SE M I N A R S I N P E R I N A T O L O G Y ] (2017) ]]]–]]] Available online at www.sciencedirect.com Seminars in Perinatology www.seminperinat.com Central line-associated bloodstream infections in the NICU: Successes and controversies in the quest for zero Renée E. Mobley, MDn, and Matthew J. Bizzarro, MD Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT article info abstra ct Keywords: Central line-associated bloodstream infections (CLABSI) are among the most common Catheter healthcare-acquired infections in the neonatal intensive care unit (NICU) population and Bacteremia are associated with an increased risk of morbidity and mortality, as well as increased Healthcare-acquired infection healthcare costs, and duration of hospitalization. Over the past decade, numerous local, statewide, and national quality improvement initiatives have resulted in a significant Newborn reduction in CLABSI rates. The majority of successful initiatives have utilized similar strategies to implement and sustain their efforts, including education of NICU staff in the principles of quality improvement, creation and implementation of central line insertion and maintenance bundles and methods for assessing compliance, formation of dedicated central line insertion and maintenance teams, and utilization of reliable and effective methods for collecting, analyzing, and displaying data. Despite this progress, continued work toward discovery of better practices, such as the safest and most effective agent for cutaneous antisepsis or identification of optimal outcome and process measures, is required if further progress is to be made. Additionally, sustained progress in reducing the burden of neonatal infections may require a shift in focus away from CLABSI and toward the reporting, investigation, and prevention of all NICU-onset bacteremia. & 2017 Elsevier Inc. All rights reserved. Introduction Preterm infants in the neonatal intensive care unit (NICU) are highly susceptible to healthcare-acquired infections (HAI) given their immature immune systems and need for invasive Abbreviations: NICU, neonatal intensive care unit; HAI, BSI, bloodstream infection; PICC, BW, birth weight; CDC, Committee; PQCNC, CHG, procedures, support devices, and prolonged hospitalization.1 Preterm infants with HAI are significantly more likely to die and, in survivors, to experience neurodevelopmental and growth impairment as compared to their uninfected counterparts.2,3 Furthermore, the adjusted costs of hospitalization healthcare-acquired infections; VLBW, peripherally inserted central catheters; CLABSI, Centers for Disease Control and Prevention; HICPAC, Perinatal Quality Collaborative of North Carolina; ELBW, chlorhexidine gluconate; SPC, statistical process control; NHSN, Infection Ratio n Corresponding author. E-mail address: renee.mobley@yale.edu (R.E. Mobley). http://dx.doi.org/10.1053/j.semperi.2017.03.006 0146-0005/& 2017 Elsevier Inc. All rights reserved. very low birth weight; central line-associated bloodstream infections; Healthcare Infection Control Practices Advisory extremely low birth weight; PI, povidone–iodine; National Healthcare Safety Network; SIR, Standardized 2 SE M I N A R S I N P E R I N A T O L O G Y and duration of NICU stay for very low birth weight (VLBW) infants with at least one bloodstream (BSI) infection may be increased by as much as $50,000 and 10 days, respectively, as compared to VLBW infants without a BSI.4 Central lines, particularly peripherally inserted central catheters (PICC), are utilized frequently in preterm infants for nutritional support and medication administration, and central line-associated bloodstream infections (CLABSI) are among the most common HAI encountered in the NICU. A CLABSI is considered a preventable hospital-acquired condition and a great deal of attention has therefore been focused on CLABSI given their high rate of associated costs and complications as well as state mandates for public reporting of institutional-specific data. Several successful quality improvement efforts to reduce CLABSI in the NICU have been reported over the last decade, with common strategies for reduction and sustainability that include a change in the mental model of CLABSI from inevitable to preventable,5 a focused effort on formal training of NICU staff in the principles of quality improvement,6–10 the creation and implementation of central line insertion and maintenance bundles based on best practice recommendations,6–11 the formation of dedicated central line teams,12,13 establishment of CLABSI prevention collaboratives,7,9,10 and data reporting and transparency.14 Concerted efforts such as these led to a 46% reduction in national CLABSI rates from 2008 to 201315 and, in the NICU population, reductions in CLABSI rates in all birth weight (BW) categories16–21 (Fig.). Despite these successes, sustainability and eradication for many institutions remain elusive. This review will focus on some of the successful principles and strategies utilized consistently in local and collaborative NICU CLABSI prevention efforts. In addition, we will explore some of the controversies and unresolved issues that remain