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Am J Perinatol 2012; 29(01): 57-64
DOI: 10.1055/s-0031-1286182
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Central Line–Associated Bloodstream Infections in Neonatal Intensive Care: Changing the Mental Model from Inevitability to Preventability

Gautham K. Suresh
1   Department of Pediatrics, Dartmouth Medical School, Lebanon, New Hampshire
,
William H. Edwards
1   Department of Pediatrics, Dartmouth Medical School, Lebanon, New Hampshire
› Author Affiliations
Further Information

Publication History

27 June 2011

05 July 2011

Publication Date:
30 August 2011 (online)

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Abstract

Previously considered unavoidable complications of hospital care (reflecting an “entitlement” mental model), health care–associated infections are now considered as medical errors and cause significant preventable morbidity and mortality in neonates. Prevention of such infections, particularly central line–associated bloodstream infections (CLABSI), should be an important patient safety priority for all neonatal intensive care units (NICUs). An important first step is to promote a mental model of CLABSIs as preventable complications of care. Other general strategies are (1) promoting an organizational culture of safety and empowerment of staff; (2) hand hygiene; (3) avoiding overcrowding and understaffing; (4) using breast milk for enteral feedings; and (5) involving families in infection prevention efforts. Specific strategies to prevent CLABSI are (1) insertion practices: insertion of all central vascular catheters under strict sterile conditions with the aid of a checklist; (2) maintenance practices: ensuring that entries into the lumen of the vascular catheter always occur under aseptic conditions, minimizing catheter disconnections, and replacement of intravenous infusion sets at recommended intervals; (3) removal of all central lines as soon as possible. Participation in national or statewide quality improvement collaboratives is an emerging trend in neonatology that can enhance CLABSI prevention efforts by NICUs.

Keywords

health care–associated infection - nosocomial infection - central line–associated bloodstream infection - patient safety - medical error - central vascular catheter
 

