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ABSTRACT
Catheter-related bloodstream infection (CRBSI) is the most common complication related to peripherally inserted central catheters in the neonatal intensive care unit. CRBSIs are responsible for many morbidities and mortalities occurring in special care nurseries. However, these vascular access devices are an essential aspect of neonatal care and therefore are indispensable. To minimize CRBSI incidences and improve patient outcomes, objectives must be established to focus on the prevention of these potentially life-threatening infections. This article identifies the interventions incorporated by our facility to prevent nosocomial bloodstream infections.
CATHETER-RELATED BLOODSTREAM INFECTIONS
Nosocomial infection is a major problem faced by premature infants in the neonatal intensive care unit (NICU). Premature infants are particularly vulnerable to infection because of their immature immune system, exposure to multiple personnel, and invasive interventions. Vascular access devices (VADs) are among the most common interventions thought to contribute to nosocomial infections.1,2 The goal of infusion therapy is to ensure that the neonate receives the most appropriate VAD to meet their needs throughout medical management. Therefore, a proactive approach guarantees timely, appropriate VAD selection and placement.3 The increasing demand for vascular access has been documented, as is the increasing incidence of catheter-related infections resulting in prolonged hospitalization and additional therapies.3-5
EVIDENCE-BASED RECOMMENDATIONS
Catheter-related bloodstream infection (CRBSI) is initiated by several different mechanisms, including contamination of the catheter by skin flora on insertion, skin bacteria migration down the cannula tract, bacteria transfer through the hub during line entry, and seeding from another site of infection.2,3,5–9 The most common sources are skin flora contaminating the external catheter, hub contamination, or both.2,10,11 CRBSIs occur at rates averaging from 3.8 to 11.3 per 1000 catheter days in pediatric and neonatal ICUs and account for approximately 30% of all nosocomial infections in this patient population.2,6,12
Studies have demonstrated that a dedicated intravenous (IV) therapy team can decrease catheter-related complications by standardizing the catheter insertion technique and monitoring catheter sites daily.3,4,13–15 The literature supports the importance of dedicated IV therapy teams to patient outcomes, including the reduction of catheter-related nosocomial infection incidences.2,4,6 The use of a dedicated IV therapy team to provide line care and maintenance, to provide ongoing staff education, to review and revise infusion-related policies and procedures, and to assist with obtaining vascular access does impact patient outcomes.2,4
Strategies for reducing complications of bloodstream infections, as identified by the Centers for Disease Control and Prevention (CDC) and others in the literature, include limiting peripherally inserted central catheter (PICC) insertion to a small group of specially trained nurses who also monitor and evaluate catheter care.3,4,14,16 The CDC's recommendation of performance indicators for reducing CRBSIs include (1) implementation of educational programs that include educational and interactive components for those who insert and maintain catheters, (2) utilization of chlorhexidine gluconate (CHG) for skin antisepsis, (3) use of maximal sterile barrier precautions (MSBPs) during catheter insertion, and (4) discontinue catheter when the device is no longer essential for medical management.
The Vermont Oxford Network National Evidence-Based Quality Improvement Collaborative for Neonatology (VON NICQ) brings together multidisciplinary improvement teams from member organizations to identify and implement better practices aimed at achieving measurable improvements in quality and safety. Centers participate in focus groups on selected topics. These groups work together to explore and examine the evidence, analyze their own practices, and develop clinical tools for improvement related to the topic area. The goal is the identification of evidence-based “potentially better practices (PBPs)” that can be shared extensively to promote improvement. In an effort to continue to reduce the occurrence of nosocomial infections, our Special Care Nursery (SCN) infection control collaborative team participated in the 2004 VON NICQ. The SCN collaborative team comprised a neonatologist, an infection control nurse, a clinical nurse specialist, a department coordinator, a nurse clinician, staff nurses, a respiratory therapist, and a pharmacist. On the basis of the VON NICQ data, a number of PBPs have been adopted by our unit.
