Use of Evidence-Based Practice to Reduce Central Line-Associated Bacteremia in a Large Level III Neonatal Intensive Care Unit: Development of a Closed Transfer Set, Change in Lipid Administration and reduction of Non-value Added Practices

2.50
Hdl Handle:
http://hdl.handle.net/10755/183142
Category:
Abstract
Type:
Presentation
Title:
Use of Evidence-Based Practice to Reduce Central Line-Associated Bacteremia in a Large Level III Neonatal Intensive Care Unit: Development of a Closed Transfer Set, Change in Lipid Administration and reduction of Non-value Added Practices
Author(s):
Fugate, Karen
Author Details:
Karen Fugate, RN-NIC, BSN, Tampa General Hospital, Tampa, FL, email: Kfugate@tgh.org
Abstract:
Purpose: To discover additional line care practices and/or streamline existing practice to decrease central line-associated bacteremia (CLAB) while still maintaining a safe, evidence-based approach to line care.

Method: A multidisciplinary team was convened to review research and literature relevant to the prevention of CLAB. The following four opportunities were identified:
1) Hub Care: The majority of CLAB in neonates results from hub colonization and subsequent intraluminal contamination.1-4 Research supports the use of one, vigorous swab prior to access only.3-5 Practice of multiple swabs prior to disconnecting from and accessing the CLAVE was a non-value added step.
2) Line Replacement: Intravenous (IV) tubing should be changed no more frequently than every seventy-two hours.6,7 Daily or more frequent changes in hyperalimentation (HAL) fluid are common in neonates secondary to labile fluid and electrolyte needs. No IV tubing existed that could accommodate the minimal fill volumes and low infusion rates typically seen in the neonatal population resulting in tubing change with every HAL change instead of the recommended tubing change interval. This non-value added practice contributed to unnecessary line manipulation increasing the risk of CLAB. A multidisciplinary team collaborated with a local vendor to develop tubing (Closed Transfer Set) with the following features: closed delivery system without stopcock, one way valve to prevent fluids from being pumped into the primary fluid bag, anti-free flow back-check valve to prevent fluids distal to valve from being aspirated into fluid delivery syringe, and a fill volume of 0.5ml. (Please contact the prlmary investigator for the graphic associated with this study.) Proximal CLAVE Change: The CLAVE can maintain a physical barrier for six days with proper disinfection prior to access.8 Current non-evidence based practice of changing the proximal CLAVE (CLAVE attached to catheter) every three days opened the line unnecessarily possibly contributing to CLAB.
4) Lipid Administration: Infusions of lipid emulsions should be completed within twelve to twenty-four hours of hanging the solution to decrease the incidence of coagulase-negative staphylococcal (CONS) bacteremia.6,7 Two Intralipid syringes were prepared in the pharmacy each morning to be changed out every twelve hours; the second syringe exceeded the recommended hang time possibly contributing to CONS bacteremia.
Based on the evidence, the following changes in practice were implemented utilizing a combination of didactic and hands-on mandatory staff education: 1)hub care disinfection using one alcohol swab firmly rotated five times over the CLAVE prior to access only; 2)tubing change every seventy-two hours using the newly developed Closed Transfer Set; 3)proximal CLAVE change every six days to coincide with every three day line change; and, 4)switch to manufacturer supplied 100ml Intralipid? bags changed every twelve hours.

Findings: CLAB were identified using the National Healthcare Safety Network (NHSN) surveillance definitions.9
Data table titles: Line Days (PICC/Broviac),Total CLAB, Infections/1000 line days. Pre-implementation (1/1/08-3/31/09) data: 5254, 23, 4.38; Post-implementation (4/1/09-9/30/09) data: 1772, 3, 1.69.

Discussion: There was a sixty percent decrease in CLAB rates from 4.38 to 1.69 infections per 1000 line days. The previous line care bundle was extremely cumbersome with many non-value added steps. The new streamlined practice was well received consequently resulting in improved compliance. Revised practice is "leaner", evidence-based, and has resulted in improved patient outcomes.

