SummaryThe newborn intensive care unit at The Children’s Hospital at Providence Alaska Medical Center modified and adopted comprehensive protocols and practices and instituted task specialization and case reviews, with the goal of eliminating catheter-related bloodstream infections in neonatal intensive care unit patients. Protocols cover proper hand hygiene, appropriate central line and hub care, daily assessment of the need for central lines, sterile preparation of total parenteral nutrition, use of central lines for medication administration, limitations on use of substances that contribute to sepsis, and promotion of early breastfeeding. The program also designates specific clinician teams responsible for line insertion and maintenance, and calls for unit clinicians to review every infection to determine its cause(s) and to develop systemic strategies for addressing them. The program has steadily reduced catheter-related bloodstream infections since its implementation, to the point that such infections have virtually been eliminated. The hospital saves an estimated $750,000 to $1,000,000 each year as a result of this initiative.Moderate: The evidence consists of trends in the incidence of catheter-related bloodstream infections since program implementation, along with estimates of the cost savings generated by avoidance of these infections.
Developing OrganizationsThe Children’s Hospital at Providence Alaska Medical Center
Newborn Intensive Care Unit
Date First Implemented2003
Age > Newborn (0-1 month)
Problem AddressedVery low birth weight (VLBW) infants treated in neonatal intensive care units (NICUs) are at high risk of catheter-related bloodstream infections. These infections often lead to sepsis (the body’s systemic response to infection), which in turn can cause lengthy hospitalizations and death.1 Evidence-based practices can prevent catheter-associated bloodstream infections, but many NICU physicians and staff do not regularly adhere to them or experience practice variations across units. Additionally, practices require special considerations for the NICU patient population.
- A common, fatal condition: Severe sepsis occurs in approximately 750,000 ICU patients each year in the United States, with almost 40 percent dying as a result.2 Bloodstream infections related to catheters are the most common cause of sepsis.3
- Particularly in VLBW infants: Premature infants are at high risk of sepsis given their vulnerable immune systems, the invasive procedures they often require, and their frequent need for central catheters.3 As many as 42 percent of VLBW infants (infants weighing less than 1,500 grams at birth) develop sepsis while in the NICU,4 and nearly 20 percent develop a bloodstream infection.5 In 2002 and 2003 (before implementation of this program), The Children’s Hospital at Providence Alaska Medical Center NICU had a hospital-acquired sepsis rate that approximated the national average. NICU clinicians at the hospital became concerned because more than half of catheter-related bloodstream infections occurred when the neonates were between 5 and 15 days old, a time period when most have an umbilical catheter in place.3
- Failure to adhere to proven infection control methods: While evidence-based practices can prevent catheter-associated bloodstream infections,6,7 NICU physicians and staff often do not follow them consistently, encounter practice variations across units, and/or may need to adopt additional practices tailored to the unique needs and routines of the NICU.
Description of the Innovative ActivityA children's hospital NICU modified and adopted comprehensive protocols and practices and instituted task specialization and case reviews designed to prevent catheter-related bloodstream infections in NICU patients. Protocols and practices cover proper hand hygiene, appropriate central line and hub care, daily assessment of the need for central lines, sterile preparation of total parenteral nutrition (TPN), use of central lines for medication administration, limitations on use of substances that can contribute to sepsis, and promotion of early breastfeeding. The program also designates specific clinician teams responsible for line insertion and maintenance, and calls for NICU clinicians to review every infection to determine its cause(s) and to develop systemic strategies for addressing them. Key program elements include the following:
- Protocols and strategies to prevent infection: The NICU has adopted and modified protocols and strategies based on best practices for infection control, as follows:
- Hand hygiene: The hospital developed rules for hand hygiene specifying that everyone entering the NICU must scrub their hands at the front sink using chlorhexidine soap; that staff cannot enter the NICU wearing jewelry or with long or artificial nails; and that staff must use alcohol-based hand gels (placed in convenient locations) prior to and following patient contact.