Because of the potential transmission of organisms from the hands of physicians, nurses, technicians, and other hospital personnel, the first PBP focuses on hand hygiene. Hand hygiene is considered the single most important procedure in preventing nosocomial infections, and both the CDC and the American Hospital Association have recommended that hand hygiene be performed before and after each patient encounter. Continuing education, monitoring, reporting, and feedback to staff on behavior and infection surveillance data has been shown to increase compliance with and the effectiveness of hand hygiene practices.2,11
Since the evidence strongly suggests that the design and management of vascular lines can play a significant role in reducing the risk of nosocomial bacterial infection, the second PBP includes several PBPs directed at those issues. These include standardization of line setups, ways to implement “closed” vascular systems (including umbilical lines), and line entry techniques (termed “hub care process”).17 The most significant PBP relates to antiseptic maneuvers surrounding hub entry.17-19 Programs and techniques that reduce hub colonization have consistently been associated with decreasing catheter-related infection rates by as much as 90%.2,11
The final PBP to be discussed is the use of MSBPs for insertion of central catheters. The use of MSBPs prevents contamination of the catheter or catheter site during insertion, thereby generating the recommendation to include the utilization of maximum precautions in our unit's policies and procedures as well as in the education provided to those involved in inserting PICC lines as part of our PICC team. The impact that these PBPs and recommendations will have on individual institutions should be evaluated by using specific performance criteria.2,11
MINIMIZING CRBSIS
The SCN at Northside Hospital in Atlanta, Georgia, is a level III NICU with 125 beds. The average daily census is 96 neonates; there were more than 2000 admissions, with more than 500 PICC insertions, during fiscal year 2007.
Our SCN infection control collaborative team developed and initiated a nosocomial infection control performance improvement initiative. The goal of the initiative was to decrease line-related nosocomial infections by 50% within 12 months. The focus of the initiative was hand hygiene practices and line care regimens. The collaborative team participated in a national collaborative with the VON to focus on reducing nosocomial infection rates. Figure 1 illustrates our declining CRBSIs by fiscal year. The text will further discuss the strategies utilized to minimize CRBSIs in our SCN.
 | FIGURE 1. CRBSI and line days. CRBSI indicates catheter-related bloodstream infection; FY, fiscal year. |
CDC RECOMMENDATIONS
Initially, 6 charge nurses attended a PICC training course and began inserting PICC lines as time allowed. The charge nurse was expected to perform insertions, dressing changes, and adjust lines, in addition to managing the daily activities of the unit.
Our PICC team was developed to accommodate the increasing number of neonates requiring PICC insertions (Figure 2). The SCN PICC team comprised 8 team members and is supervised by the PICC clinician (Box 1).
 | Box 1. PICC team time |
 | FIGURE 2. PICC insertions and admits. FY indicates fiscal year; PICC, peripherally inserted central catheter; SCN, special care nursery. |
The CDC recommends designated trained personnel for the insertion and maintenance of intravascular catheters. Peripheral venous access in newborns and infants is not only technically challenging but also inadequate in several clinical situations. Some IV antibiotics and total parentral nutrition (TPN) can cause discomfort, irritation, and phlebitis in a peripheral vein and usually require central venous access.3,20 PICC insertion requires specialized training to improve patient outcomes by diminishing catheter-related complications.2,3 The PICC nurse is responsible for safety and best practices for the patient related to infusion therapy, care, and maintenance.
PICC team members must complete a PICC training course and perform 3 successful supervised insertions to be deemed competent to perform insertions. Also, yearly competency must be maintained by team members. Table 1, the SCN PICC tool, highlights the responsibilities and competencies required to obtain and maintain team membership. Our SCN PICC team minimizes nosocomial infections by optimizing sterile technique used for catheter insertions and dressing changes through the execution of the recommendations presented in the text.6
 | TABLE 1. Continued |
 | TABLE 1. Continued |
 | TABLE 1. SCN PICC Tool |
The PICC clinician is responsible for educating staff members regarding infusion therapy; development of standards of practice, policy and procedure; development of infusion competencies; monitoring central line days; and performing and monitoring PICC insertions, along with assuming the role of SCN infection control collaborative team cochair. As recommended by the CDC, the PICC clinician assesses the knowledge of and adherence to guidelines periodically and annually through computer-based learning activities and through monitoring staff compliance with hand hygiene and line care regimens.
