Unit based procedures: impact on the incidence of nosocomial infections in the newborn intensive care unit

REVIEW

Abstract Nosocomial infections are one of the major causes of morbidity in the Newborn Intensive Care Unit (NICU). Known risk factors include birth weight, gestational age, severity of illness and its related length of stay, and instrumentation. Infections result in prolonged hospital stays and, consequently, increased hospital costs. As advances in medical technology improve mortality in the tiniest of infants, it is imperative that health care providers identify effective interventions to minimize the risks of nosocomial infections in the NICU. This article examines the effects of common procedures on the incidence of nosocomial infections. Unit-based procedures discussed include visitation, hand washing and nail care, skin and cord care, maintenance of hubs in peripheral and central lines, gowning and isolation procedures, use and misuse of antibiotics, and unit design and staffing. Investigation of these procedures in individual units may reveal areas to improve patient outcomes. © 2004 Elsevier Inc. All rights reserved.

From the Neonatal Intensive Care Unit, West Virginia University Children’s Hospital, Morgantown, WV. Address reprint requests to Judith D. Polak, MSN, RNC, NNP, Department of Pediatrics, PO Box 9214 RCBHSC, West Virginia University, Morgantown, WV 26506. © 2004 Elsevier Inc. All rights reserved. 1527-3369/04/0401-0005$30.00/0 doi:10.1053/j.nainr.2003.12.001

Unit Based Procedures: Impact on the Incidence of Nosocomial Infections in the Newborn Intensive Care Unit By Judith D. Polak, MSN, RNC, NNP, Nicki Ringler, MSN, RNC, NNP, and Brenda Daugherty, MSN, RNC, NNP

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ospital acquired infections continue to be a serious, but common, complication of hospitalization. The Centers for Disease Control and Prevention (CDC) reports that nosocomial infection rates within US hospitals increased by 37% from 1975 to 1995 at a cost of over $4.5 billion in health care dollars.1 Currently, there is a 5 to 10% attack rate or 5 to 10 infections per 1,000 patient days.1 National surveillance data of infection rates in adult intensive care units continue to be well documented in the literature. Although nosocomial infections have long been recognized as a major problem in neonatal intensive care units (NICUs),2 it hasn’t been until recently that these data have been documented in the literature.3– 6 Overall infection rates range from 8.9 to 62 infections per 1,000 patient days or 6 to 25% of the NICU population.3,4,6 As would be expected, the greatest variation is related to site-specific infection rates by birth weight. Nosocomial infections may not only be related to the patient’s primary disease process, but also directly related to actions of health care workers.3,4,7 The first national point-prevalence survey of nosocomial infections in US NICUs showed that the prevalent use of therapeutic interventions, not only emphasized the intensity of care required by the population, but also was associated with infections.4 The most common intervention associated with infection was the use of central intravascular catheters. It might be debated that nosocomial infections in the NICU environment are unpreventable in attempts to keep the smallest and sickest of babies alive. Some believe that nosocomial infections may be unavoidable even under the most optimal infection control Newborn and Infant Nursing Reviews, Vol 4, No 1 (March), 2004: pp 38 – 45

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Prevention of Nosocomial Infections in the NICU

measures. With the prevalence of infections in the most vulnerable patients, there is an urgent need for more effective prevention interventions. As there is limited control over birth weight, we must look to unit culture, environment, and procedures to reduce the risk for infections in the NICU.

The Vermont Oxford Network Approach to Reducing Infections in the NICU

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he Vermont Oxford Network (VON) is a group of health care professionals committed to improving quality of medical care for infants and their families. This network facilitates a coordinated program of research, education, and quality improvement, leading to suggestions for best practices. One subgroup identified its improvement goal as a reduction in nosocomial infection rates in newborns 501 to 1,500 grams.8 Several specific areas addressed included documentation of infection, hand washing, vascular access, care of hubs in peripheral and central lines, and skin care. Each NICU involved served as its own control in attempts to decrease the risk of nosocomial infections. By changing these unit-based practices, there was a significant decline in the incidence of coagulase negative staphylococci (CONS), although there was no noted change with other pathogens.8,9

