reducing clabsis in pediatric oncology patients
TRANSCRIPT
Reducing Central Line Associated Blood Stream Infections in Pediatric
Oncology Patients
Ashley Quinn
Central Line Associated Blood Stream Infections (CLABSIs) are preventable form of patient harm
• Definition– Bacteremia in a patient with a central line with no other identifiable source
• Epidemiology– Incidence: 60 cases per 10,000 admissions 1,2
–Mortality: 12-‐25% 3
Adults 4 Pediatrics 5
Cost $40,890 $55,000Length of Stay 14 days 18 days
Central line bundles reduced national CLABSI rates, but continue to occur despite bundle adherence
• National Healthcare Safety Network (NHSN)• Central line bundles – Evidence-‐based practices that reduce CLABSIs– Better outcomes when used together than alone
Number of CLABSIs x 1000
Number central line (CL) daysCLABSI rate =
CLABSI rateNational 6 1.2
Pediatric hematology-‐oncology 7 2.135Benchmark 8 0.878
Daily full body topical chlorhexidine gluconate(CHG) treatments consistently reduce CLABSI rates
• Reduces CLABSI rates– Adult, pediatric, and neonatal ICU 10, 11,12
– Adult medical and surgical units 13
– Burn and bone marrow transplant units 14, 10
– Long term acute care units 15
• Reduces colonization, transmission, and infection of drug-‐resistant organisms 16, 17, 18, 19
• Population In Pediatric oncology and bone marrow transplant patients
• Intervention daily topical CHG treatments,
• Comparison compared with standard daily bathing with soap and water,
• Outcome will reduce CLABSI rates below 0.878/1000 central line days within 1 year
Hypothesis
July 2013 July 2014“preCHG” “wCHG”
Soap-‐and-‐water baths Daily CHG treatments
• Outcome measures– Primary: CLABSI rates– Secondary: Pathogen isolated– Process: Compliance– Balancing: Nursing surveys
Methods
Monitoring compliance in real-‐time fostered high compliance with CHG treatments
Compliance for every patient on the unit could be simultaneously assessed in real time
CHG treatments did not reduce CLABSIs despite evidence of efficacy in similar populations
Start CHG
National Rate 2.135Benchmark 0.878
preCHG wCHGCLABSI Rate 2.90 3.39p-value 0.74
Sample size 36
Isolation of Gram negative pathogens doubled in the wCHG period
preCHG wCHG
PathogenGram + 6 7Gram – 7 13Fungus 3 0
02468101214
�Gram + Gram -‐ � Fungi
Num
ber C
LABS
IsPathogen Isolated
preCHG wCHG
Mucosal Barrier Injury (MBI) criteria attributes infection to translocation of intestinal bacteria
• MBI-‐CLABSI criteria1. Isolation of intestinal flora2. Risk factors for MBI
• Evidence of mucositis• Severe neutropenia
Epithelium
Intestinal Flora
Bloodstream
MBI-‐CLABSIIntestinal translocation
NonMBI-‐CLABSIInfected central line site
CLABSI
MBI-‐CLABSIs were 2-‐3 times more commonthan nonMBI-‐CLABSIs
5 5
11
15
02468
10121416
�preCHG � wCHG
Num
ber C
LABS
Is
CLABSIs by TypeNonMBI MBI
All CLABSIs in wCHG period show characteristics consistent with MBI (severe neutropenia, mucositis)
40%
100%100% 100%
0%
20%
40%
60%
80%
100%
�preCHG � wCHG
% CLA
BSIs with
Risk
Factors
Risk Factors for TranslocationNonMBI MBI
Pathogen Isolated Number NonMBI-‐CLABSIs
Pseudomonas aeruginosa 4
Streptococcus pneumoniae 1
Daily full body topical CHG treatments reduced the CLABSI rate below our goal
Start CHG
preCHG wCHGCLABSI Rate 0.91 0.17p-value 0.113
Sample size 6
National Rate 2.135Benchmark 0.878
• In patients with intact mucosal barriers, bundles and CHG treatments were effective in reducing CLABSIs to 0.71/1000 line days
• Future Work– Strategies to reduce bacterial translocation in patients with mucosal barrier injury including severe, prolonged neutropenia and mucositis
Conclusions
• Paul Harker-‐Murray MD, PhD• Lauren Ranallo MSN, RN, AOCNS, CPHON• Alyse Bartczak BSN, RN
Acknowledgements
Questions?