During the weekdays, members of the team are assigned as the “PICC nurse” for the unit during a 12-hour day shift. Team members perform all PICC insertions (Figure 3), conduct daily assessment of each catheter and dressing, monitor tip location on chest radiographs, perform dressing changes, troubleshoot catheter problems, perform difficult venipunctures, provide informal staff education, and conduct hand hygiene and line entry surveillance. The literature supports a proactive approach to the assessment and insertion of the most appropriate VAD to prevent unnecessary and multiple peripheral IV (PIV) attempts.3 The PICC insertion routinely occurs on our unit according to the following circumstances: (1) on the day of admission, (2) by 24 hours, if a PIV is placed on admission, (3) by day of life 7, when the umbilical venous line is removed, and (4) whenever short-term (3–7 days) or long-term (>7 days) venous access is required. Team members utilize the PICC consultation and order form (Figure 4) to identify those infants who meet the requirements for PICC placement. Potential candidates for short-term therapy may include infants with limited vascular access or experiencing multiple PIV attempts/insertions. Candidates for long-term therapy consist of (1) premature infants weighing less than 1500 g, (2) infants requiring TPN, or (3) infants receiving critical drug infusions.16,21 Once potential candidates have been identified, the PICC nurse consults with the neonatologist to obtain the physician's order for placement.
 | FIGURE 4. PICC order form. IV indicates intravenous; PICC, peripherally inserted central catheter; PIV, peripheral IV; UVC. |
 | FIGURE 3. PICC insertion form. PICC indicates peripherally inserted central catheter. |
Supplies for dressing changes were stocked individually on the supply cart with sterile gloves stored in a separate cabinet. For every dressing change, supplies were gathered and brought to the bedside.
A central line dressing change kit was created specifically for our SCN. The prepackaged kit contains all the necessary supplies required for the dressing change (mask, sterile gloves, sterile drape, antiseptic, saline wipes, Tegaderm, and scissors) and is stored on the PICC cart for easy access.
Transparent, semipermeable dressings (3M Tegaderm) have become a popular means of dressing catheter insertion sites. Transparent dressings reliably secure the device, permit continuous visual inspection of the catheter site, protect the site from contamination, and require less frequent dressing changes than do standard gauze and tape dressings.2,18 It is important to monitor the catheter site; this assessment should occur visually and by palpation through the intact dressing on a consistent basis. The NICUs report dressing changes at specified intervals with 7 days as the most reported interval.22 Reports of routine, weekly dressing changes are surfacing as components of bundles designed to reduce the incidence of CRBSI.3
The PICC nurse determines the appropriate antiseptic for the dressing change based on the established unit guidelines. Only the PICC or charge nurse may perform dressing changes utilizing the prepackaged neonatal dressing change kit. Dressing changes occur as needed when the site becomes nonocclusive. Transparent dressings with sterile gauze are changed at 48 hours. Sites with a chlorhexidine-impregnated dressing are changed per manufacturer's recommendations, every 7 days, or whenever a dressing change is performed.23 The application of the chlorhexidine-impregnated dressing is documented on the maintenance sheet and includes the lot number and expiration date. With the daily assessment, the PICC nurse documents the position of the catheter tip on the chest radiograph, along with the length of the external catheter, adjustments made to the catheter, or any identified complications (Figure 5).
 | FIGURE 5. PICC maintenance form. PICC indicates peripherally inserted central catheter. |
A care bundle is a group of evidence-based practices that, when applied individually, improve patient outcomes. When “bundled,” these practices are shown to dramatically improve outcomes for a particular disease process above and beyond what would be expected from these interventions individually.2,5,24 The central line bundle is a group of evidence-based interventions for patients with intravascular central catheters that, when implemented together, produce better outcomes than when implemented individually. The science supporting the bundle components is sufficiently established to be considered standard of care.2,24 The Institute for Healthcare Improvement (IHI) defines the key components of the central line bundle: (1) hand hygiene, (2) CHG skin antisepsis, (3) MSBPs, (4) optimal catheter site selection, and (5) daily review of line necessity. Each component of the bundle focuses on the prevention of CRBSIs at each of the mechanisms identified as potential sources of bloodstream infections.24 Therefore, distinguishing the component responsible for the prevention of CRBSIs cannot be determined when utilizing the central line bundle. However, only 3 of the components will be discussed: (1) hand hygiene, (2) CHG skin antisepsis, and (3) MSBPs.
HAND HYGIENE
Hand hygiene compliance was not monitored. All disciplines of the healthcare team could potentially have contact with patients without washing their hands between patients.
All disciplines providing patient care or services in the SCN received a position statement from the SCN infection control collaborative team. The position paper stated that all disciplines were required to perform a 30-second hand washing prior to entering the unit and hand hygiene between patients.
