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A Quality Improvement Project� In Reducing Catheter-Related Exit Site Infection In Patients Under 16 Years Old At Paediatric Oncology Ward, Sarawak General Hospital

Dr Yap Suet Li ¹, Dr Lau Puong Sing¹, Dr Teh Siao Hean¹, Chan Siew Khian ², Zalina Jimi ²

¹Paediatric Department, Sarawak General Hospital

²Paediatric Oncology Unit, Sarawak General Hospital

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Introduction

Paediatric Oncology Unit, SGH is the main referral center for childhood hemato-oncological conditions in Sarawak since its establishment in year 2002
New cases per year are reported about 60-70 cases
Almost all will require a tunneled central venous catheter (CVL, i.e. Hickman catheter or chemoport)
CVL is vital for administration of chemotherapy, antibiotics, parenteral nutrition, blood products and blood sampling

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CVL remains till completion of treatment or if infection occurs
CVL related infection remains one of the biggest causes of morbidity and mortality among our patients

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Selection of Opportunities for Improvement

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CVL exit site care post op

Transparent dressing (antisepsis impregnated, plain transparent dressing
Skin antisepsis with povidone iodine, chlorhexidine or chlorhexidine with alcohol, then apply dry gauze and changed daily or when soiled
Traditionally, the unit uses povidone iodine universally

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Catheter-related exit-site infection is defined as clinical signs of inflammation located with 2cm from the Hickman catheter insertion site in the absence of blood stream infection

Hentrich M et al, Infectious Diseases Working Party of the German Society of Hematology and medical oncology. Central venous catheter related infections in hematology and oncology: 2012 update guidelines on diagnosis, management and prevention by the Infectious Disease Party of the German Society of Hematology and Medical Oncology. Ann Onco 2014; 25(5): 936-47

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Number of CVL exit site infection in Paediatric Oncology Ward, SGH

0.67 per 1000 catheter days

1.5 per 1000 catheter days

1.8 per 1000 catheter days

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Estimated costs involved RM 12188.70 (catheters removed and medication)
Mean number of days the chemotherapy delayed were 20 days

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Keys measures for improvement

Number of CVL exit site infection per 1000 catheter days

Number of CVL exit site infection X 1000

Number of catheter days

Different units worldwide reported different incidence of infection, ranges from 1.4- 6.7 exit site infection per 1000 catheter days

Goetz AM, Wagener MM, Miller JM, Muder RR. Risk of infection due to central venous catheters: effect of site of placement and catheter type. Infect Control Hosp Epidemiol 1998; 19: 842-845

Lorente L, Henry C, Martin MM, Jimenez A, Mora M. Central venous catheter-related infection in a prospective and observational study of 2592 catheters. Crit Care 2005; 9(6): R631-5

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Ideal aim: ZERO infection per 1000 catheter days
Our standard: 0.67 exit site infection per 1000 catheter days (our lowest recorded exit site infection)
Primary aim: to REDUCE CVL exit site infection to 0.67 exit site infection per 1000 catheter days by 12 months

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General Objectives

Reduce incidence of CVL related exit site infection among paediatric oncological patients, Sarawak General Hospital

Verify incidence and rate of CVL related exit site infection
Identify risk factors of CVL exit site infection
Formulate and implement remedial actions to the risk factors
Evaluate effectiveness of remedial actions

Secondary Objectives

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Process of Information Gathering

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Preoperative factor

Patient Factor

Surgeon’s factor

Nursing factor

Lack of hand hygiene compliance

Unknown privileging status

Lack of refresher course

Lack of experience

Immuno-

compromise

Poor nutrition

Inadequate pre-op skin preparation

CATHETER- RELATED EXIT SITE INFECTION

Carer Factor

Lack of knowledge on CVL care

Inadequate protection

Antiseptic solution

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Patients admitted for

CVL insertion

PROCESS OF CARE

Low total

white counts

Satisfactory total white counts,

ANC >0.5x 10⁹/dL

Pre-operative skin preparation

Post op wound care taught by

trained nurse to caregiver

Pre-operative

blood taking

CVL insertion in OT by surgeon

Preferably defer op until

counts recovery

Discharge home with

CVL care at home by

caregiver

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No	Process	Criteria	Standard
1	Assess patient's immune status pre-operative	Patient's absolute neutrophil count is >0.5 x 10⁹/dL	100%
2	Pre-op skin preparation	1. Scrubbing of skin with chlorhexidine 4% 2. Scrubbing done twice prior CVL insertion, i.e. on the night before procedure and on the morning of procedure	100% 100%
3	CVL insertion in OT	1. Procedure done by experienced surgeon who will practice strict aseptic technique	100%
4	CVL care post op	1. All caregivers of the patients are given a standardized education on CVL care 2. All caregivers are assessed on understanding on CVL care and signs of CVL exit site infection before discharge 3. Training of caregivers is provided by privileged nurse who is experienced in CVL care	100% 100% 100%
5	CVL care on discharge	1. All caretakers must be aware of signs of CVL exit site infection so as to seek treatment if such occur	100%

