September 17, 2012

Best-practice protocol reduced CLABSI rates in pediatric cancer patients

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A best-practice central line maintenance care bundle reduced central line-associated bloodstream infection rates in hospitalized pediatric oncology patients, according to recent study findings.

“Children receiving cancer treatment are uniquely prone to invasive bloodstream infections because of their weakened immunity and because their central lines are accessed multiple times a day, with each entry posing a risk for infection,” Michael Rinke, MD, a pediatrician and a patient safety expert at the Johns Hopkins Children’s Center, said in a press release.

Previous studies have shown that meticulous daily care of the central line can cut the number of bloodstream infections in critically ill patients. Similar best-practice central line care bundles have been shown to reduce central line-associated bloodstream infection (CLABSI) rates in neonatal ICUs, pediatric parenteral nutrition patients and pediatric stem cell transplant recipients.

“Despite these efforts, no study has attempted to decrease CLABSI rates for an entire inpatient pediatric oncology cohort, including both stem cell transplant recipients and patients undergoing treatment of malignancies,” Rinke and colleagues wrote. “These patients may be different from other pediatric populations because of their immunocompromised status, their disease-specific comorbidities, and the frequency with which they use their central lines.”

To determine how a best-practice central line care bundle affected CLABSI rates among hospitalized pediatric oncology patients, as well as define the epidemiology of CLABSIs in this demographic, the researchers executed a prospective, interrupted time series study at an urban tertiary hospital of a best-practice bundle addressing all areas of central line care, including reduction of entries; aseptic entries; and aseptic procedures when changing components.

The researchers evaluated 14,987 patient days and 14,059 central line days on the pediatric oncology unit during the baseline and intervention periods (94% of patients with one or more central lines daily). During the baseline period from January to October 2009, the inpatient pediatric oncology unit experienced nine CLABSIs and 4,007 central line days, for a CLABSI rate of 2.25 CLABSIs per 1,000 central line days (95% CI, 1.02-4.26).

During the 24 months of the intervention, the inpatient unit experienced 18 CLABSIs and 10,052 central line days, for a CLABSI rate of 1.79 CLABSIs per 1,000 central line days (95% CI, 1.06-2.83).

According to study findings, CLABSI rates decreased from 2.25 CLABSIs per 1,000 central line days at baseline to 1.79 CLABSIs per 1,000 central line days during the intervention period, with an incidence rate ratio of 0.8 (P=.58).

Secondary analyses demonstrated CLABSI rates were reduced to 0.81 CLABSIs per 1,000 central line days in the second 12  months of the intervention (incidence rate ratio=0.36; P=.091). Fifty-nine percent of infections resulted from gram-positive pathogens, whereas 37% of patients with a CLABSI required central line removal. In addition, patients with Hickman catheters were more likely to have a CLABSI than patients with Infusaports (incidence rate ratio=4.62; P=.02).

“CLABSI prevention efforts focusing on central line maintenance are arduous, rely heavily on front-line staff, require patience for culture change, and likely need to use nonstatistically significant trends to motivate staff given small numbers of infections,” Rinke and colleagues wrote. “Despite these difficulties, CLABSI prevention efforts can ultimately be successful and reduce harmful infections in vulnerable populations. Further research is needed to determine if the observed reduction in harmful health care-associated infections can be sustained and spread to other non-ICU arenas, such as to ambulatory oncology patients.”


Disclosure: Milstone reported grant support from Sage Products Inc.