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)
Daily review of CVC dressing and site of insertion
Prompt removal when the central line is no longer needed.
A (High quality)
Guideline
Insertion of a CVC: checklist is used before starting the intervention. (16)
A (High quality)
Guideline
For neonatal unit
A unit guideline on CVC insertion and maintenance bundles is available and regularly updated.
B (High quality)
Guideline
The prevalence of bloodstream infections per 1000 central line-days is documented.
B (Moderate quality)
Audit report2
Training on CVC insertion and maintenance bundle elements is ensured. (15)
B (High quality)
Training documentation
For hospital
N/A
For health service
A national guideline on CVC insertion and maintenance bundles is available and regularly updated.
B (High quality)
Guideline
Central line-associated bloodstream infections rates are publicly available.
B (Moderate quality)
Audit report2
1The indicator “patient information sheet” is an example for written, detailed information, in which digital solutions are included, such as web-based systems, apps, brochures, information leaflets, and booklets.
2The indicator “audit report” can also be defined as a benchmarking 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.
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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.
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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.
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.
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.
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.
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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.
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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.
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.
