A best-practice care bundle can reduce the number of central line-associated blood stream infections (CLABSIs) in pediatric oncology patients, according to research reported in an article now available online ahead of print in Pediatrics (doi: 10.1542/peds.2012-0295). Implementation and compliance to central line care protocol can be difficult, though, the researchers noted, requiring a team effort from physicians, nurses, parents, and patients.
“It's challenging to get people to change behavior they've engaged in for years and years,” said the study's lead author, Michael L. Rinke, MD, Assistant Professor of Pediatrics in the Division of Quality and Safety at Johns Hopkins University School of Medicine. It wasn't until the second year of the study that there was more than a 60 percent decrease in central line infections, he said.
An expert not associated with the study, Michael Kelly, MD, PhD, Program Director of the Cancer and Blood Disorders Center at Children's Hospital of Wisconsin, said the study is informative because the authors were frank about the fact that they weren't always successful in the intervention and education process. “Overcoming cultural barriers and habits at hospitals are big challenges to having something like this work,” Kelly said.
First Study of Its Kind with Pediatric Focus
This is the first study to evaluate CLABSI rates for an inpatient pediatric population undergoing cancer treatment and stem cell transplant, Rinke noted. The research, funded by the National Institutes of Health, was part of a national collaborative of 27 institutions, the Hematology/Oncology quality transformation effort, organized by the Children's Hospital Association.
To determine whether a multidisciplinary, “best-practice bundle” of step-by-step, very specific instructions reduces the infections, the researchers performed a prospective study starting in November 2009 focusing on reducing central line entries, aseptic entries, and aseptic procedures when changing line components.
Oncology nurses used strict precautions, including frequent and regular central line dressing, tube and cap changes, cleaning of the line before and after each use, using sterile gloves and masks when handling the device, and hand-washing before and after handling the line. Additionally, nurses held monthly briefings to discuss every infection that occurred.
Nurses were the most important part of the study, Rinke said. “This work could not have been done without them.”
The parents of the children were also asked to provide additional oversight, and were provided with wallet flash cards on central line care. Initially parent involvement wasn't part of the study, but the nurses soon realized the important role parents could play, he noted.
There was a 20 percent decline in CLABSI rates below baseline over two years, although this was not statistically significant. A 64 percent decline below baseline was observed during the second year of intervention—“suggesting that a long ramp-up period may be necessary to achieve effective change,” the researchers wrote.
Lack of Statistical Significance Not a Concern
Rinke explained that the lack of statistically significant results was due to lower baseline rates of the infections—2.25 CLABSIs per 1,000 central line days—than many other available studies. Additionally, there were only 10 months of preintervention data. The “effect size of decline” in CLABSI rates in the second year, however, do suggest a meaningful change, he said.
If the time of the study was extended beyond two years, it likely would be clear that the number of children infected is increasingly less, commented Wilbert Mason, MD, MPH, Professor of Infectious Diseases at Children's Hospital Los Angeles. Statistical significance measured between two time periods becomes less important than the decreasing number of children infected, he said in an interview for this article.
Additionally, said Brigitta Mueller, MD, MHCM, Director of the Division of Clinical Operations, Quality and Safety, for Texas Children's Cancer and Hematology Centers, the lack of statistical significance was likely due to the fact that the data at that point was from just one institution, but data from all the participating institutions will be available soon, making statistically significant results more likely.
The study investigators also reported that while nursing compliance increased with each bundle implementation, 35 percent of patients were not receiving all the parts of the care at the end of 24 months.
Executing a central line infection prevention program in oncology patients is “incredibly difficult,” Kelly said. “It's not as though oncology patients are always seen in the same locale. They traverse different areas in the hospital such as the inpatient unit, the clinic, the ICU, radiology, and the ER.”
Implementing change can be difficult at hospitals that are part of a big alliance or conglomerate, noted Norma Kay Krumwiede, EdD, a nursing professor at Minnesota State University. It's typically much easier with a smaller number of providers.
Moreover, added Kelly, the pediatric population is also in and out of the hospital frequently, with central lines being accessed by home health nurses, making compliance problematic.
Obstacles to compliance are the same as for many other challenges in life, Rinke said. “We all go on diets and we all come off diets. People quit smoking and then start smoking again. When times get stressful, people fall back on old patterns and habits.”
There's also a financial piece that needs to be considered, said Mary Ann McKenna Moon, MSN, RN, CNS, of Minnesota State University's Glen Taylor Nursing Institute for Family and Society. Newly emerging medical devices and antimicrobial biopatches are available to help prevent central line infections, but the devices can be expensive.
To change current practices at health care institutions, staff members first have to accept that a problem exists, she continued. Internal reviews can help determine potential areas for improvement within an organization.
Additionally, practitioners need to have a long-term view of outcomes because improvements to care can take time. “Leadership has to be patient and not throw the baby out with the bathwater if they don't see a change in three months,” Rinke said.
Nurses are always at the forefront of central line care, Kelly emphasized, “so the reality is that they need to be the focus of educational initiatives.”
Nurses are also patient advocates. Mueller noted that to encourage patient advocacy at Texas Children's Hospital, nurses are empowered to question physicians about central line care. Pharmacists are also part of the effort and go on rounds so they can provide input about the use of oral instead of intravenous medications.
Parents are critical to central line care as well, said Rinke. “They are the ultimate advocates for their kids, and if they see a practitioner doing something wrong, they should feel free to speak up. This is especially useful when pediatric patients receive care outside the center—for example, in an emergency room that may not have the same protocol.
“Parents are the constant, no matter where the child is receiving care, Kelly said. “We empower our patients and parents to advocate for themselves. If they see a doctor or nurse not properly caring for a central line, they can ask the provider to call the oncology unit for instructions.”
Getting physicians on board is also necessary. For instance, Mueller noted, a successful program involves making sure all the physicians who rotate through an oncology ward remember to switch IV medications to oral drugs when possible so that health care providers don't have to go into the line. Doctors also need to allow nurses to bundle blood draws instead of performing them every time they need to get a lab test performed.
“Physicians are very data driven, and now that more research is available it will be easier to convince them to follow a new protocol to prevent central line infections. Overall, complying to a central line infection prevention program is a collaborative effort. You can't do it with just the nurses or just physicians or just parents.”
Because a third of patients in this study didn't receive care that was compliant with the bundle, “we need to be taking a look at how we are measuring competency and not allowing short cuts,” Krumwiede said. “In nursing school, we spend less than an hour on aseptic procedures.”
This study also showed that Hickman catheters caused more infections than peripherally inserted central catheters, which warrants further research, Mason noted. Determining whether antibiotic-impregnated catheters result in lower infection rates and evaluating the role of other preventive measures such as alcohol or antibiotic locks and putting alcohol or antibiotics in the central line when it's not being used may also be beneficial, he said.
Further investigation also needs to focus on the effectiveness of educating all hospital staff about central line infection prevention, not just one location such as the ICU or pediatric oncology unit, Kelly said. “More and more kids with more and more diseases have central lines, so the reality is that we need to do this at a hospital level. That's the next big research intervention, to start looking at hospital-acquired infections in a hospital population instead of a unit.”
Finally, Rinke said, additional research needs to include central line infection prevention in the ambulatory arena, outside of hospitals, where the majority of pediatric oncology patients receive their care and where the rate of infection is higher.© 2012 Lippincott Williams & Wilkins, Inc.
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