- Line and hub care: The hospital developed a protocol to be used on every patient with a central line that covers line insertion and removal, along with line and hub care. Sample protocol elements require that blood samples not be taken from lines; that sterile techniques be used for line changes; that extension sets be attached to the catheter at the time of insertion so that line care occurs away from bacteria-laden items (e.g., diapers, colostomies, other tubing); and that lines only be disconnected during a line change. Protocols also state that hub care should include a closed hub (so that the line is not accessed during hub cleaning, thus preventing bacteria entry), that an alcohol “hub scrub” be used for 5 seconds/12 strokes, and that a closed catheter sampling system be used.
- Daily assessment to limit catheter use: Nurses assess the need for central lines and umbilical lines daily, with the goal of ensuring that lines are discontinued as soon as medically possible. At the discretion of the physician or nurse practitioner, central lines may be discontinued when feedings reach 120 mL/kg. The protocol also limits use of umbilical lines to a maximum of 8 days.
- TPN administration protocols: Previously, bedside nurses primed intravenous (IV) tubing with TPN/IV solutions in nonsterile bedside locations and frequently were interrupted during preparation. Under the revised protocols, TPN preparation duties have been taken over by nursing students who have received special training on sterile techniques and how to prepare TPN solutions and prime the central lines in a sterile manner. They prepare TPN solutions in a separate sterile “nutrition prep” room where they cannot be interrupted.
- Protocol related to medication administration via central line: A protocol standardizes how lines can be accessed for medication administration, requires that medication doses be mixed in the pharmacy (rather than at the bedside), and specifies that medications be administered via a closed, sterile system.
- Limited use of substances that contribute to sepsis: The NICU limits use of intravenous lipids (a medium that easily grows bacteria), H2 blockers (which alter the stomach's pH levels, thus prompting bacterial growth), and postnatal steroids (which compromise the body’s immune system).
- Promotion of early breastfeeding: Clinicians encourage exclusive use of breast milk, since breast milk promotes development of the immune system.
- Expert teams to perform line insertion and maintenance: To reduce variations in practice patterns and allow clinicians to develop expertise, NICU-designated teams take responsibility for line insertion and maintenance, as outlined below:
- Line insertion team: A small group of nurse practitioners and physicians insert catheters in the NICU. The team implements maximum (surgical-level) barrier precautions when doing so, such as full glove and gowning and use of a wide sterile field. Clinicians also use chlorhexidine antiseptic for skin preparation prior to insertion in babies over 25 weeks gestational age.
- Line maintenance team: A maintenance team ensures best practices for care of the catheter once inserted. The team performs daily rounds on patients with central lines and performs dressing changes. The team keeps data related to the integrity of the insertion site, dressing changes, catheter tip position, and the assessment of every line being used on the unit for whether it can be discontinued that day. These data are monitored on a weekly basis. The NICU’s resource nurse (a nurse who supports other nurses rather than having assigned patients) serves as part of the team.
- Confirmation of suspected infections: To avoid misdiagnosis of infections due to contamination, the NICU clinicians draw two blood specimens from different sites to confirm the presence of an infection. Very few NICUs use this practice, as clinicians generally try to minimize needle pricks in these very fragile patients. Clinicians at The Children’s Hospital at Providence Alaska Medical Center NICU take a different view, as they believe that this approach reduces false positive results and hence the need for future needle pricks in misdiagnosed patients.
- Case review of every infection: Every infection is reviewed by NICU providers to determine the cause(s) and develop systemic solutions to prevent recurrence. Providers use an internally-developed tool to evaluate potential causes, such as having the line in place for too long, inadequate nutritional intake, multiple breaks in the line to administer medications, and breaks in protocol that occur when infants leave the NICU for surgical procedures.
- Involvement of bedside staff: Bedside staff participate in the development of practice and protocol changes and problem solving.
- Public sharing of performance data: To stimulate quality improvement and ongoing enthusiasm for the program, the hospital posts the number of days since the last infection on a visible sign near the NICU’s scrub sinks, thus allowing clinicians, parents, and visitors to clearly see how the hospital has been performing.