Hand Hygiene

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and washing before and after each patient contact is recognized as the single most important means of reducing the risk and preventing the spread of infection.10 –12 Because direct contact via the hands of nursery personnel is a major transmission route of pathogens, hand washing is essential in an effective infection control program. Hand washing removes transient flora from the hands and controls the overgrowth of potentially pathogenic flora. Steere and Mallison12, in 1975, determined that vigorous scrubbing with soap and water for at least 15 seconds removes transient bacteria. Resident flora require a longer period of hand washing and an antibacterial agent for adequate control. Recently, the use of alcohol-based hand rubs has become acceptable in restimulating attempts to improve health care workers’ hand hygiene. Because the technology to manufacture alcohol-based rubs is uncomplicated and has been available for many years, it is surprising that it has taken so long for these products to be readily available in the United States. Alcohol-based rubs are less damaging to the user’s skin, timesaving, inexpensive, and, most importantly, effective.11,13,14 New recommendations for hand hygiene have recently

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Table 1. Summary of CDC Guidelines for Hand Hygiene Indications for Hand Washing and Hand Antisepsis ● When hands are visibly dirty or contaminated, wash hands with soap and water. ● If hands are not visibly soiled, use either an alcoholbased hand rub or antimicrobial soap and water for routinely decontaminating hands. ● Decontaminate hands before and after direct contact with patients. ● Decontaminate hands after contact with inanimate objects in the immediate vicinity of the patient. Hand Hygiene Technique ● When using an alcohol-based rub, apply to one palm and rub hands together, covering all surfaces of the hands and fingers. ● When washing with soap and water, apply an amount of soap recommended by the manufacturer and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands thoroughly and dry with a disposable towel. Avoid hot water, as repeated exposure may increase the risk of dermatitis. ● Liquid, bar, leaflet, or powdered soaps are acceptable. Selection of Hand Hygiene Agents ● Provide personnel with products that are efficacious, with low irritancy potential, particularly when using multiple times per shift. ● To maximize acceptance by healthcare workers, solicit input regarding the feel, fragrance, and skin tolerance of any product under consideration. Cost should not be a primary factor in product selection ● Do not add soap to a partially empty dispenser. This can lead to bacterial contamination of the soap. Skin care ● Provide healthcare workers with hand lotions or creams to minimize irritation and contact dermatitis. Other ● Do not wear artificial nails or extenders. ● Keep natural nail tips less than 1/4 inch long. ● No recommendations can be made regarding wearing rings in the healthcare setting.

been published by the CDC in collaboration with a task force of the Society for Health Care Epidemiology of America, Association of Professionals in Infection and Epidemiology, and Infectious Disease Society of America.11 These new recommendations are designed to improve practices of all health care workers and to reduce transmission of organisms to the patients and personnel. Listed in Table 1 is a summary of the guidelines.15 Simply, improving hand hygiene can improve infection rates. Soap and sinks should be accessible. Alcohol-based rubs should be available at the entrance to the infant’s room or at each infant’s bedside. Written procedures that

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encourage routine hand washing should exist and may be posted above the sinks to remind personnel and families of good technique.

Antibiotic Usage in the NICU

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ntimicrobial agents, particularly antibiotics, are frequently used in the NICU. Despite efforts to minimize the use of antibiotics in NICU patients, many infants receive broad-spectrum antibiotics on admission to the NICU and often on several occasions thereafter because their presenting symptoms could be caused by an infection. This frequent antibiotic use has the potential to alter the infant’s established normal flora and result in the emergence of bacteria resistant to multiple antibiotics. The use of antibiotics in the NICU should be carefully monitored. The increasing threat of antimicrobial resistance, constantly changing pathogens, and very low birth weight infants affect the spread of infection in the NICU.16 When treating suspected sepsis, broad-spectrum antibiotics should be used until culture and sensitivity results are available.17 Antibiotics should be discontinued after 48 hours with negative cultures.9 This is considered to be important in limiting exposure to antibiotics and decreasing the need for vascular access. Indiscriminant use of antibiotics increases the risk of resistance to commonly used agents.17 The most commonly reported pathogen in NICU infections is CONS. The role of CONS as a true pathogen versus a contaminant of cultures is well described but continues to be a debatable subject. Identification of this organism results in clinical intervention and increased exposure to antibiotics, particularly vancomycin. The extended use of vancomycin can increase the risks of vancomycin-resistant enterococcus (VRE).18 Current recommendations suggest two blood cultures with 1 mL of blood in each be drawn to document septicemia as opposed to culture contamination.9

