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From kamishibai card to key card: a family-targeted quality improvement initiative to reduce paediatric central line-associated bloodstream infections
  1. Ranjith Kamity1,2,
  2. Melissa Grella1,
  3. Maureen L Kim1,2,
  4. Meredith Akerman3,
  5. Maria Lyn Quintos-Alagheband1,2,4
  1. 1 Pediatrics, NYU Winthrop Hospital, Mineola, New York, USA
  2. 2 Pediatrics, New York University Long Island School of Medicine, Mineola, New York, USA
  3. 3 Foundations of Medicine, New York University Long Island School of Medicine, Mineola, New York, USA
  4. 4 Quality and Safety, NYU Winthrop Hospital, Mineola, New York, USA
  1. Correspondence to Dr Ranjith Kamity, Pediatrics, NYU Winthrop Hospital, Mineola NY 11501, New York, USA; ranjith.kamity{at}


Background Central line-associated bloodstream infections (CLABSIs) are major contributors to preventable harm in the inpatient paediatric setting. Despite multiple guidelines to reduce CLABSI, sustaining reliable central line maintenance bundle compliance remains elusive. We identified frontline and family engagement as key drivers for this initiative. The baseline CLABSI rate for all our paediatric inpatient units (January 2016–January 2017) was 1.71/1000 central line days with maintenance bundle compliance at 87.9% (monthly range 44%–100%).

Objective To reduce CLABSI by increasing central line maintenance bundle compliance to greater than 90% using kamishibai card (K-card) audits and family ‘key card’ education.

Methods We transitioned our central line maintenance bundle audits from checklists to directly observed K-card audits. K-cards list the central line maintenance bundle elements to be reviewed with frontline staff. Key cards are cue cards developed using a plain-language summary of CLABSI K-cards and used by frontline staff to educate families. Key cards were distributed to families of children with central lines to simultaneously engage patients, families and frontline staff after a successful implementation of the K-card audit process. A survey was used to obtain feedback from families.

Results In the postintervention period (February 2017–December 2019), our CLABSI rate was 0.63/1000 central line days, and maintenance bundle compliance improved to 97.1% (monthly range 86%–100%, p<0.001). Of the 45 family surveys distributed, 20 (44%) were returned. Nineteen respondents (95%) reported being extremely satisfied with the key card programme and provided positive comments.

Conclusion Combining the key card programme with K-card audits was associated with improved maintenance bundle compliance and a reduction in CLABSI. This programme has the potential for use in multiple healthcare improvement initiatives.

  • continuous quality improvement
  • human factors
  • lean management
  • patient education
  • paediatrics

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  • RK and MG are joint first authors.

  • MLQ-A as the senior author.

  • Contributors RK and MG contributed equally to this paper. RK, MG, MLK and MLQ-A contributed to designing the study, intervention roll-out, data collection and analysis. MA and RK performed statistical analysis. All authors revised the manuscript and reviewed and approved the manuscript in its final form.

  • Funding The project was funded by the Departments of Quality and Safety, and Pediatrics at our institution.

  • Disclaimer The funding organisations did not have any role in the design, implementation, interpretation and reporting of the results.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. All data relevant to the study are part of our institutional quality improvement departmental records.