 38 weeks gestation and at least 7 days old (Figure 1).
Conclusions CHG-impregnated dressings can be safely and effectively applied to CHD patients’ central, intracardiac and arterial catheters with a low complication rate. Consideration of expanding utilization of CHG impregnated dressings and proving their safety and efficacy in the neonatal population is the main goal of this QI initiative in order to eliminate CLABSIs in CHD patients. With the second PDSA cycle, CHG-impregnated dressings will be placed on every CVC in patients > 7 days old and 37 weeks gestational age.
