Challenges in the Prevention of CRBSIs in Pediatrics

Catheter-related bloodstream infections (CRBSIs) cause significant mortality and morbidity each year, and also cause of healthcare-associated infections (HAIs). The Centers for Disease Control and Prevention (CDC) is in the process of releasing new guidelines for the prevention of CRBSIs, but many of these practices apply only to adult settings, and therefore the prevention of these infections is additionally challenging in pediatric settings.

Two pediatric experts were asked several key questions about best practices for prevention of CRBSIs specific to pediatrics: Donna Peace, RN, CPHQ, CIC, epidemiologist and Janet Pettit, MSN, NNP-BC, CNS, neonatal nurse practitioner.

What is the biggest struggle you have in your facility in prevention of CRBSIs?

Pettit: Initially to get staff to believe that CRBSI wasn't an entitlement when you are born prematurely and your life depends upon use of TPN via a central venous catheter (CVC). Once that was accomplished, it continues to be the performance of hand hygiene among all disciplines coming in contact with our babies.

Peace: To me, collaboration amongst the multi-disciplinary team of healthcare professionals in the prevention of these deadly infections is the largest struggle that I see in my facility. In addition, the evolution of clinical literature demonstrating best practices in the prevention of bloodstream infections proves challenging when convincing certain medical disciplines, especially physicians, of changing practices, and sustaining the transformation.

What is your role, and how do you collaborate with other disciplines to combat this problem?

Pettit: As the team leader in our effort, I was amazed at the number of staff (nurses, physicians, respiratory therapists, social workers and managers who composed our HAI prevention teams). The teams tackled all aspects critical to success -- identifying new products to use and processes to change, engaging staff in behavior change, working with non NICU staff and getting by in to our processes, communicating practice change to staff and planning celebrations. Prevention is a lot of work and takes a team of dedicated individuals to make it work. I have also discovered that we must continue to monitor process performance to identify gaps in practice that could lead to patient harm.

Peace: As an infection preventionist, my role is cross functional in the sense that on a daily basis, I interact with a variety of clinicians, patients, as well as family members. I also serve on a system wide committee charged with vascular access excellence, which includes the prevention of catheter-related bloodstream infections. One of my biggest daily challenges is adapting the message of infection prevention and control to the variety of audiences that I meet with on a daily basis.

What role does the use of Chlorhexidine gluconate (CHG) play in the prevention of CRBSIs? What do you use CHG for?

Pettit: CHG has been demonstrated as best practice for the prevention of CRBSI in many patient populations, and evolving evidence suggests that its safety track record applies to younger patient populations. We use a 3.15 percent CHG product for port and hub cleansing, as well as for skin antisepsis. For extremely low birth weight infants, we rinse the CHG off with sterile saline following the procedure.

Peace: At our facilities, we use CHG in both our skin antiseptics, and also certain dressings such as Biopatch. CHG is used for disinfecting the skin prior to the insertion of the device or routine venipuncture, and also prior to accessing any access point on the intravenous line.

What successes have you seen in your facility, and how have you achieved them?

Pettit: We have now gone approximately 18 months without a CR-BSI when previously we had a very high rate. We have also found our rates of CRBSI decline in conjunction with our CRBSI efforts.

Peace: We have had several successes that have contributed to a decrease in CRBSI. First, all needless connectors were converted from a positive displacement device to a split septum Interlink device. Next, we have a renewed and constant focus on hand hygiene and disinfection of the patients environment. Both healthcare workers and the patients families are required to perform frequent hand hygiene. The environment is cleaned and disinfected routinely using the Super Sani-Cloth product. Lastly, several years ago, we implemented a new "Scrub-the-Hub" program using a 3.15 percent Chlorhexidine gluconate/70 percent isopropyl alcohol swab pad that is used to clean the access point before every single entry to minimize contamination.

Do you believe that zero HAIs is achievable?

Pettit: Yes and No. I think that with some of our vulnerable infants we have to look beyond our current efforts to discover why some of our infants, particularly those with congenital GI malformations appear to be at increased risk of CLABSI. Are the infections due to colonization of the indwelling feeding tubes or gut translocation? If so, how will you reach the goal? To be successful, you need a team that includes support (staff time and dollars) from hospital administration and board of directors and staff believing in the goal. Cheerleaders are critical to the efforts.

Peace: Yes and No. Due to the intricacy of co-morbidities of many pediatric patients, particularly congenital abnormalities can make even the most preventable infections sometimes impossible to mitigate in these fragile patients. That being said, the goal for every patient should be zero HAIs.

What unique challenges exist in the pediatrics arena that make preventing CRBSI even more difficult?

Pettit: Prolonged need for CVC and lack of evidence (though it is evolving) supporting best practices in this myriad of age groups. Some products have not been researched with supportive for neonates and premature infants. Since this is one of the populations at highest risk it is imperative that clinicians and manufacturers work together to find solution.

Peace: In my opinion, the biggest challenge is the lack of pediatric focused research and evidence-based practice for prevention of CRBSI. In most cases, pediatric clinicians are forced to adapt the current evidence found in the adult literature to the size of a pediatric patient, which is not always effective.

Janet Pettit, MSN, NNP-BC, CNC is a neonatal nurse practitioner in Modesto, Calif. and a leading national expert on neonatal care and president of the Vascular Access Certification Corporation. Pettit recently presented research on preventing CRBSIs at the 2010 Association for Vascular Access annual conference.

Donna Peace, RN, CPHQ, CIC is a epidemiologist and national infection control expert in Atlanta. Peace recently presented research on preventing catheter related bloodstream infections at the 2010 Association for Vascular Access annual conference, and serves as the co-chair of the practice guidance committee for the Association for Professionals in Infection Control and Epidemiology (APIC).