Minimizing catheter-related bloodstream infections: one unit's approach

Correlation between visual inspection/physical exam and point-of-care ultrasound exam in the evaluation of neonatal peripheral intravenous catheter site

BACKGROUND

A peripheral intravenous catheter (PIVC) is used to administer IV fluids and medications. The most common PIVC complication is peripheral intravenous extravasation and infiltration (PIVE/I). Early visual inspection and physical exam (VI/PE) of the insertion site performed by a registered nurse (RN) are essential to prevent or limit tissue damage caused by displaced PIV catheters. Skin ultrasound (US) of the PIVC site provides rapid, real-time, high-resolution images of the anatomic structures at the point of care (POC).

OBJECTIVES

To correlate the standard practice of clinical assessment (VI/PE) with POC-US exam to determine the location and function of PIVC suspicious for malfunctioning.

DESIGN/METHODS

PIVC sites suspicious of malfunctioning were assessed by RN and findings were recorded in the electronic medical record. POC-US exam of the PIVC site was performed immediately after VI/PE. Sonographic exam included B-mode assessment of the PIVC site subcutaneous tissue characteristics and PIVC location as assessed by the Doppler flow tracing during RN's normal saline flush. RN's decision to continue or discontinue the PIVC was based solely on her/his VI/PE.

RESULTS

Forty-four infants were studied. We found sufficient disagreement between the two methodologies (p = .0074), with discordance noted in 15 (34.1%) cases. In 29 (65.9%) cases there was concordance between VI/PE and POC-US, 18 to remove and 11 not to remove PIVC (Gwet AC1 correlation coefficient = 0.34). There was no significant correlation between VI/PE finding of tissue edema, the most common initial clinical evaluation sign, and POC-US finding of tissue edema or fluid pockets (p = .67, p = .21 respectively). RN's findings during the PIVC flush with normal saline (NS) were in perfect agreement with the findings of the Doppler signal on POC-US (Gwet's AC1 = 0.82) as well as with the final US-based decision to remove PIVC (p < .0001).

CONCLUSION

We found only a fair correlation between RN's VI/PE of the suspicious PIVC site and the POC-US exam of the same site. However, our data suggest that in the evaluation of questionable PIVC, POC-US could be used in conjunction with VI/PE. This combination may improve the accuracy of decisions to remove or maintain PIVCs, which will result in a decreased number of PIVC placement attempts and complications.

[Operation and management guidelines for peripherally inserted central catheter in neonates (2021)]

Peripherally inserted central catheter (PICC) has been widely used in the neonatal intensive care unit (NICU) in recent years, but there are potential risks for complications related to PICC. Based on the current evidence in China and overseas, the operation and management guidelines for PICC in neonates were developed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) in order to help the NICU staff to regulate the operation and management of PICC.

Simulation training to improve aseptic non-touch technique and success during intravenous cannulation-effect on hospital-acquired blood stream infection and knowledge retention after 6 months: The snowball effect theory

BACKGROUND

Intravenous cannulation is a common procedure and a valuable skill in the neonatal intensive care unit. Standardized procedure and personnel training are needed in the unit to prevent hospital-acquired blood stream infections. Hence, we evaluated the effect of training using a low-fidelity simulation on the improvement of the aseptic non-touch technique during intravenous cannulation and knowledge retention after 6 months.

METHODS

The study was conducted in a tertiary care neonatal unit from June 2017 to July 2018. All the staff nurses and junior resident doctors posted in the neonatal intensive care were included in the study. A protocol and checklist score sheet was developed. The score sheet consisted of 23 items with a total score of 46. Participants were expected to obtain a minimum of 80%. A pre-test was conducted initially, followed by a formal training and then a post-test. The NITA newborn venous access mannequin was used to facilitate the training. A re-training for new nurses was conducted after 6 months. Data were analyzed using paired t-test.

