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Dangerous infections are more likely in pediatric intensive-care units

But hospitals and parents can take steps to prevent them, our investigation found

Last updated: January 2012

Having a child in intensive care is scary enough without the added worry of deadly hospital-acquired infections. But such infections occur all too often in U.S. hospitals, especially in pediatric intensive-care units, according to an investigation by the Consumer Reports Health Ratings Center. We found that pediatric ICUs often have higher infection rates than adult ICUs, and that some do much better than others at preventing infections.

The vast majority of children who enter pediatric ICUs receive high-quality and even lifesaving care from dedicated professionals and never develop infections. But pediatric ICUs, like adult units, can also be fertile ground for bloodstream infections.

Among the deadliest are infections introduced through central-line catheters. Those catheters, which deliver medication, nutrition, and fluids to critically ill patients, can also spread infection throughout the body if they aren’t inserted with absolutely sterile techniques and kept meticulously clean by the doctors, nurses, and other health-care providers. In 2009, there were an estimated 27,000 to 65,000 central-line bloodstream infections in U.S. hospitals, including 12,000 to 28,000 in ICUs, according to the Centers for Disease Control and Prevention. And up to 25 percent of them were fatal.

The consequences of those infections can be devastating, especially when they happen to children. At 18 months old, Josie King was recovering from third-degree burns suffered from climbing into a hot bath. She spent 10 days in the pediatric ICU at Johns Hopkins Hospital in Baltimore and was doing well. But after her central line was removed, Josie showed signs of severe dehydration. A central-line infection led to other medical errors that ultimately cost Josie her life. She died from dehydration and misused narcotics two days before she was to go home. Preventing the infection might have saved her life. Her mother, Sorrel King, started the Josie King Foundation, a nonprofit organization dedicated to preventing hospital infections and other medical errors, in her daughter’s memory.

A growing awareness of hospital-acquired infections over the last decade may be one reason infection rates in ICUs have declined in recent years. But they’re still too high. And too often the information isn’t easily accessible to patients. Of the 423 pediatric intensive-care units in the U.S., information on bloodstream infection rates is publicly available for less than half.

“Parents have a right to information about infections, and they are even more likely than other consumers to use that information when their children are involved,” says Lisa McGiffert, director of Consumer Union’s Safe Patient Project. Moreover, “making that information public motivates hospitals to get better,” she says.

"We’re even more concerned about pediatric ICUs that choose to conceal their infection rates."—John Santa, M.D.

What we found

Our investigation focused on the 92 pediatric intensive-care units in 31 states plus Washington, D.C., that publicly reported enough data for us to make statistically valid assessments of their rate of bloodstream infections.

It found that pediatric ICUs in our analysis had infection rates that were 20 percent higher than national rates for adult ICUs. Specifically, pediatric ICUs in our Ratings averaged 1.8 bloodstream infections for every 1,000 days children were on central lines, compared with an estimated national average of 1.5 bloodstream infections per 1,000 central line days in adult ICUs in 2009. And some pediatric ICUs in our Ratings had rates as high as 7.2, more than four times the national average for adult ICUs.

In addition, only five pediatric ICUs nationally earned our top Rating, meaning that they reported zero bloodstream infections during 2010, even though our experts say that all hospitals should aim for that level. Those five were Children's Hospitals and Clinics of Minnesota in St. Paul; Medical University of South Carolina in Charleston; Robert Wood Johnson University Hospital in New Brunswick, N.J.; Tulane Medical Center in New Orleans; and University Medical Center in Las Vegas.

Two pediatric ICUs—the University of Virginia Medical Center in Charlottesville and the Loyola University Medical Center in Maywood, Ill.—received our lowest Rating, which means they reported infection rates more than twice as high as the national average. And another 24 hospitals got our second-lowest Rating, with infection rates that were higher than the national average.

“Those hospitals have work to do, but at least they have taken the first step by making their results public,” says John Santa, M.D., director of the Consumer Reports Health Ratings Center. “Taking accountability for infections is reassuring. We’re even more concerned about pediatric ICUs that choose to conceal their infection rates.”

Santa points out that while not all states require hospitals to report their infection data to the public, any hospital can voluntarily report them to the Leapfrog Group, a nonprofit organization based in Washington, D.C., that since 2000 has worked with large employers nationwide to collect and disseminate information about individual hospitals.

