Case Study: Penn State Health Milton S. Hershey Medical Center 2024 Achievement Award

In Safe Hands—Large Division

Decreasing Central Line Blood Stream Infections in Pediatric Oncology Patients through Environmental Control

The Goal

Pediatric oncology patients are at high risk for central line blood stream infections (CLABSI) due to prolonged use of central lines and prolonged periods of neutropenia from chemotherapy. The Penn State Health Milton S. Hershey Medical Center team implemented interventions over a four-year period with a goal to decrease CLABSI rates in pediatric oncology patients and improve quality of care.

Intervention

During fiscal year 2020, the unit implemented a two RN requirement for central line blood culture draws and central line dressing changes. Resulting from that change, the unit experienced a decrease in CLABSI events.

To protect supplies from being set on potentially contaminated surfaces, the team joined the Solutions for Patient Safety’s CLABSI Hem-Onc Pioneer Cohort and implemented the intervention of utilizing a dedicated work surface for supplies for aseptic access of central lines. This was implemented in October 2021.

After achieving high-reliability and sustainability of this intervention, during June 2022 the facility implemented a 30-day room change for long-stay patients.

Results

During fiscal year 2023, CLABSI events decreased to an astounding zero events.

The facility was able to sustain this into the beginning of fiscal year 2024 and went a total of 588 days without a CLABSI!

By decreasing bioburden in the environment with more frequent room cleanings, the hospital has significantly reduced CLABSI events on their unit.

 

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Topics: Public Health, Quality Initiatives

Revision Date: 2/20/2024

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