Restriction of Central Line Insertion and Prophylactic Antibiotics Usage in Moderate and Late Preterm Infants from a Quality Improvement Perspective

Sae Yun Kim; Geun Moo Lee; Eun Sun Kim

doi:10.14734/PN.2019.30.2.71

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Kim, Lee, and Kim: Restriction of Central Line Insertion and Prophylactic Antibiotics Usage in Moderate and Late Preterm Infants from a Quality Improvement Perspective

Original Article

Perinatology 2019;30(2):71-77.

Published online: 4 June 2019

DOI: https://doi.org/10.14734/PN.2019.30.2.71

Restriction of Central Line Insertion and Prophylactic Antibiotics Usage in Moderate and Late Preterm Infants from a Quality Improvement Perspective

Sae Yun Kim, MD^1,^*, Geun Moo Lee, MD^1,^*, Eun Sun Kim, MD, PhD^1,^2,

¹Department of Pediatrics, Kangwon National University Hospital, Chuncheon, Korea

²Department of Pediatrics, Kangwon National University School of Medicine, Chuncheon, Korea

Correspondence to Eun Sun Kim, MD, PhD Department of Pediatrics, Kangwon National University School of Medicine, 1 Kangwondaehak-gil, Chuncheon 24341, Korea Tel: +82-33-258-9020 Fax: +82-33-258-2418 E-mail: naivesun@kangwon.ac.kr

^* These authors contributed equally to this work.

Received 23 September 2018 Revised 24 October 2018 Accepted 25 October 2018

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Objective

The care provided to moderate and late preterm (MLPT) infants is an area of significant practice variation and most of the quality improvement initiations are for very low birth weight infants. The objective of this study was to analyze hospital outcome changes in MLPT infants with central line insertion and prophylactic antibiotics usage restriction as a quality improvement method.

Methods

This was a retrospective cohort study for MLPT infants who were admitted at Kangwon National University Hospital neonatal intensive care unit during 2013–2016. The groups were divided into period I (from 2013 to 2014) and period II (from 2015 to 2016) based on the changes in clinical practices. Since period II, feeding protocol was changed to rapid full-feeding and central line insertion practice was restricted to cases with feeding intolerance over 3 days of life. Prophylactic antibiotics were restricted to ampicillin with gentamycin except for special cases and indications were restricted depending on maternal factors plus clinical symptoms after birth.

Results

Gestational age was lower and respiratory distress syndrome was frequent at period II. Central line insertion was reduced from period I to II (83% [147/177] vs. 36% [75/207]). Antibiotics exposures were less at period II (584 vs. 206 days per 1,000 patient-days). Clinical sepsis and central line associated bloodstream infection was significantly decreased at period II.

Conclusion

Quality improvement for reducing central line insertion and prophylactic antibiotics usage in MLPT infants may be effective to reduce the incidence of infection related complications, especially sepsis.

Keywords: Preterm infants, Anti-bacterial agents, Central venous catheters, Quality improvement

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Table 1.

Demographics and Respiratory Outcomes according to Each Period

	Period I (n=177)	Period II (n=207)	P-value
GA (weeks)	35.3±1.2	34.7±1.2	<0.001
Bwt (g)	2,382±449	2,343±440	NS
C-sec	119 (67)	162 (78)	0.016
Male	94 (53)	121 (59)	NS
1 minute AS	7 (6,7)	7 (6,7)	NS
5 minute AS	9 (8,9)	9 (8,9)	NS
SGA	24 (14)	17(8)	NS
PPROM >18 hour	13 (7)	24 (12)	NS
Maternal CCAM	1 (1)	2 (1)	NS
RDS	22 (12)	48 (23)	0.008
Ventilator	115 (65)	95 (46)	0.001
Total duration (day)	2.6±3.7	2.1±3.3	0.010
Invasive (day)	0.5±1.6	0.8±1.9	0.019
Non-invasive (day)	2.2±2.8	1.3±2.2	0.001

Values are presented as mean±standard deviation or number (%) except Apgar scores. Apgar scores were describes as median (interquartile ranges). Abbreviations: GA, gestational age; Bwt, birth weight; C-sec, Cesarean section; NS, not significant; AS, Apgar score; SGA, small for gestational age; PPROM, preterm premature rupture of membrane; CCAM, clinical chorioamnionitis; RDS, respiratory distress syndrome.

Table 2.

Periodic Changes of Target Areas in Quality Improvement (Central Lines and Nutrition)

	Period I (n=177)	Period II (n=207)	P-value
Central line	147 (83)	75 (36)	<0.001
UAC or UVC	128 (72)	2 (1)
PICC	81 (55)	73 (35)
Surgical insertion	6 (3)	0 (0)
Central line duration (day)	11.7±10.2	0.5±0.7	<0.001
Feeding start day (day)	3.2±3.0	0.7±0.8	<0.001
Full feeding (>100 mL/kg)	11.0±8.1	3.9±2.3	<0.001
day (day)
PN	156 (88)	106 (51)	<0.001
PN duration (d)	9.3±9.5	4.0±2.4	<0.001

Values are presented as mean±standard deviation or number (%). Abbreviations: UAC, umbilical arterial catheter; UVC, umbilical venous catheter; PICC, peripherally inserted central catheter; PN, parenteral nutrition.

Table 3.

Periodic Changes of Target Areas in Quality Improvement (Antibiotics)

	Period I (n=177)	Period II (n=207)		P-value
	Period I (n=177)	II-1)* (n=101)	† II-2)(n=106)	P-value
Prophylactic antibiotics use	163 (92)	114 (55)		<0.001‡∮
		89 (88)	25 (24)
Duration (day)	4.2±2.0	2.1±2.1		<0.001‡∮
		3.4±1.7	0.9±1.8
Total antibiotics use	163 (92)	135 (65)		<0.001‡∮
		96 (95)	39 (37)
Duration (day)	9.0±8.0	3.3±3.5		<0.001‡∮∥
		4.4±2.3	2.3±4.1

Values are presented as mean±standard deviation or number (%). P-values were compared between period I vs. period II. *Denotes data from March 2015 to February 2016.

^† Denotes data from March 2016 to February 2017.

^‡ P<0.05 period I vs. period II-2) by Bonferroni.

^∮ P<0.05 period II-1) vs. period II-2) by Bonferroni.

^∥ P<0.05 period I vs. period II-1) by Bonferroni.

Table 4.

Secondary Outcomes related to Quality Improvement Changes

	Period I (n=177)	Period II (n=207)	P-value
EOS	0 (0)	1 (0)	NS
LOS	7 (4)	0 (0)	0.004
Clinical sepsis	74 (42)	28 (14)	<0.001
CLABSI	7 (4)	0 (0)	0.004
Line problem	5 (3)	3 (1)	NS
Cellulitis	2 (1)	3 (2)
Necrosis	3 (2)	0 (0)
Admission days (range)	15.4±11.6 (3–63)	16.0±8.0 (4–45)	NS

Values are presented as mean±standard deviation or number (%). Abbreviations: EOS, early onset sepsis; LOS, late onset sepsis; CLABSI, central line-associated bloodstream infection; NS, not significant.

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