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SLUG Bugs Standardizing Line Care Under Guideline Recommendations Page | ii APPENDEX SECTION Appendix B: Clinical Practice Recommendations (CPR) CHNC – CIQI CENTRAL LINE CARE Clinical Practice Recommendations (CPR) The purpose of this project is to provide potentially better practices recommendations for neonatal health care professionals for the care and maintenance of Central Lines (CL) to prevent Central Line Associated Blood Stream Infection (CLABSI) in infants in the neonatal intensive care unit (NICU). Prevention of CLABSIs in the NICU will result in a decrease in both the morbidity and mortality associated with medical conditions that require neonatal intensive care, as well as an associated decrease in health care costs. HAND HYGIENE 1, 2, 3, 4, 5, 6, 7, 8, 9, 11 Hand Hygiene Definition (for staff and families) includes hand washing or use of hand sanitizer immediately before and after patient contact. Hand Hygiene Technique Alcohol Based When decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. Follow the manufacturer’s recommendations regarding the volume of product to use. Soap and Water When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet. Hand Hygiene Compliance Direct observation of staff to include physicians, nurses and all ancillary personnel Minimum 20 observations per month Consistent observers with consistent education and training Share results with staff Report results Develop monthly reports to share with staff Consider monitoring hand hygiene compliance of families and visitors Consider sharing reports of both staff and family/visitor hand hygiene with families/visitors Attachment A (samples of reporting tools for Hand Hygiene) . CENTRAL LINE INSERTION BUNDLE 10, 11 Central Vascular Catheter (CVC) - A vascular infusion device that terminates at or close to the heart or in one of the great vessels. The following are considered great vessels for the purpose of reporting central line infections and counting central line days in the National Healthcare Safety Network (NHSN) system: Aorta, pulmonary artery, superior vena cava, inferior vena cava, brachiocephalic veins, internal jugular veins, subclavian veins, umbilical vessels, external iliac veins, and common femoral veins.
Transcript of SLUG Bugs Standardizing Line Care Under Guideline...
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Appendix B: Clinical Practice Recommendations (CPR)
CHNC – CIQI CENTRAL LINE CARE Clinical Practice Recommendations (CPR) The purpose of this project is to provide potentially better practices recommendations for neonatal health care professionals for the care and maintenance of Central Lines (CL) to prevent Central Line Associated Blood Stream Infection (CLABSI) in infants in the neonatal intensive care unit (NICU). Prevention of CLABSIs in the NICU will result in a decrease in both the morbidity and mortality associated with medical conditions that require neonatal intensive care, as well as an associated decrease in health care costs.
HAND HYGIENE 1, 2, 3, 4, 5, 6, 7, 8, 9, 11
Hand Hygiene Definition (for staff and families) includes hand washing or use of hand sanitizer immediately before and after patient contact. Hand Hygiene Technique Alcohol Based When decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. Follow the manufacturer’s recommendations regarding the volume of product to use. Soap and Water When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet. Hand Hygiene Compliance Direct observation of staff to include physicians, nurses and all ancillary personnel
Minimum 20 observations per month Consistent observers with consistent education and training
Share results with staff Report results Develop monthly reports to share with staff Consider monitoring hand hygiene compliance of families and visitors Consider sharing reports of both staff and family/visitor hand hygiene with families/visitors Attachment A (samples of reporting tools for Hand Hygiene)
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CENTRAL LINE INSERTION BUNDLE 10, 11 Central Vascular Catheter (CVC) - A vascular infusion device that terminates at or close to the heart or in one of the great vessels. The following are considered great vessels for the purpose of reporting central line infections and counting central line days in the National Healthcare Safety Network (NHSN) system: Aorta, pulmonary artery, superior vena cava, inferior vena cava, brachiocephalic veins, internal jugular veins, subclavian veins, umbilical vessels, external iliac veins, and common femoral veins.
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Central Line Insertion Dedicated teams to place lines may be beneficial to promoting education and consistency of insertion process. Team members may include trained RNs, neonatologists, NNPs, surgeons, and interventional radiology physicians.
7, 12, 13
Hand hygiene before procedure Sterile Barrier Precautions
Cover patient head to toe (head may be uncovered) with appropriate monitoring devices.
All individuals actively involved in line placement must wear mask, head cover, sterile gown, and sterile gloves.
