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Monday, May 12, 2014

ONLINE FIRST: Central-Line Infections: Prevention in Outpatient Setting Requires Specialized, Specific Approach



After focusing on successfully reducing central line associated bloodstream infections (CLABSIs), as well as bacteremia, in pediatric inpatient settings, the five-year-old Children’s Hospital Association Hematology/Oncology CLABSI Collaborative is now turning its attention to outpatients.


CLABSIs were first targeted in adults in the ICU, then in patients in the pediatric ICU, and subsequently, those in the pediatric hematology/oncology department, noted Collaborative co-founder Amy L. Billett, MD, who is also Director of Safety and Quality at Dana-Farber/Boston Children’s Cancer and Blood Disorders Center and Associate Professor of Pediatrics at Harvard Medical School.


“Physicians and other health care providers have realized that how they take care of the line is a critical component of reducing infection rates,” she said. However, addressing these infections in the ambulatory setting takes a specialized approach. Ambulatory CLABSI prevention programs require a number of components for successful implementation, including:

  • Determining initial infection rates;
  • Providing training and educational tools for parents and other care providers;
  • Collaborating with visiting nurse associations (VNAs);
  • Assessing adherence to best practices; and
  • Measuring for declines in infection.


Measuring Infection Rates

The first step to establishing a program is measuring the ambulatory CLABSI infection rate, said Eric Werner, MD, Professor of Pediatrics at Eastern Virginia Medical School and a hematologist/oncologist at Children's Hospital of The King's Daughters in Norfolk, VA. “You need hospitals to measure and track how many line days there are in outpatient settings and then track the number of infections that occur.”


Another expert, Michael L. Rinke, MD, PhD, Assistant Medical Director of Pediatric Quality in the Department of Pediatrics at Children’s Hospital at Montefiore, noted that measuring ambulatory CLABSI rates hinges on being able to identify any time a patient gets a blood culture drawn. CLABSI adjudication requires trained infection preventionists following National Healthcare Safety Network guidelines, so monitoring all-cause positive blood cultures may be a good first step for medical centers. This has been shown to comparably track with CLABSI rates, and he also cited a recent study he and colleagues conducted while he was at Johns Hopkins (Pediatrics (doi: 10.1542/peds.2013-0302).


Tracking the denominator of central-line days necessitates collaboration between clinic nurses, surgeons, and oncologists constantly reporting to a centralized source on which patients have a central line, Rinke said.


Werner noted that because the number of line days is much higher in the ambulatory environment, the absolute number of infections in hematology-oncology patients is higher than in the inpatient environment.


And, Rinke said, “overall, while the initial start-up for tracking CLABSI infections is labor intensive, once the system is in place, it becomes less onerous.”


Training Caregivers

Key to establishing a program is training health providers and families so that best practices are available to all patients in the ambulatory setting. Hands-on training at Dana-Farber/Boston Children’s involves assessing what learning methods parents respond to, said Kristen Graham, RN, an outpatient nurse who is involved in the CLABSI prevention program in the Jimmy Fund Clinic. She said she often uses printed handouts on central line care and a practice dummy before walking parents through taking care of the central line on their child.  More recently, she has incorporated a new 11-part video series created by Dana-Farber/Boston Children’s for parents and visiting nurses on ambulatory CLABSI prevention.


After exploring ways to help families and visiting nurses employ central-line best practices in the home, “we soon realized that relying solely on our hands-on teaching in the hospital or during clinic visits was insufficient,” Billet said about the series. Caretakers in the ambulatory setting need specific care instructions that are readily accessible, she explained.


The videos, which were filmed in the home of a mother who had meticulously created a space to care for her child’s central line, are available at A small grant from the Boston Children’s Hospital Program for Patient Safety and Quality helped to pay for the project.


Each video addresses specific infection-prevention components such as how to wash your hands in a home sink, how to clean a surface, and how to scrub the hub. The material, which is also available in Spanish and Arabic, is presented in short, step-by-step segments so caregivers can easily and repeatedly access the information.


Billet and her team are in the process of introducing the videos to nurses during staff meetings and through internal communications channels, as well as informing current patients and caregivers about the series during clinic visits.


