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The Use of 2% Chlorhexidine (CHG) Skin Antisepsis for the Prevention of Infection with Central Venous Catheters (CVC) in a Neonatal Intensive Care Unit (NICU)
June 2007
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Fletcher Allen Health Care (a 560 bed academic medical center) has done surveillance for nosocomial RSV since at least 1990. The Vermont Children’s Hospital consists of a 20 bed Neonatal Intensive Care Unit (NICU), a 30 bed pediatric unit, a 4 bed Pediatric Intensive Care Unit (PICU) and a nursery serving almost 2500 newborns each year. In spite of a previously effective RSV policy, we saw a significant increase in nosocomial acquisition of RSV (7 cases) during the winter of 1995. PROJECT: A multidisciplinary team (including administration, pediatric infectious diseases, pediatrics and infection control) developed a comprehensive RSV isolation policy in 1996. The policy included rapid RSV screening of all pediatric admissions with any respiratory symptoms (regardless of admitting diagnosis), cohorting both patients and staff, limiting sibling visitation in the NICU during RSV season, mandatory yearly education for all pediatric personnel, family education and development of a unique RSV isolation protocol. The isolation protocol includes a combination of contact and droplet precautions, with eye protection. RESULTS: The RSV isolation policy was initially effective in reducing the rates of nosocomial RSV; there were only 4 cases in the first 4 years after implementation. There was an increase in the 2000-2001 (6 cases) and 2001-2002 (3 cases) RSV seasons. The policy was reviewed, education was emphasized, a comprehensive hand hygiene program was initiated and rates of RSV acquisition were periodically reviewed with staff. For the past 4 RSV seasons, there have been no cases of nosocomial RSV, despite a heavy burden of children with RSV admitted to Vermont Children’s Hospital during the winter months. LESSONS LEARNED: Transmission of nosocomial RSV in a children’s hospital can be successfully prevented with a comprehensive RSV control program. Screening all symptomatic pediatric admissions for RSV, meticulous adherence to RSV isolation protocols, education of staff and families and periodic feedback of nosocomial transmission rates are essential components of an effective RSV control program.
Publication Number 17-192
The Use of 2% Chlorhexidine (CHG) Skin Antisepsis for the Prevention of Infection with Central Venous Catheters (CVC) in a Neonatal Intensive Care Unit (NICU) MD Honeycutt, RN, BSN, CIC1 SB Curry, CNNP, MSN, APN2 KC Frost, CNNP, MSN, APN2 G Goins, RNC, ADN3 CH Gilliam, BSMT, CIC1 1
Epidemiology and Infection Control, Arkansas Children’s Hospital, Little Rock, AR, USA University of Arkansas for Medical Sciences-Department of Pediatrics-Divison of Neonatology, Arkansas Children’s Hospital, Little Rock, AR, USA 3 Neonatal Intensive Care Unit, Arkansas Children’s Hospital, Little Rock, AR, USA 2
ISSUE: The neonatal population, especially the low birth weight infants, is at a particularly high risk for infection due to their compromised immune status. It is necessary to utilize CVCs to administer intravenous fluids and medications. This includes the use of percutaneously inserted central catheters (PICC) as well as Broviac catheters. The insertion and use of these PICCs and Broviac catheters place these infants at a higher risk for developing a bloodstream infection (BSI). Procedures to minimize the occurrence of BSIs with CVC insertion and maintenance are an important issue. The use of CHG as a skin antisepsis has been well documented as being effective in decreasing BSIs associated with CVCs. The use in the neonatal population, however, has been limited. PROJECT: To implement measures during insertion and maintenance of CVCs as a means to decrease catheter associated BSIs in the neonatal population. The targeted population was neonates admitted to the NICU who require the placement of PICCs or Broviac catheters. Beginning in March, 2006 the use of CHG for skin antisepsis
E174
Vol. 35 No. 5
was implemented. The targeted population was neonates admitted to the NICU who require PICCs or Broviac catheters for fluid/medication administration. Due to the lack of data regarding the use of CHG in neonates, the decision was made to limit the use to those infants greater than two weeks of age or weighing more than 2 kilograms. CHG was used as a skin prep for the insertion of PICCs as well as with dressing changes. It was also used for dressing changes in those neonates with Broviac catheters. At the same time, the use of a CHG impregnated patch was implemented for those neonates with Broviac catheters. RESULTS: There were a total of 342 catheters placed during this ten month data collection period. The bloodstream infection rate with PICCs decreased from a rate of 5.4 (8 BSI/1492 catheter days) during the 2nd Quarter of 2006 to 1.7 (3 BSI/1754 catheter days) during the 4th Quarter of 2006. This demonstrates a 68% reduction in blood stream infections for these patients. The bloodstream infection rate for Broviac catheters decreased from a peak of 16.6 (2nd Quarter 2005) to 0.0 (4th Quarter 2006). There were no adverse skin conditions associated with CHG skin prep use in the PICC population. There were two patients out of 56 that developed minor skin irritation with the use of the CHG patch. LESSONS LEARNED: The use of 2% CHG in neonates for skin antisepsis for PICC placement and dressing changes as well as dressing changes with Broviac catheters has shown to be effective in reducing the bloodstream infection rate associated with these catheters. There were no adverse skin conditions with the use of 2% CHG in low birth weight neonates. CH Gilliam, BSMT, CIC, Johnson & Johnson/Biopatch, Consultant, honorarium.
