CLABSI reduction using evidence based interventions and nurse empowerment: a quality improvement initiative from a tertiary care NICU in Pakistan

Application of Multi-Department Cooperation, Intelligent Prevention, and Supervision to Reduce the Incidence of Central Line-Associated Bloodstream Infections

Central line-associated bloodstream infections (CLABSIs) can result in worse outcomes and high hospitalization cost for patients. This study aimed to assess the effectiveness of multi-department cooperation, intelligent prevention, and supervision (MDCIPS) in reducing the incidence of CLABSIs and improving the clinical outcomes of the patients. Key issues were identified through a literature review and survey on the status quo. A MDCIPS model was thus built. A total of 440 patients with indwelling central venous catheters (CVCs) were enrolled in the study. The control group (n = 219) received conventional infection-control managements, while the intervention group (n = 221) received MDCIPS interventions in addition to conventional infection-control managements. The number of CLABSIs patients, incidence of CLABSIs, average length of hospital stay, average total hospitalization cost, and disease outcomes were compared between the two groups. The intervention group had a significant reduction in the number and incidence of CLABSIs (0[0%] vs. 4[1.33%], P < 0.05). Two of the four patients with CLABSIs in the control group died. The average length of hospital stay was significantly longer in the control group than the intervention group (17 days vs. 13 days, P < 0.001). The average hospitalization cost in the control group was much higher than that in the intervention group (92.8 thousand yuan vs. 65.2 thousand yuan, P < 0.001). Patient outcome was improved in the intervention group than the control group (P = 0.001). In summary, the MDCIPS model effectively reduces the incidence of CLABSIs, alleviates the patients' economic burden, and improves the clinical outcomes of the patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12288-024-01760-8.

Implementation and long-term efficacy of a multifaceted intervention to reduce central line-associated bloodstream infections in intensive care units of a low-middle-income country

BACKGROUND

Central line-associated bloodstream infections (CLABSIs) pose a significant risk to critically ill patients, particularly in intensive care units (ICU), and are a significant cause of hospital-acquired infections. We investigated whether implementation of a multifaceted intervention was associated with reduced incidence of CLABSIs.

METHODS

This was a prospective cohort study over nine years. We implemented a bundled intervention approach to prevent CLABSIs, consisting of a comprehensive unit-based safety program (CUSP). The program was implemented in the Neonatal ICU, Medical ICU, and Surgical ICU departments at the Aga Khan University Hospital in Pakistan.

RESULTS

The three intervention ICUs combined were associated with an overall 36% reduction in CLABSI rates and a sustained reduction in CLABSI rates for > a year (5 quarters). The Neonatal ICU experienced a decrease of 77% in CLABSI rates lasting ∼1 year (4 quarters). An attendance rate above 88% across all stakeholder groups in each CUSP meeting correlated with a better and more sustained infection reduction.

CONCLUSIONS

Our multifaceted approach using the CUSP model was associated with reduced CLABSI-associated morbidity and mortality in resource-limited settings. Our findings suggest that a higher attendance rate (>85%) at meetings may be necessary to achieve sustained effects post-intervention.

Quality improvement initiative 'S-A-F-H' to reduce healthcare-associated neonatal sepsis in a tertiary neonatal care unit

BACKGROUND

Neonatal sepsis is a leading cause of morbidity and mortality among admitted neonates. Healthcare-associated infection (HAI) is a significant contributor in this cohort.

LOCAL PROBLEM

In our unit, 16.1% of the admissions developed sepsis during their stay in the unit.

METHOD

We formed a team of all stakeholders to address the issue. The problem was analysed using various tools, and the main contributing factor was low compliance with hand hygiene and handling of intravenous lines.

INTERVENTIONS

The scrub the hub/aseptic non-touch technique/five moments of hand hygiene/hand hygiene (S-A-F-H) protocol was formulated as a quality improvement initiative, and various interventions were done to ensure compliance with hand hygiene, five moments of hand hygiene, aseptic non-touch technique. The data were collected and analysed regularly with the team members, and actions were planned accordingly.

