INTRODUCTION
Central-line-associated blood stream infections (CLABSIs) serve as a significant source of morbidity, mortality, and added medical costs among pediatric hematology/oncology patients. In addition, CLABSI can introduce delays in the management of underlying malignancies. In children, CLABSIs occur at a rate of 0.7-7.4 infections per 1000 catheter days and cost an average of $45,000 per infection (Adler et al., 2006; Dudeck et al., 2011; Ingram, Weitzman, Greenberg, Parkin, & Filler, 1991; O'Grady et al., 2002; Pittet, Tarara, & Wenzel, 1994). Individual risk factors for CLABSI include lengthy hospitalization stays before central line placement, prolonged duration of catheterization, heavy microbial colonization at the central line insertion or hub site, lack of implementation of best care practices during insertion, maintenance, and blood draws from central lines (Almuneef et al., 2006; Alonso-Echanove et al., 2003; Bicudo, Batista, Furtado, Sola, & Medeiros, 2011; Knoll et al., 2011; Lorente, Henry, Martin, Jimenez, & Mora, 2005; Maki, Kluger, & Crnich, 2006; Safdar, Kluger, & Maki, 2002; Yoshida, Ishimaru, Kikuchi, Matsubara, & Asano, 2011). The depth, duration, and frequency of neutropenia seen in patients with pediatric cancer increase the risk of developing CLABSI (Farr, 1995; Link et al., 2003). The consequences of CLABSI are significant. Eight percent of ambulatory pediatric patients must have their lines or ports removed because of CLABSI (Munro et al., 1999) , 9.5% are admitted to the intensive care unit, 62% are hospitalized for at least 7 days, and 1% die during their hospitalization (Downes et al., 2008).
Although there are conflicting reports regarding whether inpatient or outpatient pediatric oncology patients are at a greater risk for developing CLABSI because of immunosuppression, the critical role of proper central line care by experienced physicians and family members is widely recognized. The degree of monitoring and care required to effectively reduce CLABSIs within this patient population mandates that a patient-centered approach to care be adopted. This stresses the importance of including patients and their families as active members in an interdisciplinary care team. For this to occur, patients and their families must be provided with sufficient background knowledge/education to enable them to feel more comfortable in participating in their own or their child's care. Disease-specific educational materials provide patients/families with a broad foundation of understanding of their or their child's illness providing the opportunity to tailor past, incoming, and future information to meet either their own or their child's needs. This is critical as it will lead to more meaningful discussion, deliberation, and joint decision making (Santarpia et al., 2002).
Given this patient population's increased risk of CLABSI and the significant morbidity/mortality and healthcare costs accompanying CLABSI, the interdisciplinary care team at our tertiary care center began implementing bundles, reducing line entries, and analyzing every case of CLABSI with the aim of reducing their local rate of infection. The implemented bundles consisted of a cohort of evidence-based interventions-hand hygiene, maximum barrier precautions on insertion, optimal insertion site, daily review of line necessity, and prompt line removal when appropriate-that, when applied together rather than individually, result in better outcomes in patients with central lines. The team later joined a national learning collaborative created by the Children's Hospital Association.
It became clear early on that there was a need to inform and engage patients and families about how to reduce the risk of CLABSI. They needed to understand why the bundles were implemented and why the interdisciplinary care team was looking for ways to reduce line entries. By informing and engaging families, there was also an opportunity for them to assist the care team in reaching our mutual goal of reducing CLABSI. Therefore, an educational brochure providing essential information about central lines, CLABSI contributing factors, and interventions to reduce the risk of CLABSI was created. The goals in creating a brochure were to educate families about CLABSI and to communicate ways for families to be active participants in helping prevent and reduce CLABSI.
METHODS
This quality improvement project was conducted at a 210-bed not-for-profit tertiary care center with a specialized pediatric hematology/oncology team offering inpatient and outpatient care. A brochure prototype and 14-question evaluation survey was developed. The survey was designed to assess family and patient's knowledge of central lines, their risks, the importance of reducing/preventing CLABSI, and what they could do to help reduce the risk. The survey was administered to families before and after reading the brochure. Figure 1A (see supplemental digital content 1, http://links.lww.com/JPSN/A7) shows the survey administered to evaluate the brochure's effectiveness.
