Cleveland Clinic’s Children’s high-volume, high-acuity hematology and oncology inpatient unit reported zero central line-associated blood stream infections (CLABSIs) in 2019.
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This sustained eradication of CLABSIs on the unit followed years of improvement, and stem in part from Cleveland Clinic Children’s developing a culture of safety and high reliability, as well as a longstanding participation in the Children’s Hospitals Solutions for Patient Safety.
“Most pediatric central line infections are related to the care and maintenance of the line, and a very important part of the maintenance bundle is to scrub the hub properly, says Amrit Gill, MD, Cleveland Clinic Children’s Patient Safety Officer. “By focusing on some simple measures while maintaining a reluctance to simplify, we have seen dramatic decreases in CLABSIs in our pediatric ICUs in the last several years. Every single CLABSI event negatively impacts patients and their families, and adds healthcare costs.”
Nurse-led prevention team establishes standards of care
After establishing a nurse-led CLABSI prevention team, Cleveland Clinic Children’s hematology-oncology unit decreased its CLABSI rates even further, from just under two per 1,000 central line (CL) days in 2016 to zero per 1,000 CL days in 2019.
“We’ve made a number of changes in an effort to reduce the number of CLABSIs on our pediatric units,” says Jane Hartman, MSN, RN, PNP-BC, an advanced practice registered nurse with Cleveland Clinic Children’s. “On our hematology and oncology unit, especially, our patients are very sick at baseline. We want to do everything we can in order to prevent patient harm.”
Process changes include process confirmation boards, regular rounding by the vascular access team and monthly audits, learning from real-time huddles at the bedside when a CLABSI occurs, the administration of prophylactic antibiotics for all patients with acute myeloid leukemia, and annual CLABSI education for all caregivers.
The CLABSI prevention team also developed three important care bundles:
- A patient care bundle, which includes three ambulations, two oral care sessions, one chlorhexidine gluconate (CHG) or soap and water bath, with a linen change and new gown daily.
- A central line maintenance bundle, which includes confirmation of clean, intact and dated dressing and tubing; no tubing on floor; and no blood in the line.
- An environmental services bundle, which includes ultraviolet disinfection of each patient room upon discharge, or at least every 30 days of admission.
Parents as partners in safety
In addition to creating new care bundles, the CLABSI prevention team also recognized that patients and their families play an important role in identifying possible gaps in care, making careful observations and voicing concerns about potential errors.
“At Cleveland Clinic Children’s, patient and family members can play an active role in their own care through participation in an advisory council. They are included in our daily rounds. We want to create an environment in which patients and their families feel comfortable taking an active role in care, and speaking up if they have any concerns,” states Lisa Bell, MSN, MHA, RN, NE-BC, a Nurse Manager and member of the CLABSI prevention team.
Among the projects undertaken by the patient and family advisory council, Speak Up for Safety was developed in 2019. Speak Up for Safety is a communication campaign with materials that explain what families should expect from caregivers in terms of communication, hand hygiene, responsiveness and central line care, and encourage them to voice any concerns.
A cultural preoccupation with failure
“With a focus on high reliability principles and a preoccupation with failure, we have seen a shift in our culture. I don’t think a nurse would let a team of doctors walk away if there’s a line they feel might be at risk. Our bedside nurses own and advocate for those lines fiercely and we are immensely proud of the work we do every day. With our commitment to resilience, we learn lessons in our huddles when we have a failure and share those lessons widely so as to prevent the failures from happening again,” Dr. Gill adds.