in the “quest for zero.” Central line insertion and maintenance Bundles A bundle is a small group of evidence-based interventions that, when implemented together, result in a better outcome than when executed individually.22 Central line insertion and maintenance bundle components are often derived from recommendations by national organizations such as the Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC) and categorized based on the quality of supporting evidence.11 Checklists are typically utilized to assist in bundle implementation by reinforcing key principles and practices, verifying compliance, and establishing a culture of responsibility among staff.6 Basic components of central line insertion bundles typically include proper hand hygiene, barrier precautions, and cutaneous antisepsis, while maintenance bundles primarily incorporate processes for central line dressing assessment and change, replacement of administration sets, and disinfection of needless connections11(Tables 1 and 2). Prompt central line removal has also been recognized and recommended as a major contributing factor in reducing ] (2017) ]]]–]]] Fig – This figure represents the National Healthcare Safety Network pooled mean central line-associated bloodstream infections per 1000 central line days for level III NICUs. Rates for the following birth weight categories are depicted: r750 g; 751–1000 g; 1001–1500 g, 1501–2500 g, and 42500 g, with data represented over six reporting periods (2006–2008, 2009, 2010, 2011, 2012, and 2013).16–21 CLABSI rates.7,9,11 The Perinatal Quality Collaborative of North Carolina (PQCNC) cited prompt central line removal as a key component to the success of their initiative.7 As part of their maintenance bundle, the PQCNC recommended that a central line be removed when 120 ml/kg/day of enteral feeds were achieved and evaluated the daily necessity of each central line by asking the question, “If a line was not in place today, would one be placed?”7 Bundle use is typically considered as “all-or-nothing” with compliance based on verifying that all elements are performed. Although this approach makes it difficult to assess the impact of any individual component, global adherence to bundle implementation and checklist use has been shown to decrease CLABSI rates in the ICU population.23 Maintenance bundle use and compliance is particularly important in the NICU, where central lines are utilized for prolonged durations.12,24 In addition, the majority of CLABSI in the NICU population appear to originate from contamination of the catheter hub making disinfection of the hub and all needleless connections a key component in CLABSI prevention.25 In a retrospective review of hospitals participating in the CDC National Health Safety Network (NHSN), it was determined that a reported bundle compliance of Z95% was required to see an associated decrease in CLABSIs.23 Schulman et al.26 demonstrated that for each 30% increase in maintenance checklist utilization, CLABSI rates in the New York State Collaborative decreased by 16.5%. Central line teams The training and implementation of a dedicated intravascular access team with a standardized approach to insertion and maintenance can reduce variability in practice, the burden of training and retraining a large staff, and, ultimately, the risk of line-related complications.12,13,27 The vast majority of central line teams in the NICU are comprised of nursing staff, and the National Association of Neonatal Nurses has published practice guidelines for central line insertion and SEM I N A R S I N P E R I N A T O L O G Y ] (2017) ]]]–]]] 3 Table 1 – Key components of central line insertion bundles. Component Utilize dedicated and trained personnel for central line insertion Supporting recommendations from 2011 CDC prevention guidelinesa    Designate only trained personnel who demonstrate competence for the insertion and maintenance of central lines (Category IA) Educate healthcare personnel regarding the indications for central line insertion, proper procedures for insertion and maintenance, and appropriate infection control methods. (Category IA) Periodically assess knowledge and adherence to guidelines for all personnel involved in central line insertion and maintenance. (Category IA) Perform appropriate hand hygiene  Wash hands with conventional soap and water or with alcohol-based hand rubs before and after palpating catheter insertion sites, inserting, replacing, or dressing an intravascular catheter (Category IB) Utilize maximum sterile barrier precautions   Sterile gloves should be worn for the insertion of central catheters. (Category IA) Use maximal sterile barrier precautions, including a cap, mask, sterile gown, sterile gloves, and sterile full-body drape, for central line insertion (Category IB) Prepare skin with an appropriate antiseptic agent  No recommendation can be made for the safety or efficacy of chlorhexidine in infants aged o2 months (Unresolved issue) Cutaneous antisepsis with a 40.5% chlorhexidine preparation with alcohol is recommended in most patient populations before central line insertion and dressing changes, but if there is a