RESULTS

A total of 29 doctors and nurses were enrolled in the training. The mean pre-test score was 29.93 compared to 42.66 in the post-test scores (mean difference 12.24(95% confidence interval: 9.39-16.05), p < 0.01. The mean scores were higher when the simulation was conducted after 6 months. There was a significant decline in blood stream infection rates from 5.5 to 1.65 per 1000 patient days (p = 0.05).

CONCLUSION

Simulation-based training of health care personnel is a good modality to improve aseptic non-touch technique during intravenous cannulation in the neonatal intensive care unit. Simulation-based training also helps in knowledge retention and standardization of training procedures.

Preventive bundles to reduce catheter-associated bloodstream infections in neonatal intensive care

This systematic survey includes a total of 27 studies published between 2002 and 2016 on the benefit of preventive bundles for the prevention of central-line associated bloodstream infections (CLABSI) in neonatal intensive care. These studies are mainly cohort studies or studies analyzing an interrupted time series before and after intervention. The studies showed heterogeneity in terms of endpoint definitions (CLABSI), details of the implemented measures, and evidence of a publication bias favoring the use of of preventive bundles. The cumulative analysis showed a statistically and clinically significant benefit of preventive bundles to avoid CLABSI in neonatal intensive care.

Human factors related to time-dependent infection control measures: "Scrub the hub" for venous catheters and feeding tubes

BACKGROUND

The use of catheter hub decontamination protocols is a common practice to reduce central line-associated bloodstream infections. However, few data exist on the most effective disinfection procedure prior to hub access accounting for human factors and time-dependent practices in real time in the clinical setting.

METHODS

An observational design with a multimodal intervention was used in this study in a neonatal intensive care unit. Direct observations on nurse compliance of scrub times with decontamination when accessing of venous catheter and feeding tube hubs were conducted during 3 phases: (1) baseline period prior to any interventions; (2) during an educational intervention phase; and (3) during a timer intervention period when using a timing device, either an actual timer or music button.

RESULTS

Overall, both education and the timing device interventions increased the mean scrub time ± SD of venous catheter hubs. Mean baseline scrub times of 10 ± 5 seconds were lower compared with 23 ± 12 seconds after educational intervention (P < .002) and 31 ± 8 seconds with timer or music button use (P < .001). Timer intervention scrub time was also more effective than education alone (P < .05). Similar findings were observed with scrub times of feeding tubes.

CONCLUSIONS

Time-based infection control measures, such as scrubbing the hub, must be implemented with aids that qualify specific times to account for human factors, to ensure adherence to time-dependent measures aimed at decreasing nosocomial infections.

Peripheral intravenous cannulation: complication rates in the neonatal population: a multicenter observational study

INTRODUCTION

Neonates admitted to a neonatal intensive care unit (NICU) rely highly on intravenous (IV) therapy, for which the peripheral intravenous cannula (PIVC) is the preferred device to allow such therapies to proceed. Placement of a PIVC is a painful procedure and repeated attempts for successful insertion should therefore be limited. We aimed to quantify the incidence, complications, and factors associated with these complications.

METHODS

We conducted a prospective observational study to examine PIVC-related complications in level III NICUs of two university medical centers (UMC) in The Netherlands. We performed descriptive analyses and binary logistic regression analysis to identify factors associated with PIVC complications.

RESULTS

A total of 518 catheters were inserted in 235 infants. The first-time success rate was 45%. The predominant reason for non-elective removal due to complications was infiltration (N = 193; 67%). No significant association was found between discipline of the inserter, vein visualization device and location of the PIVC and whether or not a catheter needed to be removed due to a complication.

CONCLUSIONS

In this study the majority of PIVCs were removed after the occurrence of a complication. The most common complication was infiltration. Strategies to identify and prevent infiltration in an NICU population are required. Future interventional studies should attempt to improve first-time insertion success and reduce PIVC failure from infiltration in the neonate. Based on the results of the present study, neonatologists and physician assistants are the preferential PIVC inserters. Advanced training of all members of vascular access specialist teams and ongoing monitoring of PIVC-related complications are recommended.

Sustained Reduction in Bloodstream Infections in Infants at a Large Tertiary Care Neonatal Intensive Care Unit

BACKGROUND

Bloodstream infections (BSI) cause significant morbidity and mortality among hospitalized infants.

