Evidence-Based Approaches to Elimination of Neonatal CLABSI

Janet Pettit DNP, NNP-BC, VA-BCJanet Pettit DNP, NNP-BC, VA-BC

Argon MedicalCalifornia Childrens Services NICU HAI

CollaborativePDI

 At the conclusion of the presentation, the participant will be able to:

Identify common components of insertion bundles used for central lines in neonatesIdentify three controversial components of maintenance bundles used for central lines in neonatesList three care processes with proven efficacy in decreasing CLABSIDistinguish two avenues beyond the insertion and maintenance bundles that have proven success in reducing and sustaining CLABSI reduction efforts

CLABSI RATES CA RNICU COLLABORATIVES- PHASES 1-3: 2006-2011 (2nd QTR)

-1.0

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

J an-06

Apr-0

6

J ul-0

6

Oct-06

J an-07

Apr-0

7

J ul-0

7

Oct-07

J an-08

Apr-0

8

J ul-0

8

Oct-08

J an-09

Apr-0

9

J ul-0

9

Oct-09

J an-10

Apr-1

0

J ul-1

0

Oct-10

J an-11

Apr-1

1

CLA

BSI/

1000

line

day

s

BASELINEN=13

PHASE 1N=13

FOLLOW-UPN=13

PHASE 2N=22

PHASE 3N=14

New CDC Definition

BASELINEN=14

CPQCC HAI Toolkit

NICU Teams

Insertion Maintenance Leadership Diagnosis

Go to website for information about bundlehttp://www.dhcs.ca.gov/ProvGovPart/initiatives/nqi/Pages/default.aspx

Maximum sterile barrier precautionsDisinfect skin with chlorhexidine or povidone

iodineDedicated team for placement & careAll supplies for procedure at bedsideHand hygiene performedInsertion checklist usedStaff empowered to stop non emergent

procedure if sterility breached

BarriersPrevious product labeling restricted use if < 2 months

of age.Updated product labeling January 2012: Use with care

in premature infants or infants under 2 months of age. These products may cause irritation or chemical burns.

Skin reactionsAbsorptionFear of the unknown

FacilitatorsEmerging evidence

Improved CLABSI reductionMinimal reactions

Adjusting use based on gestation & chronologic ageNo toxicity associated with the minimal absorptionRealization that all skin antiseptics problematic

More than half of NICUs in US are using

Should practice extend to all lines?Daily assessment of catheter needReview dressing integrity & cleanlinessUse closed system for infusion, blood sampling & medication administrationAssemble & connect infusion tubing using aseptic or sterile technique. Use consistent tubing configuration

Disinfect injection port with alcohol or chlorhexidine/alcohol for 15 seconds & allow to dry.Use of alcohol port protectors

Hand hygiene performed & clean gloves worn for catheter entry

Use prefilled, flush containing syringesStaff empowered to stop the line in non-

emergent procedure if sterility breached

Can the catheter be removed?

• Daily assessment & documentation of catheter need – Joint Commission NPSG.07.04.01 & CA requirement

• Plan for removal• Key times for removal to lessen risk

PRN change recommendedRoutine change intervals

Remove blood & drainage

Not intactUse sterile technique

Dressing typeTransparent vs. gauzeTransparent: allows direct

visualization and requires fewer changes, but no other demonstrated clinical advantage.

20

Definition of “closed”Infusion, blood

withdrawal, med administration

Close all or only central catheters

Entry point to catheter kept out of bed

Needleless connector capped with syringe at all times

System changed along with other infusion tubing

Part of Aly, 2005 bundle & adopted by many NICUs

22

Bundle componentAly 2005 & othersLack of standardization

Sterile vs aseptic techniqueResource availability

1-2 personnelSet-up carts/stationsConsistent tubing

configurationsProcedural checklist

Frequency of change

Ryder et al. Microscopic Evaluation of Microbial Colonization on Needleless Connectors. 2009. APIC Poster Presentation

Alcohol

CHG/alcohol

31% don’t

clean!

Increase contamination of vials & ampules when prepared in ward vs pharmacy Van Grafhorst Critical Care Med 2002.