Catheter-Related Practices Peripheral Intravenous Catheters Intravenous (IV) access is a necessity in the NICU either through the use of a peripheral IV (PIV) or percutaneous inserted central catheters (PICC). PIVs are very useful in providing access for parenteral nutrition and medications but have some disadvantages. The major disadvantage is frequency of infiltration because infants’ veins are small and fragile. This may require multiple IV sticks, which can increase the incidence of nosocomial infections. The incidence of infections with PIVs is usu-

ally low, but serious problems can occur because of the frequency of use.18 The most common etiology of infection with PIVs is migration of skin organisms at the insertion site into the cutaneous catheter tract, leading to colonization of the catheter tip.18 Thus, careful attention to policy and procedure in starting PIVs is very important. Good hand washing combined with appropriate aseptic technique is necessary.18 Techniques for skin antisepsis must be closely followed. Cleansing the skin around the catheter site with alcohol and povidone-iodine and allowing it to dry for one minute is widely used.19 Chlorhexidine (0.5%) also has been shown to reduce peripheral IV colonization in neonates.7 The best choice for broad-spectrum sterilization of the skin before an invasive procedure seems to be chlorhexidine. Chlorhexidine (0.5%) in combination with 70% isopropyl alcohol was equivalent to 10% povidone-iodine in reducing bacterial numbers on the skin of preterm infants,20 whereas iodine was superior to isopropyl alcohol in children and adults.21 The use of two consecutive 10 second exposures or a single 30 second exposure was superior to a single 10 second wipe in reducing colony counts using chlorhexidine.20 Chlorhexidine was also superior to 10% povidone-iodone in reducing the risk for peripheral catheter colonization in neonates.22 Furthermore, a greater increase in colonization risk occurred with duration of catheter placement for povidone-iodine compared with chlorhexidine. Chlorhexidine (2%) was associated with fewer episodes of catheter-related infections than 10% povidone-iodine or 70% alcohol when used for skin disinfection in adults before catheter insertion.23 Alcohol is drying to the skin and is highly absorbed. Alcohol should not be used for initial skin preparation or for removing other compounds, such as chlorhexidine or povidone-iodine, from the skin. The skin is best rinsed with sterile water. Securing PIVs may be done with tape or steristrips. Neither should be placed directly over the insertion site. Transparent, semipermeable dressings have become a popular means to dress insertion sites. These reliably secure the catheter; allow for continuous visual inspection of the catheter site, and require less frequent changes than standard gauze and tape dressing. The rate of colonization among catheters dressed with transparent dressings is comparable to that of those dressed with gauze.18 Percutaneously Inserted Central Catheters Percutaneously inserted central catheters have become essential in the NICU for long-term venous access to deliver parenteral nutrition and medications.8 However, catheter-related bloodstream infections (CRBSI) are a

Prevention of Nosocomial Infections in the NICU

concern in the NICU with the use of PICC lines. Golombek24 found similar rates of infection between PICCs and PIVs. Rates of CRBSI vary from 0 to 25% in PICC lines. Skin flora contaminating the external catheter, hub, or both is the common cause of CRBSI.7 The most important risk factor for the development of CRBSIs is the length of dwell time.25 The VON recommends limiting dwell time for PICC lines to 21 days.9 The incidence of CRBSI has also decreased by establishing a PICC maintenance team.24 This involves consistency in insertion techniques and maintenance of PICCs. The education of the staff inserting PICCs as well as all neonatal health care providers is very important in reducing infection rates.9 Prevention of CRBSIs starts with the insertion technique of PICC lines. The use of sterile technique is required, including hair covering, face mask, sterile gown, and gloves.26 Povidone-iodine26,27 or chlorhexidine27 is used to disinfect the site. The catheter should be inserted following hospital policy and procedure and professional standards from the National Association of Neonatal Nurses (NANN) and the Infusion Nurses Society (INS). The catheter should be secured with sterile tape or steristrips and covered by a transparent dressing.24,26,27 These transparent dressings should only be changed if they are loose or soiled.24,27,28 Frequent catheter entry may also lead to an increase in CRBSIs.25 Prevention of CRBSIs from catheter entry include: ● ● ● ● ●

Use of injection ports instead of stopcocks25,26 Minimum number of ports9 Disinfection of injection port before line entry9,25 Adherence to hand-washing hygiene25,26 Clean technique when accessing system and when changing tubing26

