Challenges In the Neonatal Care through Susan Azarian, BS, RNC-NIC

Getting caregivers to embrace the philosophical goal of zero harm is easy, but having them institute zero as an operational goal has been discovered to be a much more daunting undertaking. Establishing zero as an operational goal has been adopted by the Central Line Team at Tri-City Medical Center (TCMC) and is the bedrock of their founding principle, “One CLABSI is too many!”

The only level III Neonatal Intensive-Care Unit (NICU) in North San Diego County, TCMC admits more than 500 of their tiniest patients into their 29-bed NICU, specializing in the care of ill and premature newborn infants every year.

TCMC’s PICC (pronounced “PICK”) team is made up of eight specially trained nurses who embrace ownership of the NICU’s central line processes. Those processes are in place to ensure the safe placement and on-going maintenance of peripherally-inserted central lines.  Yet, this single-center’s dedicated central line team operated much differently before 2010. It took Isaiah, a 26-week gestational age baby who developed a CLABSI, combined with an entire process change and culture shift, to get to where TCMC’s PICC team stands today; a zero CLABSI rate in PICC lines for seven years and counting.

Starting as a per diem nurse back in 2000 to later becoming a day shift staff nurse, Susan Azarian, BS, RNC-NIC, today serves as the NICU PICC Team Coordinator at TCMC. Azarian is a certified PICC trainer and currently TCMC’s only central line educator, training all PICC team members every other year. But it wasn’t until Azarian along with a group of nursing colleagues took baby Isaiah’s case personally, that nurses would take complete ownership over the central line process.

“Caring for a sick and fragile Isaiah and witnessing his parent’s difficulty bonding with him and inability to take him home in a timely manner hit many of us. It is our professional responsibility to take care of these babies and to protect them. We need to continually look at our process and if there’s anything we can do to improve, it is OUR responsibility to do it. “

Baby Isaiah acquired a central line-associated bloodstream infection also called CLABSI following the placement of an umbilical line in 2010. TCMC had experienced a handful of healthcare-acquired infections like Isaiah’s every year, and like many hospitals they were accepted. Yet for Azarian and her team, the devastating consequences of a CLABSI on the patients, families, and staff, not just the financial ramifications, were far too great to ignore.

Prior to Isaiah’s fight against infection, the placement of a central line was at the discretion of the attending physician at TCMC. Up until 2010, physicians decided which patients qualified for PICC lines, were responsible for educating families on the risks associated with central line procedures, and determined when central lines would be discontinued. Baby Isaiah was the wakeup call that would later influence a systematic breakthrough for the NICU.

Around that time, TCMC’s clinical nurse specialist got in touch with the highly sought-after Janet Pettit, DNP, NNP-BC, CNS, VA-BC™, whose background included over 30 years of neonatal intensive care experience as a clinical nurse manager, practitioner, specialist, and educator. Pettit was known for her great knowledge on care practices for infants with vascular access devices, particularly peripherally inserted central catheters or PICCs. Committed to taking the necessary measures to ensure a case like baby Isaiah’s would never take place again, Azarian and two nursing colleagues went through an extensive PICC line training that was led by Pettit. TCMC’s NICU Medical Director, Dr. Hamid Movahhedian, MD, supported this movement by providing the initial clinical proctoring and bedside monitoring.

TCMC established zero as an operational goal when they incorporated elements of the recommended central line bundle, which research had shown would significantly decrease infections, then went beyond the bundle to develop a thorough process that would eliminate any opportunity for error. Effectively building a zero tolerance culture for CLABSI in the process.

PICC nurses maintain sterility by wearing a mask, cap, sterile gown, and gloves for PICC insertions. Similarly, dressing and tubing changes also require sterile garb and processes.  Other requirements include assessment of line necessity, proper tubing, filters, add-on devices, discontinuation stickers, and signage. Although, this nitpicky process, as Azarian calls it, goes beyond the recommended central line bundle elements, it’s TCMC’s aggregate practice that has been proven successful over the course of seven years.

TCMC also executed another monitoring technique, the implementation of daily central line, tubing, and dressing change checklists. They’ve produced placards to hang at the NICU bedsides of babies to protect their fragile lines that read, “Your baby has a special line, please contact your nurse when you want to pick up or put your baby back.” Educational materials on how to properly care for a baby’s central line to keep it working are also offered to families in both English and Spanish. These are only a few of process changes that were enforced because of specific scenarios and issues TCMC had encountered in the past. They continue to look for ways to better these processes and hold each bedside nurse accountable for care of these special lines.  “One CLABSI is too many” not only became a goal, but became an expectation. Anything else is unacceptable.

Azarian and her team can still remember the challenges and interruptions in the NICU patient care flow, but recognized that an adherence and commitment to an efficient systematic process had the capability of eliminating infection altogether. A process that is supported by NICU Clinical Manager, Nancy Myers, RNC, BSN, NE-BC and neonatologists alike, yet developed, managed, and owned entirely by bedside nurses.

“Prevention is invisible. If I place a sterile line and we take care of the line throughout the stay, the baby finishes his course and goes home happy. What you don’t see is if we had made a mistake or had broken sterility, that baby could end up on a ventilator, would have a greater financial burden, could have problems bonding with family; that is why prevention is so important, even if it goes unnoticed.” 


Additional Resources

For more information on the Patient Safety Movement’s CLABSI Blueprint, click here.

To learn more about healthcare-associated infections, click here.

Want to know more about neonatal safety and sub-challenges in neonatal care? Click here!