contraindication, tincture of iodine, an iodophor, or 70% alcohol can be used as alternatives (Category IA) Antiseptics should be allowed to dry according to the manufacturer's recommendation prior to placing the catheter (Category IB)   a Category IA: strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies. Category IB: strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale; or an accepted practice (e.g., aseptic technique) supported by limited evidence. Category IC: required by state or federal regulations, rules, or standards. Category II: suggested for implementation and supported by suggestive clinical or epidemiologic studies or theoretical rationale. Unresolved issue: represents an unresolved issue for which evidence is insufficient or no consensus regarding efficacy exists. maintenance that have set the standards for the training and ongoing competency of nursing-led teams28 (Table 3). The goal of a central line team is to advance the team concept to include full accountability for all aspects of central linerelated activities, thereby taking responsibility out of the hands of many and into the hands of a dedicated and skilled few.28 While the investment in a central line team may at first seem prohibitive, it should be weighed against the potential savings incurred from reduced CLABSI and other central line-related complications, as well as the resources spent training and retraining medical and bedside nursing staff to perform the same tasks. Taylor et al.13 investigated the impact of a dedicated nursing-led PICC team on CLABSI rates in extremely low birth weight (ELBW) infants from a single level IIIc NICU. PICC team members underwent standardized didactic and bedside training and were required to demonstrate proficiency under the supervision of a preceptor. The team developed a prioritization strategy for insertion by identifying and expediting line placement in those infants believed most likely to require prolonged intravenous access. Outcome data was compared to historical control data based on previous central line insertion and maintenance standards. The authors determined that implementation of a PICC team led to a significant decrease in the risk of CLABSI in those necessitating use of a central line for Z30 days (hazard ratio ¼ 0.48; 95% confidence interval: 0.25–0.91). They speculated that the success achieved in this cohort with the longest duration of exposure to the PICC team highlighted the importance of standardized line maintenance by a select few.13 Holzmann-Pazgal et al.12 investigated the impact of implementation of a dedicated central line maintenance team in a 118-bed NICU. Prior to establishing their team, central line insertion and maintenance bundles were part of routine practice, but all central line maintenance was performed by bedside nursing staff. The line maintenance team consisted of 33 nurses who underwent standardized training and assumed responsibility for all tubing changes, dressing changes, and blood draws and medication administration through central lines. The overall CLABSI rate decreased from 11.6 CLABSI per 1000 central line days pre-implementation to 4 per 1000 post-implementation (p o 0.001).12 The introduction of a maintenance bundle prior to creation of the line team did not reduce CLABSI rates, yet application of that same bundle by the maintenance team led to significantly improved outcomes.12 The authors speculated that a small, dedicated group performing the same tasks frequently can maintain a consistent level of skill as compared to a large group performing the same tasks sporadically. Furthermore, a dedicated line team whose lone responsibility is central line maintenance is not exposed to the same stress and strain experienced by bedside nurses performing multiple tasks and often during the period of high census and acuity.12 4 SE M I N A R S I N P E R I N A T O L O G Y ] (2017) ]]]–]]] Table 2 – Key components of central line maintenance bundles. Component Assess and document daily whether or not central line placement or continued use is necessary: a. “Do we really need to place a central line?” b. “If there was no line in place today, would we Supporting recommendations from 2011 CDC prevention guidelinesa   place one?” Use a peripherally inserted central catheter instead of a short peripheral catheter when the duration of IV therapy will likely exceed six days. (Category II) Promptly remove any intravascular catheter that is no longer essential. (Category IA) Perform appropriate hand hygiene  Wash hands with conventional soap and water or with alcohol-based hand rubs before and after palpating catheter insertion sites or dressing an intravascular catheter. (Category IB) Assess central line dressing integrity and catheter insertion site daily (at minimum)   Replace catheter dressing if damp, loosened, or visibly soiled. (Category IB) Evaluate the catheter insertion site daily by palpation through dressing to discern tenderness and by inspection if dressing is transparent. If patient has local tenderness or other signs of possible CLABSI, opaque dressings should be removed and site inspected visually. (Category II) Perform appropriate