Bellevue's NICU team

When Clara Torres first saw her daughter Aly, born premature, in the incubator at Bellevue Hospital, there were lines and tubes everywhere.

“She was only two pounds and looked so small,” Torres said. “The nurses and doctors explained why she had to have the oxygen, the central line, and so many other things in her body. I understood that the central line was something very important.”

Like Aly, the almost 500 tiny and vulnerable infants who receive care in the Bellevue Hospital Regional Perinatal Neonatal Intensive Care Unit (NICU) every year often require a central venous catheter, called a central line, to receive medicine and fluids to stay alive. That makes them most susceptible to bloodstream infections that result when bacteria enter the bloodstream, and they need nothing less than the safest and highest quality care.

“All pre-term babies end up with a central line at some point, usually within an hour or two of birth. That’s their lifeline – it’s how we feed them and administer their medication. So it’s critical for us to be extra vigilant to prevent infections,” said Dr. Karen Hendricks-Munoz, MD, director of Bellevue Hospital’s division of neonatology.

With the help of checklists, the creation of their own sterile “bundles” of equipment used to place central lines, and by educating parents, visitors and anyone who visits the unit, the NICU team lead by Hendricks-Munoz lowered infections by a dramatic 75 percent. According to statistics from the National Healthcare Safety Network (NHSN), the branch of the Centers for Disease Control and Prevention (CDC) that monitors healthcare-associated infections, the NICU team lowered central line associated blood stream infections from 9.6 infections per 1,000 days that babies were on central lines in 2009, to 2.3 infections per 1,000 days that babies were on central lines in 2010, well below the NHSN benchmark of 2.8 infections per 1,000 days. This work earned the Bellevue NICU team a President’s Choice Award during the annual event to recognize HHC Patient Safety Champions.

“In our NICUs, new parents trust us to provide the best care for their newborns with critical needs,” said HHC President Alan. D. Aviles. “Families can be assured that our expert and innovative team at Bellevue is leaving no stone unturned to protect their babies from life-threatening infections, while tending to their many other needs with the care and compassion that’s so unique to HHC.”

The NICU staff achieved this drop in infections through a multi-pronged approach. In 2008, Bellevue’s NICU and the other 17 New York State designated Regional Perinatal Centers adopted central-line insertion and maintenance bundles and agreed to use checklists to monitor maintenance-bundle adherence and report checklist use. Bundles are specific practices essential for effective and safe patient care that, when implemented together, result in improvements in patient outcomes and reduce the rate of infections.

Since pre-made sterile bundles don’t exist for neonates, the NICU staff made their own central-line insertion kits and placed them on a “line cart” so everything they need to insert the line safely – catheter, gown, gloves, drapes, antiseptic – is in one place. All staff were trained through workshops, role plays, simulation and videos in the five best practices – hand hygiene, how to drape and prep the area around the insertion site, how to gown and glove, which antiseptic to use, and how to appropriately select the site for insertion.

One effort involved everyone who stepped into the unit – housekeepers, vendors, physicians, nurses, radiologists, lab technicians, families – in hand-washing campaigns called “The Bug Stops Here” and “Clean Your Hands.”

“We not only followed best practices but looked at little details like making sure the hubs of the catheter were cleaned and scrubbed because maintenance, not insertion, often causes the problem,” said Roslyn Mayers, RN, who developed the curriculum. “We re-taught hand washing, had people change and put their street clothes in a bag outside the unit and made unannounced rounds when lines were being inserted. Our success in reducing the rates of infection translated into more babies who were able to go home sooner and stay healthy.”

June 2011