title: Rapid cycle development of a multifactorial intervention achieved sustained reductions in central line-associated bloodstream infections in haematology oncology units at a children's hospital: a time series analysis.
abstract: Immunocompromised children are at high risk for central line-associated bloodstream infections (CLABSIs) and its associated morbidity and mortality. Prevention of CLABSIs depends on highly reliable care.
  
  
  
  Since the summer of 2013, we saw an increase in patient volume and acuity in our centre. Additionally, CLABSIs rates more than tripled during this period. The purpose of this initiative was to rapidly identify and mitigate potential underlying drivers to the increased CLABSI rate.
  
  
  
  Through small tests of change, we implemented a standard process for daily hygiene; increased awareness of high-risk patients with CLABSI; improved education/assistance for nurses performing high-risk central venous catheter procedures; and developed a system to improve allocation of resources to de-escalate system stress.
  
  
  
  The CLABSI rate from June 2013 to May 2014 was 2.03 CLABSIs/1000 line days. After implementation of our interventions, we saw a significant decrease in the CLABSI rate to 0.39 CLABSIs/1000 line days (p=0.008). Key processes have become more reliable: 100% of dressing changes are completed with the new two-person standard; daily hygiene adherence has increased from 25% to 70%; 100% of nurses are approached daily by senior nursing for assistance with high-risk procedures; and patients at risk for a CLABSI are identified daily.
  
  
  
  Stress to a complex system caring for high-risk patients can challenge CLABSI rates. Identifying key processes and executing them reliably can stabilise outcomes during times of system stress.
authors.affiliation: Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: Christopher E
authors.identifier: 0000-0002-4001-9203
authors.initials: CE
authors.lastname: Dandoy
authors.affiliation: Department of Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: Jackie
authors.initials: J
authors.lastname: Hausfeld
authors.affiliation: Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: Laura
authors.initials: L
authors.lastname: Flesch
authors.affiliation: Division of Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: Deanna
authors.initials: D
authors.lastname: Hawkins
authors.affiliation: James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: Kathy
authors.initials: K
authors.lastname: Demmel
authors.affiliation: Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: Deanna
authors.initials: D
authors.lastname: Best
authors.affiliation: Division of Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: Erin
authors.initials: E
authors.lastname: Osterkamp
authors.affiliation: James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: Tracey
authors.initials: T
authors.lastname: Bracke
authors.affiliation: Division of Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: Rajaram
authors.initials: R
authors.lastname: Nagarajan
authors.affiliation: Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: Sonata
authors.initials: S
authors.lastname: Jodele
authors.affiliation: Department of Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: Julie
authors.initials: J
authors.lastname: Holt
authors.affiliation: James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: Mary Jo
authors.initials: MJ
authors.lastname: Giaccone
authors.affiliation: Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: Stella M
authors.initials: SM
authors.lastname: Davies
authors.affiliation: James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: Uma
authors.initials: U
authors.lastname: Kotagal
authors.affiliation: James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA Division of Pediatric Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Simmons
mesh_terms: D055499:Catheter-Related Infections / Q000453:epidemiology / Q000517:prevention & control*; D002405:Catheterization, Central Venous / Q000009:adverse effects*; D002648:Child; D003428:Cross Infection / Q000453:epidemiology / Q000517:prevention & control*; D006776:Hospitals, Pediatric / Q000458:organization & administration / Q000592:standards*; D006801:Humans; D006920:Hygiene / Q000193:education; D007318:Inservice Training / Q000379:methods; D016522:Oncology Service, Hospital / Q000458:organization & administration* / Q000592:standards; D012307:Risk Factors
keywords: Nosocomial infections; Paediatrics; Patient safety; Quality improvement methodologies; Root cause analysis