SLUG Bug: Quality Improvement With Orchestrated Testing Leads to NICU CLABSI Reduction

Abstract

Drs Piazza, Pallotto, and Brozanski in collaboration provided leadership for the design and analytics of the collaborative; and drafted, reviewed, and revised the manuscript. Ms Zaniletti and Mr Provost provided data analytics and critically reviewed the manuscript. All authors participated in the design and management of the collaborative, approved the fi nal manuscript as submitted, and agreed to be accountable for all aspects of the work. DOI: 10.1542/peds.2014-3642Accepted for publication Sep 21, 2015 Address correspondence to Anthony J. Piazza, MD, Department of Pediatrics, Division of Neonatal Medicine, Emory School of Medicine, 2015 Uppergate Rd, Atlanta, GA 30322. E-mail: apiazza@ emory.edu PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).Health care-associated infections (HAIs) are a burden to patients and the health care system. It is estimated that up to 50% of HAIs are preventable. 1,2 In 2002, however, HAIs in US hospitals reportedly reached ∼1.7 million, with >33 000 HAIs among infants in high-risk nurseries. 3 Central line-associated bloodstream infections (CLABSIs) have the highest cost per HAI and contribute to significant morbidities, mortality, and length of stay in the adult, pediatric, and neonatal populations. [4][5][6] The overall direct annual cost of US HAIs ranges from $35.7 to $45 billion for inpatient hospital services. 7 Although the actual cost of CLABSIs varies, the attributable cost to care is up to $69 000 per event. [7][8][9][10][11] Despite the risks with their use, central venous catheters (CVCs) play an integral role in modern health care. 12 The need for CVCs is particularly important in children's hospital NICUs for patients who abstract OBJECTIVE: Reduce central line-associated bloodstream infection (CLABSI) rates 15% over 12 months in children's hospital NICUs. Use orchestrated testing as an approach to identify important CLABSI prevention practices. METHODS:Literature review, expert opinion, and benchmarking were used to develop clinical practice recommendations for central line care. Four existing CLABSI prevention strategies (tubing change technique, hub care monitoring, central venous catheter access limitation, and central venous catheter removal monitoring) were identified for study. We compared the change in CLABSI rates from baseline throughout the study period in 17 participating centers. Using orchestrated testing, centers were then placed into 1 of 8 test groups to identify which prevention practices had the greatest impact on CLABSI reduction. RESULTS:CLABSI rates decreased by 19.28% from 1.333 to 1.076 per 1000 line-days. Six of the 8 test groups and 14 of the 17 centers had decreased infection rates; 16 of the 17 centers achieved >75% compliance with process measures. Hub scrub compliance monitoring, when used in combination with sterile tubing change, decreased CLABSI rates by 1.25 per 1000 line-days. CONCLUSIONS:This multicenter improvement collaborative achieved a decrease in CLABSI rates. Orchestrated testing identified infection prev...

Care bundles to reduce central line-associated bloodstream infections in the neonatal unit: a systematic review and meta-analysis

“…One study achieved a compliance rate of 55%, speculating this was lower than previously published rates due to anonymous bedside reporting 24. One study concluded that CLABSI rate reductions were not associated with reductions in compliance rates,21 while another study concluded that postintervention CLABSI rates were better in those units that reported checklist compliance >15% 27. However, in this multicentre study 5 out of 18 units did not submit compliance data.…”

“…All studies reported a reduction in CLABSI rates, though some did not find a reduction in rates in specific subgroups, including neonates with birth weights<751 g, 1000-1500g and >1500 g 26–28. Several centres had starting rates that were already lower than the average National Health Surveillance Network rate 21. In one multicentre study, one NNU reported 96% reduction in CLABSI rates, while another reported a 187% increase in rates 27.…”

Energy and Protein Intake During the Transition from Parenteral to Enteral Nutrition in Infants of Very Low Birth Weight

“…5 The transition from full parenteral fluids to enteral nutrition requires decisions about modifiable nutrition delivery practices, including PN, intravenous lipids, vascular access, feeding fortification, and total fluid volume. 2,4,6,7 For instance, decisions about the removal of central-line vascular access through which highly concentrated PN is delivered are influenced by efforts to reduce central line-associated blood-stream infections, 8,9 and decisions about total fluid volume can be affected by the cardiopulmonary status of infants with VLBW. 7,10 Although each decision in isolation affects the quality and quantity of nutrition delivered, the cumulative role of these decisions about nutrition delivery practices has not been delineated.…”

Quality Improvement to Reduce Neonatal CLABSI: The Journey to Zero

“…Another innovative approach to reducing neonatal CLABSI was the use of orchestrated testing by Piazza et al in the SLUG Bug trial. 4 This multicenter QI initiative was performed in 17 NICUs that participate in the Children's Hospital Neonatal Consortium. Their project began with the premise that there was already strong evidence for specific CLABSI reducing practices including good hand hygiene, sterile central line insertion, standardized dressing changes, and standard techniques for hub care, tubing changes, and line entry.…”