Reference List
1. Garland JS, Alex CP, et al. (2008). Cohort study of the pathogenesis and molecular epidemiology of catheter-related bloodstream infection in neonates with peripherally inserted central venous catheters. Infect Control Hosp Epidemiol, 29:243-249.
2. Salzman MB, Isenberg HD, Shapiro JF, Lipsitz PJ, Rubin LG (1993). A prospective study of the catheter hub as the portal of entry for microorganisms causing catheter-related sepsis in neonates. J Infect Dis, 167(2):487-490.
3. Salzman MB, Isenberg HD, Rubin LG (1993). Use of disinfectants to reduce microbial contamination of hubs of vascular catheters. J Clin Microbiol, 31(3):475-479.
4. Bouza E, Munoz P, et al. (2003). A needleless closed system device (CLAVE) protects from intravascular catheter tip and hub colonization: a prospective randomized study. J Hosp Infect, 54:279-287.
5. Brown JD, Moss HA, Elliott TS. (1997). The potential for catheter microbial contamination from a needleless connector. J Hosp Infect, 36:181-189.
6. O?Grady NP, Alexander M, et al. (2002). Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis, 35:1281-1307.
7. California Perinatal Quality Care Collaborative (CPQCC)(2002). Neonatal hospital-acquired infection prevention: neonatal perspectives, practices and priorities. Retrieved from http://www.cpqcc.org
8. ICU Medical, Inc. Extended use microbial challenge and disinfection study of the CLAVE connector. Retrieved from http://www.icumed.com/Docs-Clave/M1-1055-clave-microbial.pdf
9. Edwards JR, MStat KD, et al. (2008). National healthcare safety network (NHSN) report, data summary for 2006 through 2007, issued November 2008. Am J Infect Control, 36:609-626.
Repository Posting Date:
28-Oct-2011
Date of Publication:
28-Oct-2011
Conference Date:
2010
Conference Name:
7th Annual Florida Magnet Research Conference
Conference Host:
University of South Florida College of Nursing; Sigma Theta Tau International; Florida Organization of Nurse Executives
Conference Location:
Naples, Florida, USA
Description:
7th Annual Florida Magnet Research Conference - Theme: Research at the Point of Care. Held 11-13 February 2010 at the Naples Grande Beach Resort, Naples, Florida, USA.
Note:
This is an abstract-only submission. If the author has submitted a full-text item based on this abstract, you may find it by browsing the Virginia Henderson Global Nursing e-Repository by author. If author contact information is available in this abstract, please feel free to contact him or her with your queries regarding this submission. Alternatively, please contact the conference host, journal, or publisher (according to the circumstance) for further details regarding this item. If a citation is listed in this record, the item has been published and is available via open-access avenues or a journal/database subscription. Contact your library for assistance in obtaining the as-published article.

