American Journal of Infection Control 43 (2015) 275-9
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Major article
Successful reduction in central lineeassociated bloodstream infections in a Chinese neonatal intensive care unit Qi Zhou MD a, Shoo K. Lee MBBS, FRCPC, PhD b, Xiao-jing Hu RN, MSN a, Si-yuan Jiang MD a, Chao Chen MD, PhD a, Chuan-qing Wang PhD c, Yun Cao MD, PhD a, * a b c
Department of Neonatology, Children’s Hospital of Fudan University, Shanghai, China Department of Pediatrics, University of Toronto, Toronto, ON, Canada Department of Microbiology, Children’s Hospital of Fudan University, Shanghai, China
Key Words: Central line Infant Health careeassociated infections Practice change
Background: Few data are available on centraleline associated bloodstream infections (CLABSIs) in Chinese neonatal intensive care units (NICUs). The aims of this study were to characterize CLABSIs among neonates in a Chinese NICU and evaluate the impact of a multifaceted evidence-based practice for improving quality program to decrease CLABSI. Methods: We conducted a prospective before-after intervention study with a 1-year follow-up among patients with central lines at the NICU of the Children’s Hospital of Fudan University between January 2008 and December 2010. The study was conducted in 3 phases: before, during, and after the intervention. A multifaceted infection control program was introduced in phase 2 with successive surveillance. CLABSIs were prospectively monitored and compared. Results: A total of 171 patients with central lines (CLs) were observed; 29 of them developed CLABSI corresponding to 7.35 per 1,000 catheter days, with a CL utilization ratio of 37.9%. Overall CLABSI rate decreased gradually from 16.7 per 1,000 CL days in phase 1 to 7.6 per 1,000 CL days in phase 2 (P ¼ .08) to 5.2 per 1,000 CL days in phase 3 (P < .01). Gram-negative bacterium (54.5%) was the predominant pathogen in CLABSIs. Conclusion: A multifaceted infection control program is effective in reducing the CLABSI rate among neonates. Such interventions could be extended to other resource-limited countries. Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Central lineeassociated bloodstream infections (CLABSIs), defined as bloodstream infections that develop after 48 hours of central venous catheterization, are a significant complication for patients treated in the neonatal intensive care unit (NICU) and result in considerable morbidity and mortality, increased length of stay, and increased health care costs.1-3 Central venous catheters or central lines (CLs) have been routinely used in NICUs in developed countries to provide long-term venous access for delivering total parenteral nutrition and medication for >3 decades.4-6 By contrast, indwelling CLs were only introduced as routine practice in Chinese NICUs during the last decade because increasing numbers of very
premature babies were being resuscitated with the rapid economic development across the country. Because the use of CLs in the neonatal population continues to grow, CLABSI has become a major challenge. Most of the literature concerning CLABSI have come from studies in developed countries and use evidence-based CLABSI prevention and control practices.7-9 However, very limited data are available from developing countries, including China. The aims of this study were to characterize CLABSI in a Chinese NICU and to evaluate the impact of a multifaceted evidence-based practice for improving quality (EPIQ, http://www.epiq.ca/) program on CLABSI reduction to encourage and promote the use of surveillance and CLABSI preventive strategies in other Chinese hospitals.
* Address correspondence to Yun Cao, MD, PhD, Department of Neonatology, Children’s Hospital of Fudan University, No 399 WanYuan Rd, Shanghai, China, 201102. E-mail address: [email protected] (Y. Cao). Funding/Support: This work was supported by the Science and Technology Commission of Shanghai Municipality (grant no. 134119a0702). Conflicts of Interest: None to report.
METHODS Setting Our study was conducted in a level III NICU at Children’s Hospital of Fudan University (FUCH) from January 2008-December
0196-6553/$36.00 - Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2014.12.001
276
Q. Zhou et al. / American Journal of Infection Control 43 (2015) 275-9
2010. FUCH is a 693-bed academic tertiary care center located in Shanghai, China. The NICU had 30 beds, which was increased to 50 beds after moving to its new location in June 2008. The FUCH’s NICU is staffed by onsite board-certified physicians and neonatologists 24 h/d, 7 d/wk, with an average nurse-to-patient ratio of 1:4 or 1:5 depending on patient acuity. Three neonatologists lead daily rounds on NICU patients to review patient information and develop care plans. The NICU also offers graduate resident training rotations for postgraduate students from the internal medicine and emergency medicine training programs. CLs were first introduced in 2004 and formally adopted as routine procedure in the NICU in March 2007.
