Zero NICU CLABSIs for More than 365 Days

By Marita D’Netto, MD; Ajith Mathew, MD; and Ricardo Rodriguez, MD

More than 365 days. That’s how long Cleveland Clinic Children’s was free of central line-associated bloodstream infections (CLABSIs) across all the neonatal intensive care units (NICUs) in the Cleveland Clinic health system for a period extending from late 2013 to late 2014.

This sustained eradication of NICU CLABSIs followed and improved on Cleveland Clinic Children’s achievement in 2013 of an enterprise-wide NICU rate of 0.8 CLABSIs per 1,000 central line days, which compared favorably to the 2012 National Healthcare Safety Network (NHSN) benchmark of 1.3 CLABSIs, as detailed in Figure 1.

Figure 1. Rates of CLABSIs per 1,000 central line days for NICU patients of all gestational ages across all three Cleveland Clinic Children’s NICUs in 2013. NHSN = National Healthcare Safety Network.

CLABSI successes stem from broad quality efforts

These achievements stem in part from Cleveland Clinic Children’s long-standing participation in the Ohio Perinatal Quality Collaborative, a statewide effort to reduce the incidence of CLABSIs and necrotizing enterocolitis and to develop best practices to standardize and optimize management of neonatal abstinence syndrome.

The application of line insertion and maintenance bundles derived from this effort has had a significant impact on patient care, as demonstrated by the CLABSI data shared above, which represent a dramatic reduction in CLABSI rates in recent years.

These efforts are now augmented by early introduction of maternal breast milk for newborns, with the aim of minimizing use of formula and further reducing the incidence of late-onset infections and necrotizing enterocolitis.

Another quality payoff: exemplary VLBW mortality

As a member of the Vermont Oxford Network, Cleveland Clinic Children’s reports its NICU outcomes on a yearly basis, which are then compared with those of similar centers around the world. These outcomes place our Department of Neonatology’s NICUs among the best units in the nation, as illustrated by our 2013 risk-adjusted mortality data for babies with very low birth weight (VLBW) (Figure 2).

Figure 2. Plots from the Vermont Oxford Network showing 2013 shrunken risk-adjusted mortality rates for very-low-birth-weight infants (501 to 1,500 g) at each of Cleveland Clinic Children’s NICUs. The red lines show each NICU’s risk-adjusted mortality rate, and the dashed blue lines show the 95 percent upper and lower bounds as determined by the Vermont Oxford Network.

Quality’s role in perpetuating excellence

Commitment to quality improvement and patient safety is a foundational principle of Cleveland Clinic Children’s Department of Neonatology, which is the largest provider of neonatal intensive care in Northeast Ohio.

In addition to the deep experience resulting from our considerable patient volumes (more than 1,200 newborns admitted to our NICUs annually), the department offers leading-edge therapies including novel modalities of respiratory support, nitric oxide therapy and extracorporeal membrane oxygenation (ECMO). Other points of distinction include the following subspecialized offerings:

• A dedicated neonatal neurointensive care team
• A neurometabolic team
• An intestinal rehabilitation program
• Dedicated intensive care for infants with neonatal short gut syndrome

These programs, developed and managed by our neonatologists in collaboration with other subspecialists, have benefited patients from surrounding communities as well as from across the nation and around the world. The Department of Neonatology works closely with Cleveland Clinic Children’s Critical Care Transport fleet, allowing us to reach remote areas by ground or air. A team of caregivers trained in both critical care and neonatal transport is available to retrieve critically ill newborns, including those on ECMO or other advanced modes of respiratory support.

Additionally, with the support of Cleveland Clinic’s large maternal-fetal medicine staff, our neonatal team staffs Cleveland Clinic’s Special Delivery Unit (SDU), where babies with prenatally diagnosed medical and surgical problems can be delivered and promptly treated. The SDU also accommodates mothers with complex medical or surgical problems, making it the nation’s first such unit designed expressly to provide specialized care for both mothers and newborns with serious medical issues.

The evolving quality improvement initiatives described above are designed to build on these distinctive aspects of Cleveland Clinic Children’s family-centered neonatology care. By fostering a culture of safety and ongoing quality improvement, we are committed to continuing and enhancing our center’s impressive outcomes on clinically relevant NICU measures.

Acknowledgement

The authors thank infection control practitioner Gregory Gagliano, Department of Infection

Prevention, Cleveland Clinic’s Quality & Patient Safety Institute, for his contributions to the CLABSI data reported here.

Dr. Mathew is a staff physician in Cleveland Clinic Children’s Department of Neonatology.