Our tertiary care oncology unit experienced a 20% decline in CLABSI rates after the implementation of a best-practice central line care bundle (P = .58). Secondary analyses indicated the second year of the intervention realized a 64% decline in CLABSI rates below baseline (P = .091), suggesting that a long ramp-up period may be necessary to achieve effective change. Qualitative keys to successful implementation of this best-practice bundle included front-line staff buyin and leadership, physician support, continuous quality improvement efforts, data dissemination and transparency, and a persistent focus on expected behaviors though audits and mini-root cause analyses of all CLABSIs.
Quality improvement work and behavioral change can be slow processes that take time and energy to mature and succeed.25
Despite extensive continuous quality improvement efforts, our unit was only able to reach 65% compliance with one of the bundle elements. This speaks to the pace of behavioral change and the importance of persistence in any quality improvement effort. The apparent decline of CLABSI rates during the second year of our study suggests that commitment to quality improvement efforts must be maintained during a potentially prolonged ramp-up period to fully realize the benefit of maintenance care bundles. Front line staff attributed the apparent reduction in CLABSI rates to the consistent and sustained focus on CLABSIs on our unit and the repeated efforts to involve and listen to nurses who are dealing with central line maintenance every day. Our investigation suggests the importance of committed quality improvement efforts that look past short-term time horizons.
Although previous studies have demonstrated dramatic CLABSI reductions in 18 months or less,9,15,24
these interventions started with higher baseline CLABSI rates and therefore had larger room for improvement. We observed a baseline CLABSI rate in inpatient pediatric oncology patients of 2.25 CLABSIs per 1000 central line days, which is appreciably lower than reported in previous pediatric CLABSI reduction studies.9,11,13,14
This may have contributed to the lack of statistical significance found in our results. Despite this, there was a large effect size appreciated within our study (64% decline in the second year), and the lack of statistical significance could have been related to a limited sample size. Again, this study argues for a long-term vision when pursing quality improvement efforts.
With regard to the epidemiology of CLABSIs in hospitalized pediatric oncology patients, our study parallels previous work that found slightly more Gram-positive than Gram-negative pathogens in pediatric oncology CLABSIs.14,26,27
Although a recent study found a preponderance of Enterococcus faecalis
isolates in inpatient pediatric oncology CLABSIs,27
our study identified coagulase-negative Staphylococcus
as the most frequent isolate. The differences among studies in the distribution of pathogens suggest that regional and institutional factors probably influence the epidemiology of CLABSIs in pediatric oncology patients. Further study is needed to help clinicians determine appropriate empirical antibiotics for patients with suspected CLABSIs, and these antibiotics may need to be institution specific. Our study found significant morbidity from CLABSIs, with affected patients having their central line removed in 37% of cases. It is unclear if antibiotic-impregnated catheters and ethanol lock strategies could reduce pediatric oncology CLABSIs or reduce the frequency of central line removal after a CLABSI.28
Finally, patients with Hickman catheters were >4 times as likely to experience a CLABSI (P
= .02), a finding that may be confounded because bone marrow transplant patients often receive Hickman catheters and are likely at greater risk for infection.27
Clinicians should carefully weigh the benefits of utilizing a catheter type that has been repeatedly shown to carry a higher risk of infection in multiple pediatric oncology cohorts.3,27
There are a number of limitations to the current study. CLABSI rates have decreased nationally over the past decade.29
Given this study’s interrupted time series design, it is impossible to know if confounding factors, such as an increased national focus on CLABSIs and public CLABSI reporting efforts, contributed to the reduction of CLABSI rates.30
We have no data on whether hospital-wide awareness campaigns regarding CLABSIs affected our staff and patient behaviors. It is unclear if the results from our single-institution study can be generalized to nontertiary care inpatient pediatric oncology units that do not care for a large number of bone marrow transplant patients. Although our unit experienced an apparent decline in CLABSI rates during the second 12 months of our intervention, we must continue to observe CLABSI rates to ensure that this reduction is sustained. Given that 1 of 3 patients did not receive care completely in compliance with the bundle, additional CLABSI rate reduction may occur with improved compliance.25
Finally, our study is at risk for misclassification bias, because adjudicators may have mistakenly labeled infections as CLABSIs.22
This concern is increased in patients with mucositis and severe neutropenia, comorbidities that provide a non–central line-related reason for bacteremia but are not accounted for in the National Healthcare Safety Network CLABSI definitions.22
The risk for misclassification bias is potentially increased because the IP was not blinded to the time period of the intervention. We believe this risk is low, because rates of non-CLABSI bacteremias did not increase after implementation of the bundle.
In conclusion, this study suggests best-practice central line bundles can be implemented in inpatient pediatric oncology patients and presents practical interventions that can be applied in other institutions aiming to reduce CLABSIs. 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. 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.