Syringe contamination

Nurse filled vs. prefilled

27

The Line

Administrative involvement & support for zero HAIsEngage staff with feedback

Posting days since last CLABSIPosting rates of CLABSI

Perform investigation of each CLABSI/BSISurveillance activities for critical processes

Hand hygieneLine management and entryOff unit proceduresStop the line support

Trained personnel to perform specialized maintenance activities

Helps to ensure quality of care Means to monitor compliance

with policy Multidepartmental personnel

monitor adherence to policy Unit-based Hospital-based

Correct problem behavior while its occurring

Reward proper behavior

Developed by CCS CLABSI Prevention Collaborative

Developed by CCS CLABSI Prevention Collaborative

NHSN criteriaCulturing techniques

Feeding tubes & practices

# Line entries

Respiratory care practices

Skin assessment & # punctures

The way in which Each individual pays attention to and performs their job

PLUS

The way All individuals inter-relate, interact, and communicate while working, ultimately determines the sustainability of high quality, safe health care.

Questions: jspettit@sbcglobal.net

Chaiyakunapruk, N., Veenstra, D. L., Lipsky, B. A., & Saint, S. (2002). Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: a meta-analysis. Ann Intern Med, 136(11), 792-801. doi: 200206040-00007 [pii]

Curry, S., Honeycutt, M., Goins, G., & Gilliam, C. (2009). Catheter-associated bloodstream infections in the NICU: getting to zero. Neonatal network : NN, 28(3), 151-155.

Marschall J., Mermel, L. A., Classen, D., Arias, K. M., Podgorny, K., & Yokoe, D. S. (2008). Strategies to prevent central line associated bloodstream infections in acute care hospitals. Infection Control and Hospital Epidemiology, 29, S22-30.

Mullany, L., Darmstadt, G. L., & TielschJ. M. (2006). Safety and impact of chlorhexidine antisepsis interventions for improving neonatal health in developing countries. Pediatric Infectious Disease Journal, 25, 665-675.

O'Grady, N. P., Alexander, M., Burns, L. A., Dellinger, E. P., Garland, J., Heard, S. O., . . . (HICPAC)., H. I. C. P. A. C. (2011). 2011 Guidelines for the Prevention of Intravascular Catheter-Related Infections 1-83. Retrieved from Centers for Disease Control and Prevention website: http://www.cdc.gov/hicpac/bsi/bsi-guidelines-2011.html

Payne, N. R., Carpenter, J. H., Badger, G. J., Horbar, J. D., & Rogowski, J. (2004). Marginal increase in cost and excess length of stay associated with nosocomial bloodstream infections in surviving very low birth weight infants. Pediatrics, 114, 348-355.

Pettit, J. & Wyckoff, M. M. (2007). Peripherally inserted central catheter: Guidelines for practice. Glenview, IL: The National Association of Neonatal Nurses.

Powers, R. J., & Wirtschafter, D. W. (2010). Decreasing central line associated bloodstream infection in neonatal intensive care. Clinics in perinatology, 37(1), 247-272. doi: 10.1016/j.clp.2010.01.014

Suresh, G. K., & Edwards, W. H. (2012). Central line-associated bloodstream infections in neonatal intensive care: changing the mental model from inevitability to preventability. American journal of perinatology, 29(1), 57-64. doi: 10.1055/s-0031-1286182

Wirtschafter, D. D., Pettit, J., Kurtin, P., Dalsey, M., Chance, K., Morrow, H. W., . . . Kloman, S. (2010). A statewide quality improvement collaborative to reduce neonatal central line-associated blood stream infections. [Multicenter Study]. Journal of perinatology : official journal of the California Perinatal Association, 30(3), 170-181. doi: 10.1038/jp.2009.172

Zingg, W., Imhof, A., Maggiorini, M., Stocker, R., Keller, E., & Ruef, C. (2009). Impact of a prevention strategy targeting hand hygiene and catheter care on the incidence of catheter-related bloodstream infections. Critical care medicine, 37(7), 2167-2173; quiz 2180. doi: 10.1097/CCM.0b013e3181a02d8f