Three hundred and ninety days.That’s how long the Regional Neonatal Intensive Care Unit (RNICU) at the University of Alabama at Birmingham (UAB) has gone without a central line associated bloodstream infection (CLABSI). And that, in the world of tiny, sick babies, is huge.
Healthcare-acquired infections (HAI) are a major problem in all hospitals, said Lindy Winter, M.D., Medical Director, but particularly for premature babies. “They are more vulnerable to infections because their immune systems are immature,” she said, “and they can’t fight off bacteria in the same way that adults are able to.”
Ideally, the rate of CLABSIs in a NICU should be zero, she said. Buta few years ago UAB’s rate was higher than national benchmarks, a rate determined through a formula based on the number of days patients have an IV line and how often infections occur. It’s also a major quality indicator for hospitals, reported to the Centers for Disease Control and Prevention and required for US News & World Report’s Best Hospitals ranking.
Thus, in 2013, UAB NICU leadership launched a major initiative to bring down the rate of CLABSIs. It was not an easy task, Winter said. “It required a huge culture change,” she said, “because NICU clinicians around the country believed such infections were inevitable, a natural outcome because these infants were immunocompromised anyway and nothing could be done to prevent it.”
She and her team set out to prove them wrong. They started with operational changes in how the central line was inserted and accessed, working closely with materials management to try different products to improve sterility. They changed how the skin and devices were prepped, and moved from having a single nurse insert, access, and manage the line, including changing dressings, to a buddy system in which at least one nurse is PICC (peripherally inserted central catheter) certified.
They studied their data to see which babies were more likely to get an infection. They discovered it was those who had umbilical lines that had been inserted at birth and remained longer than five days. “We did a lot of education with providers about switching from the umbilical to a PICC line to move closer to that five-day goal,” Winter said.
They also added central lines to the list of 10 things clinicians discuss during their daily patient rounds. This, Winter said, reminds staff to think about central lines and if they were needed as part of their daily routine.
Their efforts paid off. By 2016, the NICU started seeing a steady reduction in CLABSIs. And then, starting in the summer of 2019, there were none for more than a year. “We held our breath all year,” said Winter. When they reached the 365-day mark they celebrated, ordering in food from the staff’s favorite restaurants.
The streak eventually broke when a critically ill baby developed an infection. After the emergency was over, the team instituted a “swarm,” a rapid cycle debrief to figure out what happened. “He was very sick and we had to access the line frequently for medications,” said Winter. “We think that was the issue.”
Since that one infection, there have been no others tied to central lines.
“It was such a team effort,” said Winter. It’s not just the doctors and nurses, but the respiratory therapists, housekeeping staff, even materials management, all working together to reach the goal of zero.
Editor’s Note: The UAB Department of Pediatrics Neonatology Division and its 23 board-certified neonatologists works in collaboration with the Regional Neonatal Intensive Care Unit (RNICU) at UAB and the Neonatology Intensive Care Unit (NICU) at Children’s of Alabama. The RNICU provides care for infants with varying diagnoses, including extreme prematurity and cardiac defects, in an environment equipped with the latest patient care technology. The RNICU is housed in UAB’s new Women and Infants Center. The NICU at Children’s of Alabama is a Level IV unit with 48 private rooms available for neonates and infants and provides care for patients similar to the RNICU in addition to surgical procedures, ECMO and specialized dialysis (Aquadex) for the neonatal population.