RESULTS

Over a few months, the team could reduce the incidence of HAI by 50%, which has been sustained for over a year. The improvement in compliance with the various aspects of S-A-F-H increased.

CONCLUSIONS

Compliance with hand hygiene steps, five moments of hand hygiene and an aseptic non-touch technique using quality improvement methodology led to a reduction in neonatal sepsis incidence in the unit. Regular reinforcement is required to maintain awareness of asepsis practices and implementation in day-to-day care and to bring about behavioural changes.

Reduction of Hospital-Acquired Infections Through a Nursing Education Program: A Quality Improvement Project on the Sensitization of Nursing Staff Toward Infection Control in Neonates

Background This study aimed to reduce hospital-acquired infections (HAIs) by at least 50% in our unit through a nursing education program to sensitize the nursing staff toward infection control in neonates. Methodology This pre- and post-intervention observational study was conducted in Liaquat National Hospital's Neonatal Intensive Care Unit (NICU) from October 2021 until March 2023. This observational study was conducted in three phases. In phase I (pre-implementation), all neonates with suspected HAIs were included. In phase II (implementation), the nursing staff dedicated to the NICU were trained. In phase III (post-implementation), all neonates with suspected HAIs were included. Culture-proven bloodstream infections (BSIs), urinary tract infections (UTIs), and ventilator-associated pneumonia (VAP) were the three types of HAIs. The nursing scoring was done by the principal investigator based on a questionnaire. The Shapiro-Wilk test was used to evaluate the normality of all quantitative data across all phases. Results In the pre-implementation phase, there were 24 (10.8%) HAIs, among which 19 (8.6%) were BSIs, one (0.5%) was a catheter-associated urinary tract infection (CAUTI), and seven (3.2%) were VAP. Whereas in the post-implementation phase, there were 12 (5%) HAIs, among which 10 (4.1%) were BSIs, none were CAUTIs, and five (2.1%) were VAP. There was a significant reduction of HAIs in the post-implementation phase (p < 0.01). The difference in the knowledge, assessment, and practice was statistically significant in the post-implementation phase (p < 0.01). Conclusions We established a successful cost-effective intervention to improve the awareness and compliance of NICU nurses with infection control practices. This helped us in reducing HAIs in our NICU.

Attributable Mortality for Pediatric and Neonatal Central Line-Associated Bloodstream Infections in Greece

Central line-associated bloodstream infections (CLABSIs) are the most frequent pediatric hospital-acquired infections and significantly impact outcomes. The aim of this study was to estimate the attributable mortality for CLABSIs in pediatric and neonatal patients in Greece. A retrospective matched-cohort study was performed, in two tertiary pediatric hospitals. Inpatients with a central line in neonatal and pediatric intensive care units (NICUs and PICUs), hematology/oncology units, and a bone marrow transplantation unit between June 2012 and June 2015 were eligible. Patients with confirmed CLABSI were enrolled on the day of the event and were matched (1:1) to non-CLABSI patients by hospital, hospitalization unit, and length of stay prior to study enrollment (188 children enrolled, 94 CLABSIs). Attributable mortality was estimated. During the study period, 22 patients with CLABSI and nine non-CLABSI patients died (23.4 vs. 9.6%, respectively, p  = 0.011), leading to an attributable mortality of 13.8% (95% confidence interval [CI] = 3.4-24.3%). Children in PICUs were more likely to die, presenting an attributable mortality of 20.2% (95% CI = - 1.4-41.8%), without reaching, however, statistical significance. After multiple logistic regression, patients with CLABSI were four times more likely to die (odds ratio [OR] = 4.29, 95% CI = 1.28-14.36, p  = 0.018). Survival analysis showed no difference in time to death after study enrollment between patients with CLABSI and non-CLABSI patients (log-rank p  = 0.137, overall median survival time = 7.8 months). Greek pediatric mortality rates are increased by the CLABSI occurrence, highlighting the importance of infection prevention strategies.

