Aim

The Neonatal Intensive Care Unit (NICU) at University Hospital of Wales is a regional unit caring for 34 babies with complex medical and surgical conditions. Neonatal management techniques have lead to a greater survival for low birth weight infants, these infants are however at an increased risk for short and long term morbidities. Complications include nosocomial bacteraemia.
As advances in medical technology reduce the risk of mortality in the smallest of infants, it is imperative that neonatal care providers identify effective interventions to minimise the risks of nosocomial infections.

Methodology

We identified that in the Neonatal Unit at University Hospital of Wales the rate of catheter related sepsis (CRS) of between 25-30% of infants less than 1500g was higher than the national (10-25%) and international audit figures reported by the Vermont Oxford Neonatal Network (VONN). This alone was enough to encourage the team to look at how this incidence could be reduced and care and outcome for these high risk infants improved. Intravenous access is a necessity in the neonatal unit so there was an urgent need for more effective prevention interventions. To this end we developed an improvement process with a multidisciplinary core group. The unit consultant responsible for VONN took the lead and was supported by the unit manager, practice education team, microbiology contact and named infection control nurses on the unit. This group addressed improvement aims and measures and established cycles of improvement.

A 'Hub and Line Care' strategy has been shown to reduce CRS significantly, as much as 90% in some studies.
The microbes that colonise the catheter hub are frequently those isolated from infected catheter tips and the blood stream in neonates classified as having CRS.
For hub and line care to be effective, it must be based on the understanding of the importance of hub contamination and include a variety of measures that assure consistent decontamination of the hub prior to line entry. Further measures that decrease line entry can lessen the opportunity for procedural breakdown to generate CRS.
Prevention of CRS from catheter entry include
• Use of injection ports
• Minimise number of ports
• Disinfection of port before line entry
• Clean technique when accessing and changing system
• Adherence to hand hygiene policy

Results

Successful 'Hub and Line Care' strategy should include:
1. Well written standardised procedures
2. Training and competency assessment
3. Means to increase peer pressure to conform to these procedures, with nurses working in collaboration
4. Provision for feedback on adherence to the procedure
Guidelines for changing infusion lines were developed with a group of neonatal nurses using PDSA cycles to ensure that that were fit for purpose.
These were cascaded to all staff with the Practice Education team teaching principles of hub care that underpin the importance of consistent connection decontamination prior to line entry (the use of 2% chlorhexidine 70% alcohol wipes and a 30 second scrub which is then allowed to dry) and decreasing the number of entry ports.
Together with 'Vygon' a special combined micron filter and multi port connection was developed and this has reduced the potential connections for each line. Dedicated trolleys for 'IV' use had wheels painted green, and branded with the slogan: Green for Clean.

The Practice Education team performs random checks on IV lines to ensure ports are kept to a minimum and also potential problems in practice are resolved at the time e.g. any incorrect practice is highlighted. The results are visible as the usage of the combined filter and port has increased with a decrease in triple multi port connections. This has been audited by the ordering team. It will also be audited more formally in the future and feedback to nursing staff.

Evaluation

There has been a decrease in the rate of catheter related sepsis, of approx 50% in the first 12 months.

The culture around line management has changed extensively; whilst the procedure had previously been carried out with care, it has now become a meticulous part of daily routine. The nursing staff attaches importance to the 'Green' trolleys and are empowered to challenge their incorrect use. The implementation of the care bundle was part of a wider implementation of measures to reduce infection on the unit as a whole. This has included hand washing audits, audit of cleanliness on the neonatal unit and long line insertion audit. These audits have led to solutions and implementations of new practices/equipment to improve care on the unit.

Reflection

On going education has played a huge part in this initiative, and the changes were not introduced until 75% of staff were trained. However, with experience it would have been beneficial for this number to be increased to 95%. Other initiatives, such as not changing fluids where possible during periods of high activity are also being considered to further reduce the CRS rates.

There was a slight increase in the CRS rates during July and August, which we may attribute to the change over in junior medical staff, who were unsure in their first few weeks of a new job. As a result we now have the nurse education team teaching on the SHO induction programme.

Further action

Small changes may have great impact!

Why is this an improvement ?

How does this benefit the service user ?