Transforming central line associated blood stream infection prevention in neonates: Results from a multimodal quality improvement initiative

Table 1 Demographics of study population, n (%)

Characteristics	Pre-intervention period (6 months)	Implementation period (12 months)	Sustainability period (18 months)
Total number of admissions	457	683	1218
No. of ELBW	46 (10)	77 (11.2)	160 (13.1)
Central line days	1249	1816	4145
No. of CLABSI cases	8	2	4
CLABSI rates/1000 central line days	6.4	1.1	0.96
Compliance to hand hygiene (%)	97.9%	98.1%	97.7%
Compliance to insertion bundle (%)	-	100%	97%
Compliance to maintenance bundle checklist (%)	-	Nurses 86%	Nurses 94%
		Doctors 82%	Doctors 93%
Compliance to nurses education (% staff coverage)	-	62%	81%

ELBW: Extremely low birth weight; CLABSI: Central line associated blood stream infection.

Table 2 Challenges and mitigation strategies

Challenge	Description	Mitigation strategy
Variable adherence to maintenance bundle during initial phases	Early audits revealed inconsistent compliance with maintenance checklists, particularly during night shifts and high-workload periods	Real-time feedback during bedside rounds, peer mentoring, and reinforcement of accountability through shared nurse-physician responsibility for checklist completion improved compliance to > 90% by phase 3
High staff turnover and rotational postings	Frequent rotation of fellows and nursing staff led to variability in familiarity with protocols and compromised consistency in central line care practices	A structured orientation and modular training program was institutionalized for all new staff, supplemented by quarterly simulation-based refresher sessions to reinforce core competencies
Competing clinical priorities during the COVID-19 pandemic	Redeployment of personnel, heightened infection control demands, and restricted group gatherings challenged consistent implementation and training schedules	Smaller, repeated training sessions adhering to infection control norms were conducted using audiovisual aids and virtual platforms. Dedicated infection control nurses ensured continuity of audit and feedback processes
Resistance to change and behavioral inertia	Initial reluctance among some staff members to adopt revised aseptic protocols and documentation requirements hindered early compliance	Continuous engagement through inclusive team meetings, sharing of infection data trends, and recognition of high-performing individuals fostered ownership and motivation. Behavioral reinforcement through feedback overcome resistance
Documentation fatigue and checklist overload	The introduction of multiple checklists and audit tools increased perceived workload among nurses and fellows	Redundant forms were consolidated, and electronic data entry via a simplified digital dashboard was introduced to streamline documentation and facilitate real-time data visualization
Environmental hygiene and equipment cleaning gaps	Inconsistent disinfection of high-touch equipment (syringe pumps, infusion stands) contributed to occasional breaches in asepsis	Daily cleaning schedules and visual reminder posters were implemented. Infection control nurses conducted unannounced spot checks, and cleaning logs were reviewed weekly in QI meetings
Maintaining sustainability beyond the active intervention phase	Post-implementation, the risk of gradual decline in compliance and attention to line care was recognized	Sustainability was ensured through periodic re-audits, case-based debrief sessions after any CLABSI event, and integration of bundle adherence metrics into the unit’s routine performance dashboard

COVID-19: Coronavirus disease 2019; QI: Quality improvement; CLABSI: Central line associated blood stream infection.