Reduction in Central Line-Associated Bloodstream Infections in Children with Intestinal Failure through Implementation of a Central Line Prevention Bundle: Broadening Quality Improvement Initiatives from the Hospital to the Home

Background: Children with intestinal failure (IF) are at high risk for developing central-line associated bloodstream infections (CLABSI) owing to their chronic dependence on central venous catheters for parenteral nutrition. CLABSI prevention remains a continued challenge to optimizing outcomes in children with IF.

Methods: We performed a QI initiative using a prospective, interrupted time series design to evaluate the safety and efficacy of a best-practice CLABSI prevention bundle that included ethanol lock prophylaxis (ELP) in both the hospital and home settings, on the primary outcome measure of CLABSI/1,000 catheter days.  Data on CLABSI rates and microbiology, central line insertions, repairs, and hospitalizations were collected before (1/1/2011-2/1/12) and after (2/1/12-12/31/13) bundle implementation.

Results: Twenty four children were eligible to receive the prevention bundle with ELP for a median of 266 days [range 12-635]:  median age of 3 yrs [range 0.25-18], 18 males with IF (with a median residual small bowel length of 48 cm [20-150]).   CLABSI rates decreased from 6.99 CLABSI/1,000 catheter days at baseline to 0.42 CLABSI/1,000 catheter days after bundle implementation, despite an increase in total number of catheter days.  Before bundle implementation, CLABSIs were primarily community-acquired and 35% were polymicrobial.  Fourteen children received prolonged ELP (median 415 days [range 104-635]) and required fewer central line insertions (p=0.001) and hospitalizations for fever and CLABSI (p=0.003) compared with pre-intervention.  There were no significant differences in central-line associated complications pre and post bundle implementation.

Conclusion: A best-practice CLABSI prevention bundle that included ELP in both the hospital and home was successfully implemented, well tolerated, and demonstrated a significant and sustained reduction in preventable harm in the form of CLABSI in children with IF.

Figure 1.  Shewhart U chart of CLABSI rates in 24 children with IF demonstrating sustained reduction in CLABSI rates after best-practice CLABSI prevention bundle with ELP was implemented

CLABSI prevention bundle with ELP offered to (A) eligible patients with history of ≥ 2 CLABSI and (B) all eligible patients