Specialized Settings (Ambulatory Care, Behavioral Health, Long Term Care, Home Care) Publication Number 18-193
Use of Ionic Silver and Collagen To Reduce Bioburden and Promote Healing for Improved Quality of Life in a Complex Patient MK Webb, RN, BSN, MA, CIC Infection Control Wound Care, San Mateo Medical Center, San Mateo, CA, USA ISSUE: Provide optimal standard of care based on best practice to improve patient outcomes, by removing necrotic tissue, addressing infection, social and emotional problems and preventing patient from further surgical intervention. PROJECT: Comorbidities such as SCI/neuromuscular problems, nutritional, social and emotional to name a few are things that can significantly change the outcomes of a patient. I will present a young SCI patient with paraplegia, S/ P MVA in 1985, with surgical repair of a Stage IV pressure ulcer in 1989. Admitted July 4, 2005 with Stage IV, necrotic, foul smell, extensively infected pressure ulcer covering the entire sacral, right trochanteric, perianal and vaginal vault area as well as bilateral foot ulcers. Her past history is unclear, unable to determine prior treatment regimens prior to presenting to our setting. RESULTS: Patient admitted with malformed buttock, anus and vaginal vault making any treatment option difficult. It was necessary to address infection, reduce bioburden, and promote healing. Patient with urinary and fecal incontinence, as well as monthly menses, added to problem with choosing an appropriate advanced wound care dressing. I will demonstrate with this case the progression towards healing by utilizing advanced wound care products that are bioavailable to cleanse, debride, reduce bioburden and maintain an optimal moist environment. LESSONS LEARNED: We were able to reduce and close all body wounds; leg, feet and malformed buttocks. We prevented infection of any system while residing in long term care and was discharge 15 months after admission with full body intact skin not requiring additional surgical intervention.
E173
Fletcher Allen Health Care (a 560 bed academic medical center) has done surveillance for nosocomial RSV since at least 1990. The Vermont Children’s Hospital consists of a 20 bed Neonatal Intensive Care Unit (NICU), a 30 bed pediatric unit, a 4 bed Pediatric Intensive Care Unit (PICU) and a nursery serving almost 2500 newborns each year. In spite of a previously effective RSV policy, we saw a significant increase in nosocomial acquisition of RSV (7 cases) during the winter of 1995. PROJECT: A multidisciplinary team (including administration, pediatric infectious diseases, pediatrics and infection control) developed a comprehensive RSV isolation policy in 1996. The policy included rapid RSV screening of all pediatric admissions with any respiratory symptoms (regardless of admitting diagnosis), cohorting both patients and staff, limiting sibling visitation in the NICU during RSV season, mandatory yearly education for all pediatric personnel, family education and development of a unique RSV isolation protocol. The isolation protocol includes a combination of contact and droplet precautions, with eye protection. RESULTS: The RSV isolation policy was initially effective in reducing the rates of nosocomial RSV; there were only 4 cases in the first 4 years after implementation. There was an increase in the 2000-2001 (6 cases) and 2001-2002 (3 cases) RSV seasons. The policy was reviewed, education was emphasized, a comprehensive hand hygiene program was initiated and rates of RSV acquisition were periodically reviewed with staff. For the past 4 RSV seasons, there have been no cases of nosocomial RSV, despite a heavy burden of children with RSV admitted to Vermont Children’s Hospital during the winter months. LESSONS LEARNED: Transmission of nosocomial RSV in a children’s hospital can be successfully prevented with a comprehensive RSV control program. Screening all symptomatic pediatric admissions for RSV, meticulous adherence to RSV isolation protocols, education of staff and families and periodic feedback of nosocomial transmission rates are essential components of an effective RSV control program.