What you can do

Chances are that if your child needs to be admitted to a pediatric intensive-care unit, where he or she goes will depend mostly on which hospitals are closest, your doctor’s admitting privileges, your insurance coverage, and the expertise of the clinicians and the ICU. Still, in some cases when you do have a choice, knowing the units’ infection rates might help you decide. You can also consider that information when choosing a pediatrician. Ask which hospital your doctor admits patients to, and see how its pediatric ICU performed.

Even if you don’t have a choice, knowing those rates can help you determine how vigilant you need to be during your child’s stay. And regardless of its Rating, you can help prevent infections by taking the following steps:

• Ask the staff how you can help. The ICU staff will probably welcome your participation. Unlike a nurse, “a parent at the bedside isn’t going to have a couple of patients; they have just one,” says Marlene Miller, M.D., vice chairwoman of quality and safety at Johns Hopkins Children’s Center and a professor of pediatrics. “Helping to watch that the central line stays clean, and that everyone who touches it scrubs it clean and uses sterile equipment to access it, is ideal,” he says.

• Make sure the hospital follows best practices for inserting and maintaining central lines. Those measures include disinfecting the site and changing the dressings regularly, standardizing the procedures for changing the catheter caps and tubes, and developing readily available prepackaged kits with all the necessary tools to do those jobs right. But you don’t have to know each of the steps. Simply asking about them can remind staff to be extra vigilant about adhering to the safety measures.

• Ask if the central line is still needed. “That’s a question we are supposed to ask each other every day,” says Joel Cochran, D.O., who helps oversee infection prevention at the Medical University of South Carolina, one of our top-rated pediatric ICUs. “There’s no reason a parent shouldn’t ask it, too.”

• Keep hands clean. That means making sure you, visitors, and the hospital staff wash their hands with soap or an alcohol-based solution before touching your child or the catheter.

• Watch the catheter. The line can stray near your child’s diaper, for example, and children might fiddle or even put the lines in their mouth.

• Keep a journal. Keep track of how often hospital staff change the catheter or dressing and how long the catheter has been in.

• Raise an alarm. “If things don’t seem right, trust your instincts and say something—and make sure someone responds to you,” urges McGiffert of our Safe Patient Project. “I've heard too many stories of children who died because the parents trusted the hospital’s system. Don't let anything go. You know your child, and you are part of the team.” 

• Share your story. If you or someone you care for has been harmed by a hospital-acquired infection, you can share it with our Safe Patient Project, which raises awareness about hospital safety.

See our hospital survival guide for more tips on staying safe in the hospital.

Making pediatric ICUs safer

Using central-line catheters in children presents unique challenges that can make eliminating bloodstream infections more difficult. And some experts we spoke with said that comparing infection rates at different pediatric intensive-care units is unfair because some might be larger, treat sicker patients, or perform more complicated procedures.

But our investigation and other medical research suggest that most hospitals could do much better at preventing infections, and that eliminating infections altogether should be the goal everywhere.

Young children have less-developed immune systems and are thus more susceptible to bacterial infections. That’s often especially true of very sick children in intensive care. In addition, the way central lines are used in children increases the risk of exposure to bacteria. For example, doctors and nurses tend to leave central lines in longer for children than they do for adult patients, and access the lines more frequently.

That’s often done for good reasons. It can be difficult to insert catheters in a child’s smaller veins, so once one is properly inserted doctors prefer to leave it in until they’re sure it’s no longer necessary. And once a child has a central line, it’s frequently used for blood samples, reducing a child’s exposure to traumatic needle sticks.

The downside: The more often catheters are used, and the longer they stay in, the greater the risk of infection.

Still, some pediatric ICUs have been able to dramatically reduce infections by focusing on scrupulous care not just when inserting and removing catheters but also when maintaining them, says Miller at Johns Hopkins. In a November 2011 study in Pediatrics, Miller found that 29 hospitals that had adopted strict safety procedures for at least three years were able to cut their infections by 56 percent.

And in our analysis, five hospitals earned our highest Rating, meaning that they reported no infections in 2010, and another 29 got our second-highest Rating, meaning that they reported fewer than half as many infections as the national average.