Signs and symptoms of infection should be closely monitored in infants with PICC lines. Evaluation of infection should include two blood cultures.9,25 A peripheral and central catheter culture is recommended.25 Options for treatment of CRBSIs vary but include discontinuing PICC or infusing antibiotics through the catheter with a repeat blood culture in 24 to 48 h.26 Broadspectrum antibiotics should be initiated until blood culture results are obtained.25 Newborn Skin and Cord Care A developmentally mature and intact skin seems to effectively prevent infection of the skin and impedes microbial invasion mechanically. Neonates, especially pre-

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term infants, are at high risk for infection, however, because of epidermal barrier immaturity and immaturity of the systemic immune system. Postnatal age and gestational maturity are important considerations in assessing skin maturity and in determining skin care practices because of the exposure of premature skin following birth to the dry, extrauterine environment epidermal barrier. Barrier maturation following premature birth, however, typically requires approximately two to four weeks and may require as long as eight weeks in extremely premature infants.29 Thus, the majority of the neonatal population is at risk for problems of skin integrity, and, subsequently, related nosocomial infection. Bathing the newborn has potential hygienic, esthetic, and interpersonal benefits. But, changes in the barrier properties of the skin that can occur with bathing may cause undue skin irritation and trauma. There has been little uniformity to the frequency of bathing and the use of cleansing products in the NICU. Suggestions by the Neonatal Skin Care Research-Based Clinical Guidelines include decreasing the frequency of bathing and the use of water or neutral pH cleansers.29 Emollient use has been shown to be effective in reducing dryness of skin surfaces and improving the barrier function of the skin.30 Interest in the use of emollients in neonatal care has increased since the publication of a pilot study at Stanford University involving the application of the ointment Aquaphor威 (Biersdorf Inc, Wilton, CT) twice daily for the first two weeks of life to the skin of premature infants born at less than 33 weeks’ gestation.31 These investigators found that treated neonates had fewer episodes of clinical deterioration consistent with sepsis and a lower incidence of positive blood cultures. Another randomized controlled study compared prophylactic application of Aquaphor威 with local as-needed application.32 Nosocomial infections were more frequent in the study group (applied twice per day for 14 days) than in the control group (applied at the discretion of the bedside nurse). CONS was the most common organism, occurring more frequently in the smallest infants (501 to 750 g). The use of barrier-enhancing emollients in the care of neonatal skin is now recommended and practiced routinely in many settings, especially for newborn infants less than 33 weeks’ gestation. Consider using Aquaphor威 only as needed or limiting scheduled treatment for less than two weeks in the extremely premature infant. Cord care remains controversial. No single method has proven to be superior in limiting bacterial colonization and sepsis. Dry care of the cord margin is an acceptable regimen. Alternatives include local daily application of alcohol, triple dye, or Bacitracin威 (Pfizer Inc, New York, NY). Each of theses agents can delay or reduce cord

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Polak, Ringler, and Daugherty

colonization, but their use is not clearly superior to dry care if endemic rates of omphalitis and skin infections are low. A recent study compared cord bacterial colonization among newborns whose cords were treated with alcohol, triple dye, or dry care.33 Of 766 total newborns, one infant in the dry care group developed omphalitis. Also noted was increased colonization of the cords, without sepsis, in the dry care group. The clinical significance of this is unclear. Further research is needed in this area. Isolation Isolation guidelines recommended by the CDC, and per hospital guidelines, aid in preventing the transmission of pathogens. Isolation precautions are designed to prevent the spread of microorganisms among patients, personnel, and visitors. Because the type of infection and host factors are often more difficult to control and treat in the neonatal population, interruption of the chain of infection is primarily directed at transmission. Isolated infants are those with suspected and confirmed infectious diseases. These infants are generally kept in a separate room (if possible) within the NICU. However, nurses caring for these infants usually have other “nonisolated” infants within their work assignment and, thus, increase the chance of transmission. Infants placed in isolation may serve as a reservoir for virulent strains of microorganisms. Pathogens are then transmitted to other infants when understaffing leads to decreased hand washing and other infection-preventing practices.34 The hospital is responsible for ensuring that appropriate isolation precautions are used. Each hospital should clearly designate, in the form of a written policy, which pathogens require isolation, the type of isolation needed for specific infections, and the personnel responsible for making the decision to place a patient on isolation precautions. All personnel involved in neonatal care, including ancillary departments and consulting services, are responsible for complying with isolation protocol. Tactful reminders are often necessary to make others aware of breaks in isolation technique. However, each member of the health care team must have a clear understanding of the importance of these precautions and a personal sense of responsibility in practice. An isolation room should be available for NICU patients. An area for hand washing, gowning, and storage of clean supplies should be conveniently provided at the entrance to the isolation room. While all members must commit to adhere to the isolation guidelines, bedside nurses often find themselves responsible for enforcing these rules to ancillary and consulting services.