Hand hygiene has been shown to minimize the incidence of hospital-acquired infections. Interrupting the transfer of organisms on the hands can prevent many infections, thus resulting in decreased length of hospital stay, decreased mortality and morbidity incidences, and better patient outcomes.2,11 Good hand hygiene before catheter insertion or maintenance, combined with proper aseptic technique during catheter manipulation or entry, provides protection against infection.2,18
The World Health Organization25 illustrates and describes the 5 moments for hand hygiene as occurring (1) before patient contact, (2) before an aseptic task, (3) after body fluid exposure risk and after removal of gloves, (4) after patient contact, and (5) after contact with patient surroundings. Since encouraging proper hand hygiene procedures is critical to preventing hospital-acquired infections, our SCN utilizes the illustration as part of our ongoing hand hygiene campaign. Monthly hand hygiene audits are conducted by members of the infection control collaborative team and PICC team (Figure 6). The audits are interdisciplinary and therefore include all members of the healthcare team including nurses, physicians, respiratory therapists, occupational/physical therapists, audiologists, ultrasound technicians, and x-ray technicians. Each discipline is provided with a report; in addition, reports are submitted to the hospital infection control department and to the staff via postings and communicated during staff meetings.
 | FIGURE 6. Hand hygiene prevalence audit tool. IV indicates intravenous; the JCAHO, Joint Commission on Accreditation of Healthcare Organizations. |
CUTANEOUS ANTISEPSIS
Povidone—iodine and alcohol were the only antiseptics utilized for all procedures. Large bottles of povidone—iodine were utilized for multiple patients.
Chlorhexidine gluconate and povidone—iodine are utilized on a specific patient population. Povidone– iodine is acquired in 4-oz bottles and utilized for a single patient.
In the United States, povidone—iodine has been the most commonly used antiseptic for cleansing VAD insertion sites. However, in one study, preparation of VAD insertion sites with a 2% CHG with 70% alcohol (Chloraprep) decreased bloodstream infection rates when compared with the site preparation with povidone—iodine or 70% alcohol.2,26 The agents utilized in our SCN are povidone—iodine and Chloraprep. Guidelines for usage by the unit are based on gestational age as well as on day of life. Chloraprep is the prepping agent of choice for neonates 28 weeks gestational age or more or 10 days of age or more. CHG-containing antiseptics should be used, where approved for skin preparation before and after catheter insertion.2,8,24,26 Povidone—iodine is the skin preparation for infants less than 28 weeks gestational age and younger than 10 days. According to the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN), no skin disinfectant is without potentially significant risk in the neonatal population; therefore, nurseries should evaluate the evidence and make their own decisions regarding disinfectant selections.27
The CDC emphasizes that the comprehensive strategy to maintain sterile conditions during insertion should include the following 3 components: educating individuals who insert and maintain catheters; utilization of MSBPs; and a 2% CHG preparation for skin antisepsis during VAD insertion. Prior to PICC insertion, the PICC nurse prepares the site with the approved antiseptic. After the infant is draped, a second preparation is performed with the same antiseptic moments before cannulation. Povidone—iodine can be absorbed, leading to elevation of iodine levels and hypothyroidism; therefore, it is removed with sterile water to prevent absorption of the product. The 2% CHG continues to prevent antimicrobial activity for up to 48 hours after application; however, AWHONN recommends the removal of all disinfectants with sterile water or saline solution after a procedure is completed to prevent tissue damage.27
The chlorhexidine-impregnated dressing (Biopatch) (Figure 7) diminishes heavy cutaneous colonization at the insertion site and consequently diminishes catheter tip colonization by disrupting the bacterial cell membrane through the controlled release of the antiseptic, CHG.2,23 However, the risk of local contact dermatitis under the chlorhexidine dressing limits its use in low birth-weight infants who require extended central access during the first 2 weeks of life.2,23 According to the CDC, the application of the chlorhexidine sponge dressing should not be utilized for neonates younger than 7 days or of gestational age less than 26 weeks. Our unit trialed the Biopatch dressing during the summer of 2006. On the basis of that clinical experience, guidelines were approved for usage in our SCN. Currently, the dressing is utilized on infants 10 days or older or of gestational age 28 weeks or more, the same guidelines as established for the application of Chloraprep.
 | FIGURE 7. Secure PICC dressing with Biopatch and 3 (Tegaderm. PICC indicates peripherally inserted central catheter. |
MAXIMAL STERILE BARRIER PRECAUTIONS
Utilization of maximum sterile barrier precautions was an established practice for all central line insertions. Admission carts housed supplies for insertion of umbilical lines; however, a standardized cart for PICC insertion was not yet established.
