Simple Outpatient Protocols Reduce CLABSI by 48%

Training young cancer patients and their families basic methods of preventing central line-associated bloodstream infections could have implications beyond pediatric oncology, since healthcare is increasingly delivered in outpatient settings.

Training pediatric patients and their parents in basic infection-prevention protocols such as hand hygiene, the use of gloves and masks, and proper tube and needle replacement dramatically lowered bloodstream infections for children with central lines receiving outpatient chemotherapy.

A study published this week in Pediatrics by researchers at The Children's Hospital at Montefiore (CHAM) found that the protocols reduce Central Line-Associated Bloodstream Infection (CLABSIs) by 48% and bacteria in the blood by 54%.

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The study's author, Michael L. Rinke, MD, says the findings could have implications beyond pediatric oncology because more healthcare is delivered in outpatient settings.

"Our goal is that this starts in ambulatory pediatric oncology patients, but spreads to other kids using central lines, and then spreads to adults with central lines, and then spreads to anyone dealing with a medical device at home," says Rinke, assistant medical director of pediatric quality at CHAM.

"All of those devices confer risk and if we take the time to do really great education with clinicians, patients and their families and involve them in the process and show them the process toward keeping things as safe as possible we can have really big wins in terms of patient lives and medical dollars."

Rinke says earlier research has shown that children receiving outpatient chemotherapy develop three times as many bloodstream infections from their central lines than do children in hospitals. In addition to the serious and potentially fatal health risks that come with bloodstream infections, they can cost up to $45,000 for additional treatment.

The CHAM study used a multidisciplinary team led by nurses who worked with Rinke to educate clinic nurses, homecare nurses and patient families on how to safely and reliably manage central lines. Infection rates of 330 patients who received the intervention were compared to 339 patients who received ambulatory care before the intervention started.

Assessments were completed pre- and post-intervention to compare CLABSI rates and positive blood culture rates. Rinke says the intervention may have prevented more than 70 hospital admissions for children with cancer and saved hundreds of thousands of dollars in additional healthcare costs.     

"The goal of any pediatric oncologist is not to admit their patients," Rinke says. "These kids go through so much already and to have them in the hospital for an infection they didn't need to get is heartbreaking for everyone involved. Any time we can keep them out of the hospital that is a huge win. And it also a huge win for the medical system in terms of dollar because each of those hospitalizations cost real money for insurance companies and hospitals that don't get reimbursed for these infections all the time any more. It a real quality of life issue for the kids to say nothing of the risk for mortality and lasting morbidity."

Clinicians leading the study saw that homecare nurses and families received additional training in hand hygiene, tube changing and the use of needles, gloves, masks and dressings. Teams held regular meetings, webinars, and learning sessions to discuss quality improvement practices and to identify lessons learned from every infection.

Families also received education on central line safety, were asked to monitor provider compliance and regularly were asked to demonstrate their own abilities to care for their child's central line.

Rinke says the common-sense protocols are easy to implement, but can prove challenging to maintain. "It's the same thing when people floss when they're about to go to the dentist," he says. "We need to be reminded, but more importantly we need to have systems in place to make sure everybody does the right thing every time."

Rinke says the critical component to reducing infections was letting front-line nurses and patients' families lead the way.

"If I was the one leading this project it never would have gone anywhere. It was getting nurses involved, getting homecare nurses involved, and getting patients and their families involved that drove this project. You have to empower them," he says.

"I told them: 'We need your help. Tell us the best way to do this. If you see a doctor or a nurse treating your child's line in the wrong way stop them. We want you to stop them and here is a respectful way to do that. Here is a script on how to do that to make sure your child gets the best line care possible.'"

"The important thing we can take from this in addition to what has already been said in a lot of studies about improving central line infections is that you can do it in the ambulatory setting, outside the controlled inpatient doctor-and-nurse-only-taking-care-of-the-line-setting. You can get parents and patients involved and you can trust them to be advocates for better line care for their own lines and to do it well."