Surveillance and attribution of ambulatory central line-associated bloodstream infections in a pediatric healthcare system


      • Ambulatory CLABSIs are not regularly tracked in complex ambulatory populations.
      • We developed an institutional workflow to identify and track outpatient CLABSIs.
      • We defined surveillance criteria including based on standard NHSN definitions.
      • This is a novel approach to attribute infections by lead and supporting divisions.
      • Our surveillance and attribution methods also incorporate home infusion patients.


      Central line-associated bloodstream infections (CLABSI) in ambulatory pediatric populations are difficult to track at an institutional level, especially for complex patients seen by multiple divisions and home health infusion agencies.


      A multidisciplinary team comprised of key stakeholders from divisions with the most patients discharged with a central line utilized Lean Six Sigma methodology of Define-Measure-Analyze-Design-Verify (DMADV) to create a standardized data collection process for all ambulatory CLABSIs and infection event reviews.


      A surveillance workflow was created to track, identify, and confirm ambulatory CLABSIs in all patients with an indwelling central line. Defined surveillance criteria included scope of patients eligible for ambulatory CLABSI surveillance, numerator definitions, and denominator calculations. Additionally, a novel attribution method was created for ambulatory CLABSIs in complex patient populations shared among multiple divisions and home care infusion services.


      This report is a novel institutional approach to accurately surveil, attribute, and calculate ambulatory CLABSI data in a pediatric healthcare system.

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        • Nailon RE
        • Rupp ME.
        Surveillance of home health central venous catheter care outcomes: challenges and future directions.
        Am J Infect Control. 2019; 47: 1382-1387
        • Keller SC
        • Williams D
        • Rock C
        • Deol S
        • Trexler P
        • Cosgrove SE.
        A new frontier: central line–associated bloodstream infection surveillance in home infusion therapy.
        Am J Infect Control. 2018; 46: 1419-1421
        • Seddik TB
        • Tian L
        • Nespor C
        • Kerner J
        • Maldonado Y
        • Gans H.
        Risk factors of ambulatory central-line associated bloodstream infection in pediatric short bowel syndrome.
        JPEN J Parenter Enteral Nutr. 2020; 44: 500-506
        • Raphael BP
        • Hazekamp C
        • Samnaliev M
        • Ozonoff A.
        Analysis of healthcare institutional costs of pediatric home parenteral nutrition central line infections.
        J Pediatr Gastroenterol Nutri. 2018; 67: e77-e81
        • Rinke ML
        • Bundy DG
        • Milstone AM
        • et al.
        Bringing central line–associated bloodstream infection prevention home: CLABSI definitions and prevention policies in home health care agencies.
        Jt Comm J Qual Patient Saf. 2013; 39: 361-370
        • Leeman H
        • Cosgrove SE
        • Williams D
        • Keller SC.
        Assessing burden of central line–associated bloodstream infections present on hospital admission.
        Am J Infect Control. 2020; 48: 216-218
        • Keller SC
        • Alexander M
        • Williams D
        • et al.
        Perspectives on central-line–associated bloodstream infection surveillance in home infusion therapy.
        Infect Control Hosp Epidemiol. 2019; 40: 729-731
      1. Centers for Disease Control and Prevention. Device-associated module: bloodstream infection event (central line-associated bloodstream infection and non-central line associated bloodstream infection). Accessed September 11, 2020.

        • Rinke ML
        • Heo M
        • Saiman L
        • et al.
        Pediatric ambulatory central line–associated bloodstream infections.
        Pediatrics. 2021; 147e20200524
        • Ross VM
        • Guenter P
        • Corrigan ML
        • Kovacevich D
        • et al.
        Central venous catheter infections in home parenteral nutrition patients: outcomes from Sustain: American society for parenteral and enteral nutrition's national patient registry for nutrition care.
        Am J Infect Control. 2016; 44: 1462-1468
        • Gabel ME
        • Neumeister SW
        • Meyers JM
        • Schriefer JA.
        A quality improvement bundle to reduce ambulatory CLABSI: the importance of a multidisciplinary team.
        Pediatr Qual Saf. 2021; 6: e500
        • Drews B
        • Macaluso M
        • Piper H
        • Channabasappa N.
        Caregiver education reduces the incidence of community-acquired CLABSIs in the pediatric patient with intestinal failure.
        Gastroenterol Nurs. 2017; 40: 458-462
        • Altounji D
        • McClanahan R
        • O'Brien R
        • Murray P
        Decreasing central line–associated bloodstream infections acquired in the home setting among pediatric oncology patients.
        J Pediatr Oncol Nurs. 2020; 37: 204-211
        • Rinke ML
        • Milstone AM
        • Chen AR
        • et al.
        Ambulatory pediatric oncology CLABSIs: epidemiology and risk factors.
        Pediatr Blood Cancer. 2013; 60: 1882-1889