Model of Good Care

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Methodology

Cross sectional study
Project proposal and data collection Nov-Dec 2015
Two phases of change

1^st Jan-30^th June 2016

Institute change in skin antisepsis in CVC care post op from povidone iodine to 2% chlorhedixine+ 70% isopropyl alcohol

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1^st July-31^st Dec 2016

More refined changes to CVL care put in place

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Inclusion criteria

All paediatric oncology patients who have a Hickman catheter inserted and received treatment in Paediatric Oncology Ward, Sarawak General Hospital since 1^st Jan 2016

Exclusion criteria

Patients less than 1 month old or more than 16 years old
Paediatric oncology patients who have a Hickman catheter inserted by a facilities other than Sarawak General Hospital

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Process of information gathering

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Variables	What	Where	Who	How
Pre-op skin preparation Trainer’s factors	Number of optimal pre-op skin preparation Hand hygiene compliance rate among nurses Level of experience (no of privileged nurse and no of formal training)	Paediatric Oncology Ward Paediatric Oncology Ward/Paediatric Daycare Paediatric Oncology Ward/Paediatric Daycare	Project members Infection control linked nurse Project members	Questionnaire Ward audit Nursing sisters’ record

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Variables	What	Where	Who	How
Patient’s factor Caregiver’s factor	Absolute neutrophil count before operation Nutrition (BMI) before operation Understanding score	Paediatric Oncology Ward Paediatric Oncology Ward Paediatric Paediatric Oncology Ward/Paediatric daycare	Project members Project members Project members	Case notes Case notes Questionnaire
Surgeon’s factor	Surgeon’s experience (years of training)	Paediatric Oncology Ward	Project members	Patient’s case notes

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Results

Risk factors	Criteria	% of infection
Absolute neutrophil count	<0.5 x10⁹/dL >0.5 x 10⁹/dL	27% 73%
Body mass index	<15 kg/m² >15 kg/m²	46% 54%
Surgeons’ years of training	Medical Officer Specialist Consultant	0% 56% 44%

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Risk factors	Criteria	Percentage achieved
Understanding score of caregivers	% of parents getting full score	22%
Trainers factors	Hand hygiene compliance rate % of nurses who are privileged No of formal training in CVL care received in past 2 years	82.7% 0% 0%
Pre-operative skin preparation	% of optimal skin preparation which it is done with 4% chlorhexidine twice	59%

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Strategy for Change

1^st phase

Involves change of antiseptic solution from povidone-iodine to 2% chlorhexidine + 70% alcohol
Darouiche et al found that 2% chlorhexidine + 70% alcohol is more superior in reducing catheter related infection than povidone iodine
Traditionally all our dressing was done with povidone iodine as concern of damage of CVL by alcohol
Only one patient reported allergy to chlorhexidine
2% Chlorhexidine + 70% alcohol was found friendly to the catheter

Darouiche et al. Chlorhexidine-Alcohol versus Povidone Iodine for Surgical Site Antisepsis. N Engl J Med 2010; 362(1): 18-26

Molinari C, Parodi S, Longo S, Saracco P, Castagnola E, Haupt R. Central venous catheter-related complications in children with oncological/hematological disease: an observational study of 418 devices An Onco 2005; 16(4): 648-654

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Effects of Change

After 1^st phase

1^st phase

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Strategy for Change

2^nd phase

All skin preparation with 4% chlorhexidine pre-op were done twice, either by parents who are supervised or by nurses
All nurses were privileged for CVL care
Re-training by nurses using custom made educational video followed by assessment by nursing sisters
Training of caregivers

Custom-made educational video
Hands-on skills demonstration by nurses
Custom-made pamphlets in three languages

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After 1^st phase

After 2^nd phase

2^nd phase

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Risk factors	Criteria	Percentage (pre-remedial)	Percentage (post-remedial)
Understanding score of caregivers	% of parents getting full score	22%	44%
Trainers factors	Hand hygiene compliance rate % of nurses who are privileged No of formal training in CVL care received in past 2 years	82.7% 0% 0%	84.7% 100% 100% (all given refresher course)
Pre-operative skin preparation	% of optimal skin preparation which it is done with 4% chlorhexidine twice	59%	100%

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Number of CVL exit site infection in 2016 (in total) following two phases of intervention was 0.756 per 1000 catheter days compared to 1.86 per 1000 catheter days from preceding year.

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What happens now in year 2017?

0.67

1.5

1.8

0.756

0.62

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Next step

Consider collaboration with infection control unit to develop strategies to improve hand hygiene e.g. hand hygiene bundles which include education, feedback, reminders, ABHR and administrative support
Post test assessment to caregiver 1 month after the CVL.
Reinforce caregivers’ training if fail post test
Regularly display the educational video to caregivers every fornightly in the ward

Gould D, Drey N. Types of interventions used to improve hand hygiene compliance and prevent healthcare associated infections. J Infect Prev 2013; 14(3): 88-93

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