A survey of central venous catheter practices in Australian and New Zealand tertiary neonatal units
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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Cited by (25)
An audit of central venous catheter insertion and management practices in an Australian tertiary intensive care unit: A quality improvement project
2022, Intensive and Critical Care NursingCitation Excerpt :There were a number of areas related to aseptic technique during insertion and management which required improvement such as nurses assisting insertion not wearing masks and hats (60% of the audited insertions), and inadequate access-port (or hubs) cleansing (92% of all audited occasions). A survey of Australian and New Zealand tertiary neonatal units reported that the duration of cleaning time for access ports varied significantly in practice (Taylor et al., 2014). Recommendations related to these areas are clearly stated in current CPGs (Australian and New Zealand Intensive Care Society, 2012; Loveday et al., 2014; O'Grady et al., 2011) and were included in the local CVC management protocol.
Risk factors for umbilical vascular catheter–related adverse events: A scoping review
2022, Australian Critical CareCitation Excerpt :Current international recommendations9 endorse removing umbilical catheters as soon as possible when no longer required, using UVCs up to 14 days if managed aseptically and removing UACs within 5 days. However, umbilical catheter practice in relation to dwell time varies among Australian and New Zealand NICUs.10 Although a vital component of modern-day care in the NICU, adverse events can occur during catheter insertion or dwell time.
Maximal sterile barrier precautions independently contribute to decreased central line–associated bloodstream infection in very low birth weight infants: A prospective multicenter observational study
2019, American Journal of Infection ControlCitation Excerpt :The practice of PICC placement in neonates varies among institutions and countries. Three previous studies reported that the percentage of institutions that routinely used MSB implementation during PICC placement was 26.5% in 19 NICUs in Australia/New Zealand, 62.7% in 190 NICUs in the United States, and 90.4% in 110 NICUs in the United States and Canada combined.6,16,17 In this study, we found that NICU caregivers in Japan adopted various kinds of sterile precautions and that adherence to MSB implementation was very low at 13.9%.
Dwell time and risk of central-line-associated bloodstream infection in neonates
2017, Journal of Hospital InfectionCitation Excerpt :The PICC CLABSI rate in our study was lower than or comparable to several previous studies, but higher than that found in a multi-centre study by Milstone et al. in which 4797 PICCs were placed in 3967 neonates with a CLABSI rate of 1.66 per 1000 catheter-days [22–25]. However, the babies in that study had a substantially higher median birth weight of 2000 g. Not all studies on CLABSI reported on the presence of concurrent or subsequent CVCs, and differences in study populations and definitions make direct comparisons problematic [26]. First, in the context of neonatal sepsis, the definitions of LOS and CLABSI among large national and international networks such as the NICHD, Vermont Oxford Network, Canadian Neonatal Network, and ANZNN are essentially consistent [15,18–20].
Reduced nosocomial infection rate in a neonatal intensive care unit during a 4-year surveillance period
2017, Journal of the Chinese Medical AssociationCitation Excerpt :For several decades, there has been controversy over whether or not the inanimate environment of a NICU is associated with the risk of nosocomial infection, but there have been scant few studies on this issue.6,8–11 Furthermore, the Institute for Healthcare Improvement recently developed the concept of “bundles” to help health care providers more reliably deliver the best possible care for patients undergoing particular treatments with inherent risks.12–15 However, limited information is available on bundle care in neonates.
Prevention of Vascular Catheter-Related Bloodstream Infections
2016, Infectious Disease Clinics of North AmericaCitation Excerpt :In patients without chlorhexidine allergy, the skin should be disinfected with an alcoholic chlorhexidine solution containing more than 0.5% chlorhexidine and allowed to dry before catheter insertion.35,36 Although there is concern for absorption across the skin of very low birth weight neonates and potential neurotoxicity as well as contact dermatitis, clinicians in many neonatal intensive care units have formulated protocols for the use of chlorhexidine in some groups of premature infants.37–40 A process to ensure adherence to appropriate insertion procedures should be in place.