JHQ 311: A Process Evaluation Approach to Central-Line Associated Bloodstream Infection Reduction in a Neonatal Population-JHQ 311 Article

JHQ 311 Article

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This article describes a quality-improvement initiative to reduce central line–associated bloodstream infections (CLABSI) in the M Health Fairview Neonatal Intensive Care Unit (NICU), where the 2019 CLABSI rate (2.15 per 1,000 central line days) exceeded national and pediatric network benchmarks and was associated with high mortality and cost. Prior prevention efforts relied largely on bundle adherence self-audits and staff education, which tended to overestimate compliance and did not reveal process barriers.<br /><br />An interdisciplinary team (physicians, nurses, advanced practice providers, quality and infection prevention experts) used factor analysis to identify where CLABSIs were occurring and to narrow scope. CLABSIs were strongly associated with lower gestational age and lower birth weight; most events occurred in the Small Baby Unit (infants <32 weeks), particularly among those <750 g. Because no infections occurred within 72 hours of line insertion, the team focused on maintenance rather than insertion practices, especially within the first two weeks after placement.<br /><br />The team created 18 detailed process maps covering daily central line maintenance activities (e.g., tubing/connector changes, medication administration, dressing changes, lab draws, bathing, documentation, and responses to complications). Using Failure Modes and Effects Analysis (FMEA), they identified 86 potential failure modes and prioritized 21 high-to-moderate risks using risk priority numbers (RPNs) based on severity, occurrence, and detectability. Key problems included inadequate scrub/dry time, unnecessary line access for blood draws, lack of standardized clean workspaces, inconsistent line-change frequency, and hand hygiene barriers.<br /><br />Interventions included standardized clean spaces, algorithms to reduce line access, standardized maintenance kits and line-change schedules, improved disinfection products (including alcohol caps), hand-hygiene accessibility improvements, and structured daily discussion of line necessity. Over four years, CLABSI events fell from 15 (2019) to 2 (2023), an 86.6% reduction; the rate dropped to 0.32 per 1,000 line days (85% reduction), and days between events increased substantially. Average RPN scores for prioritized failure modes decreased by 33%, supporting meaningful process-risk reduction. The authors emphasize sustained monitoring and iterative FMEA updates, aiming ultimately for zero CLABSI events.

Keywords

CLABSI reduction

Neonatal Intensive Care Unit (NICU)

central line maintenance

Failure Modes and Effects Analysis (FMEA)

risk priority number (RPN)

Small Baby Unit

very low birth weight infants

line access reduction algorithms

standardized clean workspace

alcohol disinfection caps