Implementation Of a Comprehensive Unit-Based Protocol For Prevention Of Neonatal Catheter Associated Blood Stream Infections

Objective: To reduce the observed NCABSI rate in the neonatal intensive care unit (NICU) from baseline standardized infection ratio (SIR) of 1.55 in fiscal year (FY) 2012 to <0.79 in FY13 through a Comprehensive Unit-based Safety Program (CUSP).

Design: A surveillance study involving at-risk neonates born during FY13 at an academic Level III NICU. By applying CUSP methodology, which is evidence-based for evaluating local safety processes to identify and learn from errors, we aimed to eliminate neonatal central line associated blood stream infections (NCABSI). The emphasis was on insertion techniques and appropriate maintenance of central catheters, as well as, changing the local safety culture with promotion of a shared mental model among all staff members.

Sample: Consecutive neonates with umbilical arterial and venous catheters, and percutaneous central venous catheters.

Methods:  A multidisciplinary team of frontline providers was assembled, culture of safety survey was measured, deficits were identified, and an improvement plan was generated. Prevention and maintenance measures were developed, including optimal hand hygiene compliance, insertion and maintenance bundles, and institution of electronic medical record central line documentation.

Implementation Strategies: Feeding practice was standardized for extremely low birth weight infants with discontinuation of central access when feeds established at 100-120ml/kg/day. Nursing audits for compliance of maintenance bundle documentation and daily review of central lines with justification for continued use were regularly assessed. Maintenance interventions included 1) placement of an absorptive foam disk impregnated with 250microg/mg of chlorhexidine gluconate over insertion sites for infants ≥ 2kg, or at 2 weeks of age for infants < 2kg irrespective of gestational age and, 2) passive disinfection of access ports with 70% isopropyl alcohol port protectors. NCABSI was reported as Standardized Infection Ratio (SIR) = actual/expected number of infections.

Results: Following implementation of CUSP, 282 central lines were placed in 167 infants (56% male), median gestation age 32 weeks (range 23-41 weeks), mean birth weight 1899 ± 1096 grams. Forty percent of infants were ≥34 weeks gestation with main indication for access being hypoglycemia (35%). Bedside RN documentation audits showed 100% compliance. The mean number of line days was 10 ± 8 days with reduction of central line access by 2- 3 days per patient. NCABSI SIR FY13 0.32 (compared to FY 12 of 1.55).

Conclusion/Implications for nursing practice: Through implementation of CUSP initiative, heightened awareness among nursing team members, of the shared responsibility for safety processes is required for elimination of NCABSI.  By adapting our culture of safety, we were able to achieve a 5-fold decrease in the rate of NCABSI.

Keywords: neonatal, bloodstream infections, central access, CUSP