Cover Gowns Although the use of cover gowns in neonatal settings is widespread, there is much variability in gowning policy implementation among institutions. Some require gowning on entrance into the neonatal area while others require gowns only while in direct patient care areas. Finally, some nurseries necessitate cover gowns only during direct patient contact. While the number of studies investigating the effectiveness of cover gowns in the neonatal environment is limited, none of the studies found any difference in infection rates associated with routine use of cover gowns.35 Therefore, available research does not support routine cover gown use as a measure to substantially reduce infection transmission. The CDC advises cover gowns only for isolation purposes and the American Academy of Pediatrics (AAP) no longer advocates routine use of cover gowns in nurseries or the NICU. Current Occupational Safety and Health Administration (OSHA) standards require all personnel wear personal protective equipment while providing care in which there is a potential for contamination with blood or other body fluids. Therefore, it is recommended that personnel who are holding or feeding babies wear an impermeable cover gown due to the risk for contact with emesis from the infant. Cloth gowns, used in many nurseries, are not impermeable and thus, do not meet the above-mentioned requirements. In summary, based on current research and recommendations from the CDC, AAP, and OSHA, a reasonable practice would be to only require cover gowns for those caring for infants in isolation and during times of feeding or other care activities that hold potential for contamination with blood or body fluids. It should be noted that appropriate attire, such as masks, caps, shoe covers, goggles, and gloves should also be used in caring for infants in isolation. Cover gowns are also recommended when the caretaker’s duties include the handling of more than one infant, with the gown changed between patients.36 Use of maximum sterile barrier protections is necessary for placement of all central lines, including sterile gowns, mask, head covering, large sterile drape, and sterile gloves. Kits containing all required materials, or a central location of these supplies, may increase compliance.7 This stricter barrier approach results in significantly fewer infections than the previous commonly used method of only sterile gloves and face masks.36 Visitation The benefits of family visitation have been well established, but need to be weighed against the potential risks of transmitting pathogens to neonates. Many hospitals allow unlimited visitation for immediate family, including sib-

Prevention of Nosocomial Infections in the NICU

lings. This practice should continue to be encouraged. Limited studies indicate that bacterial colonization or subsequent infection is not increased in neonates who have been visited by siblings. However, thorough screening is necessary to restrict those, regardless of age, who have been exposed to communicable diseases such as chicken pox or tuberculosis or have symptoms of infectious diseases such as fever, diarrhea, or a productive cough. A brief parental interview or written list noting recent exposures and verifying that visiting siblings are up to date with immunizations is appropriate. Unit Design The nursery’s overall physical condition, along with nurse:patient ratio and size of the neonatal service all play a part in infection control. However, though difficult, assessing a neonatal unit’s design, routine infection prevention measures, and staffing may reveal areas in which minor changes may improve patient outcomes. Adequate distance between beds and equipment avoids crowding and reduces accidental contamination. Recommended standards for newborn intensive care design exist and give hospitals guidelines to control infections. Each infant bed space should contain a minimum of 120 square feet, excluding aisles and sinks, with eight feet between beds. There should be an adjacent aisle to each bed space with a minimum width of four feet. Also, traffic to and from other hospital services should not pass through the area designated for neonates.37 While not a physical aspect of NICU unit designs, the specific routine of how infants are assigned and moved between rooms affects infection control. Infants in special care nurseries are often frequently moved using the “graduated care” concept, eg, infants are moved to other areas as their level of care changes.34 While nurse staffing and unit space demands often dictate this practice, infants are exposed to an increased variety of pathogens with each move. Staffing Nurse patient ratios and nursing skill mix significantly affect inpatient mortality.35 Overcrowded, understaffed nurseries make frequent hand washing between infant contacts difficult.38 Haley and Bregman34 found the rate of clustered infections to be 16 times greater after periods of critical understaffing than after times of adequate staffing. Thus, adequate nurse staffing patterns are imperative in reducing infection rates. Staffing should be planned to allow sufficient time for patient care activities and hand washing between patient contacts. Breaks in aseptic technique and reduced attention to time-dependent infection