Infection control measures against multidrug-resistant Gram-negative bacteria in children and neonates

The increase in infections caused by multidrug-resistant (MDR) Gram-negative bacteria in neonatal and pediatric intensive care units over recent years is alarming. MDR Klebsiella pneumoniae, Pseudomonas aeruginosa and Acinetobacter baumannii have constituted the main causes of the MDR Gram-negative bacteria problem. The implementation of infection control measures such as hand hygiene, cohorting of patients, contact precautions, active surveillance and environmental cleaning could diminish their spread. Recently, water safety has been identified as a major component of infection control policies. The aim of the current review is to highlight the effectiveness of these infection control measures in managing outbreaks caused by MDR Gram-negative bacteria in neonatal and pediatric intensive care units and highlight future perspectives on the topic.

A Quality improvement initiative to reduce central line-associated bloodstream infections in a neonatal intensive care unit in a low-and-middle-income country

BACKGROUND

Premature and sick neonates in the neonatal intensive care unit (NICU) are in need of central lines placing them at high risk of contracting a central line-associated bloodstream infection (CLABSI). CLABSI extends length of stay to 10-14 days post negative cultures and increases morbidity, use of multiple antibiotics, mortality and hospital cost. To reduce CLABSI rate at the American University of Beirut Medical Center NICU, the National Collaborative Perinatal Neonatal Network developed a quality improvement project to reduce CLABSI rate by 50% over a 1-year period and to sustain reduced CLABSI rate.

METHODS

Central line insertion and maintenance bundles were implemented for all infants admitted to the NICU necessitating central lines placement. Bundles included hand washing, wearing protective material and sterile drapes during central lines insertion and maintenance.

RESULTS

CLABSI rate decreased by 76% from 4.82 (6 infections; 1244 catheter days) to 1.09 (2 infection; 1830 catheter days) per 1000 CL days after 1 year. Following the bundles' success in reducing CLABSI rate, they were incorporated permanently to NICU standard procedure and bundle checklists were added to the medical sheets. CLABSI rate was maintained at 1.15 per 1000 CL days during the second year. It then decreased to 0.66 per 1000 CL days in the third year before reaching zero in the fourth year. In total, zero CLABSI rate was sustained for 23 consecutive months.

CONCLUSION

Reducing CLABSI rate is necessary to improving newborn quality of care and outcome. Our bundles were successful in drastically reducing and sustaining a low CLABSI rate. It was even successful in achieving a zero CLABSI unit for 2 years.

Bloodstream infections in neonates with central venous catheters in three tertiary neonatal intensive care units in Pune, India

BACKGROUND

Neonates admitted to the neonatal intensive care unit (NICU) are at risk for healthcare-associated infections, including central line-associated bloodstream infections. We aimed to characterize the epidemiology of bloodstream infections among neonates with central venous catheters admitted to three Indian NICUs.

METHODS

We conducted a prospective cohort study in three tertiary NICUs, from May 1, 2017 until July 31, 2019. All neonates admitted to the NICU were enrolled and followed until discharge, transfer, or death. Cases were defined as positive blood cultures in neonates with a central venous catheter in place for greater than 2 days or within 2 days of catheter removal.

RESULTS

During the study period, 140 bloodstream infections were identified in 131 neonates with a central venous catheter. The bloodstream infection rate was 11.9 per 1000 central line-days. Gram-negative organisms predominated, with 38.6% of cases caused by Klebsiella spp. and 14.9% by Acinetobacter spp. Antimicrobial resistance was prevalent among Gram-negative isolates, with 86.9% resistant to third- or fourth-generation cephalosporins, 63.1% to aminoglycosides, 61.9% to fluoroquinolones, and 42.0% to carbapenems. Mortality and length of stay were greater in neonates with bloodstream infection than in neonates without bloodstream infection (unadjusted analysis, p < 0.001).

CONCLUSIONS

We report a high bloodstream infection rate among neonates with central venous catheters admitted to three tertiary care NICUs in India. Action to improve infection prevention and control practices in the NICU is needed to reduce the morbidity and mortality associated with BSI in this high-risk population.

