179 - Reducing CLABSI's in a Pediatric Acute Care Unit
Sunday, April 26, 2026
9:30am - 11:30am ET
Publication Number: 3172.179
Mojan Azarmi, Lucile Packard Children's Hospital Stanford, Mountain View, CA, United States; Lauren Destino, Lucile Packard Children's Hospital Stanford, Menlo Park, CA, United States; Tayler Brown, Lucile Packard Children's Hospital Stanford, Santa Clara, CA, United States; Rachel Bensen, Stanford University School of Medicine, Palo Alto, CA, United States; Kathleen Boyd, Stanford University, Palo Alto, CA, United States
Fellow Lucile Packard Children's Hospital Stanford Mountain View, California, United States
Background: Central line-associated bloodstream infections (CLABSIs) pose significant risks for pediatric patients, including prolonged hospital stays, organ damage from sepsis, increased antibiotic use, and invasive medical procedures. One acute care unit in our quaternary academic children’s hospital saw an increase in central line infections reporting eight CLABSIs from June 2023 to January 2024 (2.73 per 1,000- line days), surpassing the Solutions for Patient Safety (SPS) benchmark of 1.2 CLABSIs per 1,000 line days. Unique features of this unit include the immunocompromised state of the patients, the high proportion of newly hired frontline staff and the presence of multiple sub-speciality rounding teams. Objective: A multidisciplinary collaborative including physician and nursing leaders, bedside nurses and representatives from the Family Advisory Council, came together with the goal of achieving a 10% CLABSI reduction rate, less than 1.78 events per 1,000-line days on the unit by the end of FY25. Design/Methods: A3 methodology was leveraged to understand the current state contributing to the increase in CLABSIs on this unit. Some highlighted risk factors included low compliance with timely completion of CLABSI bundles (the series of evidence-based interventions that healthcare providers complete in caring for patients with central lines), increased frequency of line access, opportunities to improve patient room cleanliness and caregiver preferences for line management. A key driver diagram was created with multidisciplinary input (Figure 1). A multi-prong approach was deployed to address the educational needs of the current staff, standardizing daily bundle review times, engaging nurse hospital hospital-acquired conditions (HAC) champions to manually audit bundle care at the bedside and provide real-time peer education, and highlighting current data/progress with leadership rounds to underscore the importance of this work. Data analysis was performed using statistical process control charts (Figure 2). Results: The collaborative noted a 75% reduction of CLABSI events from FY24 to FY25 with a rate of 0.58 per 1,000 line days. Bundle compliance increased from 60.4% to 64.8%.
Conclusion(s): Renewed focus on active line care, supported by peer mentoring and HAC champion monitoring, aided in reducing CLABSI rates. Greater multidisciplinary engagement across the unit further contributed to success, highlighting the importance of teamwork, meticulous line maintenance, and a strong culture of safety. Sustainability efforts include integrating line discussions into daily rounds to sustain vigilance and accountability.