The SCN PICC cart was developed and contains the required supplies for insertion. The cart is transported to the bedside, allowing the PICC team to institute each component of the central line bundle with each insertion.
Vascular access devices carry a significantly greater risk for infection than do PIVs; therefore, the level of barrier precautions required to prevent infection during insertion of VADs should be more rigorous.2,11 MSBPs have been shown to reduce the risk of infection by 6 to 7 times over the use of sterile gloves and drapes alone. MSBPs during insertion of VADs (sterile gloves, long-sleeved sterile gown, mask, cap, and large sterile sheet drape) diminish the incidence of CRBSI when compared with standard precautions (sterile gloves and small drape). For the infant, maximal barrier precautions include draping the neonate from head to toe with sterile drapes with a small opening for the site of insertion.24 MSBPs should be the standard of care during VAD insertion.2,8,11 The IHI recommends maintaining equipment readily stocked and available in a cart for central line placement. This practice alleviates the difficulty of finding necessary equipment required to institute MSBPs, and thereby promotes compliance.24
Since PICC insertion is considered a minor procedure (duration of 5–10 minutes), hand washing is performed for a full 2 minutes with a CHG-enhanced soap.28 Barrier protective equipment is donned, and then the infant is draped. To drape the baby, 4 to 5 sterile cloth towels are placed strategically for complete coverage (Figure 8). Cloth drapes are preferred because we believe they maintain their position better than do paper or plastic drapes, thus decreasing the potential for contamination. Figure 9 depicts our PICC cart with a list of recommended supplies to stock. The PICC nurse utilizes the top surface of the PICC cart to prepare a sterile field for the procedure. The IHI recommends the utilization of a central line insertion checklist that incorporates the 5 elements of the central line bundle. The PICC cart serves this function by the incorporation of the supplies required to execute the components of the bundle: (1) CHG-enhanced soap (hand hygiene), (2) sterile cloth drapes (MSBPs), (3) Chloraprep (skin antiseptic), (4) SCN PICC tool (optimal site selection), and (5) PICC insertion and maintenance form (daily review of line necessity).
 | FIGURE 9. SCN PICC cart. PICC indicates peripherally inserted central catheter; SCN, special care nursery. |
 | FIGURE 8. Maximal sterile barrier precautions. |
VERMONT OXFORD PBPS
Substantial proportions of CRBSIs are preventable through the manner in which care is provided.2,5,11 Attention to simple and practical interventions minimizes the risk for intravascular CRBSI.2,8 Nurses caring for infants with VADs must be knowledgeable about effective management to prolong the catheter's dwell time and prevent complications and injury to the infant. Providing education and training regarding the indications for the use of intravascular catheter, maintenance of intravascular catheters, and appropriate infection control measures to prevent intravascular catheter-related infections is crucial.
Guidelines for the reduction of hub colonization instituted by the SCN included the development of a standardized hub care practice, educating the staff regarding hub care practices, compliance measures, feedback regarding adherence to the practice, and surveillance monitoring.11 The SCN infection control collaborative team was instrumental to the development of the hub and line care program. Initially, the team was responsible for reviewing and analyzing the current practices of the unit. Policies and procedures were revisited along with direct observation of line care and maintenance practices on the unit. This information was compiled and analyzed by the collaborative team. On the basis of the data obtained and the PBPs shared during the VON NICQ, the focus was aimed toward the mechanisms that could potentially lead to hub contamination: (1) how blood was collected via stopcocks, (2) how IV medications were administered, (3) procedure for medication administration on a syringe pump, and (4) procedure for changing IV fluids. A “Hub and Line Care Maintenance” program was created by the PICC clinician in collaboration with the SCN infection control collaborative team.
HUB CARE
Healthcare providers did not utilize an antimicrobial soap or alcohol-based foams or gels. Staff wore artificial nails and utilized personal lotions.
Two percent CHG-enhanced soaps are stocked at each sink in the SCN. Alcohol-based foams are placed at each patient's bedside. Jewelry and personal lotions are prohibited in the SCN.
