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Central venous catheter infection prevention

Authors

Helder O, Tissières P, Mader S, Thiele N, Borghesi A

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User group

Healthcare professionals, neonatal units, hospitals, and health services

Statement of standard

Each hospital has central venous catheters insertion and maintenance bundles, that are consistently applied to reduce the incidence of central line-associated bloodstream infections.

Rationale

Central venous catheters (CVC) are intravascular devices used in NICU settings. In addition to ensuring long-term intravenous access to preterm and critically ill infants, CVC are used for the administration of parenteral nutrition and medications that cannot be safely administered through a peripheral intravenous catheter. (1) CVC are important components of care, but their use is associated with an increased risk of central line-associated bloodstream infections (CLABSI). (2) CLABSI are in turn responsible for considerable mortality, morbidity, prolonged hospital stay, and additional costs for healthcare systems. (3)

Definitions of neonatal bloodstream infection vary across studies. (4–6) Bloodstream infection according to the Centers for Disease Control and Prevention (CDC), can be considered to be CVC-related if a catheter has been in place for at least 24 hours or if it was removed less than 48 hours before the infection. (7)

The prevalence of CLABSI is usually expressed as CLABSI per 1000 central line-days. (8) Reported incidence in neonatal units varies depending on several factors, including the hospital site and the gestational age group, and may be as high as >10.0 per 1000 central line-days. (9,10)

The Institute for Health Improvement (IHI) and the CDC, developed ‘care bundles’ that aim to reduce the incidence of CLABSI. Care bundles (defined as small, straightforward set of evidence-based practices, according to the IHI) can be divided into two subgroups: insertion bundles and maintenance bundles. (11,12)

Basic elements for the care bundles are maximal sterile barrier precautions during insertion, skin antisepsis, and hand hygiene. Care bundles have proven effective in reducing the incidence of CLABSI in neonatal units. (8)

Benefits

Short-term benefits

  • Reduced risk of CLABSI (1–3,8–10,13)
  • Reduced risk of comorbidity associated with bloodstream infections (consensus)
  • Reduced mortality (consensus)
  • Reduced stress for parents (consensus)

Long-term benefits

  • Reduced risk of antibiotic resistant bacteria (consensus)
  • Reduced risk of poor neurodevelopmental outcome (consensus)
  • Reduced healthcare costs (8)
  • Reduced length of hospital stay (8)

 

Components of the standard

Component Grading of evidence Indicator of meeting the standard
For parents and family    
1. Parents are informed and instructed by healthcare professionals about hand hygiene. (14,15) (see TEG Patient safety & hygiene practice) A (High quality)
B (High quality)
Patient information sheet
       
2. Parents are asked to instruct the own family and relatives to apply hand hygiene guidelines. B (Moderate quality) Patient information sheet
       
For healthcare professionals    
3. A unit guideline on central venous catheter (CVC) insertion and maintenance bundles is adhered to by all healthcare professionals. (3,14) A (High quality)
B (High quality)
Guideline
       
4. Training on insertion and maintenance bundle elements is attended by all responsible healthcare professionals. B (High quality) Training documentation
       
5. An insertion bundle is used: (8) A (High quality) Guideline
 
  • Antiseptic technique for healthcare provider’s hand hygiene
   
 
  • Maximal sterile barrier precautions (caps, masks, sterile gowns, sterile gloves)
   
 
  • Patient’s skin antisepsis with chlorhexidine
   
 
  • Full-drape
   
       
6. A maintenance bundle is used: (8) A (High quality) Guideline
 
  • Applying hand hygiene
   
 
  • Aseptic performance before catheter manipulation
   
 
  • Disinfection of CVC hubs
   
 
  • Daily review of CVC dressing and site of insertion
   
 
  • Prompt removal when the central line is no longer needed
   
       
7. Insertion of a CVC: checklist is used before starting the intervention. (16) A (High quality) Guideline
       
For neonatal unit    
8. A unit guideline on CVC insertion and maintenance bundles is available and regularly updated. B (High quality) Guideline
       
9. The prevalence of bloodstream infections per 1000 central line-days is documented. B (Moderate quality) Audit report
       
10. Training on CVC insertion and maintenance bundle elements is ensured. (15) B (High quality) Training documentation
       
For hospital    
  N/A    
       
For health service    
11. A national guideline on CVC insertion and maintenance bundles is available and regularly updated. B (High quality) Guideline
       
12. Central line-associated bloodstream infections rates are publicly available. B (Moderate quality) Audit report
       

Where to go

Further development Grading of evidence
For parents and family  
  • Facilitate parents to use publicly available central line-associated bloodstream infections (CLABSI) rates to question variation between hospitals.
B (Moderate quality)
For healthcare professionals  
N/A  
For neonatal unit  
  • Ensure an incidence <5 CLABSI per 1000 central line days. (17)
B (Moderate quality)
  • Report all deviations from guideline practice as clinical incidents using the hospital reporting system (critical incidence reporting system).
B (Moderate quality)
For hospital  
  • Prepare fluids and medication under optimal aseptic conditions.
B (High quality)
For health service  
  • NICU benchmarking: report the prevalence of CLABSI per 1000 central line days.
B (Moderate quality)
  • Provide benchmarking standards: excellent performance <3.5 CLABSI per 1000 central line days, moderate performance 3.6 to 5 CLABSI per 1000 central line days, and poor performance ≥5.1 CLABSI per 1000 central line days.
B (Moderate quality)
   