Consensus on Quality Indicators for Pediatric Oncology Nursing Care in Mainland China: A Delphi Method and Analytic Hierarchy Process

Background: Because routine nursing quality indicators are not suitable to evaluate pediatric oncology nursing care, this study aimed to identify a set of quality indicators for pediatric oncology nursing care in mainland China. Method: This prospective investigation utilized a modified Delphi technique and an analytic hierarchy process. A survey questionnaire was developed using a literature review and semi-structured interviews. Fifteen invited experts evaluated the importance of potential indicators through three rounds of Delphi survey by email in 2018. The importance weight of each indicator was identified through analytic hierarchy process. Results: In the Delphi survey, the average authoritative coefficient was 0.93-0.96 for each round of the inquiry. After three rounds of survey, 29 quality indicators were identified as important nursing outcomes for assessing the quality of pediatric oncology nursing care in mainland China. The importance rating mean score of indicators ranged between 4.67 and 5.00 on a 5-point scale, and the variation coefficient ranged between 0 and 0.19. Expert-assigned indicator importance weight varied between 0.0040 and 0.0870. Conclusion: This study identified an indicator system with 29 nursing-sensitive quality indicators that may represent potential indicator candidates for quality assessment of pediatric oncology nursing practice in mainland China.

Infection prevention and care bundles addressing health care-associated infections in neonatal care in low-middle income countries: a scoping review

BACKGROUND

Health care-associated infections (HCAI) in neonatal units in low- and middle-income countries (LMIC) are a major cause of mortality. This scoping review aimed to synthesise published literature on infection prevention and care bundles addressing neonatal HCAI in LMICs and to construct a Classification Framework for their components (elements).

METHODS

Five electronic databases were searched between January 2001 and July 2020. A mixed-methods approach was applied: qualitative content analysis was used to build a classification framework to categorise bundle elements and the contents of the classification groups were then described quantitatively.

FINDINGS

3619 records were screened, with 44 eligible studies identified. The bundle element Classification Framework created involved: (1) Primary prevention, (2) Detection, (3) Case management, and Implementation (3 + I). The 44 studies included 56 care bundles with 295 elements that were then classified. Primary prevention elements (128, 43%) predominated of which 71 (55%) focused on central line catheters and mechanical ventilators. Only 12 elements (4%) were related to detection. A further 75 (25%) elements addressed case management and 66 (88%) of these aimed at outbreak control.

INTERPRETATION

The 3 + I Classification Framework was a feasible approach to reporting and synthesising research for infection-relevant bundled interventions in neonatal units. A shift towards the use in infection prevention and care bundles of primary prevention elements focused on the neonate and on commonly used hospital devices in LMIC (e.g., self-inflating bags, suctioning equipment) would be valuable to reduce HCAI transmission. Detection elements were a major gap.

FUNDING

This work was made possible in part by the John D. and Catherine T. MacArthur Foundation, the Bill & Melinda Gates Foundation, ELMA Philanthropies, The Children's Investment Fund Foundation UK, The Lemelson Foundation, and the Ting Tsung and Wei Fong Chao Foundation under agreements to William Marsh Rice University. The project leading to these results has also received the support of a fellowship from the "la Caixa" Foundation (ID 100010434). The fellowship code is LCF/BQ/EU19/11710040. EJAF is an Academic Clinical Fellow whose salary is funded by the UK National Institute for Health Research (NIHR). NES receives a Research Training Program Scholarship (Australian Commonwealth Government).

Does the antimicrobial-impregnated peripherally inserted central catheter decrease the CLABSI rate in neonates? Results from a retrospective cohort study

BACKGROUND

The use of antimicrobial-impregnated peripherally inserted central catheters (PICCs) has been introduced in the last few years to neonatal units aiming to reduce central line-associated bloodstream infection (CLABSI).

METHODS

This retrospective observational study aimed to compare the CLABSI rates and other catheter-related parameters including the insertion success rates and catheter-related complications in the antimicrobial-impregnated and conventional (ordinary) PICCs in NICU between 2017 and 2020.