Zero infections

Infection fighters
Melinda Biller, R.N., and Joel Cochran, D.O., implemented an effective prevention program.

The experience at the Medical University of South Carolina is particularly notable.

In January 2009, its pediatric intensive-care unit reported six infections for every 1,000 days a child was on a central line, says Melinda Biller, R.N., nurse manager for its pediatric ICU. That’s a rate she calls “horrific,” and one that would have earned it our worst Rating. That’s when she and her colleagues implemented “Our Journey to Zero,” an infection-prevention program that required, among other things, a new hospital culture that viewed infections as preventable, not inevitable. “We had this concept that there were always going to be infections,” Biller says. “That was where the culture had to be changed. We had to tell ourselves zero really is a possibility.” They’ve now gone 23 months without a central-line blood stream infection, she says.

Cochran, also at the Medical University of South Carolina, says change started at the top. “I was probably a worse offender than anyone,” he says. “If they had a line and they didn’t have an infection, I’d leave it in because we can draw blood easily without having to stick the patient for labs.” But now, he says, “the whole culture has changed; instead of a convenience it is a risk.”

Comparing hospitals

The two hospitals that got our lowest rating—the University of Virginia Medical Center and the Loyola University Medical Center—both told us that their low scores in part reflect the high-risk nature of the populations they serve in their pediatric intensive-care units, their patient’s long length of stay, and the complex nature of the procedures they perform.

Miller, at Johns Hopkins, agrees that those factors can make it difficult to compare hospitals. Pediatric ICUs at large teaching hospitals usually have more beds and take in more patients than smaller ICUs, and many of their patients have been referred by other hospitals that can’t treat them. They’re generally sicker, making them more likely to develop an infection caused by bacteria in their own bodies rather than the central line, Miller says.

However, we limited our analysis to hospitals with large enough samples to yield statistically meaningful results. As a result, our Ratings mainly compare hospitals that treat the sickest patients in their regions. And the variations in infection rates are still wide. “Dealing with sicker patients does create challenges,” Santa says. “But we’ve been impressed that some institutions have made substantial gains in reducing infections, despite treating the most difficult patients.”

For example, all five of our top-rated pediatric ICUs are in teaching hospitals that serve similar populations and perform similar procedures to those in the lower-rated hospitals. And while the University of Virginia Medical Center had a particularly busy pediatric ICU—reporting 2,501 days that children were on central lines—the top five hospitals reported between 1,041 and 1,745 central-line days. Loyola University Medical Center reported just 974 central-line days.

Moreover, both of the lowest-rated hospitals acknowledged they are trying to do better. They said that they had implemented policies that would improve their infection rates, including standardized central-line insertion and maintenance practices. Loyola University Medical Center’s statement says that it had only one infection between January and October 2011. And a spokesman from the University of Virginia told us that its pediatric ICU’s infection rate has been “less than five infections per 1,000 days with a patient on a central line in each of the first three quarters of 2011.” But anything higher than three infections per 1,000 central-line days is still worse than the national average.

Ratings of pediatric intensive-care units

We compared central-line infection data for pediatric intensive-care units at 92 hospitals in 31 states and Washington, D.C. Our information comes from the state reports and from the Leapfrog Group a nonprofit organization based in Washington, D.C., that since 2000 has worked with large employers nationwide to collect and disseminate information about individual hospitals. Some states may have released more recent infections data that has not been included in these Ratings.

Note that these Ratings refer only to the pediatric intensive-care units in each hospital, not all their ICUs and not other measures in our hospital Ratings, such as surgical-site infections or patient experience. In some cases, hospitals might have done better or worse in those measures. For example, the Medical University of South Carolina got our top Rating for bloodstream infections in its pediatric ICUs but only a middle Rating for preventing bloodstream infections in its ICUs overall. On the other hand, Loyola University Medical Center, which got our lowest Rating for its pediatric ICU, got an average Rating for all of its ICUs combined.

For information on more than 3,000 hospitals in all states, including infection Ratings for over 1,000 hospitals, see our hospital Ratings (available to subscribers). Or try our new hospital Ratings app, which can be downloaded from the iTunes app store for $2.99.

   

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