  • References

  • 1 Gerberding JL. Hospital-onset infections: a patient safety issue. Ann Intern Med 2002; 137: 665-670
    PubMedGoogle Scholar
  • 2 Gardam MA, Lemieux C, Reason P, van Dijk M, Goel V. Healthcare-associated infections as patient safety indicators. Healthc Pap 2009; 9: 8-24
    PubMedGoogle Scholar
  • 3 Centers for Disease Control and Prevention. National Healthcare Safety Network (NHSN). Available at: http://www.cdc.gov/nhsn/ . Accessed August 2011
    PubMedGoogle Scholar
  • 4 Klevens RM, Edwards JR, Richards Jr CL , et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep 2007; 122: 160-166
    PubMedGoogle Scholar
  • 5 Scott II RD. The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention. Available at: http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf . Accessed August 2011
    PubMedGoogle Scholar
  • 6 Elward AM, Hollenbeak CS, Warren DK, Fraser VJ. Attributable cost of nosocomial primary bloodstream infection in pediatric intensive care unit patients. Pediatrics 2005; 115: 868-872
    CrossrefPubMedGoogle Scholar
  • 7 Payne NR, Carpenter JH, Badger GJ, Horbar JD, Rogowski J. Marginal increase in cost and excess length of stay associated with nosocomial bloodstream infections in surviving very low birth weight infants. Pediatrics 2004; 114: 348-355
    CrossrefPubMedGoogle Scholar
  • 8 Stoll BJ, Hansen NI, Adams-Chapman I , et al; National Institute of Child Health and Human Development Neonatal Research Network. Neurodevelopmental and growth impairment among extremely low-birth-weight infants with neonatal infection. JAMA 2004; 292: 2357-2365
    CrossrefPubMedGoogle Scholar
  • 9 Bassler D, Stoll BJ, Schmidt B , et al; Trial of Indomethacin Prophylaxis in Preterms Investigators. Using a count of neonatal morbidities to predict poor outcome in extremely low birth weight infants: added role of neonatal infection. Pediatrics 2009; 123: 313-318
    Google Scholar
  • 10 Benneyan JC. Statistical quality control methods in infection control and hospital epidemiology, part I: Introduction and basic theory. Infect Control Hosp Epidemiol 1998; 19: 194-214
    CrossrefPubMedGoogle Scholar
  • 11 Benneyan JC. Statistical quality control methods in infection control and hospital epidemiology, Part II: Chart use, statistical properties, and research issues. Infect Control Hosp Epidemiol 1998; 19: 265-283
    CrossrefPubMedGoogle Scholar
  • 12 Edwards WH. Preventing nosocomial bloodstream infection in very low birth weight infants. Semin Neonatol 2002; 7: 325-333
    PubMedGoogle Scholar
  • 13 Simpson KR. Creating a culture of safety: a shared responsibility. MCN Am J Matern Child Nurs 2000; 25: 61
    CrossrefPubMedGoogle Scholar
  • 14 Sexton JB, Helmreich RL, Neilands TB , et al. The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res 2006; 6: 44
    CrossrefPubMedGoogle Scholar
  • 15 Zohar D, Livne Y, Tenne-Gazit O, Admi H, Donchin Y. Healthcare climate: a framework for measuring and improving patient safety. Crit Care Med 2007; 35: 1312-1317
    CrossrefPubMedGoogle Scholar
  • 16 Jackson J, Sarac C, Flin R. Hospital safety climate surveys: measurement issues. Curr Opin Crit Care 2010; September 4 (Epub ahead of print)
    PubMedGoogle Scholar
  • 17 Jones KJ, Skinner A, Xu L, Sun J, Mueller K. The AHRQ Hospital Survey on Patient Safety Culture: a tool to plan and evaluate patient safety programs. In: Henriksen K, Battles JB, Keyes MA, Grady ML, eds. Advances in Patient Safety: New Directions and Alternative Approaches. Vol. 2: Culture and Redesign. Rockville, MD: Agency for Healthcare Research and Quality; 2008
    Google Scholar
  • 18 Speroff T, Nwosu S, Greevy R , et al. Organisational culture: variation across hospitals and connection to patient safety climate. Qual Saf Health Care 2010; 19: 592-596
    CrossrefPubMedGoogle Scholar
  • 19 Houang ET, Hurley R. Anonymous questionnaire survey on the knowledge and practices of hospital staff in infection control. J Hosp Infect 1997; 35: 301-306
    CrossrefPubMedGoogle Scholar
