CLABSI SUPPLEMENTAL CALL

1. CLABSI SUPPLEMENTAL CALL Prevention of Central Venous Catheter-Associated Bloodstream Infections in Neonates June 19, 2012 Jeffery S. Garland, MD, SM Wheaton Franciscan Healthcare St. Joseph Hospital

2. CLABSI Prevention in Adult ICUs vs. NICUs • Sick adults vs. sick neonates • Pathogenesis of catheter infections in adults vs. neonates • Antiseptics used for each population • Line placement and line care in adults vs. neonates • Adult care givers vs. neonatal caregivers • Wisconsin neonatal experience vs. Michigan experience

3. Are Sick Neonates Just Small, Sick Adults? Probably more similar than different: • Both can require ventilator support • Both can have congestive heart failure • Both often require pressor therapy and toxic medications • Both can have CVC infections

4. Pathogenesis of CLABSI in Neonates 67 percent due to hub contamination 13 percent due to catheter tract contamination

5. Garland et al., Pediatrics 2001 Maki et al., ICAAC 2000 Comparison of Adult and Neonatal Results to Evaluate Efficacy of Chlorhexidine Impregnated Dressing to Prevent CLABSI

6. Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 Prepare clean skin with a > 0.5% chlorhexidine preparation with alcohol before central venous catheter. If there is a contraindication to chlorhexidine, tincture of iodine, an iodophor (povidone-iodine) or 70% alcohol can be used as alternatives. (Category IA) No recommendation can be made for the safety or efficacy of chlorhexidine in infants aged <2 months. Unresolved issue.

7. Povidone Iodine vs. CHG for Central Catheter Placement Most adult ICUs use CHG Meta-analyses and a large randomized trial (Timsit, JAMA) with a CHG impregnated gauze support the use of CHG or the novel gauze in adults Many hospital infection control personnel would like to have “one-size fits all” because what works in adults should work in neonates, or does it?

8. Comparison of Peripheral Catheter Colonization Rates Among Povidone-Iodine (PI) Treated Sites vs. Chlorhexidine Treated Sites

9. Chlorhexidine Impregnated Patch in Neonates

10. Burn Caused by Chlorhexidine Impregnated Patch

11. Chlorhexidine vs. Povidone Iodine Among Neonates with PICCs

12. CHG Absorption 5/10 with a measurable concentrations after first application 7/10 had a measurable concentration (range 13-100 ng/ml) during catheterization Serum concentrations increased after first or second dressing change in 6/7 neonates with measurable concentrations

13. Povidone-iodine vs. CHG in NICU Lack of data because of FDA stance Industry stance Thus: Neonatal caregivers have to accept the risk of CHG to reduce CVC related blood stream infections National experience

14. National vs. Wisconsin Skin Antisepsis Use

15. Will Adult Insertion Checklist be Enough to Reduce CLABSIs Among Neonates? Provonost initiative in Michigan (NEJM, 2006) to reduce catheter associated blood stream infections in adult ICU patients • Used five evidence based CDC guidelines for central venous catheter related infections • proper hand washing prior to insertion • full-barrier precautions at insertion • CHG • avoid femoral site • remove unnecessary catheters

16. Will Insertion Checklist Be Enough to Reduce CLABSIs Among Neonates?

17. Line Placement and Line Care in Adults vs. Neonates Pronovost initiative, insertion bundles, insertion checklist etc…. all are directed at just 13% of infections causing CVC infections Until recently most neonatal initiative were also concentrating on sources of infection at the time of insertion, which would miss the most important source----hub contamination!!

18. Why is the Hub So Important in Neonates? Catheter access • Mean 4.5 times/day • sick neonates 20-50 times/day Mechanical access ports Environment Developmental care

19. Environment and Developmental Care in the NICU

20. Wheaton-St Joseph-HUB AND CLAVE CARE 1. Wash hands/gloves on 2. Place sterile gauze under hub/clave 3. Scrub the clave with alcohol for 15 seconds. 4. Administer medication through clave IV push or over pump 5. Disconnect medication/tubing and scrub clave with alcohol for 15 seconds. 6. Flush clave with .5cc- 1 cc of normal saline

21. Hub, Tubing Change and Dressing Change Checklist Reminders

22. Daily Line Goals

23. Nine State Collaborative to Reduce CVC Infections Among Neonates 9 state initiative headed up by Marty McCaffrey, Keith M. Cochran • Approx 100 NICUs, 13/17 Wisconsin NICUs Aim: reduce CVC infections by 75 % in participating state NICUs. Use evidence based guidelines for insertion and maintenance of catheters

24. Mock-up of Data Collection Pertaining to Catheter Maintenance for the Initiative Maintenance Information Patient ID:______________ Date of Maintenance: Shift of Data Collection: Day Night Line discontinued today Catheter: Broviac  Other PICC UAC UVC Today, this patient was on enteral feeds:  <120 ml/kg/day  >= 120 ml/kg.day In MD bedside rounds today decided the baby still needs this line: Yes No Don’t know

25. Mock-up of Data Collection Pertaining to Catheter Maintenance for the Initiative Was catheter accessed for any reason during your shift? Yes  No If yes, did staff glove before access?  Without Prompting  With prompting  Not done If yes, did staff perform hand hygiene before and after gloving?  Without Prompting  With prompting  Not done If yes, was the hub/connector cleaned for at least 15 seconds?  Without Prompting  With prompting  Not done If yes, check all used for hub prep:  Chlorhexidine  Povidone Iodine  Alcohol  Sterile Water

26. Mock-up of Data Collection Pertaining to Catheter Maintenance for the Initiative If yes, was solution allowed to completely dry?  Without Prompting  With prompting Not done Was infusion tubing changed during your shift?  Yes  No If yes, did staff at a minimum wear gloves?  Without Prompting  With prompting  Not done

27. Differences in Adult ICU Culture and NICU CultureAttending Staff Issues Adult ICU attendings: Many different types, (intensivist, cardiologist, all sorts of surgeons, pulmonologist etc…) • All may have vested interest that often involves protecting turf • All may have different opinions as to how their patients central venous catheters will be managed • Fellow and resident teams common • Closed vs. Open units

28. Differences in Adult ICU Culture and NICU Culture-Attending Staff Issues NICU attendings: • Most Level III NICUs have one neonatal attending group with and without a cadre of NNPs. • Fellows and residents may or may not be present, usually they are in large academic centers. • Most patient care policies are freely discuss among all caregivers without much turf dispute. • Surgeons, cardiologist and other consultants are usually “guests” rather than drivers of day to day care.

29. Differences in Adult ICU Culture and Neonatal ICUType of patient Adult ICUs • Patients with open wounds, foley’s, abdominal drains, chest tubes and other tubes draining from various orifices. NICUs • Most sick NICU patients do not have these drains or wounds—an OG or NG with or without an ET tube--that is about it. • Immature immune system

30. Differences in Adult ICU and Neonatal ICU Culture Nursing Staff Adult ICU nurses: • Turn over low • Shorter stays for adults, not as attached to the transient population NICU nurses: • Turn over exceedingly low (30 years of collaboration) • Very long stays for VLBW, nurses very attached, because they dictate so much of the care the infants receive. • Because of developmental care they have a vested interest in “protecting” their patients

31. Wisconsin vs. Michigan Experience

33. Thank You Questions?

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