Context of the InnovationThe Children’s Hospital at Providence Alaska Medical Center, which serves Anchorage and surrounding areas, has approximately 2,700 births annually, representing nearly a quarter of births in Alaska. The hospital has a 47-bed NICU that handles more than 500 admissions annually, including approximately 100 VLBW infants and other infants who require surgery. The impetus for this program came from NICU clinicians, who became concerned about several cases where babies died or had serious long-term illness as a result of catheter-related infections. These clinicians wanted to adopt new processes to eliminate these infections among NICU patients.
ResultsThe program has steadily reduced catheter-related bloodstream infections since its implementation, to the point that such infections have virtually been eliminated. The hospital saves an estimated $750,000 to $1,000,000 each year as a result of this initiative.
Moderate: The evidence consists of trends in the incidence of catheter-related bloodstream infections since program implementation, along with estimates of the cost savings generated by avoidance of these infections.
- Steady decline in infections after implementation: Catheter-related bloodstream infections declined steadily in the first few years after program implementation (from a baseline of approximately 10 infections per 1,000 line days), with annualized declines of approximately 60 percent in both 2004 and 2005 (to 4 infections per 1,000 line days).
- Near elimination of infections in recent years: As of July 2011, the hospital had not had an umbilical line–associated bloodstream infection in 4 years, and had not experienced a catheter-related bloodstream infection in the first 15 days of a baby's life in more than 3 years (since March 2008). The hospital has had only one central line–associated bloodstream infection since July 2008, and only one bloodstream infection associated with the placement of a surgical line since June 2009. (This infection was caused by surgical practices outside the NICU). As of August 2011, the NICU has not had a catheter-related bloodstream infection for more than 15 months.
- Significant cost savings: Hospital leaders estimate that the near elimination of these infections saves between $750,000 and $1,000,000 each year.
Planning and Development ProcessSelected steps included the following:
- Reviewing literature and historical data: The NICU’s multidisciplinary professional practice committee collected and reviewed literature on best practices related to infection control and historic data (from 2002 and 2003) on sepsis and bloodstream infections in the hospital.
- Meetings with staff: A neonatologist and the hospital’s staff educator met with nurses to identify challenges and brainstorm changes to bedside practices that could prevent infections.
- Testing process changes: Suggested practices were tested using rapid-cycle improvement projects and tools from the Vermont Oxford Network. (See the Tools and Other Resources section for more information on this network.)
- Training: An outside consultant provided onsite training for 8 hours to members of the line insertion and maintenance teams on best practices in these areas. The staff educator provided a shorter version of the class to all registered nurses. Training is currently provided internally on an as-needed basis.
- Protocol development: Based on literature on best practices, the hospital adapted adult central line and hub care protocols for use in the NICU.
Resources Used and Skills Needed
- Staffing: The program required no new permanent staff hires, as related activities are integrated into the everyday responsibilities of existing staff, including the resource nurse on duty during each shift. However, the hospital does hire 15 student nurses on a per diem basis to handle the priming of IV tubing for IV fluid/TPN, allowing the nurse to remain at the patient bedside; student nurses work a minimum of 12 hours per week and prioritize their work hours around IV fluid/TPN arrival times.
- Costs: Data on program costs are unavailable. The primary development costs consist of salary and benefits for staff time spent on training. Ongoing costs include compensation to the student nurses and the purchase of additional sterile equipment and supplies. These costs are far outweighed by the savings generated due to avoided infections.
Funding SourcesThe Children’s Hospital at Providence Alaska Medical Center
Tools and Other ResourcesThe Vermont Oxford Network is a voluntary membership of hospitals that addresses issues related to the medical care of newborn infants. Among various activities, it maintains a database that tracks infants weighing 401 to 1,500 grams at birth, and those born at a gestational age between 22 and 30 weeks. The database includes any baby who meets these criteria born at a member hospital or transferred to one within 28 days of birth. The database collects information on approximately 45,000 VLBW infants each year, representing roughly two-thirds of all VLBW births in the United States. The database provides benchmark reports to participating hospitals and to those engaged in outcomes research in this area. More information about the database, other tools, and membership can be found at: http://www.vtoxford.org.