Full metadata record

DC FieldValue Language
dc.type.categoryAbstracten_US
dc.typePresentationen_GB
dc.titleUse of Evidence-Based Practice to Reduce Central Line-Associated Bacteremia in a Large Level III Neonatal Intensive Care Unit: Development of a Closed Transfer Set, Change in Lipid Administration and reduction of Non-value Added Practicesen_GB
dc.contributor.authorFugate, Karenen_US
dc.author.detailsKaren Fugate, RN-NIC, BSN, Tampa General Hospital, Tampa, FL, email: Kfugate@tgh.orgen_US
dc.identifier.urihttp://hdl.handle.net/10755/183142-
dc.description.abstractPurpose: To discover additional line care practices and/or streamline existing practice to decrease central line-associated bacteremia (CLAB) while still maintaining a safe, evidence-based approach to line care.<br/><br/>Method: A multidisciplinary team was convened to review research and literature relevant to the prevention of CLAB. The following four opportunities were identified:<br/>1) Hub Care: The majority of CLAB in neonates results from hub colonization and subsequent intraluminal contamination.1-4 Research supports the use of one, vigorous swab prior to access only.3-5 Practice of multiple swabs prior to disconnecting from and accessing the CLAVE was a non-value added step. <br/>2) Line Replacement: Intravenous (IV) tubing should be changed no more frequently than every seventy-two hours.6,7 Daily or more frequent changes in hyperalimentation (HAL) fluid are common in neonates secondary to labile fluid and electrolyte needs. No IV tubing existed that could accommodate the minimal fill volumes and low infusion rates typically seen in the neonatal population resulting in tubing change with every HAL change instead of the recommended tubing change interval. This non-value added practice contributed to unnecessary line manipulation increasing the risk of CLAB. A multidisciplinary team collaborated with a local vendor to develop tubing (Closed Transfer Set) with the following features: closed delivery system without stopcock, one way valve to prevent fluids from being pumped into the primary fluid bag, anti-free flow back-check valve to prevent fluids distal to valve from being aspirated into fluid delivery syringe, and a fill volume of 0.5ml. (Please contact the prlmary investigator for the graphic associated with this study.) Proximal CLAVE Change: The CLAVE can maintain a physical barrier for six days with proper disinfection prior to access.8 Current non-evidence based practice of changing the proximal CLAVE (CLAVE attached to catheter) every three days opened the line unnecessarily possibly contributing to CLAB.<br/>4) Lipid Administration: Infusions of lipid emulsions should be completed within twelve to twenty-four hours of hanging the solution to decrease the incidence of coagulase-negative staphylococcal (CONS) bacteremia.6,7 Two Intralipid syringes were prepared in the pharmacy each morning to be changed out every twelve hours; the second syringe exceeded the recommended hang time possibly contributing to CONS bacteremia. <br/>Based on the evidence, the following changes in practice were implemented utilizing a combination of didactic and hands-on mandatory staff education: 1)hub care disinfection using one alcohol swab firmly rotated five times over the CLAVE prior to access only; 2)tubing change every seventy-two hours using the newly developed Closed Transfer Set; 3)proximal CLAVE change every six days to coincide with every three day line change; and, 4)switch to manufacturer supplied 100ml Intralipid? bags changed every twelve hours.<br/><br/>Findings: CLAB were identified using the National Healthcare Safety Network (NHSN) surveillance definitions.9 <br/>Data table titles: Line Days (PICC/Broviac),Total CLAB, Infections/1000 line days. Pre-implementation (1/1/08-3/31/09) data: 5254, 23, 4.38; Post-implementation (4/1/09-9/30/09) data: 1772, 3, 1.69.<br/><br/>Discussion: There was a sixty percent decrease in CLAB rates from 4.38 to 1.69 infections per 1000 line days. The previous line care bundle was extremely cumbersome with many non-value added steps. The new streamlined practice was well received consequently resulting in improved compliance. Revised practice is &quot;leaner&quot;, evidence-based, and has resulted in improved patient outcomes. <br/><br/>Reference List<br/>1. Garland JS, Alex CP, et al. (2008). Cohort study of the pathogenesis and molecular epidemiology of catheter-related bloodstream infection in neonates with peripherally inserted central venous catheters. Infect Control Hosp Epidemiol, 29:243-249.<br/>2. Salzman MB, Isenberg HD, Shapiro JF, Lipsitz PJ, Rubin LG (1993). A prospective study of the catheter hub as the portal of entry for microorganisms causing catheter-related sepsis in neonates. J Infect Dis, 167(2):487-490.<br/>3. Salzman MB, Isenberg HD, Rubin LG (1993). Use of disinfectants to reduce microbial contamination of hubs of vascular catheters. J Clin Microbiol, 31(3):475-479.<br/>4. Bouza E, Munoz P, et al. (2003). A needleless closed system device (CLAVE) protects from intravascular catheter tip and hub colonization: a prospective randomized study. J Hosp Infect, 54:279-287. <br/>5. Brown JD, Moss HA, Elliott TS. (1997). The potential for catheter microbial contamination from a needleless connector. J Hosp Infect, 36:181-189.<br/>6. O?Grady NP, Alexander M, et al. (2002). Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis, 35:1281-1307.<br/>7. California Perinatal Quality Care Collaborative (CPQCC)(2002). Neonatal hospital-acquired infection prevention: neonatal perspectives, practices and priorities. Retrieved from http://www.cpqcc.org<br/>8. ICU Medical, Inc. Extended use microbial challenge and disinfection study of the CLAVE connector. Retrieved from http://www.icumed.com/Docs-Clave/M1-1055-clave-microbial.pdf <br/>9. Edwards JR, MStat KD, et al. (2008). National healthcare safety network (NHSN) report, data summary for 2006 through 2007, issued November 2008. Am J Infect Control, 36:609-626.en_GB
dc.date.available2011-10-28T16:16:21Z-
dc.date.issued2011-10-28en_GB
dc.date.accessioned2011-10-28T16:16:21Z-
dc.conference.date2010en_US
dc.conference.name7th Annual Florida Magnet Research Conferenceen_US
dc.conference.hostUniversity of South Florida College of Nursingen_US
dc.conference.hostSigma Theta Tau Internationalen_US
dc.conference.hostFlorida Organization of Nurse Executivesen_US
dc.conference.locationNaples, Florida, USAen_US
dc.description7th Annual Florida Magnet Research Conference - Theme: Research at the Point of Care. Held 11-13 February 2010 at the Naples Grande Beach Resort, Naples, Florida, USA.en_US
dc.description.noteThis is an abstract-only submission. If the author has submitted a full-text item based on this abstract, you may find it by browsing the Virginia Henderson Global Nursing e-Repository by author. If author contact information is available in this abstract, please feel free to contact him or her with your queries regarding this submission. Alternatively, please contact the conference host, journal, or publisher (according to the circumstance) for further details regarding this item. If a citation is listed in this record, the item has been published and is available via open-access avenues or a journal/database subscription. Contact your library for assistance in obtaining the as-published article.-
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