PBPs emphasize the importance of vigorous hand hygiene for 10 to 15 seconds before and after patient contact, after using gloves during patient care and when in contact with patient equipment, and the addition of waterless alcohol-based foams maintained at the bedside to enhance hand decontamination compliance.2,11,17 CHG and triclosan were the 2 antiseptic agents recommended during the VON NICQ collaborative. Both products are relatively fast acting and have broad Gram-negative and Gram-positive activity.28 Our facility adopted the 2% CHG antiseptic soap, due to reports of less irritation. Dermatitis and dryness can result from repeated hand washing. This irritation can lead to decreased compliance with hand hygiene practices. Therefore, it is recommended that lotion be used frequently. However, lotions must be compatible with the antiseptic soap utilized; thus, the companion lotion was also acquired and both products were strategically mounted at each sink.
Alcohol-based waterless foams may be useful as an adjunct to hand washing. These products contain alcohol, 60% to 70%. They are useful when patient contact is urgently needed and if the hands are not visibly soiled.29,30 There is strong evidence that hand antisepsis can reduce transmission of nosocomial microorganisms. Alcohol-based foams reduce bacterial counts on the hands of healthcare providers more efficiently than do plain or antimicrobial soaps, can be made more accessible than sinks, and require less time to use and cause less skin irritation and dryness than washing hands with soap and water. During routine patient care, hand hygiene with an alcohol-based foam is significantly more effective in decontaminating hands than hand washing with an antiseptic soap.29,30
HUB CARE PRACTICE
Lines were entered without vigorously cleaning the hub and without utilizing gloves. Healthcare providers also did not routinely change the hubs on catheters. Multiple line entries were used for medication administration.
Healthcare providers must utilize gloves and cleanse the hub before each line entry (Box 2). Hubs are changed weekly, after blood draws, or when the hub becomes soiled. Infants requiring frequent sedation are placed on continuous infusions. Once infants reach ½ to 2/3 volume of full feeds, IV medications are converted to oral preparations if applicable.
 | Box 2. Hub care |
The microorganisms that colonize the catheter hub are most commonly the same as those isolated from infected catheter tips and the bloodstream in neonates diagnosed as having a CRBSI.2,11,19 Salzman and colleagues discovered that 99% of hub decontamination was accomplished by mechanical friction, and the remaining decontamination was accomplished efficiently by the utilization of 70% alcohol. Protocols for disinfecting, accessing, and changing the hub have been established in our unit's policies and procedures in accordance with VON PBPs, Infusion Nurses Society's (INS's), and manufacturer's recommendations.2,11,18
Education focuses on preventing the entry of microbes into the vascular system and is emphasized to all staff members. The nurses and respiratory therapist are aware of the importance of accessing the silicone membrane hub by utilizing these essential techniques: (1) performing hand hygiene; (2) donning gloves; (3) establishing a sterile work area; and (4) cleansing the hub vigorously with alcohol for 10 seconds, using sufficient friction and allowing the hub to dry prior to entry. As part of the protocol, hubs are changed weekly, specifically on Sunday, or after a blood draw per manufacturer's and INS's standards.
Monthly line entry surveillance is conducted to monitor compliance to the policies related to line entry practices (performing hand hygiene, donning gloves, cleansing the hub for the recommended time frame, and allowing the hub to dry completely before entry). This is a very difficult observation to make anonymously; therefore, bedside nurses participating in our hospital-wide Clinical Advancement Program collect these data while providing bedside care.
STANDARDIZATION OF LINE SETUPS
Healthcare providers did not utilize sterile gloves or prepare a sterile field to change fluids. Administration sets comprised multiple connections. Healthcare providers did not routinely wipe down surfaces prior to hanging fluids.
A sterile work field is created for fluid changes, including utilizing sterile gloves when connecting administration setups. Specially bonded bisets and trisets were constructed with bonded hubs to decrease the number of connections required during fluid changes; this also provided a leur-locking system for the administration set and a designated medication port when utilizing the triset (Box 3).
 | Box 3. Procedure for tubing changes |
Based on the VON NICQ PBPs, changes in practice regarding tubing changes were initiated. The PBPs include utilizing the minimum number of ports on line setups, standardized management for changing TPN, and intralipid infusions and antiseptic maneuvers surrounding hub entry.2,11,17 Staff members are educated via computer-based learning activities and are required to perform a return demonstration. Currently, the bedside nurse changes fluids by utilizing aseptic technique. All fluids are changed on a sterile barrier with sterile gloves, and all connections are made aseptically prior to accessing the fluids: (1) utilizing nonsterile gloves, the nurse cleanses the infusion pumps and bedside cart with an antimicrobial wipe, (2) a clean pad is placed on the bedside cart, (3) the exposed inner surface of the opened tubing packages provides a sterile work field on top of the pad, and (4) the nurse dons sterile gloves and prepares to assemble the tubing, securing all connections aseptically before “spiking” the new fluids.