  • 20 Kennedy AM, Elward AM, Fraser VJ. Survey of knowledge, beliefs, and practices of neonatal intensive care unit healthcare workers regarding nosocomial infections, central venous catheter care, and hand hygiene. Infect Control Hosp Epidemiol 2004; 25: 747-752
    CrossrefPubMedGoogle Scholar
  • 21 Larson EL, Early E, Cloonan P, Sugrue S, Parides M. An organizational climate intervention associated with increased handwashing and decreased nosocomial infections. Behav Med 2000; 26: 14-22
    CrossrefPubMedGoogle Scholar
  • 22 Furman C, Caplan R. Applying the Toyota Production System: using a patient safety alert system to reduce error. Jt Comm J Qual Patient Saf 2007; 33: 376-386
    PubMedGoogle Scholar
  • 23 Shannon RP, Frndak D, Grunden N , et al. Using real-time problem solving to eliminate central line infections. Jt Comm J Qual Patient Saf 2006; 32: 479-487
    PubMedGoogle Scholar
  • 24 Stapleton FB, Hendricks J, Hagan P, DelBeccaro M. Modifying the Toyota Production System for continuous performance improvement in an academic children's hospital. Pediatr Clin North Am 2009; 56: 799-813
    CrossrefPubMedGoogle Scholar
  • 25 Pronovost P, Needham D, Berenholtz S , et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006; 355: 2725-2732
    CrossrefPubMedGoogle Scholar
  • 26 Pessoa-Silva CL, Dharan S, Hugonnet S , et al. Dynamics of bacterial hand contamination during routine neonatal care. Infect Control Hosp Epidemiol 2004; 25: 192-197
    CrossrefPubMedGoogle Scholar
  • 27 Sax H, Allegranzi B, Uçkay I, Larson E, Boyce J, Pittet D. “My five moments for hand hygiene”: a user-centred design approach to understand, train, monitor and report hand hygiene. J Hosp Infect 2007; 67: 9-21
    CrossrefPubMedGoogle Scholar
  • 28 Sax H, Allegranzi B, Chraïti MN, Boyce J, Larson E, Pittet D. The World Health Organization hand hygiene observation method. Am J Infect Control 2009; 37: 827-834
    CrossrefPubMedGoogle Scholar
  • 29 Allegranzi B, Pittet D. Role of hand hygiene in healthcare-associated infection prevention. J Hosp Infect 2009; 73: 305-315
    CrossrefPubMedGoogle Scholar
  • 30 Boyce JM, Pittet D ; Healthcare Infection Control Practices Advisory Committee. Society for Healthcare Epidemiology of America. Association for Professionals in Infection Control. Infectious Diseases Society of America. Hand Hygiene Task Force. Guideline for Hand Hygiene in Health-Care Settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol 2002; 23 (12 Suppl) S3-S40
    CrossrefPubMedGoogle Scholar
  • 31 Erasmus V, Daha TJ, Brug H , et al. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol 2010; 31: 283-294
    CrossrefPubMedGoogle Scholar
  • 32 Pittet D. Improving adherence to hand hygiene practice: a multidisciplinary approach. Emerg Infect Dis 2001; 7: 234-240
    CrossrefPubMedGoogle Scholar
  • 33 Pittet D, Simon A, Hugonnet S, Pessoa-Silva CL, Sauvan V, Perneger TV. Hand hygiene among physicians: performance, beliefs, and perceptions. Ann Intern Med 2004; 141: 1-8
    CrossrefPubMedGoogle Scholar
  • 34 Pessoa-Silva CL, Posfay-Barbe K, Pfister R, Touveneau S, Perneger TV, Pittet D. Attitudes and perceptions toward hand hygiene among healthcare workers caring for critically ill neonates. Infect Control Hosp Epidemiol 2005; 26: 305-311
    CrossrefPubMedGoogle Scholar
  • 35 Larson E, Girard R, Pessoa-Silva CL, Boyce J, Donaldson L, Pittet D. Skin reactions related to hand hygiene and selection of hand hygiene products. Am J Infect Control 2006; 34: 627-635
    CrossrefPubMedGoogle Scholar
  • 36 Suresh G, Cahill J. How “user friendly” is the hospital for practicing hand hygiene? An ergonomic evaluation. Jt Comm J Qual Patient Saf 2007; 33: 171-179
    PubMedGoogle Scholar
  • 37 Pittet D. The Lowbury lecture: behaviour in infection control. J Hosp Infect 2004; 58: 1-13
    CrossrefPubMedGoogle Scholar
  • 38 Whitby M, Pessoa-Silva CL, McLaws ML , et al. Behavioural considerations for hand hygiene practices: the basic building blocks. J Hosp Infect 2007; 65: 1-8
    PubMedGoogle Scholar
