Central Line Infection Prevention in Newborns

Royal Prince Alfred (RPA) Hospital implemented an education, audit and training package for staff in its Newborn Care Unit, to reduce infections related to central line use in vulnerable newborns.

Aim

To reduce central line-associated blood stream infections (CLABSI) in newborns at RPA Hospital in line with NSW benchmarks.

Benefits

• Reduces the CLABSI rate in sick newborn infants.
• Improves long-term developmental outcomes in infants.
• Reduces central line use and dwell time in newborns and premature infants.
• Reduces length of stay and hospital costs associated with late-onset sepsis.
• Improves staff efficiency and productivity in Newborn Care Unit nurseries.
• Enhances collaboration between departments and disciplines.
• Aligns to National Safety and Quality in Healthcare Service Standards.

Background

Prevention of CLABSI is a key objective for the improvement of patient safety and the reduction of mortality, hospital stay and healthcare costs at RPA Hospital. It is also a National Safety and Quality in Healthcare Service Standard and included in Direction Two of the NSW Health Strategic Planning Framework. An audit conducted in 2012 showed an unacceptably high rate of CLABSI in the Newborn Care Unit at RPA compared to benchmarked data in NSW, at 8.5 per 1000 central line days in newborns and 13.4 per 1000 central line days in infants born at less than 29 weeks gestation.

Research shows that CLABSI are responsible for 69 per cent of late-onset sepsis in newborns¹, with late-onset sepsis a significant risk factor for increased mortality and prolonged hospital stay². In infants that survive, there are poorer long-term growth and development outcomes^3,4, with associated morbidity and increased healthcare costs⁵. It was determined that reducing the CLABSI rate would have a positive impact on the short and long-term health of newborns at RPA Hospital, while potentially reducing length of stay and hospital costs.

Implementation

• A multidisciplinary team was formed, comprising nursing and medical staff with an interest in infectious diseases from the Newborn Care and Infectious Diseases Units. Areas where CLABSI prevention had failed were reviewed and solutions researched and proposed.
• A bundle of evidence-based interventions on central line practices were introduced to the Newborn Care Unit, implemented via a structured education, audit and training program. Interventions included skills such as insertion and maintenance of central lines, hand hygiene, staff assertiveness and audit feedback.
• A central line policy was developed to clarify and define interventions, as well as ongoing education, audit and training requirements⁶.

Project status

Sustained – The project has been implemented and is sustained in standard business.

Key dates

• Project start date: March 2013
• Project evaluation date: November 2014 (followed by yearly audits)

Implementation site

Royal Prince Alfred Hospital Newborn Care Unit, SLHD

Partnerships

Sepsis Prevention in NICUs Group (SPRING), NSW Perinatal Services Network

Results

• A retrospective cohort analysis was undertaken, to document central line use and infection rates before and after implementation of the project.
• Results showed significantly reduced central line use and dwell time, as well as reduced CLABSI rates over a significant period of time.
• The CLABSI rate in newborns reduced from 8.5 per 1000 central line days in 2012 to 2.3 per 1000 central line days in 2014-5.
• The CLABSI rate in infants born at less than 29 weeks gestation reduced from 13.4 per 1000 central line days in 2012 to 1.9 per 1000 central line days in 2014-5.
• The audit did not contain enough data to show reduced mortality or non central line-related morbidity, however the reduced rate of CLABSI is likely to have a beneficial impact in these areas.
• The education, audit and training package continues to be the standard of care at RPA Hospital and is applicable to other neonatal intensive care units around Australia and the world.
• The success of this project has been recognised in prestigious journals including Infection Control and Hospital Epidemiology⁷, as well as international media.
• This project received the 2016 NSW Health Award – Harry Collins Award. View the project summary and video from the Award

Lessons learnt

• The project fostered a culture of safety in the Newborn Care Unit, as ongoing education allowed staff to be involved, take ownership of and advocate for the interventions. This also helped promote changes to other staff, parents and carers.
• The project requires interdisciplinary and interdepartmental collaboration to work. The team used an open and honest approach to examine failures and find ways to succeed. By facilitating open communication, respectful feedback and assertiveness, the team was able to empower staff to speak up and put their patients first.

References

1. Kaplan HC, Lannon C, Walsh MC et al. Ohio statewide quality-improvement collaborative to reduce late-onset sepsis in preterm infants. Pediatrics 2011;127(3):427-35.
2. Stoll BJ, Hansen NI, Fanaroff AA et al. Late-onset sepsis in very low birth weight neonates: the experience of the NICHD Neonatal Research Network. Pediatrics 2002; 110(2 Pt 1):285-91.
3. Schlapbach LJ, Aebischer M, Adams M et al. Impact of sepsis on neurodevelopmental outcome in a Swiss National Cohort of extremely premature infants. Pediatrics 2011;128(2):e348-57.
4. Stoll BJ, Hansen NI, Adams-Chapman I et al. Neurodevelopmental and growth impairment among extremely low-birth-weight infants with neonatal infection. JAMA 2004;292:2357-65.
5. Payne NR, Carpenter JH, Badger GJ et al. Marginal increase in cost and excess length of stay associated with nosocomial bloodstream infections in surviving very low birth weight infants. Pediatrics 2004;114(2):348-55.
6. Sydney Local Health District. Women and Babies: Procedure for Insertion of Peripherally Inserted Central Catheters. RPAH_PC2017_002. Camperdown, NSW: SLHD; 2017.
7. McMullan R, Gordon A. Impact of a central line infection prevention bundle in newborn infants. Infection Control & Hospital Epidemiology 2016;37:1029-36.

Further reading

• Royal Prince Alfred. Women and Babies: Infection Prevention and Control in NICU. RPAH_GL2015_ 1. Camperdown, NSW: SLHD; 2015.

Contact

Rowena McMullan
Neonatal Staff Specialist
Newborn Care, RPA Women and Babies
Royal Prince Alfred