PURPOSE

Reduction of BSIs has emerged as an important patient safety goal. Implementation of central line insertion bundles, standardized line care protocols, and health care provider education programs have reduced BSI in NICUs around the country. The ability of large tertiary care centers to decrease nosocomial infections, including BSI, has been demonstrated. However, long-term BSI reductions in infants are not well documented. We sought to demonstrate that a low incidence of BSI can be maintained over time in a tertiary care NICU.

RESULTS

Baseline BSI incidence for infants admitted to the NICU was 5.15 and 6.08 episodes per 1000 infant-days in 2005 and 2006, respectively. After protocol implementation, the incidence of BSI decreased to 2.14/1000 infant-days and 2.44/1000 infant-days in 2008 and 2009, respectively. Yearly incidence remained low over the next 4 years and decreased even further to 0.20 to 0.45 infections per 1000 infant-days. This represents a 92% decrease in BSI over a period of more than 5 years.

IMPLICATIONS FOR PRACTICE

Implementation of a nursing-led comprehensive infection control initiative can effectively produce and maintain a reduction in the incidence of BSI in infants at a large tertiary care NICU.

IMPLICATIONS FOR RESEARCH

Additional research is needed to effectively expand prevention of central line-associated BSIs to BSIs of all etiologies.

Aspiration and evaluation of gastric residuals in the neonatal intensive care unit: state of the science

The routine aspiration of gastric residuals (GR) is considered standard care for critically ill infants in the neonatal intensive care unit (NICU). Unfortunately, scant information exists regarding the risks and benefits associated with this common procedure. This article provides the state of the science regarding what is known about the routine aspiration and evaluation of GRs in the NICU focusing on the following issues: (1) the use of GRs for verification of feeding tube placement, (2) GRs as an indicator of gastric contents, (3) GRs as an indicator of feeding intolerance or necrotizing enterocolitis, (4) the association between GR volume and ventilator-associated pneumonia, (5) whether GRs should be discarded or refed, (6) the definition of an abnormal GR, and (7) the potential risks associated with aspiration and evaluation of GRs. Recommendations for further research and practice guidelines are also provided.

Effect of a vascular access team on central line-associated bloodstream infections in infants admitted to a neonatal intensive care unit: a systematic review

OBJECTIVE

To review the effect of a vascular access team on the incidence of central line-associated bloodstream infections in infants admitted to a neonatal intensive care unit.

DATA SOURCES

MEDLINE, CINAHL, Embase, Web-of-Science and the Cochrane Library were searched until December 2013.

STUDY SELECTION

Studies that evaluated the implementation of a vascular access team, and focused on the incidence of central line-associated bloodstream infections in infants admitted to a neonatal intensive care unit, were selected.

DATA EXTRACTION

Incidence rates of central line-associated bloodstream infections were extracted, as well as information on vascular access team tasks and team composition. The quality of studies was critically appraised using the McMaster tool for quantitative studies.

DATA SYNTHESIS

Seven studies involving 136 to 414 participants were included. In general, the implementation of a vascular access team coincided with the implementation of concurrent interventions. All vascular access teams included nurses, and occasionally included physicians. Main tasks included insertion and maintenance of central lines. In all studies, a relative decrease of 45-79% in central line-associated bloodstream infections was reported.

CONCLUSIONS

A vascular access team is a promising intervention to decrease central line-associated bloodstream infections in infants admitted to a neonatal intensive care unit. However, level of evidence for effectiveness is low. Future research is required to improve the strength of evidence for vascular access teams.

