Reducing central line-associated bloodstream infections in children

Affecting every patient population, central line-associated bloodstream infections (CLABSIs) increase morbidity and mortality.  Although much has been published on adult CLABSIs, information on pediatric CLABSIs has lagged.

In 2005, the pediatric intensive care unit (PICU) at UC Davis Medical Center in Sacramento, California, had a CLABSI rate of 9.6 per 1,000 central-line days. This rate exceeded the National Healthcare Safety Network (NHSN) mean PICU rate of 6.6 per 1,000 central-line days. We set out to reduce our rate by developing a novel CLABSI prevention bundle. Our goal was to sustain a rate below the NHSN national benchmark.

At the same time, we joined the National Association of Children’s Hospitals and Related Institutions collaborative aimed at reducing pediatric CLABSIs. In this article we share our experience over several years so readers can see how preventing CLABSIs requires constant vigilance.

First intervention

When we started the project in 2006, we had three aims—compliance with appropriate hand hygiene, a central-line insertion bundle, and a central-line maintenance bundle. Today, these are still our goals.

Hand hygiene

Our goal was 100% compliance with appropriate hand hygiene by every provider before and after patient care by January 2007. Compliance was assessed by random observation using a standardized hand hygiene audit form.

We focused on increasing compliance by providing better access to and increasing staff acceptance of hand hygiene products. We reviewed the unit layout and elicited staff feedback on the location and type of our hand hygiene products. We found these products were inaccessible in some locations; what’s more, our staff complained they caused skin irritation. The solution was to increase accessibility at the point of use and to switch to alcohol foam products.

We educated staff on proper hand hygiene techniques through one-to-one teaching and testing. We also created a hand hygiene video addressing proper technique and its importance to patient safety. This video is now part of our standard hospital orientation for all new employees.

Central-line insertion bundle

Our goal was to achieve 95% compliance with a central-line insertion bundle for all lines inserted in the PICU by April 2007. Compliance was assessed by direct observation and completion of a central-line insertion checklist by a nurse observer.

We also developed conversational aids to empower nursing staff to speak up if they observed breaks in technique, and created a central-line insertion cart to ensure all needed materials were easily accessible. (See Conversational aids to boost compliance.)

Central-line maintenance bundle

Our goal was to demonstrate 95% compliance with a central-line maintenance bundle for all central lines in PICU patients by November 1, 2007. Compliance was assessed by direct observation using a standard audit tool. We quickly realized the new maintenance bundle was a large-scale project with many different components, which would require nursing staff to change their practice in many ways. So we developed a step-by-step program to be rolled out over an extended period to help staff assimilate the new practices. (See Six steps to a cleaner line.) Within 1 year of implementation, the central-line insertion and maintenance bundles had reduced our CLABSI rates to 2.5 per 1,000 line days.

The setback—and a key realization

The PICU was able to sustain low rates for 2 years. But due to budget cuts in 2009, our committee was disbanded and our monitoring efforts ended. In early 2010, the annual hospital-acquired infection report showed a dramatic rise in our 2009 CLABSI rate—almost to our 2007 preintervention rate. We believe this stemmed from lack of close monitoring.

Reflecting on our past efforts, we concluded that although staff had complied with the new policies and monitoring, they hadn’t truly embraced the need for the change. Bedside staff hadn’t been the driving force for change, so they hadn’t taken ownership of the interventions. Staff buy-in was essential for a true culture change—and that meant a new committee had to be formed.

The recovery

To achieve a more grassroots approach, the new committee was led by and composed of bedside nurses. Nurses held each other accountable for central-line practices and participated in monitoring compliance with the maintenance bundle. Nurses took each infection personally, giving each infection a face, not just a number. Nursing staff now had ownership of the CLABSI reduction program.

In 2012, our CLABSI rate declined, matching the low levels achieved in 2007. In May 2013, we were 1 week shy of going an entire year without a single CLABSI. (See CLABSI rates over time.) When the most recent CLABSI occurred, staff took it as a personal shortcoming. We used this as a learning opportunity to improve our practice. It taught us that for any change to be truly effective, the motivation must come from within each nurse. Success hinges on staff members’ desire for change, not a mandate to change.

Click here for a central-line insertion checklist.


Centers for Disease Control and Prevention. National Nosocomial Infections Surveillance (NISS) System Report, data summary from January 1992 through June 2004. Am J Infect Control. 2004;32(8):470-85.

Gaur AH, Miller MR, Gao C, et al. Evaluating application of the National Healthcare Safety Network central-line associated bloodstream infection surveillance definition: a survey of pediatric intensive care and hematology/oncology units. Infect Control Hosp Epidemiol. 2013;34(7):663-70.

Li S, Faustino EV, Golombek SG. Reducing central line infections in pediatric and neonatal patients. Curr Infect Dis Rep. 2013;15(3):269-77.

Miller MR, Griswold M, Harris JM 2nd, et al. Decreasing PICU catheter-associated bloodstream infections: NACHRI’s quality transformation efforts. Pediatrics. 2010;125(2):206-13.

O’Grady NP, Alexander M, Burns LA, et al.; Healthcare Infection Control Practices Advisory Committee. Guidelines for the prevention of intravascular catheter-related infections, 2011. Clin Infect Dis. 2011;52(9):e162-e193.

Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725-32.

Wilson MZ, Deeter D, Rafferty C, Comito MM, Hollenbeak CS. Reduction of central line-associated bloodstream infections in a pediatric hematology/oncology population. Am J Med Qual. 2014;29(6):484-90.

The authors work at UC Davis Medical Center in Sacramento, California. Virpal Donley is an assistant nurse manager in the PICU. Sherri Reese is an infection preventionist.

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