“AIM FOR ZERO”

Preventing NICU Bloodstream Infection following

Implementation of a Central Venous Line Bundle

Whitelaw J McPhee A 2014

Background

Catheter Related Blood Stream Infections

(CRBSI)

Infections a significant cause of death and

morbidity particularly in preterm infants

CRBSI are the predominant cause of neonatal late onset sepsis

CRBSI are essentially are preventable life threatening events

CRBSI Classification

Positive blood culture in absence other focus of infection

Line within 48 hours prior to BSI

Supportive haematological evidence of sepsis

Usually clinical signs or symptoms of localized infection

May be clinically unwell

CRBSI Measurement

Numerator: Number of CRBSI X 1000

Denominator: Central line days

Separate rates calculated for 2 birth weight categories: 1) <1000gms 2) ≥1000gms

NICU Demographics WCH 5044 births in 2012

NICU 14 funded beds

2013 Average occupancy 102 (86-114)

410 admissions: 19.5% <1000 grams

324 central venous lines (267 PCVC’s 57 UVC’s ) (51.2% in LBW group)

Innate Neonatal Risk Factors

Immature immunity

Immature gut

Deficient barrier function

Invasive device dependence

High frequency of handling by multiple HCW’s

The Problem: NICU CRBSI

7.0 /1000 line days <1000gms birth weight

8.2 /1000 line days ≥ 1000gm birth weight

Mean 14.5 days to onset of PCVC infection indicating line maintenance practices a problem

Low hand hygiene compliance (53.1%)

The Solution

Central Venous Line Care Bundle

A group of evidence based infection prevention

and control interventions that when bundled

together are more effective than any single action

Bundle Principles

1. Effective hand hygiene

2. Maximum sterile barrier precautions for line insertion

3. Chlorhexidine Gluconate skin antisepsis

4. Asepsis (ANTT)for insertion / maintenance

5. Daily assessment of central line necessity

The ANTT Model

ANTT designed for all invasive clinical procedures ‘from the community to the operating theatre’

ANTT is a Theory & Practice Framework teaching 10 foundation principles

of standardised safe aseptic practice

NICU ANTT Implementation

Launch; ward teaching board

Pre audits of clinical practice

Training : Mandatory elements

Recruitment of local trainers

Assessment 1.Theoretical:workbook

2. Practical assessment:

Assessment : post audit & annual update

Bundle Method

Bundle strategic plan for collaborative review

Hand hygiene education/audits

Implementation of ANTT

Multidisciplinary Clinical Guideline

Clinical credentialing of central line insertion

Visual teaching aids

Line data collection & surveillance

Insertion Bundle Principles

Hand Hygiene (5 & 3 minute surgical scrubs)

Catheter type/site selection

Maximal Barrier precautions: all participants

Surgical ANTT

Chlorhexidine prep (3 step prep)

Checklist & procedure sheet

documentation

Maintenance Bundle Principles

Hand Hygiene: “bare below the elbows”

ANTT

Chlorhexidine: “scrub the hub”

New administration sets for each new catheter

Emergency lines replaced by 24 hours

Daily review of line necessity

Suspected infection: tip culture

Aseptic blood culture collection

Outcomes

Hand Hygiene Compliance

HHA audit cycles

per cent

NICU Outcomes: ANTT % Compliance Insertion Bundle

0

20

40

60

80

100

120

ANTT Principles

Pre ANTT 54 100 63 72 63 54 18

Post ANTT 85 100 100 100 100 100 50

hand

hygienedon gloves aseptic field key parts non touch chlorhex

max barrier

precautions

per cent

NICU Outcomes: % ANTT Compliance Maintenance Bundle

0

20

40

60

80

100

120

ANTT Principles

Pre ANTT 71 55 50 57 76 32

Post ANTT 100 100 93 100 100 93

hand

hygiene

don

gloves

aseptic

fieldkey parts non touch chlorhex

per cent

Outcomes NICU CRBSI per 1000 line days

July 2010-December 2013: 6 monthly intervals

5.7

4

3.1

1.51.8

2.7

0

8.2

4.6

0 0 0 0

9.1 9.1 9.1 9.1 9.1 9.1 9.1

2.1

0

1

2

3

4

5

6

7

8

9

10

July-Dec 10 Jan-June 11 July-Dec 11 Jan-June 12 July-Dec 12 Jan-June 13 July-Dec 13

<1000gm

≥1000gm

CDC target 9.1 (<1000g)

Sustainability

Regular audits & prompt feedback

Mandatory HHA competency all new staff

IP&C orientation all new staff

Regular feedback

Staff incentives

Implementation Issues

Education: Capturing all staff

Medical Registrar / Nursing rotations

3 shifts

Sustaining Credentialing/Audit

ANTT (medical)

Hand Hygiene ( mandatory competency)

Practice change

Checklist

Lessons Learned

Culture

change

Continuity

IP&C resources

Collaboration

Multidisciplinary

Ownership

Consistency

Education Feedback Evaluation

Cost

Health care Community

Family

References 1. Australian Commission on Safety and Quality in Health Care Central

Line Insertion & Maintenance Guideline April 2012

2. CDC Healthcare Infection Control Practices Advisory Committee (HICPAC) 2011 Guidelines for the Prevention of Intravascular Catheter-Related Infectionshttp: //www.cdc.gov/hicpac/BSI/BSI-guidelines-2011. www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf

3. Institute for Healthcare Improvement 100,000 Lives Campaign Prevent Central Line Infections http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/ImplementtheCentralLineBundle.htm

4. NHMRC (2010) AUSTRALIAN GUIDELINES FOR THE PREVENTION AND CONTROL OF INFECTION IN HEALTHCARE Commonwealth of Australia 2010 http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/CD33_InfectionControlGuidelines2010.pdf

5. Rowley S, Aseptic Non Touch Technique , www.antt.org.uk enquiries@antt.org.uk