Central Line Associated Blood Stream Infection (CLABSI) in Neonates

1. Central Line Associated Blood Stream Infection (CLABSI) in Neonates

2. Background • Health care associated infections, and in particular, CLABSI are an important cause of increased morbidity and mortality • Increasingly, these infections are recognised as preventable life threatening adverse events

3. Biologically, neonates may be more at risk than older children or adults • Naïve immune system • Immature gut • Deficient barrier function of skin • The use and duration of use of central lines have been described as independent factors for late on-set sepsis

4. Central line infection rates in neonates • Umbilical venous catheters (UVC) • 3.8 to 7.2/ 1000 UVC days • Peripherally inserted central catheters (PICC) • 4.7 to 13.1/ 1000 PICC days • Surgically inserted central catheters (SICC) • 8.1 to 12.1/ 1000 SICC days • All central lines • 2.6 to 15.1/ 1000 central line days.

6. Primary prevention (avoiding central line insertion) is often not feasible in premature and critically ill neonates. • However, it is feasible to secondary prevention strategies such as • Optimal hand hygiene practices • Use of maximum sterile barrier precautions for line insertion • Use of Chlorhexidine Gluconate for skin antisepsis • Antisepsis measures for maintenance of central line • Daily assessment of the need for a central line

7. Care Bundle • “ A bundle is a structured way of improving the processes of care and patient outcomes: a small, straightforward set of practices — generally three to five — that, when performed collectively and reliably, have been proven to improve patient outcomes.” • Institute of Healthcare Improvement • N.B. • The changes in a bundle are not new: they are well established evidence-based practices but are often not applied uniformly, making treatment unreliable.

9. What are we trying to accomplish? • We will reduce newly diagnosed CLABSIs to < 2/1000 central line days among newborn infants admitted to the neonatal unit over a period of 12 months at RHSC, Glasgow. • Increase the time interval between two consecutive CLABSIs

10. How do we know that change is an improvement? • Process measures: • Compliance with hand washing • Compliance with sterile central line insertion • Compliance with sterile maintenance of line • Daily review of need for central line • Balancing measures: • Increase in number of re-insertion of central lines • Outcome measures: • Rate of CLABSI developed 48 hours after admission to the neonatal unit.

11. What change can we make that will result in improvement? • Establish central line infection prevention team • Development of CLABSI prevention bundle • Educating and training staff on indications for central line, procedure for insertion & maintenance and infection control measures • Standardising the equipment • Review each central line infection to learn from any failures • Regular feed back to the staff

12. Operational definitions • Central line: • Umbilical venous catheter (UVC) • Umbilical arterial catheter (UAC) • Peripherally inserted central catheter (PICC) • Surgically inserted central catheter (SICC)

13. Operational definitions • Central line infection: • least one central line (UAC, UVC, PICC, SICC) in-situ • Absence of another clinically or radiologically appreciated infectious focus • Presence of one or more positive blood cultures and one of the following criteria being met: • At least one blood culture growing a recognised pathogen (recognised pathogens are those not named as common skin contaminants) • At least one blood cultures growing recognised contaminant (coagulase negative staphylococci (including S.Epidermidis); Diptheroids [Corynebacterium spp]; Bacillus spp; Propionbacterium spp viridans group streptococci; Aerococcus spp; Micrococci spp) and presence of one or more clinical or laboratory signs of generalised infection (e.g., rise in temperature or hypothermia, recurrent apnea/ desaturations / bradycardia, rise in CRP etc).

14. Central line care bundle • Line Kit/ Cart • A separate trolley for UAC/UVC & PICC line set up • Hand hygiene • Monthly anonymous audits of hand washing • Maximum barrier precaution • Clinicians placing the lines should adhere to strict aseptic technique and wear sterile gown, gloves, hat and mask • Disinfection with appropriate antiseptic • 0.5% Chlorhexidine and 70% Alcohol for skin antisepsis • 2% Chlorhexidine and 70% Alcohol (Chlorprep) for access

15. Educating and training staff • Training of doctors on aseptic insertion of UAC, UVC, PICC • Training of nursing staff on aseptic procedure in preparing and connecting IV infusions • Supervision by trained personnel

16. Central line care bundle • Standardised insertion technique and dressing Antisepsis guidelines Umbilical Catheters Peripherally inserted central catheters (PICC Lines)

18. Compliance with Hand washing

19. Insertion check list

20. Compliance with insertion check list

21. Central line maintenance bundle • Catheter care • Monitoring of central line for integrity and cleanliness • For SICC lines, change dressing once a week • Replace continuous administration sets and smart sites • every week: Wednesday and Sunday • immediately after blood products • Daily review of need for central line

22. Central line maintenance check list

23. Compliance with maintenance bundle

24. Compliance with central line dressing

25. Compliance with changing of smart sites

26. Central line care bundle • Surveillance • Investigation and analysis of each central line infection to learn from any failures • Data collection • Data display • Regular feed back to the staff • Monthly reports

27. Rate of Blood Stream Infection

28. Central line summary data (Dec 2010 to May 2011)

29. Central line infection Summary data (Dec 2010 to May 2011)

30. Central line infection Summary data (Dec 10 to May11)

31. Central line infection continuous data (Dec 10 to May11)

32. Team • N Brindley: Surgical Lead • M Liddell: Nursing Lead • R Montgomerie: Nursing project lead • A Kelly: Nurse educator • C Lucas: Microbiology representative • A Patel: Pharmacy representative • S Guthrie: Neonatal trainee representative • M Steven: Surgical trainee representative • R Wilson: ANNP representative • L Todd: Ward Clerk • D Anand: Medical & Project Lead

35. Sepsis rates in VLBW Neonates • Early onset sepsis (≤ 72 hours) • 1.5% to 1.9% • Late onset sepsis (>72 hours) • 21% to 25%