OBJECTIVE: Despite the magnitude of the problem of catheter-associated bloodstream infections (CA-BSIs) in children, relatively little research has been performed to identify effective strategies to reduce these complications. In this study, we aimed to develop and evaluate effective catheter-care practices to reduce pediatric CA-BSIs.STUDY DESIGN AND METHODS: Our study was a multi-institutional, interrupted time-series design with historical control data and was conducted in 29 PICUs across the United States. Two central venous catheter–care practice bundles comprised our intervention: the insertion bundle of pediatric-tailored care elements derived from adult efforts and the maintenance bundle derived from the Centers for Disease Control and Prevention recommendations and expert pediatric clinician consensus. The bundles were deployed with quality-improvement teaching and methods to support their adoption by teams at the participating PICUs. The main outcome measures were the rate of CA-BSIs from January 2004 to September 2007 and compliance with each element of the insertion and maintenance bundles from October 2006 to September 2007.RESULTS: Average CA-BSI rates were reduced by 43% across 29 PICUs (5.4 vs 3.1 CA-BSIs per 1000 central-line-days; P .0001). By September 2007, insertion-bundle compliance was 84% and maintenance-bundle compliance was 82%. Hierarchical regression modeling showed that the only significant predictor of an observed decrease in infection rates was the collective use of the insertion and maintenance bundles, as demonstrated by the relative rate (RR) and confidence intervals (CIs) (RR: 0.57 [95% CI: 0.45–0.74]; P .0001). We used comparable modeling to assess the relative importance of the insertion versus maintenance bundles; the results showed that the only significant predictor of an infection-rate decrease was maintenance-bundle compliance (RR: 0.41 [95% CI: 0.20–0.85]; P = .017).CONCLUSIONS: In contrast with adult ICU care, maximizing insertion-bundle compliance alone cannot help PICUs to eliminate CA-BSIs. The main drivers for additional reductions in pediatric CA-BSI rates are issues that surround daily maintenance care for central lines, as defined in our maintenance bundle. Additional research is needed to define the optimal maintenance bundle that will facilitate elimination of CA-BSIs for children.
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机译：目的：尽管儿童导管相关的血流感染（CA-BSI）问题非常严重，但为确定减少这些并发症的有效策略进行的研究相对较少。在这项研究中，我们旨在开发和评估减少儿科CA-BSI的有效导管护理实践。研究设计与方法：我们的研究是多机构，间断的时间序列设计，具有历史控制数据，在29个PICU中进行全美国。我们的干预包括两个中央静脉导管护理实践包：从成人的努力中获得的小儿定制护理元件插入束，以及从疾病控制与预防中心的建议以及儿科临床专家的共识得出的维持束。捆绑包中部署了质量改进教学和方法，以支持参与PICU的团队采用它们。主要结果指标是2004年1月至2007年9月的CA-BSI发生率以及2006年10月至2007年9月的插入和维护捆绑包各要素的合规性。结果：29个PICU中的平均CA-BSI率降低了43％ （每1000个中心线天5.4与3.1个CA-BSI对比; P <.0001）。到2007年9月，插入捆绑包合规率为84％，维护捆绑包合规率为82％。分层回归模型显示，观察到的感染率下降的唯一重要预测因素是插入和维持束的集体使用，如相对率（RR）和置信区间（CIs）所示（RR：0.57 [95％CI ：0.45-0.74]; P <.0001）。我们使用可比较的模型来评估插入包与维护包的相对重要性。结果表明，感染率降低的唯一重要预测指标是维持捆绑的依从性（RR：0.41 [95％CI：0.20–0.85]; P = .017）。结论：与成人ICU护理相反，最大程度地增加了插入量-bundle合规性不能帮助PICU消除CA-BSI。降低儿科CA-BSI费率的主要驱动因素是围绕我们的维护包中定义的中心线日常维护的问题。需要进一步的研究来确定最佳的维护捆绑，这将有助于消除儿童的CA-BSI。
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