Infants may require a continuous infusion of 1 or more fluids along with continuous or intermittent medication administration.3 To minimize entry into the VAD and decrease the risk of contamination, intermittent injection tubing should remain attached to the primary administration set and is not removed after each injection.1,3 Therefore, we utilize a customized single (Baxter Interlink Minivolume Catheter Extension Set) and triset (Baxter Interlink Minivolume 3 Lead Catheter) interlink system to minimize contamination (Figure 10).
 | FIGURE 10. Tri-set (Mini-volume 3 lead catheter, Threaded Cannula, & Interlink injection site). |
All “clear” fluids are changed every 24 hours, and administration sets infusing through a central or peripheral line are changed every 72 hours. TPN, intralipid, and administration sets infusing through central or peripheral lines are changed every 24 hours.2 Staff nurses have been instructed to set up umbilical and peripheral arterial catheters by utilizing a closed system developed by the clinical leadership. This setup entails replacing the heparinized syringe normally found on the stopcock with a split septum hub (Baxter Interlink Injection Site) (Figure 11). Specimens are withdrawn via the split septum hub followed by flushing with heparin through the hub. Specimens obtained from a peripheral arterial are collected via the T-connector hub as usual, and the split septum hub attached to the stopcock is accessed to flush the line and calibrate the transducer.
 | FIGURE 11. Closed system setup. |
As a unit, we have learned that continuing education related to infection control measures that minimize CRBSIs must be constantly presented to the staff to maintain performance compliance. Therefore, each fiscal year, the SCN leadership identifies a performance improvement initiative that focuses primarily on infection control and prevention.
CONCLUSION
Premature and critically ill neonates in the NICUs are a population at exceedingly high risk for CRBSIs. These nosocomial bloodstream infections can occur from several different points of entry. Therefore, it is our belief that multiple strategies must be initiated to prevent these potentially life-threatening infections. It is paramount for healthcare professionals to implement preventative strategies directed toward each point of entry in an attempt to minimize CRBSI. For this to occur within our facility, the SCN infection control collaborative team and SCN PICC team conduct monthly meetings to discuss CRBSIs as well as all major infections. The goal of the meetings is to review surveillance data, identify areas of needed improvement, formulate educational opportunities and present the information, and provide recommendations for improvement and education.
The objective for our collaboration with the VON NICQ was to obtain and implement strategies that could potentially minimize and/or prevent many nosocomial infections acquired by our most fragile patients. The interventions our facility utilize include (1) the VON NICQ's PBPs related to hand hygiene practices, management of vascular lines with emphasis on hub care, and the use of MSBPs during VAD insertion; and (2) the CDC's Central Line Bundle Package, which also incorporates hand hygiene practices and MSBPs, in addition to 2% CHG for skin antisepsis and a dedicated PICC team. Continuing education regarding these interventions and surveillance monitoring is vital to experience and maintain positive patient outcomes.
Since our collaboration with the VON NICQ, many positive outcomes have occurred. In our SCN, catheter-related infections have reduced by more than 50% since the incorporation of the VON NICQ PBPs, along with the CDC's performance indicators. Our infants do not experience the pain associated with multiple venipunctures, our babies are receiving the most appropriate therapy via the most appropriate VAD, and the potential for a CRBSI continues to decline. The challenge posed by the VON NICQ collaborative states, “Nosocomial (health-care acquired) infection for the very low birth-weight infants must be dramatically reduced if not entirely eliminated.” We have chosen to pursue that challenge.
Acknowledgments
We thank our clinical nurse specialist, the SCN infection control collaborative team and, the SCN PICC team. We also thank the 280 neonatal intensive care nurses who are essential to the success we are experiencing in our Special Care Nursery; Helen Tucker, RN, for creating the graphs; and Kathy De Nell, RNC, BSN, for the photography.
References
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