All individuals not actively involved in line placement but present in patient space during line insertion must wear mask and head cover.
Site Preparation 14
< 2 months OR corrected-GA or weight as defined by unit specific policy used to define immature skin o 70% Alcohol prep and /or Betadine prep o Scrub time – suggest 30 second minimum o Dry time – suggest 30 second minimum (up to 2 minutes)
> 2 months OR corrected-GA or weight as defined by unit specific policy used to define mature skin o ChloraPrep or comparable chlorhexidine unit-based product
o Scrub time – suggest 30 second minimum o Dry time – suggest 30 second minimum (up to 2 minutes)
o Groin (not a preferred site for central access) Suggest 2 minute scrub with minimum of 60 second dry time (up to 2 minutes)
Document central venous catheter tip by radiograph and in chart. Site Dressing
Apply sterile dressing as per manufacturer specifications Central Line Insertion Compliance Checklist for compliance with insertion on each line placed. Attachment B (samples of reporting tools for Line Insertion)
CENTRAL LINE USE AND MAINTENANCE 7, 10, 13, 14, 15, 16, 17, 18, 19
Maintenance bundle compliance to include dressing change, chart documentation, daily assessment need, medication delivery, tubing change and blood draw components of policy/procedure. Central Line Dressing Change Dressing change per NICU protocol
Broviac – weekly and prn if dressing becomes wet, soiled or non-occlusive
PICC (central and midline) – weekly and prn if dressing becomes wet, soiled or non-occlusive
Subclavian/Jugular/Femoral – change weekly and prn if dressing becomes wet, soiled or non-occlusive
No occlusive dressing for UAC and UVC
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Some centers utilize two staff members for dressing changes
Position line hub and catheter away from dirty areas such as ostomy, diaper or exposed viscera Hand hygiene before procedure Current dressing may be removed with clean gloves with hand hygiene performed after removal of gloves Barrier Precautions for dressing change
Dressing changes require sterile technique. All individuals actively involved in dressing change must wear mask and sterile gloves
o Some centers add clean gown/head covering. o Some centers use sterile barrier to cover patient head to toe
Site Dressing
Apply sterile dressing as manufacturer specifications.
Track date/time of dressing change, insertion, and removal. Site Preparation
< 2 months OR corrected-GA or weight as defined by unit specific policy used to define immature skin o 70% Alcohol prep and /or Betadine prep o Scrub time – 30 second minimum o Dry time – 30 second minimum (up to two minutes recommended)
> 2 months OR corrected-GA or weight as defined by unit specific policy used to define mature skin o ChloraPrep or comparable chlorhexidine unit-based product
o Scrub time – suggest 30 second minimum o Dry time – suggest 30 second minimum (up to 2 minutes)
o Groin/axilla 2 minute scrub with minimum of 60 second dry time (up to two minutes recommended)
Central Line Hub Care/Blood Draws/Medication Infusion Definition of Hub/Entry Point
Any time there is an opening or access of the CVC at the hub/cap/manifold for a break in the system. Review Unit-Based Protocols for Central Line Set-Up
Minimize/standardize number of entry ports.
Consider line set ups to avoid entry ports remaining in bed Blood Draws/Medication Delivery/Fluid and Tubing Change Blood Draws/Medication Delivery/Fluid Change
Hand hygiene before procedure.
Limit line entry access (medications and blood draws)
Follow hub scrub (see below)
Tubing Change
Hand hygiene before procedure
Sterile vs. Clean Technique (scant literature to support either protocol; divided practices exist among participating centers)
Options include:
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o Sterile technique: minimum to include sterile gloves and mask with use of sterile barrier under the CVC.
o Clean technique: minimum to include clean gloves with sterile gauze barriers under the CVC.
Scrub the Hub 12, 20
o 70% Alcohol prep or ChloraPrep as per NICU protocol. o Scrub time – 15 second minimum (up to 60 seconds). o Dry time – until dry.
Multiple Medication/Simultaneous Line Entry o Repeat hub scrub as per NICU protocol.
Tubing Change Schedule o Hyper alimentation (HAL) tubing: 24-72 hours (up to 96 hours may be safe). o Lipids: 24 hours. o Crystalloids: 24-96 hours (up to 7days may be safe).
