Methods

The neonatal central line-associated bloodstream infection (NCLABSI) project time line was rapid with all project data and deliverables planned for over an 11-month time frame. To initiate the project, the following were completed in the first four months: identification of States and State leaders, NICU recruitment by State leaders, action plan creation, designation of key metrics and development a data collection system. Recruitment included 9 States and 100 NICUs.

A key element in the execution of NCLABSI was the formal introduction of CUSP principles to all participants. The Missouri Center for Patient Safety (MOCPS) was selected to lead this effort. The NCLABSI action plan focuses on central line insertion and maintenance (a summary of the maintenance bundle can be found in Table 1). Insertion elements were based on the Centers for Disease Control and Prevention (CDC) recommendations and were similar to those used in other CLABSI collaboratives. Given the longer dwell time for NICU central lines, NCLABSI also uniquely concentrated on maintenance activities related to central lines. This unique concentration included maintenance bundle elements based on CDC recommendations but also included a recommendation to consider removing central lines when infants reached enteral feeding levels of 120 cc/k/day. NCLABSI also intended daily reporting on maintenance practice for every NCLABSI line. 

Table 1. NCLABSI maintenance bundle summary

Maintenance	Considerations
Assessment & Site Care
1. Daily assessment and documentation of catheter need included as part of multidisciplinary rounds and review of daily goals
2. Removal of catheters in place for nutritional purposes when infant reaches ≥120 ml/kg/day enteral nutrition
3. Review dressing integrity and site cleanliness daily	No routine dressing changes, perform p.r.n. using sterile technique and chlorhexidine gluconate or povidone-iodine for skin antisepsis
Tubing, injection ports, catheter entry
1. Use "closed" systems for infusion, blood draws and medication administration	May use manufactured or improvised closed system. If stopcocks are used, port(s) are capped with swab-able needleless connector(s). Define consistent practice to be used when accessing catheters.
2.  Assemble and connect infusion tubing using aseptic or sterile technique. Configure tubing consistently for each type of arterial or venous access device.	Sterile technique ideally includes sterile barrier for tubing assembly and wearing of face mask, hat, sterile gloves and two staff members performing connection to central catheter. Aseptic technique includes clean barrier for tubing assembly and wearing of clean gloves.
3.  Scrub needleless connector using friction with either alcohol or CHG/alcohol swab for at least 15 sec. prior to entry. Allow surface to dry prior to entry.
4.  Clean gloves for all device entries & hand hygiene utilized before and after glove use	Standard precautions
5.  Use pre-filled, flush containing syringes wherever feasible	Higher risk of contamination when flush withdrawn from another container by a nurse.
6.  Staff empowered to stop non-emergent procedure if sterile technique not followed

As with the On the CUSP: Stop BSI project, the NCLABSI project included both a technical intervention and an adaptive intervention. 

For these interventions, the national project team provided the State clinical leads and their units with the following resources and educational materials:

1. Project Charter.
2. Leadership Role Descriptions.
3. Data Dictionary.
4. Hospital Tool Kit.
5. Action Plan.
6. CUSP Manual Adapted for NCLABSI.
7. CUSP Content Calls (seven total) and CUSP Coaching Calls (five total) presented by the Missouri Center for Patient Safety.
8. Pilot CUSP Toolkit.
9. Team Check-Up Tool.
10. On the CUSP: Stop BSI project website.
11. National Faculty Participation at Site Visit/Statewide Collaborative Meeting.
12. State Clinical Lead Calls and Face-to-Face Meetings.

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