Nursing Surveys
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Definitely Somewhat No
Num
ber o
f Respo
nses
Interferes with Other Work
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Patient factors Workflow factors Non identified
Num
ber o
f Respo
nses
Barriers
All CLABSIs
National Rate 1.303, 1.534Benchmark 0.878
Study Period preCHG wCHGCLABSI Rate 2.90 3.39p-value 0.74Shifts 0 0Trends 1Runs 9 (3-11) 6 (3-10)
Start CHG
CHG treatments did not reduce NonMBI CLABSIs
Start CHG
preCHG wCHGCLABSI Rate 0.91 0.85p-value 1.0
Sample size 10
National Rate 2.135Benchmark 0.878
NonMBI CLABSIs
National Rate 1.303, 1.534Benchmark 0.878
Study Period preCHG wCHGCLABSI Rate 0.91 0.85p-value 1.0Shifts 1Trends 0 0Runs 7 (3-11) 7 (3-11)
Start CHG
NonMBI CLABSIs with Pseudomonas excluded
National Rate 1.303, 1.534Benchmark 0.878
Study Period preCHG wCHGCLABSI Rate 0.91 0.17p-value 0.113Shifts 1Trends 0 0Runs 7 (3-11) 7 (3-11)
Start CHG
Neutropenia Data
NonMBI CLABSI MBI CLABSIpreCHG wCHG p preCHG wCHG p
Duration 17±11 28±14 0.43 21±19 35±28 0.21Time 2.5±0.7 7.0±7.8 0.50 6.8±5.5 7.8±10.1 0.74
Line Type
NonMBI CLABSI MBI CLABSI
preCHG wCHG p preCHG wCHG p
Tunneled 2 3
0.074
4 7
0.883PICC 0 2 6 8
Port 3 0 2 2
Line Location
NonMBI CLABSI MBI CLABSI
preCHG wCHG p preCHG wCHG p
Tunneled 0 0
0.114
0 6
0.039PICC 5 3 7 4
Port 0 2 5 7
References1. Srinivasan, A; Wise, A; Bell, M; Cardo, D; Edwards, J; Fridkin, S; Jernigan, J; Kallen, A; McDonald, LC; Patel, PR;
Pollock, D. Vital Signs: Central Line–Associated Blood Stream Infections — United States, 2001, 2008, and 2009. MMWR, 2011. 60(8):243-‐248.
2. Wisplinghoff, H; Bischoff, T; Tallent, SM; Seifert, H; Wenzel, RP; Edmond, MB. Nosocomial Bloodstream Infections in US Hospitals: Analysis of 24,179 Cases from a Prospective Nationwide Surveillance Study. CID, 2004. 39:309-‐317.
3. O’Grady, NP; Alexander, M; Dellinger, EP; Gerberding, JL; Heard, SO; Maki, DG; Masur, H; McCormick, RD; Mermel, LA; Pearson, ML; Raad, II; Randolph, Al; Weinstein. RA. Centers for Disease Control and Prevention Guidelines for the Prevention of Intravascular Catheter-‐Related Infections. MMWR 2002;51(RR-‐10):1-‐29.
4. Pittet, DT; Wenzel, RP. Nosocomial Bloodstream Infection in Critically Ill Patients: Excess Length of Stay, Extra Costs, and Attributable Mortality. JAMA, 1994. 271:1598-‐1601.
5. Goudie, AD; Brady, PQ; Rettiganti, M. Attributable Cost and Length of Stay for Central Line–Associated Bloodstream Infections. Pediatrics, 2013. 133(6): 1525-‐1532.