central line dressing change, when required: a. Two-person procedure b. Site cleansed with appropriate solution c. Cleansing solution allowed to air- dry completely  Replace dressings on short-term central line sites at least every 7 days for transparent dressings, except in pediatric patients in which the risk for dislodging the catheter may outweigh the benefit of changing the dressing. (Category IB). Antiseptics should be allowed to dry according to the manufacturer's recommendation. (Category IB) Develop and use standardized intravenous tubing setup and changes    Maintain aseptic technique when changing IV tubing setup and changes a  In patients not receiving blood, blood products or fat emulsions, replace continuously used administration sets, including secondary sets and add-on devices, no more than at 96-hour intervals, but at least every 7 days. (Category IA) Replace tubing used to administer blood, blood products, or fat emulsions (those combined with amino acids and glucose in a 3-in-1 admixture or infused separately) within 24 hours of initiating the infusion. (Category IB) Minimize contamination risk by scrubbing the access port with an appropriate antiseptic (chlorhexidine, povidone–iodine, an iodophor, or 70% alcohol) and accessing the port only with sterile devices. (Category IA) Category IA: strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies. Category IB: strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale; or an accepted practice (e.g., aseptic technique) supported by limited evidence. Category IC: required by state or federal regulations, rules, or standards. Category II: suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale. Unresolved issue: represents an unresolved issue for which evidence is insufficient or no consensus regarding efficacy exists. Cutaneous antisepsis Identifying the most effective topical antiseptic for central line insertion and maintenance is an important aspect of CLABSI prevention, but remains elusive in the NICU population. Historically, povidone–iodine (PI) has been that agent in most NICUs but, in adult and pediatric patients, chlorhexidine gluconate (CHG) with alcohol is recommended over PI for cutaneous antisepsis prior to central line placement.11 CHG is also utilized in the healthcare setting for central line dressing changes and for bathing of ICU patients29 and has been shown to decrease HAI, including CLABSIs.30 In the NICU patient population, the most recent CDC/HICPAC Guidelines for the Prevention of Intravascular Catheter-Related Infections state, “no recommendation can be made for the safety or efficacy of chlorhexidine in infants o2 months,” further identifying this as an “unresolved issue.”11 The Food and Drug Administration (FDA) recommends “use with care in premature infants or infants under 2 months of age” related to concerns over local skin reactions, including dermatitis and chemical burns.31 This is a change, however, and up until 2012 the FDA did not approve of its use for cutaneous antisepsis in children o2 months of age. Limited data exist in preterm neonates with respect to the safety and efficacy of CHG for prevention of CLABSI. In 2001, Garland et al.32 conducted a multicenter randomized clinical trial comparing the use of cutaneous antisepsis with 70% alcohol and the use of a CHG-impregnated disk as part of the central line dressing with 10% PI and no CHG disk. In total, 705 neonates with a mean BW of approximately 1630 g were enrolled and no significant differences in CLABSI and BSI without a source were observed between groups.32 Of note, 15.3% of infants in the CHG group required crossover to the PI group for contact dermatitis versus none in the PI group.32 In 2009, Garland et al. published a trial in which infants were randomized to receive application of 2% CHG or 10% PI as skin SEM I N A R S I N P E R I N A T O L O G Y ] (2017) ]]]–]]] 5 Table 3 – Key components for developing a dedicated central line team based on guidelines from the National Association of Neonatal Nurses 28.     Obtain hospital support for adequate staffing and financial support of the team Develop written criteria/job description for qualifying team members Develop standardized protocols for insertion and maintenance to minimize complications Develop and implement didactic and clinical training curriculum for prospective team members, to include but not be limited to: o o o o o o o o o  Indications and contraindications for line placement Risk-benefit analysis of the procedure Knowledge of anatomy and physiology of the venous and arterial systems Application of sterile technique Pain management Assessment and management of complications Routine catheter care and maintenance Institutional-specific quality improvement processes Proper documentation Define guidelines for obtaining and maintaining competency, to include but not be limited to: o Successful completion of competency assessment by an expert PICC team member o Successful completion of a minimum of three supervised successful insertions prior to independent practice o Successful completion of a minimum of three successful insertions per year to maintain competency   