RESULTS

Our dedicated PICC team including physicians and nurses inserted 1,242 conventional (PremiCath and NutriLine) and 791 antimicrobial-impregnated PICCs (PremiStar) over the study period from 2017 to 2020. Of those 1,242 conventional PICCs, 1,171 (94.3%) were 1 Fr single lumen and only 71 (5.7%) were 2 Fr double lumen. The mean ± SD [median (IQR)] for the birth weight in all babies who had a PICC line was 1,343.3 ± 686.75 [1,200 (900, 1,500)] g, while the mean ± SD for the gestational age was 29.6 ± 4.03 [29 (27, 31)] weeks. The mean ± SD [median (IQR)] age at the time of insertion for all catheters was 9.3 ± 21.47 [2 (1, 9)] days, while the mean ± SD [median (IQR)] dwell time was 15.7 ± 14.03 [12 (8, 17)] days. The overall success rate of the PICC insertion is 1,815/2,033 (89.3%), while the first attempt success rate is 1,290/2,033 (63.5%). The mean ± SD [median (IQR)] gestational age, birth weight, age at catheter insertion, and catheter dwell time were 28.8 ± 3.24 [29, (26, 31)] weeks, 1,192.1 ± 410.3 [1,150, (900, 1,450)] g, 6.3 ± 10.85 [2, (1, 8)] days, and 17.73 ± 17.532 [13, (9, 18)] days in the antimicrobial-impregnated catheter compared with 30.1 ± 4.39 [29, (27, 32)] weeks (P < 0.001), 1,439.5 ± 800.8 [1,240, (920, 1,520)] g (P < 0.001), 11.1 ± 25.9 [1, (1, 9)] days (P < 0.001), and 14.30 ± 10.964 [12, (8, 17)] days (P < 0.001), respectively, in the conventional PICCs. The use of the antimicrobial-impregnated catheter was not associated with any significant reduction in the CLABSI rate (per 1,000 days dwell time), either the overall [P = 0.11, risk ratio (RR) (95% CI): 0.60 (0.32, 1.13)] or the yearly CLABSI rates.

CONCLUSIONS

The use of miconazole and rifampicin-impregnated PICCs did not reduce the CLABSI rate in neonates compared with conventional PICCs. However, it has a higher overall rate of elective removal after completion of therapy and less extravasation/infiltration, occlusion, and phlebitis compared with the conventional PICCs. Further large RCTs are recommended to enrich the current paucity of evidence and to reduce the risk of bias. Neonatal PICCs impregnation by other antimicrobials is a recommendation for vascular access device manufacturers.

Antifungal susceptibility profile of invasive Candida glabrata isolates (2009-2020) from a tertiary care hospital laboratory in Pakistan

Introduction. Invasive infections with Candida glabrata are a global concern due to poor clinical outcomes and propensity to acquire resistance to antifungal agents. Hypothesis/Gap Statement. Monitoring emerging resistance and trends in Candida glabrata, an important agent of candidemia in Pakistan, is critical for patient management; data that is missing from Pakistan. Aim. Thus, this study evaluated antifungal resistance and MICs) distribution in invasive C. glabrata isolates from Pakistan. Methods. This cross-sectional and retrospective study was conducted from January 2009 to March 2020 at a clinical laboratory in Pakistan that has a nation-wide network. Antifungal susceptibility data of 277 candidemia, deep organ and soft tissue (invasive) C. glabrata sensu lato isolates against fluconazole, itraconazole, voriconazole, posaconazole, anidulafungin, micafungin, caspofungin and amphotericin B was retrieved. Susceptibility testing was performed using colorimetric broth microdilution and interpreted using CLSI criteria. Demographics, clinical history and outcome were studied. Chi-square test was used to demonstrate association between antifungal resistance and clinical characteristics of the patients. Results. We identified 277 patients with invasive C. glabrata infection. Of which 48 (18.4%) isolates were resistant to fluconazole (MIC ≥64 mg l^-1), one isolate each was resistant to amphotericin (MIC=2 mg l^-1), anidulafungin (MIC=1 mg l^-1) and micafungin (MIC=0.5 mg l^-1). MIC₉₀ for fluconazole was 64 mg l^-1 and other triazoles 2 mg l^-1, caspofungin 0.12 mg l^-1, anidulafungin 0.06 mg l^-1, micafungin 0.03 mg l^-1 and amphotericin 0.5 mg l^-1. Fluconazole MIC ≥64 mg l^-1, caspofungin MIC >0.06 mg l^-1 and amphotericin MIC >0.25 mg l^-1 (above MIC₅₀) were significantly associated with patient being alive at the time of reporting, no use of healthcare devices, nor infection with other fungi. Fluconazole resistance was significantly associated with prior antifungal use by the patient. Conclusion. Surveillance data of antifungal resistance among common Candida species should be monitored closely for identification of resistant strains.

