Increased Caregiver Interaction with the NICU Environment during Medication Administration May Contribute to Higher Infection Rates: A Pilot Observational Study

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

Publication History

Received: 09 October 2024

Accepted: 24 June 2025

Article published online:
14 July 2025

• References

• 1 Fleischmann C, Reichert F, Cassini A. et al. Global incidence and mortality of neonatal sepsis: a systematic review and meta-analysis. Arch Dis Child 2021; 106 (08) 745-752
• 2 Martius JA, Roos T, Gora B. et al. Risk factors associated with early-onset sepsis in premature infants. Eur J Obstet Gynecol Reprod Biol 1999; 85 (02) 151-158
• 3 Stoll BJ, Hansen N, Fanaroff AA. et al. Late-onset sepsis in very low birth weight neonates: the experience of the National Institute of Child Health and Development Neonatal Research Network. Pediatrics 2002; 110: 285-291
• 4 Goldstein ND, Tuttle D, Tabb LP, Paul DA, Eppes SC. Spatial and environmental correlates of organism colonization and infection in the neonatal intensive care unit. J Perinatol 2018; 38 (05) 567-573
• 5 Ferry A, Plaisant F, Ginevra C. et al. Enterobacter cloacae colonisation and infection in a neonatal intensive care unit: retrospective investigation of preventive measures implemented after a multiclonal outbreak. BMC Infect Dis 2020; 20 (01) 682-688
• 6 Yeo KT, Octavia S, Lim K. et al. Serratia marcescens in the neonatal intensive care unit: a cluster investigation using molecular methods. J Infect Public Health 2020; 13 (07) 1006-1011
• 7 Saporito L, Graziano G, Mescolo F. et al. Efficacy of a coordinated strategy for containment of multidrug-resistant gram-negative bacteria carriage in a neonatal intensive care unit in the context of an active surveillance program. Antimicrob Resist Infect Control 2021; 10 (01) 30-41
• 8 Chavignon M, Reboux M, Tasse J. et al. Persistent microbial contamination of incubators despite disinfection. Pediatr Res 2021; 90 (06) 1215-1220
• 9 Mobley RE, Bizzarro MJ. Central line associated bloodstream infections in the neonatal intensive care unit: successes in the quest for zero. Semin Perinatol 2017; 41: 166-174
• 10 National Healthcare Safety Network. Bloodstream infection event (Central line-associated bloodstream infection and non-central line associated bloodstream infection). Centers for Disease Control. 2024 Jan. Accessed June 30, 2025 at: https://www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf
• 11 Smeulers M, Verweij L, Maaskant JM. et al. Quality indicators for safe medication preparation and administration: a systematic review. PLoS One 2015; 10 (04) e0122695
• 12 Chaturvedi RR, Etchegaray JM, Raaen L, Jackson J, Friedberg MW. Technology isn't the half of it: Integrating electronic health records and infusion pumps in a large hospital. Jt Comm J Qual Patient Saf 2019; 45 (10) 649-661
• 13 Grissinger M. The five rights: a destination without a map. P&T 2010; 35 (10) 542
• 14 Langley GJ, Moen RD, Nolan KM. et al. The improvement guide: A practical approach to enhancing organizational performance. 2nd ed. Jossey-Bass; 2009
• 15 Benneyan JC. Number-between g-type statistical quality control charts for monitoring adverse events. Health Care Manag Sci 2001; 4 (04) 305-318
• 16 Friard O. Behavioral observation research interactive software. Accessed June 30, 2025 at: https://www.boris.unito.it/
• 17 Parker A. Identification of potential causes for increased central line associated bloodstream infection rates in the University of Utah NICU [Senior Honors Thesis]. Salt Lake City, UT: University of Utah; 2023
• 18 Singhal N, Kumar M, Kanaujia PK, Virdi JS. MALDI-TOF mass spectrometry: an emerging technology for microbial identification and diagnosis. Front Microbiol 2015; 6: 791
• 19 National Healthcare Safety Network. Bloodstream infection event (Central line-associated bloodstream infection and non-central line associated bloodstream infection). Centers for Disease Control; 2024
• 20 Osman AH, Darkwah S, Kotey FCN. et al. Reservoirs of nosocomial pathogens in intensive care units: a systematic review. Environ Health Insights 2024;18:11786302241243239
• 21 Hartz LE, Bradshaw W, Brandon DH. Potential NICU environmental influences on the neonate's microbiome: a systematic review. Adv Neonatal Care 2015; 15 (05) 324-335
• 22 Otter JA, Yezli S, Salkeld JA, French GL. Evidence that contaminated surfaces contribute to the transmission of hospital pathogens and an overview of strategies to address contaminated surfaces in hospital settings. Am J Infect Control 2013; 41 (Suppl. 05) S6-S11
• 23 Meyer J, Nippak P, Cumming A. An evaluation of cleaning practices at a teaching hospital. Am J Infect Control 2021; 49 (01) 40-43
• 24 Bardach NS, Cabana MD. The unintended consequences of quality improvement. Curr Opin Pediatr 2009; 21 (06) 777-782