The 5 Million Lives Campaign. Getting Started Kit: Prevent Central Line Infections How-to Guide is available from the AHRQ Quality Tools database at: http://www.innovations.ahrq.gov/content.aspx?id=2399.
Getting Started with This Innovation
- Enlist program champion: A clinician who adamantly believes that central line infections can and should be eliminated is needed to engage staff in performance improvement and culture change.
- Obtain feedback and ideas from frontline staff: Bedside nurses truly understand work flow, and hence are ideally positioned to offer innovative ideas for improvement. Involving bedside staff in changing policies, protocols and practices will promote strong buy-in to the goal of eliminating infections.
- Divide duties to develop expertise and limit practice variation: Create teams of providers who become expert at sterile central line insertion and maintenance, and assign medication and TPN preparation duties so they can be completed away from the bedside. Assigning these tasks to a limited number of clinicians can reduce variation and hence improve quality.
- Consider use of student nurses: Student nurses can be an inexpensive source of high-quality labor (since they are paid an hourly rate with no benefits). If necessary, however, TPN preparation can be assigned to a specific set of staff nurses.
Sustaining This Innovation
- Support learning culture: Encourage frontline nurses to continually consider how infections can spread and to suggest changes to improve infection control. Test changes in a small way and then spread successful processes across the unit.
- Review infection cases: Each infection should be reviewed by a multidisciplinary team to determine the cause(s) and develop systemic strategies to prevent recurrence.
- Track and share meaningful data: Sharing data on the number of days since the last infection can encourage nurses and other clinicians to adhere rigidly to infection-control practices so as to perpetuate the positive trend.
- Accept changes in use of central lines over time: Initially, the hospital’s NICU clinicians routinely discontinued central lines as early as possible, which is considered a best practice. Over time, however, they became more confident in their ability to prevent infections, and hence a little less restrictive in selecting patients who could benefit from central line use and more comfortable in leaving lines in a little longer when medically beneficial. (Clinicians still remove umbilical lines, which are more difficult to keep sterile, as early as possible.)
Contact the InnovatorJack Jacob, MD
Alaska Neonatology/Pediatrix Medical Group
3300 N. Shore Dr.
Anchorage, AK 99502
Debra Sims, RNC
Neonatal Intensive Care Unit
The Children’s Hospital at Providence Alaska Medical Center
3200 Providence Dr
P.O. Box 196604
Anchorage, AK 99519
Phone: (907) 212-2446
Grace Schmidt, RNC
NICU Staff Registered Nurse
The Children’s Hospital at Providence Alaska Medical Center
3200 Providence Dr
P.O. Box 196604
Anchorage, AK 99519
Phone: (907) 212-3614
Innovator DisclosuresDr. Jacob, Ms. Sims and Ms. Schmidt reported having no financial interests or business/professional affiliations relevant to the work described in this profile.
References/Related ArticlesJacob J, Sims D, Van de Rostyne C, et al. Toward the elimination of catheter-related bloodstream infections in a newborn intensive care unit (NICU). Jt Comm J Qual Patient Saf. 2011 May;37(5):211-6. [PubMed]
Angus DC, Linde-Zwirble WT, Lidicker J, et al. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001;29(7):1303-10. [PubMed]
Jacob J, Sims D, Van de Rostyne C, et al. Toward the elimination of catheter-related bloodstream infections in a newborn intensive care unit (NICU). Jt Comm J Qual Patient Saf. 2011 May;37(5):211-6. [PubMed]
Stoll BJ, Hansen N, Fanaroff AA, et al. Late-onset sepsis in very low birthweight neonates: The experience of the NICHD Neonatal Research Network. Pediatrics. 2002 Aug;110(2 Pt 1):285-91. [PubMed]
Render ML, Brungs S, Kotagal U, et al. Evidence-based practice to reduce
central line infections. Jt Comm J Qual Patient Saf. 2006;32(5):253-60.
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Original publication: October 12, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: November 20, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: October 16, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.