Nurse-driven quality improvement interventions to reduce hospital-acquired infection in the NICU

Hospital-acquired infections are a leading cause of morbidity and mortality in neonatal intensive care units. Central line-associated blood stream infection (CLABSI) and ventilator-associated pneumonia (VAP) are costly, preventable infections targeted for eradication by the Centers for Disease Control and Prevention. After evaluation of current practice and areas for improvement, neonatal-specific CLABSI and VAP bundles were developed and implemented on the basis of available best evidence. The overall goal was to reduce infection rates at or below benchmarks set by National Healthcare Safety Network. All neonates with central lines (umbilical or percutaneous) and/or patients who were endotracheally intubated were included. All patients were risk stratified on the basis of weight per National Healthcare Safety Network reporting requirements: less than 750 g, 751-1000 g, 1001-1500 g, 1501-2500 g, and greater than 2500 g. The research was conducted as a quality improvement study. Neonatal-specific educational modules were developed by neonatal nurse leaders for CLABSI and VAP. Bundle development entailed combining select interventions, mainly from the adult literature, that the nurse leaders believed would reduce infection rates. Nursing practice guidelines and supply carts were updated to ensure understanding, compliance, and convenience. A CLABSI checklist was initiated and used at the time of line insertion by the nurse to ensure standardized infection control practices. Compliance audits were performed by nurse leaders weekly on intubated patients to validate VAP bundle implementation. CLABSI and VAP bundle compliance was audited and infection rates were measured before and after both bundle implementations following strict National Healthcare Safety Network inclusion criteria for CLABSI and VAP determination. The reduction in CLABSI elicited 84 fewer hospital days, estimated cost savings of $348,000, a 92% reduction in CLABSI (preintervention to postintervention), and a reduction in central line days by 27%. The reduction in VAP resulted in 72 fewer hospital days, estimated cost savings of $300,000, 71% reduction in VAP (preintervention to postintervention), and a reduction in vent days by 31%. Nurses are central in hospital efforts to improve quality care. The bundled interventions provided the nurses with a structure to successfully implement a systematic process for improvement. Nursing leaders ensured that bundles were implemented strategically and provided consistent and specific feedback on intervention compliance with quarterly CLABSI and VAP rates. Real-time feedback assisted the registered nurses, neonatal nurse practitioners, and physicians appreciation of the effectiveness of the change in practice. Finally, empowering the bedside nurse to lead the bundle implementation increased personal ownership and compliance and ultimately improved practice and patient outcomes.

Peripherally inserted central catheter complications in neonates with upper versus lower extremity insertion sites

PURPOSE

To compare peripherally inserted central catheter (PICC) complication rates in upper versus lower extremity insertion sites in neonates.

SUBJECTS

Neonates who had PICCs inserted while hospitalized in an urban, 84-bed, level III neonatal intensive care unit in the southwestern United States between 2004 and 2009 were included in the study. A total of 559 neonates with 626 PICCs were reviewed. Neonates who were transferred out of the hospital with an indwelling PICC or had incomplete PICC data were excluded (n = 29).

DESIGN

Comparative descriptive.

METHOD

Retrospective review of PICC records. Demographic data, neonate survival to PICC removal, PICCs inserted by non-PICC team members, and complications were compiled. Complications included presumed sepsis, occlusion, leaking, infiltration/edema, inadvertent removal, phlebitis, pleural effusion, tip malposition, and catheter breakage. The complications were analyzed between extremities using chi-square or independent-samples t test where appropriate.

MAIN OUTCOME MEASURES

Type and rate of complication requiring PICC removal and the extremity used for insertion.

PRINCIPAL RESULTS

A total of 374 PICCs (59.7%) were inserted in upper extremities and 252 (40.3%) in lower extremities. The upper and lower extremity groups were comparable in all variables except neonate survival to PICC removal, which was greater in neonates with lower extremity PICCs (95.2% in upper extremities vs 98.8% in lower extremities; P = .01). No significant difference (P = .08) was found in the overall complication rate (27% in upper extremity PICCs vs 21% in lower extremity PICCs). Presumed sepsis was the most common complication requiring PICC removal in both extremity groups. At the time of removal, upper extremity PICCs were more likely to have a noncentral tip than lower extremity PICCs (15% vs 4%, respectively). In PICCs removed because of complications, noncentral tips were found to be statistically significant in upper extremity PICCs (P < .0001).