  • 39 Pessoa-Silva CL, Hugonnet S, Pfister R , et al. Reduction of health care associated infection risk in neonates by successful hand hygiene promotion. Pediatrics 2007; 120: e382-e390
    CrossrefPubMedGoogle Scholar
  • 40 Sax H, Uçkay I, Richet H, Allegranzi B, Pittet D. Determinants of good adherence to hand hygiene among healthcare workers who have extensive exposure to hand hygiene campaigns. Infect Control Hosp Epidemiol 2007; 28: 1267-1274
    CrossrefPubMedGoogle Scholar
  • 41 Mathai E, Allegranzi B, Seto WH , et al. Educating healthcare workers to optimal hand hygiene practices: addressing the need. Infection 2010; 38: 349-356
    CrossrefPubMedGoogle Scholar
  • 42 Andersen BM, Lindemann R, Bergh K , et al. Spread of methicillin-resistant Staphylococcus aureus in a neonatal intensive unit associated with understaffing, overcrowding and mixing of patients. J Hosp Infect 2002; 50: 18-24
    CrossrefPubMedGoogle Scholar
  • 43 Haley RW, Bregman DA. The role of understaffing and overcrowding in recurrent outbreaks of staphylococcal infection in a neonatal special-care unit. J Infect Dis 1982; 145: 875-885
    CrossrefPubMedGoogle Scholar
  • 44 Sarvikivi E, Lyytikäinen O, Salmenlinna S , et al. Clustering of Serratia marcescens infections in a neonatal intensive care unit. Infect Control Hosp Epidemiol 2004; 25: 723-729
    CrossrefPubMedGoogle Scholar
  • 45 Clements A, Halton K, Graves N , et al. Overcrowding and understaffing in modern health-care systems: key determinants in meticillin-resistant Staphylococcus aureus transmission. Lancet Infect Dis 2008; 8: 427-434
    CrossrefPubMedGoogle Scholar
  • 46 Harbarth S, Sudre P, Dharan S, Cadenas M, Pittet D. Outbreak of Enterobacter cloacae related to understaffing, overcrowding, and poor hygiene practices. Infect Control Hosp Epidemiol 1999; 20: 598-603
    CrossrefPubMedGoogle Scholar
  • 47 Farrington M, Trundle C, Redpath C, Anderson L. Effects on nursing workload of different methicillin-resistant Staphylococcus aureus (MRSA) control strategies. J Hosp Infect 2000; 46: 118-122
    CrossrefPubMedGoogle Scholar
  • 48 Hugonnet S, Harbarth S, Sax H, Duncan RA, Pittet D. Nursing resources: a major determinant of nosocomial infection?. Curr Opin Infect Dis 2004; 17: 329-333
    CrossrefPubMedGoogle Scholar
  • 49 Blatnik J, Lesnicar G. Propagation of methicillin-resistant Staphylococcus aureus due to the overloading of medical nurses in intensive care units. J Hosp Infect 2006; 63: 162-166
    CrossrefPubMedGoogle Scholar
  • 50 Borg MA, Suda D, Scicluna E. Time-series analysis of the impact of bed occupancy rates on the incidence of methicillin-resistant Staphylococcus aureus infection in overcrowded general wards. Infect Control Hosp Epidemiol 2008; 29: 496-502
    CrossrefPubMedGoogle Scholar
  • 51 Hylander MA, Strobino DM, Dhanireddy R. Human milk feedings and infection among very low birth weight infants. Pediatrics 1998; 102: E38
    CrossrefPubMedGoogle Scholar
  • 52 Rønnestad A, Abrahamsen TG, Medbø S , et al. Late-onset septicemia in a Norwegian national cohort of extremely premature infants receiving very early full human milk feeding. Pediatrics 2005; 115: e269-e276
    CrossrefPubMedGoogle Scholar
  • 53 Furman L, Taylor G, Minich N, Hack M. The effect of maternal milk on neonatal morbidity of very low-birth-weight infants. Arch Pediatr Adolesc Med 2003; 157: 66-71
    CrossrefPubMedGoogle Scholar
  • 54 Sisk PM, Lovelady CA, Dillard RG, Gruber KJ, O'Shea TM. Early human milk feeding is associated with a lower risk of necrotizing enterocolitis in very low birth weight infants. J Perinatol 2007; 27: 428-433
    CrossrefPubMedGoogle Scholar
  • 55 Meinzen-Derr J, Poindexter B, Wrage L, Morrow AL, Stoll B, Donovan EF. Role of human milk in extremely low birth weight infants' risk of necrotizing enterocolitis or death. J Perinatol 2009; 29: 57-62
    CrossrefPubMedGoogle Scholar
  • 56 The Joint Commission. Facts about Speak Up™ Initiatives. Available at: http://www.jointcommission.org/facts_about_speak_up_initiatives/ . Accessed August 2011
