Elsevier

Australian Critical Care

Volume 27, Issue 1, February 2014, Pages 36-42
Australian Critical Care

A survey of central venous catheter practices in Australian and New Zealand tertiary neonatal units

https://doi.org/10.1016/j.aucc.2013.11.002Get rights and content

Abstract

Background

Infection is the most common problem with central venous catheters (CVCs) in neonates. There are two published guidelines, including the Centers for Disease Control and Prevention (CDC), for the prevention of intravascular catheter-related infection that describes evidence-based practice to reduce nosocomial infection.

Objective

Our aims were to survey current medical and nursing management of central venous catheters in tertiary neonatal intensive care units in Australia and New Zealand and to compare with the CDC evidence-based practice guideline.

Methods

A cross sectional survey was performed across 27 Australian and New Zealand neonatal units in September 2012. Two web-based questionnaires were distributed, one to medical directors related to the insertion of CVCs while CVC “maintenance” surveys were sent to nurse unit managers.

Results

Seventy percent (19/27) medical management and 59% (16/27) on nursing management surveys were completed. In all neonatal intensive care units (NICUs) there were guidelines for CVC maintenance and for 18 out of 19 there were guidelines for insertion. In the seven units using femoral lines, three had a guideline on insertion and four for maintenance. CVC insertion was restricted to credentialed staff in 57.9% of neonatal units. Only 26.5% used full maximal sterile barriers for insertion. Skin disinfection practices widely varied. Dressing use and dressing change regimens were standardised; all using a semi-permeable dressing. Duration of cleaning time of the access point varied significantly; however, the majority used a chlorhexidine with alcohol solution (68.8%). Line and fluid changes varied from daily to 96 h. The majority used sterile gloves and a sterile dressing pack to access the CVC (68.8%). In the majority of NICUs stopcocks were used (62.5%) with a needle-less access point attached (87.5%). In less than 50% of NICUs education was provided on insertion and maintenance.

Conclusion

There is diversity of current practices and some aspects vary from the CDC guideline. There is a need to review NICU current practices to align with evidence based guidelines. The introduction of a common guideline may reduce variations in practice.

Introduction

The neonatal population is at increased risk of infection due to an underdeveloped immune system1 and the immaturity of the skin barrier.2 The characteristics of the Neonatal Intensive Care Unit (NICU) environment such as incubator humidity and warmth, overcrowding, multiple procedures, indwelling devices, ventilation, and use of parenteral nutrition also greatly increase the risk of infection.3, 4, 5, 6, 7, 8, 9 Central venous catheters (CVCs) are commonly used in the NICU for intravenous nutrition, administration of medications and monitoring, which further increases the neonates susceptibility to blood stream infection.10

The reported incidence of central line associated blood stream infection (CLABSI) varies with case definition and with the demographic characteristics of the population studied. CLABSI reported to the National Healthcare Safety Network (NHSN) demonstrated extremely low birth weight infants have more central line related infections. The NHSN CLABSI rates range from 3.1 per 1000 catheter days for infants weighing 750 g or less to 1.4 per 1000 per catheter days for infants >1501 g.11 Other studies reported wide variation in the infection rates ranging from 0 to 29% of catheters placed and from 2 to 49 per 1000 catheter days.9, 12, 13, 14, 15, 16, 17 Neonates, particularly very low birth weight (VLBW) infants with CLABSI, have an increased risk of mortality with attributable mortality ranging from 4 to 20%18 and a range of important morbidities including the need for intensive care, mechanical ventilation, bronchopulmonary dysplasia, necrotising enterocolitis, retinopathy of prematurity and prolonged hospitalisation.18, 19, 20, 21 Treatment costs are doubled when an infant has a blood stream infection and length of stay increases between 6.8% and 16.1%.22

The Centers for Disease Control and Prevention (CDC) in the United States and the National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England (epic 2) both have published guidelines for the prevention of infection in intravascular devices.23, 24 Neither of these guidelines is specific to neonates, however, both have subsections dedicated to the neonatal population and also include evidence from neonatal trials. The CDC guidelines are the most recent, developed by a multidisciplinary group to provide evidence based recommendations to prevent catheter related infection across all healthcare disciplines. Other surveys in adult intensive care have shown a lack of knowledge in CVC practices25 and diversity in practice that lacks consistency with the CDC guidelines.26, 27 Although the CDC guidelines have existed since 1981, how these are integrated in neonatal care is unknown. This study was carried out to determine current practices in Australian and New Zealand tertiary neonatal units and to compare these practices to the CDC evidence-based guidelines and reveal any variation in practice.

Section snippets

Materials and methods

A cross sectional descriptive study utilising a survey methodology was performed using an on-line tool ‘Survey Monkey’. To ensure the accuracy of the data, the survey was separated into two components. Catheter insertion is generally a medical procedure whereas maintenance of the catheter is a nursing responsibility. It was therefore deemed appropriate to direct insertion and general medical care to the medical director or representative and maintenance and ongoing nursing care to the Nurse

CVC insertion (medical management)

Out of the 27 surveys sent to the medical directors, 19 surveys were fully completed (70%) and included representation from all but two regions across Australia and New Zealand. Seventeen of the respondents were consultants (89%) and two were senior nurses (9%).

All the units used umbilical venous catheters (UVCs) and peripherally inserted central venous catheters (PICCs). Only seven (36.8%) used femoral venous catheters and 10 (52.6%) used tunnelled catheters. All the units had a written

Discussion

This survey provided a snapshot of current practices surrounding CVC management in Australian and New Zealand tertiary neonatal units. Reported practices varied across neonatal units and were not always consistent with the published guidelines. We compared the results to the CDC guideline and summarised compliance as a percentage in Table 5.

Conclusion

This survey has demonstrated that the evidence based guidelines are not always followed in Australian and New Zealand tertiary neonatal units, leading to diversity in clinical practice. There is a need for senior medical and nursing staff to review their guidelines to ensure they are following the best available evidence. It is unclear why many aspects of the CDC guideline have not been adopted into clinical practice. It could be hypothesised the reason for poor compliance is health care

Acknowledgements

We would like to thank all the neonatal unit staff who completed the survey. We would also like to thank those staff who pilot tested the survey.

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