reducing clabsis in pediatric oncology patients

Reducing Central Line Associated Blood Stream Infections in Pediatric

Oncology Patients

Ashley Quinn

Central Line Associated Blood Stream Infections (CLABSIs) are preventable form of patient harm

• Definition– Bacteremia in a patient with a central line with no other identifiable source

• Epidemiology– Incidence: 60 cases per 10,000 admissions 1,2

–Mortality: 12-‐25% 3

Adults 4 Pediatrics 5

Cost $40,890 $55,000Length of Stay 14 days 18 days

Central line bundles reduced national CLABSI rates, but continue to occur despite bundle adherence

• National Healthcare Safety Network (NHSN)• Central line bundles – Evidence-‐based practices that reduce CLABSIs– Better outcomes when used together than alone

Number of CLABSIs x 1000

Number central line (CL) daysCLABSI rate =

CLABSI rateNational 6 1.2

Pediatric hematology-‐oncology 7 2.135Benchmark 8 0.878

Daily full body topical chlorhexidine gluconate(CHG) treatments consistently reduce CLABSI rates

• Reduces CLABSI rates– Adult, pediatric, and neonatal ICU 10, 11,12

– Adult medical and surgical units 13

– Burn and bone marrow transplant units 14, 10

– Long term acute care units 15

• Reduces colonization, transmission, and infection of drug-‐resistant organisms 16, 17, 18, 19

• Population In Pediatric oncology and bone marrow transplant patients

• Intervention daily topical CHG treatments,

• Comparison compared with standard daily bathing with soap and water,

• Outcome will reduce CLABSI rates below 0.878/1000 central line days within 1 year

Hypothesis

July 2013 July 2014“preCHG” “wCHG”

Soap-‐and-‐water baths Daily CHG treatments

• Outcome measures– Primary: CLABSI rates– Secondary: Pathogen isolated– Process: Compliance– Balancing: Nursing surveys

Methods

Monitoring compliance in real-‐time fostered high compliance with CHG treatments

Compliance for every patient on the unit could be simultaneously assessed in real time

CHG treatments did not reduce CLABSIs despite evidence of efficacy in similar populations

Start CHG

National Rate 2.135Benchmark 0.878

preCHG wCHGCLABSI Rate 2.90 3.39p-value 0.74

Sample size 36

Isolation of Gram negative pathogens doubled in the wCHG period

preCHG wCHG

PathogenGram + 6 7Gram – 7 13Fungus 3 0

02468101214

�Gram + Gram -‐ � Fungi

Num

ber C

LABS

IsPathogen Isolated

preCHG wCHG

Mucosal Barrier Injury (MBI) criteria attributes infection to translocation of intestinal bacteria

• MBI-‐CLABSI criteria1. Isolation of intestinal flora2. Risk factors for MBI

• Evidence of mucositis• Severe neutropenia

Epithelium

Intestinal Flora

Bloodstream

MBI-‐CLABSIIntestinal translocation

NonMBI-‐CLABSIInfected central line site

CLABSI

MBI-‐CLABSIs were 2-‐3 times more commonthan nonMBI-‐CLABSIs

5 5

11

15

02468

10121416

�preCHG � wCHG

Num

ber C

LABS

Is

CLABSIs by TypeNonMBI MBI

All CLABSIs in wCHG period show characteristics consistent with MBI (severe neutropenia, mucositis)

40%

100%100% 100%

0%

20%

40%

60%

80%

100%

�preCHG � wCHG

% CLA

BSIs with

Risk

Factors

Risk Factors for TranslocationNonMBI MBI

Pathogen Isolated Number NonMBI-‐CLABSIs

Pseudomonas aeruginosa 4

Streptococcus pneumoniae 1

Daily full body topical CHG treatments reduced the CLABSI rate below our goal

Start CHG


Sample size 6


• In patients with intact mucosal barriers, bundles and CHG treatments were effective in reducing CLABSIs to 0.71/1000 line days

• Future Work– Strategies to reduce bacterial translocation in patients with mucosal barrier injury including severe, prolonged neutropenia and mucositis

Conclusions

• Paul Harker-‐Murray MD, PhD• Lauren Ranallo MSN, RN, AOCNS, CPHON• Alyse Bartczak BSN, RN

Acknowledgements

Questions?

Nursing Surveys

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Definitely Somewhat No

Num

ber o

f Respo

nses

Interferes with Other Work

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Patient factors Workflow factors Non identified

Num

ber o

f Respo

nses

Barriers

All CLABSIs

National Rate 1.303, 1.534Benchmark 0.878

Study Period preCHG wCHGCLABSI Rate 2.90 3.39p-value 0.74Shifts 0 0Trends 1Runs 9 (3-11) 6 (3-10)

Start CHG

CHG treatments did not reduce NonMBI CLABSIs

Start CHG


Sample size 10


NonMBI CLABSIs


Study Period preCHG wCHGCLABSI Rate 0.91 0.85p-value 1.0Shifts 1Trends 0 0Runs 7 (3-11) 7 (3-11)

Start CHG

NonMBI CLABSIs with Pseudomonas excluded


Study Period preCHG wCHGCLABSI Rate 0.91 0.17p-value 0.113Shifts 1Trends 0 0Runs 7 (3-11) 7 (3-11)

Start CHG

Neutropenia Data

NonMBI CLABSI MBI CLABSIpreCHG wCHG p preCHG wCHG p

Duration 17±11 28±14 0.43 21±19 35±28 0.21Time 2.5±0.7 7.0±7.8 0.50 6.8±5.5 7.8±10.1 0.74

Line Type

NonMBI CLABSI MBI CLABSI

preCHG wCHG p preCHG wCHG p

Tunneled 2 3

0.074

4 7

0.883PICC 0 2 6 8

Port 3 0 2 2

Line Location

NonMBI CLABSI MBI CLABSI

preCHG wCHG p preCHG wCHG p

Tunneled 0 0

0.114

0 6

0.039PICC 5 3 7 4

Port 0 2 5 7

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reducing clabsis in pediatric oncology patients

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