CONCLUSIONS

No significant difference was found in complications that necessitated PICC removal between upper versus lower extremity PICC insertion sites. Catheter tip location may have a significant impact on complications and deserves further investigation. The choice of a PICC insertion site in neonates should be based on the quality of appropriate, available veins and the preference and skill of the inserter. Every effort should be made to achieve and maintain a centrally located PICC tip.

Sustained reduction in neonatal nosocomial infections through quality improvement efforts

BACKGROUND

Although reports of reduced nosocomial infections (NI) in very low birth weight infants have been published, the durability of these gains and changes in secondary outcomes, and clinical practices have less often been published.

METHODS

This was a retrospective, observational study of NI reduction in very low birth weight infants at two hospital campuses. The intervention began in 2005 with our renewed quality improvement efforts to reduce NI. We compared outcomes before (2000-2005) and after (2006-2009) the intervention by using univariate and multiple regression analyses.

RESULTS

We reduced NI by 50% comparing 2000-2005 to 2006-2009 (23.6% vs 11.6%, P < .001). Adjusting for covariates, the odds ratio for NI was 0.33 (confidence interval, 0.26 - 0.42, P < .001) in the more recent era. NI were lower even in infants with birth weight 501-1000 grams (odds ratio = 0.38, confidence interval, 0.29 - 0.51, P < .001). We also reduced bronchopulmonary dysplasia (30.2% vs 25.5%, P = .001), median days to regain birth weight (9 vs 8, P = .04), percutaneously placed central venous catheter use (54.8% vs 43.9%, P = .002), median antibiotic days (8 vs 6, P = .003), median total central line days (16 vs 15, P = .01), and median ventilator days (7 vs 5, P = .01). We sustained improvements for three years.

CONCLUSIONS

Quality improvement efforts were associated with sustained reductions in NI, bronchopulmonary dysplasia, antibiotic use, central line use, and ventilator days.

Patient safety in the NICU: a comprehensive review

Patient safety is a worldwide priority aimed at preventing medical errors before they cause death, harm, or injury. Medical errors impact 1 in 10 patients worldwide (WHO), and their implications may include death, permanent, or temporary harm, financial loss, and psychosocial harm to the patient and in some cases to the caregiver. The unique aspects and the complexity of the neonatal intensive (NICU) environment, in addition to the vulnerability of the neonatal population increase the risk for medical errors. The following article offers an overview of safety issues specific to neonatal intensive care and provides strategies and examples on how to ensure safe practice. In particular, the authors focus on strategies to improve the team process. Practice recommendations and research implications are presented.

Effect of a dedicated percutaneously inserted central catheter team on neonatal catheter-related bloodstream infection

PURPOSE

To evaluate whether the establishment of a dedicated percutaneously inserted central catheter (PICC) team is associated with reduced risk of catheter-related bloodstream infection (CRBSI) in the neonatal intensive care unit.

SUBJECTS

Participants were extremely low-birth-weight infants admitted to a level IIIC neonatal intensive care unit.

DESIGN

A before- versus after-intervention study design was implemented. Intervention group participants were admitted after April 2006 when the PICC team was established, dedicating line insertion and maintenance responsibilities to the team. Historical control group participants were managed via the previous standard of care.

METHODS

The risk of CRBSI over time was estimated by Kaplan-Meier analyses and the effect of the PICC team on CRBSI risk was evaluated after controlling for covariables in a Cox proportional hazards model.

PRINCIPAL RESULTS

Mean birth weight and gestational age were similar between groups. After controlling for gestational age, central line days, respiratory support days, and average daily census at time of admission in a Cox regression model, the intervention group had 49% lower risk of CRBSI in patients who had a central line in place for more than 30 days. There was no difference in rate of CRBSI between groups that had central lines of short or intermediate duration (<30 days).

CONCLUSIONS

Catheter-related bloodstream infection in extremely low-birth-weight infants requiring long-term central venous access was reduced by nearly half after the institution of a dedicated PICC team in the neonatal intensive care unit. Standardizing PICC line placement is important, but standardizing line maintenance is essential to improvement of CRBSI rates.