Abstract
Objective
After nearly 3 years without a single central line-associated bloodstream infection
(CLABSI), our neonatal intensive care unit (NICU) experienced a significant rise in
CLABSI rates beginning in 2019. The increase coincided with changes made to the intravenous
(IV) medication pump integration process, which added more safety checks and procedural
steps. This study aimed to investigate the potential association between these process
changes and increased CLABSI and non-CLABSI (bloodstream infection, BSI) rates prior
to inclusion in a future QI project Key Driver Diagram.
Study Design
This observational pilot study used a mixed-methods approach, including statistical
process control analysis to confirm a special-cause increase in CLABSI rate, human
factors observations, and environmental microbiome sampling focusing on the equipment
involved in the IV pump integration. We compared these findings to the CLABSI and
BSI rates to identify temporal and geographic associations.
Results
Following the 2019 implementation of IV pump integration, statistically significant
increases in CLABSI and BSI rates were observed. The enhanced safety checks added
steps to IV medication administrations, with timestamp observation indicating up to
14 location changes around the bed spaces and a mean of 5.5 minutes for any IV medication
administration. Environmental microbial sampling showed a 27% positivity rate. The
highest microbial burden was found on patient-specific mobile equipment (30%) used
during IV medication administration, including isolettes, IV hubs, and glove boxes,
compared with other equipment (26%) like nursing computers or ventilators (p = 0.093). A strong overlap was observed between the microorganisms found in the NICU
environment and those responsible for positive patient blood cultures, particularly
coagulase-negative Staphylococcus (CONS).
Conclusion
Though not statistically significant, the findings suggest that the added complexity
and extended duration of the modified IV pump integration process may have increased
the frequency of caregiver interactions with the NICU environment, exposing immune-vulnerable
NICU patients to a higher risk of infection. Further human factors analysis and quality
improvement efforts are necessary to simplify the IV medication administration process,
reduce environmental microbial loads, and decrease infection rates.
Key Points
Increased CLABSI/BSI rates post-IV pump integration.
High microbial load on equipment related to the IV medication administration process.
Process changes with IV pump integration to enhance patient safety may have unintended
consequences, like increasing caregiver-environment interaction and patient infection
rates.
Keywords hospital acquired infection (HAI) - central line-associated bloodstream infection
(CLABSI) - contamination - NICU environment - human factors - process change - IV
pump integration - patient safety
