A Human Factors Approach to Central Line Associated Bloodstream Infection (CLABSI) Prevention and Safety Culture in the Pediatric Intensive Care Unit Pilot Report

Abstract

BACKGROUND: Healthcare Associated Infections (HAI’s) continue to present challenges for healthcare Quality and Patient Safety experts despite great progress that has been made since the introduction of evidence-based “care bundles”, continuous surveillance and expanded, public reporting to centralized databanks. Central line-associated bloodstream infections (CLABSIs) comprise approximately 15% of HAIs seen in hospitalized children, although the consensus is that most are preventable. Studies have shown that they increase morbidity, mortality, hospital expenditures and length of stay (AHRQ, 2013). According to the Centers for Disease Control, CLABSI rates have decreased by more than 50% since 2001 (MMWR, 2011), but the Agency for Healthcare Research and Quality National Patient Safety goal of zero infections (AHRQ, 2010) has yet to be achieved and/or sustained at most centers. After three years without a CLABSI, our tertiary care medical-surgical Pediatric Intensive Care Unit experienced an unexpected spike to 8 infections in 2017. Hospital-based nursing peer-to-peer maintenance (MTN) bundle compliance audits, an essential component of CLABSI prevention, did not offer insight into a specific cause but did reveal variable practices associated with high nursing turnover at both the leadership and staff levels. An in-depth review of each CLABSI event revealed shared patient characteristics that we suspected were increasing risk. Chief among them was the presence of intestinal failure with prolonged dependence on stable intravenous access to provide nutrition and needed medications. However, several cultures grew skin flora, rather than intestinal bacteria, implicating additional factors besides translocation. The high CLABSI rate drew the attention of Hospital administration, eager to reverse the trend, and led to low staff morale and declining scores on staff satisfaction surveys. Application of Human Factors Engineering principles in the ICU has been associated with CLABSI reduction (Drews, 2017; Holden, 2013), but this approach has not yet been widely adopted in Pediatrics. We proposed that the application of Human Factors principles to our current prevention efforts would further elucidate factors contributing to risk and offer solutions that would decrease the CLABSI rate, improve safety culture and increase staff satisfaction.