Application of a quality improvement strategy to reduce the incidence density of catheter-associated urinary tract infections (CAUTI) and central line-associated bloodstream infections (CLABSI) in two pediatric oncologic intensive care units (PICUs)

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Abstract Background Healthcare-associated infections (HAIs) in pediatric intensive care units (PICUs) significantly complicate hospitalization and can increase length of stay, morbidity, mortality, and treatment costs. Applying bundles to prevent catheter-associated HAIs is essential and quality improvement (QI) tools can support their reduction. Methods Barretos Children’s Cancer Hospital has two 6-bed oncology PICUs. We used the Kamishibai board, a QI tool, to reduce catheter-associated urinary tract infections (CAUTIs) and central line-associated bloodstream infections (CLABSIs) in these units. The aim was to reduce baseline CAUTI and CLABSI incidence density by 50% in 12 months. We deployed boards for these infections, with four process indicators each, forming prevention bundles, adapted from Brazilian Ministry of Health, "Health in Our Hands" materials. Before implementation, data on CAUTI and CLABSI were collected for 12 months. Implementation began in September 2024 and is ongoing. During the first two weeks, we conducted four Plan-Do-Study-Act cycles to test adaptations, conduct trainings on how to properly check the bundles, reviewed correct technique then adopted the final version. Teams completed the boards weekly. Each day, four cards were filled out for each board — one for each indicator — using a randomly selected patient. If all actions related to an indicator were correctly performed, a green card was placed; if there was any error, a red card was placed. At the end of each week, the infection control specialist reviewed, analyzed the red cards, and provided feedback and ongoing education to the team to improve the process. Results In the pre-implementation phase, there were 450 admissions across both PICUs. For CAUTI, there were 5 episodes, with a baseline incidence density of 7.41. For CLABSI, 16 episodes, with a baseline incidence density of 6.5. After implementation, there were 457 admissions, there was one episode of CAUTI, with incidence density decreasing to 1.96, surpassing the AIM target. We documented 11 CLABSI episodes, with incidence density decreasing to 3.45, but not yet surpassing the AIM target. As a balance measure, in the first weeks the multidisciplinary team reported that completing the board increased their workload. However, after clarification meetings involving leadership, concerns decreased and team participation improved. Conclusion This project was effective in reducing incidence density of CAUTI and CLABSI. The aim target was achieved for CAUTI, and was partially met for CLABSI. Engagement of the entire multidisciplinary team, supported by continuous feedback, is essential. Next, we hope to apply a similar approach to improving hand hygiene.

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