patient with a CL in place and who had at least 1 of the following clinical signs: fever (temperature of 38 C), hypothermia 48 hours and who had been hospitalized in the NICU for 5 days during the study period. Patients were recruited consecutively and followed until death, discharge, or transfer from the NICU to a level II nursery. The ethics committee of the hospital approved the study protocol. Information on patient demographics, background medical history, type of catheter inserted, catheter position on radiograph, duration of CL use, problems or complications associated with the CL, reasons for removal, type of organism and antimicrobial susceptibility, infections at other sites, antibiotic treatment, and length of hospital stay were collected for each study patient. All the attending neonatologists in the NICU have 1 or 2 years clinical training in Canada Neonatal Network Hospitals and received standardized training about CLABSIs and the EPIQ program before our study started, to reduce subjective bias. In addition, a team composed of an attending neonatologist, NICU nurse, and infection control professional would review the patients in the NICU and check the CLABSI cases submitted to ensure data quality. All data collection sheets were reviewed by a trained research physician for potential errors. The staff responsible for data collection and analysis were blinded to the infection control program.
This prospective before-and-after study was conducted in 3 phases: the baseline phase (phase 1; January 1, 2008-December 31, 2008), the intervention phase (phase 2; January 1, 2009-December 31, 2009), and the follow-up phase (phase 3; January 1, 2010December 31, 2010). Continuous prospective surveillance of CLABSIs was performed throughout the entire project. We adopted the EPIQ program developed by the Canadian Neonatal Network (CNN).13 Prior to commencing the project, a CNN team conducted a 2-day training workshop in Shanghai to train an EPIQ team, composed of key physicians and nursing leaders in the NICU. The EPIQ team then reviewed the literature on CLABSI prevention and practice bundles previously used by the CNN and developed the strategies for adoption in this study. They also provided training to other NICU members and provided oversight for conduct of the study.
CLABSI definitions The Centers for Disease Control’s National Healthcare Safety Network (NHSN) definitions were used to define CLABSI.10,11 CLABSI was considered if the CL was in use at the time of or during the 48 hours preceding the development of bloodstream infection. Laboratory-confirmed CLABSI When CLABSI was suspected, blood cultures were drawn peripherally for all cases. Standard laboratory methods were used to identify microorganisms, and standardized susceptibility testing was performed. A primary laboratory-confirmed bloodstream infection was defined as (1) a patient with a recognized pathogen cultured from 1 blood culture, where the organism cultured was not related to an infection at another site, and the patient had 1 of the following infection signs or symptoms: fever (temperature of 38 C), hypothermia
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Major article
Successful reduction in central lineeassociated bloodstream infections in a Chinese neonatal intensive care unit Qi Zhou MD a, Shoo K. Lee MBBS, FRCPC, PhD b, Xiao-jing Hu RN, MSN a, Si-yuan Jiang MD a, Chao Chen MD, PhD a, Chuan-qing Wang PhD c, Yun Cao MD, PhD a, * a b c
Department of Neonatology, Children’s Hospital of Fudan University, Shanghai, China Department of Pediatrics, University of Toronto, Toronto, ON, Canada Department of Microbiology, Children’s Hospital of Fudan University, Shanghai, China
Key Words: Central line Infant Health careeassociated infections Practice change
Background: Few data are available on centraleline associated bloodstream infections (CLABSIs) in Chinese neonatal intensive care units (NICUs). The aims of this study were to characterize CLABSIs among neonates in a Chinese NICU and evaluate the impact of a multifaceted evidence-based practice for improving quality program to decrease CLABSI. Methods: We conducted a prospective before-after intervention study with a 1-year follow-up among patients with central lines at the NICU of the Children’s Hospital of Fudan University between January 2008 and December 2010. The study was conducted in 3 phases: before, during, and after the intervention. A multifaceted infection control program was introduced in phase 2 with successive surveillance. CLABSIs were prospectively monitored and compared. Results: A total of 171 patients with central lines (CLs) were observed; 29 of them developed CLABSI corresponding to 7.35 per 1,000 catheter days, with a CL utilization ratio of 37.9%. Overall CLABSI rate decreased gradually from 16.7 per 1,000 CL days in phase 1 to 7.6 per 1,000 CL days in phase 2 (P ¼ .08) to 5.2 per 1,000 CL days in phase 3 (P < .01). Gram-negative bacterium (54.5%) was the predominant pathogen in CLABSIs. Conclusion: A multifaceted infection control program is effective in reducing the CLABSI rate among neonates. Such interventions could be extended to other resource-limited countries. Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Central lineeassociated bloodstream infections (CLABSIs), defined as bloodstream infections that develop after 48 hours of central venous catheterization, are a significant complication for patients treated in the neonatal intensive care unit (NICU) and result in considerable morbidity and mortality, increased length of stay, and increased health care costs.1-3 Central venous catheters or central lines (CLs) have been routinely used in NICUs in developed countries to provide long-term venous access for delivering total parenteral nutrition and medication for >3 decades.4-6 By contrast, indwelling CLs were only introduced as routine practice in Chinese NICUs during the last decade because increasing numbers of very
premature babies were being resuscitated with the rapid economic development across the country. Because the use of CLs in the neonatal population continues to grow, CLABSI has become a major challenge. Most of the literature concerning CLABSI have come from studies in developed countries and use evidence-based CLABSI prevention and control practices.7-9 However, very limited data are available from developing countries, including China. The aims of this study were to characterize CLABSI in a Chinese NICU and to evaluate the impact of a multifaceted evidence-based practice for improving quality (EPIQ, http://www.epiq.ca/) program on CLABSI reduction to encourage and promote the use of surveillance and CLABSI preventive strategies in other Chinese hospitals.