Review relevant literature annually to facilitate best practice Perform targeted data collection for outcome monitoring, to include but not be limited to: o o o o o o o  Patient's weight, gestational age, and day of life at time of insertion Indication(s) for central line placement Central line specifics (e.g., brand, size, number of lumens, lot number) Location of insertion site Any complications during insertion, dwell, or removal Duration of central line use Reason for removal Review outcomes and quality improvement efforts with team members regularly preparation for catheter insertion and dressing changes. The FDA limited enrollment to infants 47 days old and with BW greater 41500 g. No statistically significant differences in BSI were again noted between groups.33 Severe contact dermatitis did not occur in either group, but 7 of 10 infants in the CHG group had measurable serum concentrations of chlorhexidine.33 Chapman et al. also demonstrated systemic absorption of CHG when used for cutaneous antisepsis prior to PICC placement in 10 of 20 infants studied. Of note, the cohort had a median gestational age of 28 weeks and were between 2 and 14 days of life. The highest serum concentrations were detected 2–3 days after CHG application and reached levels higher than those observed by Garland et al.33,34 In 2014, Quach et al.35 performed a retrospective cohort study aimed at characterizing the effect of CHG bathing versus bathing with mild soap on CLABSI rates in a 24-bed level III NICU. Infants with a central venous catheter and a BW 4 1000 g or those with a BW r 1000 g but 428 days of life were considered eligible for CHG bathing. A 65% decrease in CLABSI rates was observed in the intervention period, and no cases of dermatitis were reported (systemic absorption was not measured). However, the authors acknowledged that their NICU “does not tend to admit very small and young premature babies” and that the majority of infants (74%) in the intervention group were 435 weeks’ gestation, which make it difficult to generalize their results.35 Lack of data supporting the efficacy of CHG in preventing CLABSI combined with some safety concerns has translated into variance in practice among NICUs. In a 2009 survey of 90 NICUs in the United States, 55 (61%) reported using CHG, most commonly for dressing changes and catheter hub disinfection, and 70% of responders reported using CHG for cutaneous antisepsis prior to central venous catheter insertion. In total, 51% of the centers that reported using CHG limited its use on the basis of BW, gestational age, and/or chronological age with 51% reporting adverse skin reactions and 65% reporting concerns regarding the use of CHG in the NICU population.36 Currently, there is no consensus regarding the ideal agent for cutaneous antisepsis in the NICU population. The limited amount of data from randomized trials in the NICU population has not revealed a reduction in CLABSI with the use of CHG, but the highest risk population (i.e., ELBW infants) for both CLABSI and potential adverse reactions has not been studied. Also, concerns regarding the potential neurotoxic effects of CHG absorption have not been substantiated. Thus, this issue remains “unresolved.” In the level IV NICU at YaleNew Haven Children’s Hospital, we have been able to sustain 6 SE M I N A R S I N P E R I N A T O L O G Y reductions in CLABSI and all late-onset sepsis rates for several years without a single cutaneous application of CHG.37,38 One approach to the use of CHG is perhaps best mirrored by Quach et al.35 who, in reference to CHG bathing in the NICU, stated “when infection rates remain high despite compliance with standard measures, additional interventions can be considered.” CLABSI prevention collaboratives National and statewide quality improvement collaboratives have contributed greatly to the decrease in CLABSI and, in many ways, have created the model for project implementation, data tracking, and sustainability. The collaborative model moves efforts beyond the institutional level and allows for multiple sites to join together with a unified goal of improving care. This is accomplished through sharing of experiences, development of implementation strategies for evidence-based practice guidelines, and pooling of data.9,10,39 Collaboratives also create an opportunity to educate multidisciplinary NICU staff in the principles and strategies of quality improvement, thereby laying the groundwork for future endeavors.39 In 2006, 13 NICUs in the California Perinatal Quality Care Collaborative aimed to reduce their overall CLABSI rate by 25%.10 They formed multidisciplinary leadership teams in each NICU, held regular conference calls and site visits, and implemented evidence-based practices for hand hygiene, line placement and management, and CLABSI diagnosis. Members of the collaborative were educated in the principles of a high reliability organization in an effort to change the culture of the NICU and the attitude toward HAI. These principles and strategies included the use of new and existing observation tools to improve compliance and awareness, the use of checklists, implementation of “stop the line” to promote a culture of safety, daily huddles to improve situational awareness, root cause analyses to investigate confirmed and nearmiss events, auditing tools for monitoring critical processes, the use of Ishikawa (i.e., “fishbone”) diagrams, and statistical process control (SPC) methods.10,39 The collaborative achieved its goal of reducing CLABSI from 4.32 per 1000 line days in the baseline period to 3.22 per 1000 line days in the follow-up period.10 In 2007, a collaborative of 19 NICUs in New York State participated in a quality improvement initiative aimed at reducing CLABSI rates.9 It was one of the first formal CLABSI prevention initiatives that took advantage of mandated HAI reporting to encourage accountability and cooperation among providers. Transparency was promoted through sharing of baseline performance data and identification of high performing candidate host institutions to assist in identifying potential best practices. Similar to the California collaborative, a Quality Improvement Panel was developed to, among other things, review data integrity and develop and assist with implementation of central line care bundles. The effort resulted in a 67% reduction in statewide CLABSI rates (6.4 CLABSI per 1000 central line days versus 2.1; p o 0.0005).26 The collaborative was able to determine the independent effect of increased compliance with maintenance bundles on ] (2017) ]]]–]]] reduced CLABSI rates. The authors speculated that “repetitive, structured social interaction in our network helped participants feel that they were a meaningful part of an important community of practice.”26 The PQCNC focused on NICU CLABSI prevention as a statewide initiative in 2009.7 In total, 13 North Carolina NICUs participated in the initiative, with each site assembling a multidisciplinary team of providers that participated in monthly web conferences and quarterly in-person learning sessions. The major objectives of these meetings were to provide formal education in the principles of quality improvement as well as to promote transparency and open discussion as learning experiences. Statistical process charts were created to monitor the impact of certain interventions on CLABSI rates, which were ultimately decreased by 71% (3.94 CLABSI per 1000 central line days versus 1.16; p ¼ 0.01). The reduction in CLABSI was sustained over a 1-year period, with success primarily attributed to the dedication of providers, the active involvement of families and the impact of the family experience, the inclusion of bundle elements that focused on central line maintenance care and reduced dwell time, and a data-reporting system that required multiple NICU providers to review line maintenance practices on a daily basis. It is estimated that, at the time of their publication, the PQCNC CLABSI initiative was responsible for saving 17 lives and $19,152,000 in hospital charges.7 Outcome measures, data tracking, and analysis Data reporting, tracking, and analysis are a key component to all quality improvement efforts, including those aimed at sustained reductions in CLABSI. Several outcome measures collected by the National Healthcare Safety Network (NHSN) are utilized to monitor and compare institutional data and outcomes. CLABSI rate is the primary metric followed and is reported as the number of CLABSI per 1000 central line days. NICU CLABSI rates are subdivided into BW categories. The current NHSN pooled mean benchmark CLABSI rates for level III NICUs are as follows: r750 g: 2.1 CLABSI per 1000 central line days; 751–1000 g: 1.3 CLABSI per 1000 central line days; 1001–1500 g: 0.8 CLABSI per 1000 central line days; 1501– 2500 g: 0.6 CLABSI per 1000 central line days; 42500 g: 0.7 CLABSI per 1000 central line days.16 Unfortunately, published baseline rates are not current and may not be an accurate standard for comparison. CLABSI rates reported in 2016, for example, are being benchmarked against published rates from 2013.16 CLABSI data may also be reported and compared using the Standardized Infection Ratio (SIR). The SIR is calculated by dividing the number of observed CLABSI by the number of expected CLABSI, with the number of expected CLABSI based on national published rates.40 Currently, for acute care hospitals, the NHSN utilizes baseline data from 2006 to 2008 to calculate the SIR,21 which, as previously highlighted, may not represent an accurate or current estimate for comparison. Given some of the issues identified with utilizing published data for comparison, many institutions have chosen to collect and analyze their own data. SPC methods are the most useful way to accomplish this via utilization of time series analysis SEM I N A R S I N P E R I N A T O L O G Y to present longitudinal data in graphical form.39 SPC charts are designed to separate the effects of common cause variation (i.e., random variation that occurs naturally with any process) from special cause variation (i.e., that which can be attributed to a specific factor or intervention).10 Control charts, or U-charts, can be created by calculating a centerline and upper and lower control limits from baseline data. Points above or below