The quality improvement project was conducted in three phases. Table 1 outlines the participants in each phase. During Phase 1, feedback was collected from all study participants in the form of a four-question postsurvey feedback questionnaire. Figure 1B (see supplemental digital content 1, http://links.lww.com/JPSN/A7) illustrates the postsurvey feedback questionnaire. Feedback obtained from patients and the family advisory board (FAB) was used to revise the brochure. Content was revised and validated over several cycles. In Phase 2, families were given the survey before and after reading the brochure and asked how it could be a more useful educational tool. The brochure was revised and presented to the cancer FAB, and final revisions were made.
During Phase 3, participant's answers on the survey before and after reading the brochure were compared to evaluate the brochure's effectiveness. Patients and their family were encouraged throughout to become active participants of the interdisciplinary care team. To further encourage patient and family participation in the interdisciplinary care team's effort to reduce CLABSI, the team discussed key issues pertaining to the care of the patient's central line with the patient and their family during family-centered rounds (FCRs). During FCRs, pertinent and problem-focused patient data are presented to the patient/family by the interdisciplinary care team. The patient and their family are then asked about their goals, concerns, and interpretation of the presented information. These are reviewed and discharge goals, and/or a plan is developed together with the patient/family. The frequency of patient/family discussion with the interdisciplinary care team on central line care and how to reduce the patient's risk was recorded each morning during FCR. The frequency of patient/family discussion with the interdisciplinary care team on reducing line entries on FCR before and after Phase 3 of the quality improvement project was measured to evaluate if the brochure encouraged families to become active members of the interdisciplinary care team working to reduce/prevent CLABSI. Figure 2 illustrates key FCR discussion points. Figure 3 (see supplemental digital content 2, http://links.lww.com/JPSN/A8) displays the finalized brochure.
RESULTS
Feedback from patients and the FAB was used to revise the brochure launched in Phase 1. Figure 4 shows the difference in prebrochure and postbrochure scores of each of the 10 families involved in Phase 2 of the quality improvement project. A univariable analysis of prebrochure and postbrochure quiz scores was conducted using a paired Student's t test. The difference between scores was found to be statistically significant (p = .00215).
A Student's t test was repeated to analyze prebrochure and postbrochure quiz scores obtained in Phase 3. The difference between the scores was found to be statistically significant (p = .0001 x 10-11; Figure 5).
The means, standard deviations, and standard errors were calculated and can be found in the Figures 4 and 5 legend. Figure 6 depicts the difference between Phase 2 and Phase 3. The mean prebrochure and postbrochure survey scores were analyzed to assess how effectively the quality improvement team incorporated patient/family feedback from Phase 1 and Phase 2 into the educational brochure. The difference in the prebrochure and postbrochure survey scores was significant, p = .05025, suggesting that the feedback from patients/families during both Phases 1 and 2 was effective in making the educational brochure a more effective educational tool.
To evaluate whether the brochure encouraged families to become active members of the health care team, the frequency of patient/family discussion with the interdisciplinary care team on central line care was measured. Figure 2 outlines the four key components of patient/family and interdisciplinary care team interactions measured. A score ranging between 0/4 and 4/4 was given to each inpatient unit room the interdisciplinary care team rounded on. The score was based on the number of designated questions (Figure 2) that were addressed during FCR. At the end of the week, the mean score was calculated. The mean scores from each phase were compared. Figure 7 depicts the mean score from each week and compares the mean scores from each phase of the study. The differences in the mean scores between Phases 1 and 2 as well as between Phases 2 and 3 were analyzed using a Student's t test. The difference in mean scores between Phases 1 and 2 was not found to be statistically significant (p = .2702); however, the difference in mean scores between Phases 2 and 3 was significant (p = .00011). The significant difference in frequency of patient/family discussion with the interdisciplinary care team on central line entries between Phases 2 and 3 suggests the educational brochure was effective at encouraging patient/family participation in central line entry reduction.
DISCUSSION
Patients with cancer are often immunocomprised and have central lines inserted for a prolonged period, leaving them at a higher risk for developing CLABSI infections. Patients with pediatric cancer have a particularlyheightened risk from exposure to bacteria/infections from their classmates, friends, and siblings (Downes et al., 2008).