* Address correspondence to Yun Cao, MD, PhD, Department of Neonatology, Children’s Hospital of Fudan University, No 399 WanYuan Rd, Shanghai, China, 201102. E-mail address: [email protected] (Y. Cao). Funding/Support: This work was supported by the Science and Technology Commission of Shanghai Municipality (grant no. 134119a0702). Conflicts of Interest: None to report.
METHODS Setting Our study was conducted in a level III NICU at Children’s Hospital of Fudan University (FUCH) from January 2008-December
0196-6553/$36.00 - Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2014.12.001
276
Q. Zhou et al. / American Journal of Infection Control 43 (2015) 275-9
2010. FUCH is a 693-bed academic tertiary care center located in Shanghai, China. The NICU had 30 beds, which was increased to 50 beds after moving to its new location in June 2008. The FUCH’s NICU is staffed by onsite board-certified physicians and neonatologists 24 h/d, 7 d/wk, with an average nurse-to-patient ratio of 1:4 or 1:5 depending on patient acuity. Three neonatologists lead daily rounds on NICU patients to review patient information and develop care plans. The NICU also offers graduate resident training rotations for postgraduate students from the internal medicine and emergency medicine training programs. CLs were first introduced in 2004 and formally adopted as routine procedure in the NICU in March 2007.
patient with a CL in place and who had at least 1 of the following clinical signs: fever (temperature of 38 C), hypothermia 48 hours and who had been hospitalized in the NICU for 5 days during the study period. Patients were recruited consecutively and followed until death, discharge, or transfer from the NICU to a level II nursery. The ethics committee of the hospital approved the study protocol. Information on patient demographics, background medical history, type of catheter inserted, catheter position on radiograph, duration of CL use, problems or complications associated with the CL, reasons for removal, type of organism and antimicrobial susceptibility, infections at other sites, antibiotic treatment, and length of hospital stay were collected for each study patient. All the attending neonatologists in the NICU have 1 or 2 years clinical training in Canada Neonatal Network Hospitals and received standardized training about CLABSIs and the EPIQ program before our study started, to reduce subjective bias. In addition, a team composed of an attending neonatologist, NICU nurse, and infection control professional would review the patients in the NICU and check the CLABSI cases submitted to ensure data quality. All data collection sheets were reviewed by a trained research physician for potential errors. The staff responsible for data collection and analysis were blinded to the infection control program.
This prospective before-and-after study was conducted in 3 phases: the baseline phase (phase 1; January 1, 2008-December 31, 2008), the intervention phase (phase 2; January 1, 2009-December 31, 2009), and the follow-up phase (phase 3; January 1, 2010December 31, 2010). Continuous prospective surveillance of CLABSIs was performed throughout the entire project. We adopted the EPIQ program developed by the Canadian Neonatal Network (CNN).13 Prior to commencing the project, a CNN team conducted a 2-day training workshop in Shanghai to train an EPIQ team, composed of key physicians and nursing leaders in the NICU. The EPIQ team then reviewed the literature on CLABSI prevention and practice bundles previously used by the CNN and developed the strategies for adoption in this study. They also provided training to other NICU members and provided oversight for conduct of the study.
CLABSI definitions The Centers for Disease Control’s National Healthcare Safety Network (NHSN) definitions were used to define CLABSI.10,11 CLABSI was considered if the CL was in use at the time of or during the 48 hours preceding the development of bloodstream infection. Laboratory-confirmed CLABSI When CLABSI was suspected, blood cultures were drawn peripherally for all cases. Standard laboratory methods were used to identify microorganisms, and standardized susceptibility testing was performed. A primary laboratory-confirmed bloodstream infection was defined as (1) a patient with a recognized pathogen cultured from 1 blood culture, where the organism cultured was not related to an infection at another site, and the patient had 1 of the following infection signs or symptoms: fever (temperature of 38 C), hypothermia