the centerline or outside of the control limits after an intervention and sustained for a pre-defined period of time can be utilized to determine special cause variation.41,42 Collaboratives in particular have demonstrated effective use of this method of data presentation and analysis both as an educational tool and a meaningful way to assess the impact of individual quality improvement interventions.7,10 ] (2017) ]]]–]]] 7 and prepare for the consequences appears to be intensifying and moving us further away from our intended goal. In some institutions, identification of a CLABSI triggers a root cause analysis and action plan, but what if the central line is not determined to be the source and the BSI is not a CLABSI? The process should not progress or halt simply based on whether or not a particular surveillance definition is met. The fact is that all HAI are “healthcare-acquired” and, therefore, whether the source is a surgical site, the hands of a provider, or a central line, all should warrant the same level of attention and detail if the goal is to eliminate all NICUacquired infections and their associated consequences. This might be better-accomplished if, as suggested by Rock et al.,48 NICUs were to collectively move toward the reporting and investigating all NICU-onset bacteremia (e.g., all late-onset sepsis), of which CLABSI is only one component. Moving beyond CLABSI Conclusion The NHSN was primarily designed for individual institutions to conduct data surveillance and benchmarking in an effort to drive quality improvement efforts. In recent years, these and similar data have been utilized for other purposes. Hospital report cards allow consumers to compare institutions in their area based on a number of quality and performance measures, including CLABSI rates.43 Similar data are also utilized by the Centers for Medicare and Medicaid Services and private insurers as part of the Hospital-Acquired Condition Reduction Program aimed at reducing payments to the lowest performing institutions.44 As a result, CLABSI rates have become an area of intense focus and scrutiny. It is therefore imperative that reported data be accurate. In 2008, the NHSN definition of a CLABSI was modified in an effort to provide more stringent criteria for commensal species-related laboratory-confirmed bloodstream infections.45,46 Several centers acknowledged that this definition change alone dramatically reduced their reported CLABSI rates.37,39 A second modification to the CLABSI definition in 2013 had a similar effect. The new definition utilized calendar days instead of hours to compare the dwell time of a central line with the onset of a HAI.40 Hazamy et al. applied both the 2012 (prior) and 2013 (current) definitions to data from the New York State Department of Health and in doing so observed a 16% reduction in CLABSI rates. The authors noted that New York State ICUs had reported a 16.4% reduction in CLABSIs from 2012 to 2013, suggesting that the definition change alone could be responsible for the majority of change.47 In 2016, Rock et al.48 suggested that it may be time to move away from CLABSI reporting and instead focus on a metric that is more objective, easier to understand, requires less resources to analyze and report, and is less subjected to the current stigmata and repercussions associated with CLABSI. The authors suggest that all hospital-onset bacteremia to be reported as the primary HAI outcome measure and, in an effort to validate its use, were able to demonstrate significant associations between changes in rates of hospital-onset bacteremia and CLABSI.48 The current level of scrutiny regarding whether or not a BSI is a CLABSI and the amount of time and resources subsequently spent trying to support or refute that categorization CLABSI are a major source of morbidity, mortality, and increased healthcare costs in the NICU population. The majority of successful prevention efforts have focused on implementing evidence-based practices, assuring compliance, and reducing variability. Perhaps the best model for improvement, culture change, and sustainability has been exemplified through statewide collaborative efforts. These collaboratives share similar qualities that can be seen in most successful quality improvement initiatives, including a change in the attitude and approach to a common problem, the use of transparency and shared experiences as learning opportunities, an understanding of the principles and strategies of quality improvement, the identification and implementation of best practices, the selection of well-defined outcome measures, and the meaningful presentation and tracking of data. The CLABSI experience has laid the foundation for future quality improvement efforts which, with respect to HAI, should now begin to focus on the reduction of all NICU-acquired infections and their associated morbidity and mortality. refere nces 1. Brodie SB, Sands KE, Gray JE, et al. Occurrence of nosocomial bloodstream infections in six neonatal intensive care units. Pediatr Infect Dis J. 2000;19(1):56–65. 2. Stoll BJ, Hansen N, Fanaroff AA, et al. 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