title: Decreasing PICU catheter-associated bloodstream infections: NACHRI's quality transformation efforts.
abstract: OBJECTIVE
  Despite the magnitude of the problem of catheter-associated bloodstream infections (CA-BSIs) in children, relatively little research has been performed to identify effective strategies to reduce these complications. In this study, we aimed to develop and evaluate effective catheter-care practices to reduce pediatric CA-BSIs.
  
  
  METHODS
  Our study was a multi-institutional, interrupted time-series design with historical control data and was conducted in 29 PICUs across the United States. Two central venous catheter-care practice bundles comprised our intervention: the insertion bundle of pediatric-tailored care elements derived from adult efforts and the maintenance bundle derived from the Centers for Disease Control and Prevention recommendations and expert pediatric clinician consensus. The bundles were deployed with quality-improvement teaching and methods to support their adoption by teams at the participating PICUs. The main outcome measures were the rate of CA-BSIs from January 2004 to September 2007 and compliance with each element of the insertion and maintenance bundles from October 2006 to September 2007.
  
  
  RESULTS
  Average CA-BSI rates were reduced by 43% across 29 PICUs (5.4 vs 3.1 CA-BSIs per 1000 central-line-days; P < .0001). By September 2007, insertion-bundle compliance was 84% and maintenance-bundle compliance was 82%. Hierarchical regression modeling showed that the only significant predictor of an observed decrease in infection rates was the collective use of the insertion and maintenance bundles, as demonstrated by the relative rate (RR) and confidence intervals (CIs) (RR: 0.57 [95% CI: 0.45-0.74]; P < .0001). We used comparable modeling to assess the relative importance of the insertion versus maintenance bundles; the results showed that the only significant predictor of an infection-rate decrease was maintenance-bundle compliance (RR: 0.41 [95% CI: 0.20-0.85]; P = .017).
  
  
  CONCLUSIONS
  In contrast with adult ICU care, maximizing insertion-bundle compliance alone cannot help PICUs to eliminate CA-BSIs. The main drivers for additional reductions in pediatric CA-BSI rates are issues that surround daily maintenance care for central lines, as defined in our maintenance bundle. Additional research is needed to define the optimal maintenance bundle that will facilitate elimination of CA-BSIs for children.
authors.affiliation: MSc, Johns Hopkins University, Johns Hopkins Children's Center, CMSC 1-141, 600 N Wolfe St, Baltimore, MD 21287, USA. mmille21@jhmi.edu
authors.forename: Marlene R
authors.initials: MR
authors.lastname: Miller
authors.forename: Michael
authors.initials: M
authors.lastname: Griswold
authors.forename: J Mitchell
authors.initials: JM
authors.lastname: Harris
authors.forename: Gayane
authors.initials: G
authors.lastname: Yenokyan
authors.forename: W Charles
authors.initials: WC
authors.lastname: Huskins
authors.forename: Michele
authors.initials: M
authors.lastname: Moss
authors.forename: Tom B
authors.initials: TB
authors.lastname: Rice
authors.forename: Debra
authors.initials: D
authors.lastname: Ridling
authors.forename: Deborah
authors.initials: D
authors.lastname: Campbell
authors.forename: Peter
authors.initials: P
authors.lastname: Margolis
authors.forename: Stephen
authors.initials: S
authors.lastname: Muething
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Brilli
mesh_terms: D016470:Bacteremia / Q000517:prevention & control*; D017848:Blood-Borne Pathogens; D002405:Catheterization, Central Venous / Q000009:adverse effects* / Q000379:methods; D002648:Child; D002985:Clinical Protocols; D016638:Critical Illness; D003428:Cross Infection / Q000517:prevention & control*; D006801:Humans; D015278:Intensive Care Units, Pediatric; D016014:Linear Models; D010043:Outcome and Process Assessment, Health Care; D011785:Quality Assurance, Health Care