From kamishibai card to key card: a family-targeted quality improvement initiative to reduce paediatric central line-associated bloodstream infections

RK and MG are joint first authors.

MLQ-A as the senior author.

Introduction

Despite widespread initiatives to improve the quality and safety of healthcare, many patients continue to suffer preventable harm from central line-associated bloodstream infections (CLABSIs) worldwide.^{1 2} The Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) reported that in 2017, about 24 000 CLABSIs occurred in acute care hospitals in the USA alone, despite 50% fewer infections from 2008.^{3 4} In addition to increased morbidity and mortality, the annual economic impact of CLABSI accounts for about US$ one billion of direct healthcare costs (based on 2013 data, USA).^{5 6} Harm events, such as CLABSI in paediatric patients, are often multifactorial, rendering them challenging to prevent. They can result from a breakdown at any of the multiple steps necessary for central line care, including hand hygiene, medication administration, fluid changes, dressing changes and accessing central lines. Each of the aforementioned steps further involves multiple processes that require adherence to specific infection prevention strategies, such as the use of alcohol or chlorhexidine wipes, alcohol caps on central line hubs, scrub and dry times, and chlorhexidine bathing.^7–10

The CLABSI reduction practices vary widely across the world.¹¹ Multiple guidelines are available across the world for CLABSI prevention in the form of clinical bundles, from various regulatory agencies, including the CDC (USA), European Centre for Disease Prevention and Control and National Institute for Health and Care Excellence (England and Wales).^{12 13} Clinical care ‘bundles’ are sets of three to five evidence-based practices created based on the current best practices and are proven to improve outcomes when performed collectively as intended.^{14 15} Adherence to such standardised bundles for CLABSI prevention also improves paediatric outcomes, as shown by the Children’s Hospitals Solutions for Patient Safety Network (SPS) in the USA.¹⁶ Despite evidence supporting the use of standardised bundles, ensuring reliable bundle compliance at the point of care remains a challenge for most healthcare organisations, and harm events from CLABSI continue to occur.

It is widely accepted that drifts in care practices at the frontline are usually followed by adverse outcomes,¹⁷ which was noted in our institution as well. Despite achieving the desired central line maintenance bundle...