BY HEATHER LINDSEY
A central line “care bundle” implemented in the ambulatory setting reduced the rates of central line-associated bloodstream infections (CLABSIs) and bacteremia by 48 and 54 percent, respectively, in children with cancer, according to data available online ahead of print in Pediatrics (doi: 10.1542/peds.2013-0302).
“We were very pleased with the study results,” said the lead author, Michael L. Rinke, MD, PhD, Assistant Medical Director of Pediatric Quality at Children’s Hospital at Montefiore, who practiced at Johns Hopkins at the time the research was conducted. “We weren’t sure if the care bundles would work at all. To see reductions in both CLABSI and bacteremia was very impressive and exciting. We’re happy with the movement we’ve made, but we are always striving for more.”
Measuring infection rates in ambulatory patients is “incredibly hard to do,” commented Amy L. Billett, MD, 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. “The fact that clinicians were also able to bring down infection rates is phenomenal.”
Still, she cautioned, the study was conducted at a single institution, and whether the results are replicable in other centers remains unknown.
Rinke and his colleagues at Johns Hopkins analyzed data from an “interrupted time-series” study of a multidisciplinary, central line maintenance care bundle administered by clinic nurses, home care nurses, and families taking care of ambulatory pediatric cancer patients.
The researchers compared all positive blood cultures from a baseline period, retrospectively evaluated for potential CLABSI from January 2009 to November 10, with a post–central line maintenance care bundle implementation period, prospectively evaluated from December 2010 to November 2012.
Overall, 330 children had central line days recorded in the baseline period compared with 339 in the intervention period.
Self-audits were collected from clinic and home care agency nurses to ensure that health care providers were adhering to best practices for asepsis and family education. Bacteremia and CLABSI rates, as well as bundle compliance rates, were posted in the clinic and emailed to health care providers. Root-cause analyses of infection were also conducted.
A total of 520 unique patients with 763 central lines were included in the cohort. The baseline CLABSI incidence rate was 0.63 per 1,000 central line days compared with an intervention rate of 0.32 per 1,000 central line days, equaling a significant mean decrease of 48 percent. The baseline incidence rate of bacteremia was 1.27 per 1,000 central line days versus an intervention rate of 0.59 per 1,000 central line days, resulting in a significant mean decrease of 54 percent.
During the last three months of the intervention period, audits indicated that clinic nurse compliance rates for aseptic entries, aseptic central line component change, and family assessment were 100, 85, and 81 percent, respectively.
One study limitation to consider is that infection preventionists determine whether patients have an ambulatory CLABSI, said Rinke. “We need to make sure that there’s a singular definition of CLABSI so everyone can compare research results and benchmark against one another.” Some researchers are using the National Healthcare Safety Network (NHSN) definition, he noted.
“Some people worry about the definition not being the most accurate and subject to adjudication errors,” commented Aditya H. Gaur, MD, Associate Member in the Department of Infectious Diseases at St. Jude Children’s Research Hospital. “But what’s interesting is that the study also shows a decrease in overall bacteremia rates, which are a cleaner outcome measure,” he said.
While the bundle reduced all-cause positive blood cultures, which could be an objective measure for program success, more studies are still needed, Rinke said.
Another study limitation was that outpatient central line care was self-reported by nurses and other clinicians, which may result in some bias, said J. Allyson Hays, MD, Assistant Professor of Pediatrics in the Division of Hematology & Oncology at Children's Mercy Hospital. However, a chart review of 520 patients probably isn’t feasible, she added.
Additionally, Hays said, CLABSI rates have been decreasing for a number of years due to public awareness and infection-reduction programs and whether those had an impact on the study results is unknown.
Implementing Ambulatory Care Bundles
Generally, medical centers can adapt their in-hospital central line care bundles to address ambulatory patients, explained Charles Bailey, MD, PhD, an oncologist and Attending Physician at Children’s Hospital of Philadelphia and Assistant Professor of Pediatrics at the University of Pennsylvania Perelman School of Medicine. “In our experience, it’s possible to implement many elements of the inpatient care bundle in the outpatient setting.”
In an academic medical center, implementing an infection prevention program across the inpatient, ambulatory and home-care settings is feasible, said Susan Wade Murphy, RN, MSN, Senior Clinical Director of Home Care Services at Cincinnati Children's Hospital Medical Center (CCHMC). Auditing within the home environment requires organization and a supervisory staff that can observe nurses and patients and their families, she said.
“The success of our bundle is standardization,” explained Jennifer M. Gold, RN, Clinical Director of the Home Care Agency & Liaison Resource Staff at CCHMC. The practice the families witness on the floor is the same practice taught by the home care liaison and what the field nurses are teaching or performing in the home. “There’s no variation,” she said. For example, all nursing staff there recently underwent a four-hour prevention standard training session, based on the Toyota Model, to ensure standardized practice of bundle care.
Additionally, Billett said, health care providers teaching parents about central line care during a clinic visit must “make clear the differences parents will face translating these lessons to the home setting. For example, you have to consider where the sink is and how to make a clean surface at home.”
Nurses at Johns Hopkins were “front and center” in the effort to educate patients and their families about the ambulatory care bundle, Rinke said. Overall, education is a small part of implementing the ambulatory infection prevention bundles. Encouraging participants to make the bundles a habit and to perform tasks consistently is what takes more time and investment, he said.
In the study, about one in five care encounters were not completely compliant with the maintenance care bundle. This was due to a number of reasons, Rinke said. For example, some children were terrified of masks and refused to put them on. Others didn’t want to get their dressings changed according to schedule. Educating parents on how compliance protects their children can address these challenges, he said.
Adolescents also sometimes became frustrated about their condition and weren’t always cooperative with the maintenance central line care bundles, Rinke added. “They don’t want to feel different, and we need to find ways to motivate them.”
Ensuring that everyone in the home is compliant with care is important, said Susan Spear, RNIII, CPN, Home Care Liaison, at CCHMC. “One of the issues we have seen in the home setting is that parents will enlist the help of other caregivers, such as a babysitter or aunt or uncle, who haven’t been part of the care team and haven’t received education about the bundle.”
Gaur noted that checklists summarizing central line care bundle elements can help with compliance. Ongoing repetition and reminders of the tasks that need to be performed is critical, and at some point, technology-based prompts and reminders can be integrated into the infection-prevention program.
Whether an increase in compliance rates would further decrease infection rates in the ambulatory setting is still unknown, said Billett. However, studies of central line care in pediatric ICUs do indicate that providing best practices reduces CLABSI rates, she said.
Generally, care bundles are not costly in a traditional sense, Hays said. The equipment needed is standard in the clinic, but time and investment are required to educate providers and ensure compliance.
Rinke noted that investing in maintenance central line care bundles can offset the cost of infection. A CLABSI can cost anywhere from $16,000 to $45,000, according to available literature, and this current project potentially saved the health care system half a million dollars, he said. Investing in quality improvement around an ambulatory central line care bundle costs about $20,000 to $30,000.
“There’s no question of the value of preventing infection when considering the cost of caring for a patient with infection,” Murphy said. The combination of the infection’s impact on quality of life, the need for rehospitalization, and the effect on outcomes makes investing in prevention a priority.
And, noted Billett, reducing CLABSI rates improves health outcomes for patients and reduces overall health care costs, even if the individual institution doesn’t see the savings in its bottom line -- “Working hard to reduce CLABSI is clearly the right thing to do.”