The Centers for Disease Control and Prevention (CDC) reports proper hand hygiene, proper aseptic technique aimed at the removal of transient organisms and soil from skin, and a reduction in line entries as key factors influencing the likelihood of a patient developing a CLABSI (O'Grady et al., 2011). The guidelines specified by the CDC can be easily adhered to with patients/families and the interdisciplinary care team working together. Several studies have reported the benefits of including patients and their families in the interdisciplinary care team to try and reduce CLABSI. Santarpia et al. (2002) reported that, when patients and their caregivers are given detailed instructions on the use and care of central lines focusing on basic aseptic techniques, CLABSIs were reduced from 6 per 1000 catheter days to 3 per 1000 catheter days (Santarpia et al., 2002). Moller, Borregaard, Tvede, and Adamsen (2005) reported that the incidence of CLABSI is reduced from 4.22 per 1000 catheter days to 1.92 per 1000 (p < .05) when patients are given instructions on how to properly care for their central lines (Moller et al., 2005). Moller and Adamsen (2010) reported that patients and their families felt more self-reliant and accountable for their own care when provided with patient education (Moller & Adamsen, 2010). This translates into an increased desire to act as part of the healthcare team and reduced CLABSI.
In the present quality improvement project, an educational brochure was created by collaborating with patients and families and used as a means to encourage patient/family discussion with the interdisciplinary care team on central line maintenance and care in an effort to reduce CLABSI. The ability of the brochure to serve as an educational tool was evaluated through a survey administered before and after viewing the brochure. The ability of the brochure to increase patient/family discussions with the interdisciplinary care team on central line care and maintenance was evaluated by recording the frequency of such discussions during FCR. The improvement between prebrochure and postbrochure survey scores and the increase in patient/family discussion with the interdisciplinary care team on central line care and maintenance once the brochure was introduced was statistically significant (p = .0001 x 10-11).
The results of the present quality improvement project support previous work showing that the delivery of family-centered care, through inclusion of patients and their families, reduces CLABSI (Moller & Adamsen, 2010; Moller et al., 2005; Santarpia et al., 2002). Core concepts of family-centered care include dignity and respect, information sharing, participation, and collaboration. Dignity and respect are delivered through healthcare practitioners listening and honoring the patients' and families' perspectives and incorporating their knowledge, values, beliefs, and cultural backgrounds into the planning and delivery of care. Information sharing entails healthcare practitioners communicating and sharing complete, unbiased, and accurate information with patients and families in a timely manner to facilitate patients' and families' effective participation in care and decision making. Dignity and respect, information sharing, and participating were values reflected in the educational brochure. Collaboration entails patients, families, healthcare practitioners, and leaders collaborating in policy and program development, implementation, and evaluation as well as in the delivery of care. In the present quality improvement project, collaboration was clearly exhibited in planning and developing the educational brochure with the FAB and patients/families.
The frequency of interactions between patients/families and the interdisciplinary care team during FCRs was used to evaluate whether the brochure encouraged families to become active members of the interdisciplinary care team working to reduce/prevent CLABSI. FCRs emphasize and enable the key values of patient- and family-centered care: the patient/family and interdisciplinary care providers are all experts and partners, the patient and families are participating in the decision-making process, and information sharing is open and timely (nothing about me without me). The present quality improvement project suggests that, through patient-centered care, focusing on the key values of dignity and respect, information sharing, participation, and collaboration, pediatric oncology patients/families are able to become active participants in the interdisciplinary care team.
The CDC has published guidelines to address how healthcare facilities can best prevent CLABSI (O'Grady et al., 2011). On the basis of our results, the creation of a patient/family-tailored educational brochure outlining the CDC's guidelines in an accessible easy-to-learn format encourages patients/families to take an active role in the interdisciplinary care team. Results from the current quality improvement project are limited in that our interdisciplinary care team has not yet linked the implementation of the educational brochure and consequential increase in patient/family involvement to a reduction in CLABSI rates. Future studies are needed to evaluate the effect of the brochure and patient/family involvement in the interdisciplinary care team on CLABSI rates. Our quality improvement project additionally involves a relatively small population of participants. To make an association between the implementation of the brochure and patient/family involvement in the interdisciplinary care team with a reduction in CLABSI rates, our project would have to be expanded to include more patients/families and other healthcare institutions. The creation and implementation of an educational brochure is a low-cost feasible method of intervention that could easily be done by a diverse range of healthcare institutions and consequently target patients from diverse demographic/socioeconomic backgrounds. By expanding the current quality improvement project in such a way, we could state with a greater degree of confidence that patient education and inclusion in the interdisciplinary care team could lead to reduced CLABSI rates and improved patient care.
Acknowledgments
Many thanks to the Cancer Family Advisory Board; Beth Palazzo, RN, BSN, CPON; and the clinical teams on the medical surgical floor and the clinic who assisted in developing and implementing this work.
References