Spectrum and Antifungal Resistance of Candidemia in Neonates With Early- and Late-Onset Sepsis in Pakistan

BACKGROUND

Neonatal candidemia leads to high morbidity and mortality in developing countries. We studied the trends, spectrum and antifungal resistance in neonatal candidemia isolates from the year 2014 to 2019.

METHODS

This was a cross-sectional study conducted at the Aga Khan University, Pakistan. Neonates with positive blood cultures with Candida species were retrospectively identified from the laboratory database (2014-2018) and prospectively in 2019 where clinical information was also collected as part of routine laboratory reporting.

RESULTS

We identified 669 neonates with Candida species in blood cultures. Three hundred forty-six neonates had early-onset disease (EOD age ≤7 days) and 323 had late-onset disease (LOD age >7 days). Non-albicans Candida species (86.7%) were predominant versus C. albicans (13.3%; P-value 0.024) with Candida tropicalis being most common in both EOD and LOD. Candida pelliculosa and Candida guilliermondii were associated with EOD and C. albicans with LOD. Isolation of fluconazole nonsusceptible non-albicans Candida species was significantly higher in early-onset (5.9%) versus late-onset (2%) neonatal candidemia (P-value 0.005; crude odds ratio [COR] 2.73, 95% CI: 1.34-5.53). LOD in neonates was more likely associated with the use of vancomycin (COR 3.89, 95% CI: 1.39-10.89). EOD was more likely seen in patients with vaginal delivery (COR 4.16, 95% CI: 1.42-12.23) and in neonates with respiratory distress leading to intensive care unit admission (COR 3.31, 95% CI: 1.05-10.42).

CONCLUSIONS

Non-albicans Candida species were increasingly isolated from neonates with candidemia during recent years from Pakistan. Amphotericin remains first-line option for neonatal candidemia in our setting as fluconazole nonsusceptible Candida species are commonly isolated.

Sustaining compliance with hand hygiene when resources are low: A quality improvement report

Background

Sustainability of hand hygiene is challenging in low resource settings. Adding ownership and goal setting to the WHO-5 multimodal intervention may help sustain high compliance.

Aim

To increase and sustain compliance of nursing and medical staff with hand hygiene in a tertiary referral center with limited resources.

Methods

A quality improvement initiative was conducted over two years (2016–2018). After determining baseline compliance rates, the WHO-5 multimodal intervention was implemented with staff education and training, system change, hospital reminders, direct observation and feedback, and hospital safety climate. Additionally, the medical staff was responsible for continuous surveillance of compliance (ownership) until rates above 90% were achieved and sustained (goal setting).

Results

Of 2987 observations collected between August 2016 and April 2018, 1630 (54.5%) were before, and 1357 (45.5%) were after patient encounters. The average overall compliance with hand hygiene was sustained at 94% for nursing and medical staff. Two instances of drops below 90% were associated with incidence of nosocomial Rotavirus infections. There were no similar infections during intervention periods with compliance rates above the set goal. Analysis using p-charts revealed significant improvement in compliance rates from baseline (χ² (1) = 7.94, p = 0.005).

Conclusion

Adding ownership and goal setting to the WHO-5 multimodal intervention may help achieve, and sustain high rates of compliance with hand hygiene. Involving health care workers in quality improvement initiatives is feasible, durable, reliable, and cheap, especially in settings with limited financial resources.