Development of a Central Line Team to Reduce CLABSI in a Level IV NICU

Introduction: Central line-associated bloodstream infections (CLABSI) contribute significantly to morbidity and mortality of the neonatal population. In 2019, the 74-bed Level IV Neonatal Intensive Care Unit at M Health Fairview Masonic Children's Hospital had a CLABSI incidence rate significantly higher than national benchmarks, with a rate of 2.15 per 1000-line days and an estimated cost exceeding $720,000. Multiple improvement projects were implemented, but there was a lack of sustainment that failed to significantly impact the CLABSI rate. Additionally, the unit experienced low compliance with maintenance bundle elements and experienced ongoing patient safety events. Literature highlighted the effectiveness of dedicated nurse teams for teaching and monitoring central line maintenance to reduce CLABSI rates.1,2 Method: The NICU established a team of dedicated nurses for central line maintenance rounding, peer coaching, and assistance with high-risk, low-frequency procedures. Supported by interdisciplinary collaboration and a comprehensive onboarding program, the Central Line Team (CLT) launched in April 2022. The CLT aimed to improve adherence to the central line maintenance bundle and reduce CLABSI rates. Ten nurses were selected via an application process to form the CLT, with each member spending 50% of their time as bedside nurses and 50% in the CLT role. A CLT member was scheduled from 11 am to 11 pm daily to interact with bedside nurses across all shifts. Training for CLT members included peer feedback techniques, crucial conversations, high-reliability principles, and quality improvement (QI) methodology. CLT responsibilities include rounding on all patients with central lines to assess and reinforce best practices, educating nurses on central line bundle elements, and collaborating with bedside staff to create proactive plans for high-risk patients. Results: After 60 days post implementation, a survey of nursing staff indicated that 84% of respondents (N = 51) had interacted with a CLT member, and 90% felt that the CLT was a valuable source of central line knowledge. Nurses appreciated the opportunity to ask peers questions about central lines and felt comfortable being audited by peers. Comparing the 7 months before and after CLT implementation, the number of monthly audits increased by 215%, although bundle compliance remained unchanged. The CLABSI rate per 1000-line days improved by 40%, decreasing from 1.07 to 0.64. High harm safety events decreased by 11% during this period (Table 1). Table 1. - Measures Pre-CLT (09/21-03/22) Post-CLT (05/22-11/22) Comments Adherence to maintenance bundle elements 36-64%/moAv. 44% compliance 33-73%/moAv. 43% compliance No apparent change in adherence; increased accuracy in audit results No. maintenance bundle audits Av. 23 audits/mo, including 10 observational Av. 72 audits/mo, including 41 observational 215% increase in moly bundle audits CLABSI rate per 1000-line days 1.074 .64 40% reduction Rolling 6-mo CLABSI rate per 1000-line days 1.016 (16 mo prior) .764 33% reduction No. Safety Event Total: 43Av. 6.14/mo, including 1.28 high harm events Total: 48Av. 6.85/mo, including 1.14 high harm events Similar # of reports; 11% decrease in moly high harm events Discussion: Since the CLT's implementation, the CLABSI rate has significantly decreased, with no serious safety events occurring. The success of the CLT is attributed to dedicated time for CLT roles, passionate CLT nurses, application of QI principles, and strong leadership support. The CLT became safety leaders in the unit, positively impacting overall serious safety events. Despite bundle compliance remaining below target, the increase and standardization of observational audits provided higher quality information for identifying and addressing areas of focus. The CLT's use of QI methodology has allowed for impactful changes in individual bundle elements, even with minimal overall compliance change. Future for the CLT include ongoing monitoring of CLABSI measures, identifying trends requiring targeted improvement, and spreading the concept of specialized CLTs to pediatric and adult intensive care units. ACKNOWLEDGMENTS The authors acknowledge the following personnel for assistance with study: Maria Raines, DNP, MS, APRN, ACNS-B; Briana Bitterman, BSN, RNC-NIC, VA-BC; Kendra Bruns, BSN, RNC-NIC, C-ELBW; Kate Cady, BSN, RN, VA-BC; Jennifer Fitzgerald, BSN, RNC-NIC, CHPPN, VA-BC; Marisa Tiffany BSN, RNC-NIC; Rachel Palermo, MSN, RNC-NIC, NE-BC; Megan Sigrist, BSN, RN, IBCLC; Elise Stepka, BSN, RNC-NIC; Kaylene Paulson, BSN, RNC-NIC