Context This audit was carried out in Wrexham Maelor Hospital’s (WMH) neonatal unit (NNU) and conducted by the authors (two FY2 doctors and Staff Grade paediatrician). The guideline which has been implemented was approved by both medical and nursing teams.
Problem A prospective audit performed in 2010–2011 showed that Wrexham Maelor Hospital’s (WMH) neonatal unit (NNU) had a high rate of central-line associated bloodstream infections (CLABSI) as compared to the rate reported by Centres for Disease Control and Prevention (USA). CLABSI have a high cost in terms of both morbidity and financial expenditure, and are preventable.
Assessment of problem and analysis of its causes To quantify the problem the infection rate was expressed as number of central lines days per one CLABSI. CLABSI was defined as growth of the same organism in blood and central line tip cultures (obtained within 48 hrs of each other). The causes of CLABSI were assessed using CDC recommendations (Guideline for the prevention of intravascular catheter-related infections, 2011, CDC, USA). To impose the changes, CDC recommendations were adapted, local guideline developed and medical and nursing staff educated.
Intervention A guideline was introduced in January 2013 that recommended use of 0.5% chlorhexidine in 70% alcohol (Hydrex® Pink), “check and do” list for clinicians, purchase of bundled supplies, continuous staff education, and nurse empowerment to stop non-urgent insertions if proper procedures were not followed.
Study design This was a prospective re-audit.
Strategy for change The “check-and-do” list was approved by the medical and nursing teams. The results of the initial audit were presented to the paediatric team along with the new guideline. It was agreed that the guideline would be followed and completed check and do list inserted into the notes of every patient who had a central line inserted from June 2013 onwards. The re-audit looked at the rate of CLABSI for all central lines (long lines, umbilical venous catheters [UVCs] and umbilical arterial catheters [UACs]) inserted between June 2013 and May 2014, and was prospective.
Measurement of improvement The results of these pre- and post-guideline audits were compared. The CLABSI rate in the pre-guideline audit was 10 in 179 long line days. In the re-audit, the CLABSI rate was 0 in 201 long line days, and 3 in 530 all central line days (long lines, UVCs and UACs; Note the pre-guideline audit only looked at infections associated with long lines). The difference between the distributions of gestational age in the audits was non-significant (Mann-Whitney test).
Effects of changes The re-audit data showed that the rate of CLABSI in the NNU have significantly decreased since the implementation of the guideline. CLABSI-associated morbidity and mortality have also decreased, which clearly benefited the patient group.
Lessons learnt It is helpful when implementing change and new guidance to work as a multi-disciplinary team. We found that by doing so, the new guidance was well received and adhered to.
Message for others We would recommend that all neonatal units establish an ongoing audit of CLABSI, and produce a guideline and "check and do" list if there is not already one in use. Our experience showed that significant reduction in CLABSI rate can be achieved in a relatively small NNU, over a relatively short time scale with similar effectiveness to that shown in larger NNUs and with close to zero additional costs.
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