Getting started

Initial steps
For parents and family
  • Parents and family are verbally informed by healthcare professionals about hand hygiene.
For healthcare professionals
  • Attend training on insertion bundles.
  • Attend training on maintenance bundles (for nurses).
For neonatal unit
  • Develop and implement a unit guideline on central venous catheter (CVC) insertion and maintenance bundles.
  • Develop information material on hand hygiene for parents.
  • Document all bloodstream infections among admitted infants.
  • Document the number of central line days.
  • Provide appropriate equipment.
For hospital
  • Support healthcare professionals to participate in training on CVC insertion and maintenance bundle elements.
For health service
  • Develop and implement a national guideline on CVC insertion and maintenance bundles.
  • Publish the incidence of central line-associated bloodstream infections per 1000 catheter days.
 

Sources

  1. Simpson CD, Hawes J, James AG, Lee K-S. Use of bundled interventions, including a checklist to promote compliance with aseptic technique, to reduce catheter-related bloodstream infections in the intensive care unit. Paediatr Child Health. 2014 Apr;19(4):e20-23.
  2. Fisher D, Cochran KM, Provost LP, Patterson J, Bristol T, Metzguer K, et al. Reducing central line-associated bloodstream infections in North Carolina NICUs. Pediatrics. 2013 Dec;132(6):e1664-1671.
  3. Zachariah P, Furuya EY, Edwards J, Dick A, Liu H, Herzig CTA, et al. Compliance with prevention practices and their association with central line-associated bloodstream infections in neonatal intensive care units. Am J Infect Control. 2014 Aug;42(8):847–51.
  4. Stoll BJ, Hansen N, Fanaroff AA, Wright LL, Carlo WA, Ehrenkranz RA, et al. Late-onset sepsis in very low birth weight neonates: the experience of the NICHD Neonatal Research Network. Pediatrics. 2002 Aug;110(2 Pt 1):285–91.
  5. Stoll BJ, Hansen N, Fanaroff AA, Wright LL, Carlo WA, Ehrenkranz RA, et al. Changes in pathogens causing early-onset sepsis in very-low-birth-weight infants. N Engl J Med. 2002 Jul 25;347(4):240–7.
  6. Camacho-Gonzalez A, Spearman PW, Stoll BJ. Neonatal infectious diseases: evaluation of neonatal sepsis. Pediatr Clin North Am. 2013 Apr;60(2):367–89.
  7. Stronati M, Borghesi A. Neonatal Bacterial and Fungal Infections. In: Neonatology. 2nd ed. Springer International Publishing Switzerland;
  8. Ista E, van der Hoven B, Kornelisse RF, van der Starre C, Vos MC, Boersma E, et al. Effectiveness of insertion and maintenance bundles to prevent central-line-associated bloodstream infections in critically ill patients of all ages: a systematic review and meta-analysis. Lancet Infect Dis. 2016 Jun;16(6):724–34.
  9. McMullan R, Gordon A. Impact of a Central Line Infection Prevention Bundle in Newborn Infants. Infect Control Hosp Epidemiol. 2016 Sep;37(9):1029–36.
  10. Steiner M, Langgartner M, Cardona F, Waldhör T, Schwindt J, Haiden N, et al. Significant Reduction of Catheter-associated Blood Stream Infections in Preterm Neonates After Implementation of a Care Bundle Focusing on Simulation Training of Central Line Insertion. Pediatr Infect Dis J. 2015 Nov;34(11):1193–6.
  11. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006 Dec 28;355(26):2725–32.
  12. Holzmann-Pazgal G, Kubanda A, Davis K, Khan AM, Brumley K, Denson SE. Utilizing a line maintenance team to reduce central-line-associated bloodstream infections in a neonatal intensive care unit. J Perinatol Off J Calif Perinat Assoc. 2012 Apr;32(4):281–6.
  13. Erdei C, McAvoy LL, Gupta M, Pereira S, McGowan EC. Is zero central line-associated bloodstream infection rate sustainable? A 5-year perspective. Pediatrics. 2015 Jun;135(6):e1485-1493.
  14. Bellissimo-Rodrigues F, Pires D, Zingg W, Pittet D. Role of parents in the promotion of hand hygiene in the paediatric setting: a systematic literature review. J Hosp Infect. 2016 Jun;93(2):159–63.
  15. Sax H, Allegranzi B, Chraïti M-N, Boyce J, Larson E, Pittet D. The World Health Organization hand hygiene observation method. Am J Infect Control. 2009 Dec;37(10):827–34.
  16. Bowen JR, Callander I, Richards R, Lindrea KB, Sepsis Prevention in NICUs Group. Decreasing infection in neonatal intensive care units through quality improvement. Arch Dis Child Fetal Neonatal Ed. 2017 Jan;102(1):F51–7.
  17. Dudeck MA, Horan TC, Peterson KD, Allen-Bridson K, Morrell G, Anttila A, et al. National Healthcare Safety Network report, data summary for 2011, device-associated module. Am J Infect Control. 2013 Apr;41(4):286–300.

November 2018 / 1st edition / next revision: 2023

Recommended citation EFCNI, Helder O, Tissières P et al., European Standards of Care for Newborn Health: Central venous catheter infection prevention. 2018.

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