    PubMedGoogle Scholar
  • 57 Agency for Healthcare Research and Quality. AHRQ, American Academy of Pediatrics Announce Partnership on 20 Tips to Help Prevent Medical Errors in Children. Available at: http://www.ahrq.gov/news/press/pr2003/20tipschpr.htm . Accessed August 2011
    PubMedGoogle Scholar
  • 58 Longtin Y, Sax H, Leape LL, Sheridan SE, Donaldson L, Pittet D. Patient participation: current knowledge and applicability to patient safety. Mayo Clin Proc 2010; 85: 53-62
    CrossrefPubMedGoogle Scholar
  • 59 McGuckin M, Storr J, Longtin Y, Allegranzi B, Pittet D. Patient empowerment and multimodal hand hygiene promotion: a win-win strategy. Am J Med Qual 2011; 26: 10-17
    CrossrefPubMedGoogle Scholar
  • 60 Pittet D, Panesar SS, Wilson K , et al. Involving the patient to ask about hospital hand hygiene: a National Patient Safety Agency feasibility study. J Hosp Infect 2011; 77: 299-303
    CrossrefPubMedGoogle Scholar
  • 61 Davis RE, Koutantji M, Vincent CA. How willing are patients to question healthcare staff on issues related to the quality and safety of their healthcare? An exploratory study. Qual Saf Health Care 2008; 17: 90-96
    CrossrefPubMedGoogle Scholar
  • 62 Longtin Y, Sax H, Allegranzi B, Hugonnet S, Pittet D. Patients' beliefs and perceptions of their participation to increase healthcare worker compliance with hand hygiene. Infect Control Hosp Epidemiol 2009; 30: 830-839
    CrossrefPubMedGoogle Scholar
  • 63 Frey B, Ersch J, Bernet V, Baenziger O, Enderli L, Doell C. Involvement of parents in critical incidents in a neonatal-paediatric intensive care unit. Qual Saf Health Care 2009; 18: 446-449
    CrossrefPubMedGoogle Scholar
  • 64 O'Grady NP, Alexander M, Dellinger EP , et al. Guidelines for the prevention of intravascular catheter-related infections. The Hospital Infection Control Practices Advisory Committee, Center for Disease Control and Prevention, U.S. Pediatrics 2002; 110: e51
    CrossrefPubMedGoogle Scholar
  • 65 Mannan K, Chow P, Lissauer T, Godambe S. Mistaken identity of skin cleansing solution leading to extensive chemical burns in an extremely preterm infant. Acta Paediatr 2007; 96: 1536-1537
    CrossrefPubMedGoogle Scholar
  • 66 Garland JS, Alex CP, Henrickson KJ, McAuliffe TL, Maki DG. A vancomycin-heparin lock solution for prevention of nosocomial bloodstream infection in critically ill neonates with peripherally inserted central venous catheters: a prospective, randomized trial. Pediatrics 2005; 116: e198-e205
    CrossrefPubMedGoogle Scholar
  • 67 Toltzis P. Antibiotic lock technique to reduce central venous catheter-related bacteremia. Pediatr Infect Dis J 2006; 25: 449-450
    PubMedGoogle Scholar
  • 68 Horbar JD, Rogowski J, Plsek PE , et al; NIC/Q Project Investigators of the Vermont Oxford Network. Collaborative quality improvement for neonatal intensive care. Pediatrics 2001; 107: 14-22
    CrossrefPubMedGoogle Scholar
  • 69 Horbar JD, Plsek PE, Leahy K ; NIC/Q 2000. NIC/Q 2000: establishing habits for improvement in neonatal intensive care units Pediatrics 2003; 111 (4 Pt 2) e397-e410
    PubMed
  • 70 Rogowski JA, Horbar JD, Plsek PE , et al. Economic implications of neonatal intensive care unit collaborative quality improvement. Pediatrics 2001; 107: 23-29
    CrossrefPubMedGoogle Scholar
  • 71 Wirtschafter DD, Powers RJ, Pettit JS , et al. Nosocomial infection reduction in VLBW infants with a statewide quality-improvement model. Pediatrics 2011; 127: 419-426
    CrossrefPubMedGoogle Scholar
  • 72 Kaplan HC, Lannon C, Walsh MC, Donovan EF ; Ohio Perinatal Quality Collaborative. Ohio statewide quality-improvement collaborative to reduce late-onset sepsis in preterm infants. Pediatrics 2011; 127: 427-435
    CrossrefPubMedGoogle Scholar
  • 73 Schulman J, Stricof R, Stevens TP , et al; New York State Regional Perinatal Care Centers. Statewide NICU central-line-associated bloodstream infection rates decline after bundles and checklists. Pediatrics 2011; 127: 436-444
    CrossrefPubMedGoogle Scholar