Monitor Compliance for Maintenance Bundle Compliance Attachment C (samples of self reporting tools for central line use and maintenance)
Minimum of ten monthly self-report monitors (each self report includes a 12 hour shift) for maintenance bundle compliance to include dressing change, medication delivery, tubing change, and blood draw components of policy/procedure.
Minimum ten monthly observations
Report results Develop reports to share with staff
REMOVAL 16, 17, 18
Daily Central Vascular Catheter Need and Assessment Documentation
Daily assessment of central line need and utilization
Things to consider
mechanical issues in the past 24 hours (line clotted-TPA used, line to be repaired)
frequency of line entry Monitor Compliance for Daily Need for Central Vascular Catheter Attachment D (samples of self reporting tools for central line removal)
Checklist for ongoing need for access, frequency of line entry, line complications, and/or mechanical problems.
Report results to staff.
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CVC – CLABSI REVIEW FORM 8, 9
Attachment D (samples of self reporting tools for CLABSI review)
ROOT cause analysis
Formal reaction team for bedside analysis suggested with when CLABSI is identified
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REFERENCES (*followed by strength of evidence rating)
1. Helder O, Brug J, Looman, Goudoever J, Kornelisse R. The impact of an education program on hand hygiene compliance and nosocomial infection incidence in an urban Neonatal Intensive Care Unit: An intervention study with before and after comparison. Intl Jrn of Nursing Studies 2010, 47, 1245-1252. IIb
2. Sakamoto F, Yamada H, Suzuki C, Sugiura H, Tokuda Y. Increased use of alcohol-based hand
sanitizers and successful eradication of methicillin-resistant Staphylococcus aureus from a neonatal intensive care unit: A multivariate time series analysis. Am J Infec Control 2010, 38, 529-34. III
3. Crivaro V, Di Popolo A, Caprio A, Lambiase A, Di Resta M, Borriello T, Scarcella A, Triassi M, Zarrilli R.
Pseudomonas aeruginosa in a neonatal intensive care unit: molecular epidemiology and infection control measures. BMC Infectious Diseases 2009, 9, 70-77. IIb
4. Gill C, Mantaring J, Macleod W, Mendoza M, Mendoza S, Huskins W, Goldman D, Hamer D. Impact of
Enhanced Infection Control at 2 Neonatal Intensive Care Units in the Philippines. Clinical Infectious Diseases 2009, 48, 13-21. IIb
5. Picheansathian W, Pearson A, Suchaxaya P. The effectiveness of a promotion programme on hand
hygiene compliance and nosocomial infections in a neonatal intensive care unit. International Journal of Nursing Practice 2008, 14, 315-321. IIb
6. Pessoa-Silva C, Hugonnet S, Pfister R, Touveneau S, Dharan S, Posfay-Barbe K, Pittet D. Reduction
of Health Care Associated Infection Risk in Neonates by Successful Hand Hygiene Promotion. Pediatrics 2007, 120, e382-e390. IIb
7. Wirtschafter DD, Petti J, Kurtin P, et al. A statewide quality improvement collaborative to reduce
neonatal central line- associated blood stream infections. J Perinatol 2010, 30, 170-81. IV
8. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006, 355, 2725-32. IV
9. Guidelines for Hand Hygiene in Health Care Settings MMWR October 25, 2002 / Vol. 51 / No. RR-16;
Accessed from http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf. IV
10. 5 Million Lives Campaign. Getting Started Kit: Prevent Central Line Infections How-to Guide. Cambridge, MA: Institute for Healthcare Improvement, 2008. Accessed from www.ihi.org/ihi/programs/campaign/centrallineinfection.htm. IV
11. O’Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, Lipsett PA, Masur H, Mermel
LA, Pearson ML, Raad II Randolph A, Rupp ME, Saint S, and the Healthcare Infection Control Practices Advisory Committee (HICPAC) Guideline for the prevention of intravascular catheter-related infections. Atlanta, GA: Centers for Disease Control and Prevention, 2011. Accessed from http://www.cdc.gov/hicpac/BSI/BSI-guidelines-2011.html. IV
12. Powers R J, Wirtschafter DW. Decreasing central line associated bloodstream infection in neonatal intensive care. Clin Perinatol 2010, 37, 247-272. IV
13. Linck D, Donze A, Hamvas A. Neonatal Peripherally Inserted Central Catheter Team. Advances in Neonatal Care 2007, 7(1), 22-29. IV
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14. Pettit J, Wyckoff M, editors. NANN (National Association of Neonatal Nurses) peripherally inserted central catheters guideline for practice. 2
nd edition. Glenview (IL): National Association of Neonatal
Nurses; 2007. IV
15. Schulman, et al. Statewide NICU Central-Line-Associated Bloodstream infection Rates Decline after Bundles and Checklists. Pediatrics 2011, 127, 436-444. IIb
16. Costello, JM. Systematic intervention to reduce central line associated bloodstream infection rates in a
pediatric cardiac intensive care unit. Pediatrics 2009. III
