The Level IIIC Neonatal Intensive Care Unit (NICU) at Cook Children’s Medical Center (CCMC) recognized that overall central line infections rates were above those in similar NICUs around the country. (See Figures 1 and 2 for profiles of CCMC, and its NICU, respectively.)

Monthly data on central line-associated blood stream infections (CLABSIs) were first collected according to National Healthcare Safety Network (NHSN) guidelines. In 2006, the NICU’s annual rate of infections per 1,000 central line days was 7.5, which was above the NHSN average of 5.8 infections per 1,000 central line days. In January 2007, the unit saw a spike in CLABSIs of 17 infections per 1,000 central line days.

When the unit looked at potential causes of the infections it became clear that there was no consistency in how any of the central lines were managed. Over 50 physicians and neonatal nurse practitioners were able to place peripherally inserted central catheters (PICC). Variations in central line insertion and maintenance practices were potentially contributing to the high infection rate. NICU leaders and staff began focusing on ways to decrease CLABSIs, especially by creating consistency in the processes associated with PICC lines.

A staff member who was a student in a nursing master’s program suggested the idea of a PICC team to limit the number of clinicians who place those lines. This evidence-based suggestion was refined into a quality improvement (QI) plan centered on creating
a two-person team to place and manage the majority of central lines on the unit. The hypothesis was that fewer people inserting and maintaining lines would create less of a chance for lapses from best practice techniques, ultimately decreasing CLABSIs and the substantial morbidity and mortality associated with these infections. The goal of achieving a 50% decrease in CLABSIs within the first 18 months of implementation was set.

A proposal for a dedicated unit-based line insertion team consisting of two full-time nurses was presented and accepted by hospital administration. This proposal coincided with a decrease in patient census in the NICU, which provided the opportunity to modify two existing nursing positions to PICC nurses without
affecting the staffing level on the unit. The project was implemented with no additional full-time employees (FTEs) required and therefore incurred minimal initial costs. One of the nurses hired had experience in placing PICC lines and was able to train the other team member. Training took place over a one-month period. During this time both team members completed competency assessments on the insertion of PICC lines with the medical staff of the NICU. Since each case of CLABSI adds an estimated $34,508 to the cost of care, the PICC team proposal was highly costeffective (O’Grady et al., 2002).

The PICC team was established in July 2007. Once the two PICC nurses were hired and trained, a central line insertion and maintenance protocol was developed by the PICC team members, NICU leadership, Infection Control, and Neonatology. Using evidence from the literature in conjunction with guidelines from the CDC (Centers for Disease Control and Prevention), a protocol was developed for insertion and dressing change procedures based on techniques that had been shown to lower infection risk (Brooker & Keenan, 2007; Danks, 2006; Eggimann & Pittet, 2002; O’Grady et al., 2002; Rickard, 2003).