6. Johnson, NB; Hayes, LD; Brown, K; Hoo, EC; Ethier, KA. CDC National Health Report: Leading Causes of Morbidity and Mortality and Associated Behavioral Risk and Protective Factors—United States, 2005–2013. MMWR 2014;63(5):1-‐27.
7. National Healthcare Safety Network (NHSN) Report, Data Summary for 2013, Device-‐associated Module. Am J Infect Control 2015;43(3): 206–221.
8. SPS CLABSI Workgroup. (June 2016). Reducing CLABSI in Hematology-‐Oncology Populations [PDF].9. "Our Results." Solutions For Patient Safety. N.p., n.d. Web. 06 Sept. 2016.10. Climo, M.Y., DS; Warren, DK; Perl, TM; Bolon, M; Herwaldt, LA; Weinstein, RA; Sepkowitz, KA; Jernigan, JA;
Sanogo, K; Wong, ES, Effect of Daily Chlorhexidine Bathing on Hospital-‐Acquired Infection. The New England Journal of Medicine, 2013. 368(6): p. 533-‐542.
11. Milstone, A.E., A; Xiaoyan, S; Zerr, DM; Orscheln, R; Speck, K; Obeng, D; Reich, NG; Coffin, SE; Perl, TM, Daily chlorhexidine bathing to reduce bacteraemia in critically ill children: a multicentre, cluster-‐randomised, crossover trial. Lancet, 2013. 9872: p. 1099-‐1106.
References12. Quach, C.M., AM; Perpete, C; Bonenfant, M; Moore, DL; Perreault, T, Chlorhexidine Bathing in a Tertiary Care
Neonatal Intensive Care Unit: Impact on Central Line–Associated Bloodstream Infections. Infection Control and Hospital Epidemiology, 2014. 35(2): p. 158-‐163.
13. Medina, A.S., T; Pelter, M; Brancamp, T, Decreasing Central Line–Associated Bloodstream Infections in the Non-‐ICU Population. J Nurs Care Qual, 2014. 29(2): p. 133-‐140.
14. Popp, J.L., AJ; Nappo, R; Richards, WT; Mozingo, DW, Hospital-‐acquired infections and thermally injured patients: Chlorhexidine gluconate baths work. American Journal of Infection Control, 2014: p. 129-‐132.
15. Edwards, M.P., J; Kochvar, G, Quality improvement intervention reduces episodes of long-‐term acute care hospital central lineeassociated infections. American Journal of Infection Control, 2014: p. 735-‐738.
16. Armellino, D.W., J; Parmentier, D; Musa, N; Eichorn, A; Silverman, R; Hirschwerk, D; Farber, B, Modifying the risk: Once-‐a-‐day bathing “at risk” patients in the intensive care unit with chlorhexidine gluconate. American Journal of Infection Control, 2014: p. 571-‐573.
17. Lin, M.L., K; Blom, DW; Lyles, RD; Weiner, S; Poluru, KB; Moore, N; Hines, DW; Weinstein, RA; Hayden, MK, The Effectiveness of Routine Daily Chlorhexidine Gluconate Bathing in Reducing Klebsiella pneumoniaeCarbapenemase-‐Producing Enterobacteriaceae Skin Burden among Long-‐Term Acute Care Hospital Patients.Infection Control and Hospital Epidemiology, 2014. 35(4): p. 440-‐442.
18. Chen, W.S., L; Lianhong, L; Xin, W; Zhang, W, Effects of daily bathing with chlorhexidine and acquired infection of methicillin-‐resistant Staphylococcus aureus and vancomycin-‐resistant Enterococcus: a meta-‐analysis. J ThoracDis, 2013. 5(4): p. 518-‐524.
19. Viray, M.M., JC; Coopersmith, CM; Kollef, MH; Fraser, VJ; Warren, DK, Daily Bathing with Chlorhexidine-‐based Soap and the Prevention of Staphylococcus aureus Transmission and Infection. Infection Control and Hospital Epidemiology, 2014. 35(3): p. 243-‐250.