17. Miller M, et al. Decreasing PICU catheter-associated bloodstream infections: NACHRI’s quality transformation efforts. Pediatrics 2010, 125(2), 206-213. IV
18. Bizarro, MJ, et al. A quality improvement initiative to reduce central line-associated bloodstream infections in a neonatal intensive care unit. Infection Control & Epidemiology 2010, 31(3), 241-248. IIb
19. Sharpe EL. Tiny patients, tiny dressings; a guide to the neonatal PICC dressing change. Adv Neonatal Care 2008, 9, 150-62. IV
20. Kaler W, Chinn R. Successful disinfection of needless access ports: A matter of time and friction. JAVA 2007, 12(3), 140-142. IIb
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Acknowledgement An interdisciplinary team of neonatal health care professionals of eight member hospitals developed this Clinical Practice Recommendations (CPR) document. In addition infectious disease and central line experts have externally reviewed this CPR: Alexis Elward, MD, MPH Associate Professor of Pediatrics Washington University School of Medicine Director of Infectious Disease St. Louis Children’s Hospital Debbie Linck, RN Staff Nurse and PICC Chair Newborn Intensive Care Unit St. Louis Children’s Hospital Marian Michaels, MD Professor of Pediatrics Infectious Disease Children’s Hospital of Pittsburgh Dawn Thomas, MSN, RN, CPN, VA-BC Interim Unit Director – BB and the IV Team Children’s Hospital of Pittsburgh of UPMC Systematic Methods Representative from eight member hospitals who developed this are expert neonatal clinicians and researchers familiar with guideline development methodology. Individual members of the CPR development team have no conflicts of interests (COI) to disclose. A thorough systematic review along with benchmarking across centers was conducted specifically to inform practice decisions. For each practice recommendation, the level of evidence and strength of the recommendation were assigned and followed by expert external review. Recommendations This document is not intended to be adopted as a whole bundle. Our aim is to reduce CLABSI rates and improve patient outcomes at both the local and collaborative level. Since site variation is a great learning opportunity, we want centers to adopt individual practice recommendations that best fit their local center’s processes. CHNC – CIQI This CPR document will be reviewed annually and updated every 5 years.
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Attachment A-1: Example Hand Hygiene – Nurse Practitioner
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Attachment A-2: Example Hand Hygiene Data Collection Tool – Inpatient Observer
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Attachment A-3: Example Hand Hygiene Self Reporting Tool
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Attachment A-4: Example Hand Hygiene Template
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Attachment A-5 Example Hand Hygiene Collection Tool
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Attachment A-6: Example Family/Visitor Hand Hygiene Observation
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Attachment B-1: Example Central Line Insertion Checklist
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Attachment B-2: Example Example Central Line Insertion Checklist
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Attachment B-3: Example Central Line Insertion Checklist
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Attachment C-1: Example Maintenance Dressing Change Observation
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Attachment C-2: Example Maintenance Hub Care Observation
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Attachment C-3: Example Maintenance Hub Care Self Reporting Tool
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Attachment C-4: Example Maintenance Monitoring
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Attachment C-5: Example Maintenance Bundle Compliance Checklist
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Attachment D-1: Example Daily Goals
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Attachment D-2: Example Daily Goals
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Attachment D-3: Example Daily Goals
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Attachment D-4: Example Daily Goals
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Attachment D-5: Example Daily Goals
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Attachment E-1a: Example BSI Review
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Attachment E-1b: Example BSI Review
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Attachment E-2: Example BSI Review
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Attachment E-3: Example BSI Review
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Attachment E-4: Example
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Attachment E-5: Example