“We’re also in the middle of making these videos part of our education for all new patients,” she said. For example, a laminated bookmark that promotes the series and includes a QR code so people can use their smartphones to easily access the videos has been added to all of the center’s new patient materials.


One advantage of using the videos as a resource for ambulatory central line care is that they “are accessible 24-7 and right at your fingertips, since just about everyone has a computer or a smartphone they can access,” Billet said. Additionally, viewing the videos may be easier for families than calling the staff at the hospital to review information.


The infection-prevention team is also soliciting input from patients and families, both in formal patient advisory meetings and informal settings, and while the team is not currently seeking funding to update the videos, they may do so in the future, she said.


Overall, the videos address important topics that are easy to understand, Rinke added. “They seem great for both families and clinicians and will likely go a long way to standardizing line care and line care education.”  


Working with VNAs

Reaching out to visiting nurse associations (VNAs) is another important component to creating an ambulatory central line care program, Billett said.


For example, sharing the CLABSI-prevention videos with VNAs raised awareness of the importance of central line care and sparked discussion about some of the barriers to implementation. Some of the challenges cited were "as mundane as the family dog bounding in or other children clamoring for attention,” Billet said.


To resolve the problem, she and her colleagues had to create and maintain open lines of communication, address questions about the center’s recommendations and help nurses resolve any impediments.


The communication between visiting nurses and Dana-Farber/Boston Children’s “is amazing,” said Vivian Burton, RN, MSN, Maternal/Child Health Program Manager at Home Health VNA in Lawrence, Massachusetts. She speaks to someone on the ambulatory CLABSI prevention team at least a day and sometimes many times a day.

“We also make sure communication is all set with the family before the patient comes on the service,” she said, adding that Home Health VNA tries to schedule the first patient visit with a line-care nurse from Dana-Farber/Boston Children’s.


Additionally, a line care nurse from Dana-Farber/Boston Children’s also attends a Home Health VNA CLABSI annual training workshop to ensure that care in the home is consistent with the medical center’s practices. At the last gathering, Home Health VNA nurses felt their practices, policies, and procedures were validated and accurately followed the medical center’s approach to care, Burton noted. 

Werner said that in his experience, visiting nurse services have sometimes cited obstacles to proper central-line care due to the state of the homes where they work. While not every home is as clean as a hospital or is an environment that is easily disinfected, a little education and a few affordable resources can ensure good care.  “Bringing in a card table and a drape so you’re not using the kitchen table is sometimes all that’s needed,” he said. “And families are highly incentivized to do this correctly. If you’re dedicated to doing it right, you can do it right.” 


Ensuring and Assessing Adherence to Best Practices

Once they know best practices, patients and their families need to be empowered to speak up if they see health care providers not properly caring for the central line, Werner said. Facilities also need to measure program adherence. For example, in the ambulatory setting, patients may be seen by various home heath companies, parents who are caring for the line, as well as nurses and other providers in emergency rooms and in surgery or radiation centers, making this a challenge.


Auditing all participants in a CLABSI prevention program in some way is important, Rinke noted. The Johns Hopkins program conducted three-month return demonstrations of families who manipulated central lines at home, and investigators also collected self-audits from clinic and home care agency nurses. Asking the front-line clinic and home care nurses for their input is the best way to generate ideas of program assessment, he added.


Measuring a Decline in CLABSI Rates

Finally, to ensure that an ambulatory CLABSI prevention program is working, facilities need to measure whether infection rates have declined, Werner remarked, pointing to Johns Hopkins as one example of an institution that has been able to measure decreased rates: A central line care bundle implemented in the ambulatory setting there reduced CLABSI rates and bacteremia by 48 and 54 percent, respectively, in pediatric cancer patients, as shown in the paper by Rinke et al.


And although it was a single-institution study, Billet described the ability of researchers to measure difficult-to-track outpatient infections and reductions of these infections as “phenomenal.”


Dana-Farber/Boston Children’s has begun measuring its ambulatory rates and expects to analyze and report on its results in the future, Billet said. In the meantime, she hopes that other centers will use the videos to help with ambulatory central-line care, in addition to sharing their own practices.


“Our goal in doing this is not to just make infection rates better for our patients, but for all patients,” she concluded.




Related Articles

Previous OT articles about the team’s approach with pediatric patients were published in the 11/10/12, 9/10/13, and 12/25/13 issues.