Reducing CLABSI by Increasing Frequency of Incubator Changes

Background: Babies born younger than 28 weeks, extremely low gestational age newborns (ELGAN), require central access for nutrition and medications, but their fragile skin and weak immune system increase risk for central line-associated blood stream infections (CLABSIs). CLABSI increases mortality, poor growth, poor neurodevelopmental outcomes, and longer hospital stays. After implementation of a CLABSI prevention team, overall CLABSI rates decreased but persisted in the ELGAN population. Pseudomonas was the predominant organism cultured, which prompted a focus on potential environmental causes. Objective: Current practice was to change incubators every 30 days or as needed for all patients. Infants on high-frequency ventilation were often excluded. ELGAN can require several weeks of high-frequency ventilation, increasing time spent in the same incubator. With a goal to decrease CLABSI in this population, we proposed that increased frequency of incubator changes would improve environmental cleanliness. Incubators were changed every 14 days. Methods: Using quality improvement methodology of plan-do-study-act cycles, incubator changes occurred in one patient at a time. The team huddled to plan each patient move, assign roles, and then evaluate success. Through plan-do-study-act cycles, changes were made to enable the patient to stay on the ventilator, and a checklist was developed to ensure stable vital signs and temperature. Results: Our unit had over 300 days without a CLABSI. We also had no safety events, hypothermia, or unplanned extubations during the trials. Our overall CLABSI rate reduced from 0.33 infections per 1000 line days to 0.29. Incubator changes at 14 days are now established as standard of care for the ELGAN population. Conclusions: Implementing frequent incubator changes contributed to a reduction of CLABSI by 13%. Preliminary data suggest that more frequent bed changes contribute to a reduction in other types of infections, including invasive pseudomonas. Next steps are to evaluate changing incubators every 2 weeks in all neonatal patients.