Publication Number 17-192
The Use of 2% Chlorhexidine (CHG) Skin Antisepsis for the Prevention of Infection with Central Venous Catheters (CVC) in a Neonatal Intensive Care Unit (NICU) MD Honeycutt, RN, BSN, CIC1 SB Curry, CNNP, MSN, APN2 KC Frost, CNNP, MSN, APN2 G Goins, RNC, ADN3 CH Gilliam, BSMT, CIC1 1
Epidemiology and Infection Control, Arkansas Children’s Hospital, Little Rock, AR, USA University of Arkansas for Medical Sciences-Department of Pediatrics-Divison of Neonatology, Arkansas Children’s Hospital, Little Rock, AR, USA 3 Neonatal Intensive Care Unit, Arkansas Children’s Hospital, Little Rock, AR, USA 2
ISSUE: The neonatal population, especially the low birth weight infants, is at a particularly high risk for infection due to their compromised immune status. It is necessary to utilize CVCs to administer intravenous fluids and medications. This includes the use of percutaneously inserted central catheters (PICC) as well as Broviac catheters. The insertion and use of these PICCs and Broviac catheters place these infants at a higher risk for developing a bloodstream infection (BSI). Procedures to minimize the occurrence of BSIs with CVC insertion and maintenance are an important issue. The use of CHG as a skin antisepsis has been well documented as being effective in decreasing BSIs associated with CVCs. The use in the neonatal population, however, has been limited. PROJECT: To implement measures during insertion and maintenance of CVCs as a means to decrease catheter associated BSIs in the neonatal population. The targeted population was neonates admitted to the NICU who require the placement of PICCs or Broviac catheters. Beginning in March, 2006 the use of CHG for skin antisepsis
E174
Vol. 35 No. 5
was implemented. The targeted population was neonates admitted to the NICU who require PICCs or Broviac catheters for fluid/medication administration. Due to the lack of data regarding the use of CHG in neonates, the decision was made to limit the use to those infants greater than two weeks of age or weighing more than 2 kilograms. CHG was used as a skin prep for the insertion of PICCs as well as with dressing changes. It was also used for dressing changes in those neonates with Broviac catheters. At the same time, the use of a CHG impregnated patch was implemented for those neonates with Broviac catheters. RESULTS: There were a total of 342 catheters placed during this ten month data collection period. The bloodstream infection rate with PICCs decreased from a rate of 5.4 (8 BSI/1492 catheter days) during the 2nd Quarter of 2006 to 1.7 (3 BSI/1754 catheter days) during the 4th Quarter of 2006. This demonstrates a 68% reduction in blood stream infections for these patients. The bloodstream infection rate for Broviac catheters decreased from a peak of 16.6 (2nd Quarter 2005) to 0.0 (4th Quarter 2006). There were no adverse skin conditions associated with CHG skin prep use in the PICC population. There were two patients out of 56 that developed minor skin irritation with the use of the CHG patch. LESSONS LEARNED: The use of 2% CHG in neonates for skin antisepsis for PICC placement and dressing changes as well as dressing changes with Broviac catheters has shown to be effective in reducing the bloodstream infection rate associated with these catheters. There were no adverse skin conditions with the use of 2% CHG in low birth weight neonates. CH Gilliam, BSMT, CIC, Johnson & Johnson/Biopatch, Consultant, honorarium.
Specialized Settings (Ambulatory Care, Behavioral Health, Long Term Care, Home Care) Publication Number 18-193
Use of Ionic Silver and Collagen To Reduce Bioburden and Promote Healing for Improved Quality of Life in a Complex Patient MK Webb, RN, BSN, MA, CIC Infection Control Wound Care, San Mateo Medical Center, San Mateo, CA, USA ISSUE: Provide optimal standard of care based on best practice to improve patient outcomes, by removing necrotic tissue, addressing infection, social and emotional problems and preventing patient from further surgical intervention. PROJECT: Comorbidities such as SCI/neuromuscular problems, nutritional, social and emotional to name a few are things that can significantly change the outcomes of a patient. I will present a young SCI patient with paraplegia, S/ P MVA in 1985, with surgical repair of a Stage IV pressure ulcer in 1989. Admitted July 4, 2005 with Stage IV, necrotic, foul smell, extensively infected pressure ulcer covering the entire sacral, right trochanteric, perianal and vaginal vault area as well as bilateral foot ulcers. Her past history is unclear, unable to determine prior treatment regimens prior to presenting to our setting. RESULTS: Patient admitted with malformed buttock, anus and vaginal vault making any treatment option difficult. It was necessary to address infection, reduce bioburden, and promote healing. Patient with urinary and fecal incontinence, as well as monthly menses, added to problem with choosing an appropriate advanced wound care dressing. I will demonstrate with this case the progression towards healing by utilizing advanced wound care products that are bioavailable to cleanse, debride, reduce bioburden and maintain an optimal moist environment. LESSONS LEARNED: We were able to reduce and close all body wounds; leg, feet and malformed buttocks. We prevented infection of any system while residing in long term care and was discharge 15 months after admission with full body intact skin not requiring additional surgical intervention.