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control measures are possible causes of the inverse relationship between nurse staffing and nosocomial infection rates.38 The Joint Commission on Accreditation of Hospitals stresses that “nursing personnel in all areas must be assigned in a manner that minimizes the risk of cross infection and accidental contamination.”39 Furthermore, adequate staffing is more critical in special care units, where virulent pathogens and immunocompromised patients are more common.34,38 Patterns of nurse staffing, not simply the number of nurses, need to be assessed to provide consistent care standards. Many hospitals are reducing health care costs by decreasing nursing numbers or by using less trained nurses in place of unit-specific registered nurses. Similar to the effects seen with understaffing, an increase in the number of resource or agency nurses may increase infection rates. Bloodstream infection rates in an adult surgical intensive care unit were related to a lower regular nurse: patient ratio and an increased number of resource pool nurse:patient ratios. Unlike earlier work, the overall nurse: patient ratio did not vary significantly between control and case patients. This is the first study to suggest the importance of the composition of nurse skill mix.40 No longer can overall nurse hours be enough; properly trained nurses to specialty areas are mandatory to reduce infection rates. Hospital pool nurses, or agency nurses, may be less familiar with unit special infection disease prevention measures. The Nosocomial Infections Surveillance System showed the mean number of hospital beds to be decreasing while the mean number of intensive care beds is increasing. This environmental change in health care results in a larger critically ill patient population, needing more intensive nursing care and ICU bed space. Hospitals need to aim attention at increasing specialty nurse:patient ratios, rather than decreasing the presence of properly trained registered nurses at the bedside.38 Technological advancement and medical management have made it possible to save smaller and more critical infants in recent years. However, with this progression, the present day “standard” neonatal step-down infant often still requires central lines, parenteral nutrition, and respiratory support, much like an intensive care infant of years past. Hospital administration needs to recognize these changes in infant acuity and provide staffing based on current infant needs rather than long established norms to reduce infection rates. While the issues of nurse understaffing and unit overcensus are strongly linked, overcensus creates separate problems. Overcrowding leads to an expected transmission of nosocomial infections between infants either by airborne spread or by decreased distance between infants, leading to inadvertent cross-contamination of equipment. Also, overcrowded nurseries allow more infants to be

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exposed to transmitted pathogens. Clustered infections were seven times greater after periods of critically increased census than after periods of routine census.34 The nosocomial infection rate of Serratia marcensens in a pediatric cardiac ICU was correlated to patient census and nurse staffing.38 Also, increased patient census, inadequate cohorting of infected infants secondary to staffing limitations, and overall reduction of full-time nursing staff contributed to an outbreak of parainfluenza virus type 3 in an intermediate care nursery.41 While it may seem apparent that an increased number of nursing hours worked decreases nosocomial infections, a threshold does exist. Above this threshold of nursing hours worked, nosocomial infections begin to increase. Archibald and coworkers,38 theorized that the increased number of nurses needed in times of high census and overcrowding led to a higher risk of direct or indirect transmission of nosocomial infections between patients. Unwillingness to Change Patient outcomes, including nosocomial infection rates, are directly caused by the behaviors of all bedside care providers. There exists a large gap in how care practices should be carried out and how care practices are actually carried out. This discrepancy hinders infection prevention measures. Infection control is often discussed as a top priority within a unit, but daily struggles of understaffing, high acuity, and overcensus cause infection prevention to be an afterthought. Health care workers may not see the direct link between their lapses in infection control and patient infection rates. For example, failure to administer a pain medication to a postoperative patient allows the health care worker to clearly see the cause and effect, a patient in pain, of their actions. Conversely, failure to adhere to proven infection control practices does not have such a clearly observable outcome.35 While there is a high probability for behavioral change while the practices are still being developed, only recently established, or weakly linked to unit norms, long-standing behaviors tightly tied to existing practice are less likely to be changed. Furthermore, practices not responsive to prior attempts to change are even more difficult to alter. It is distressing that health care workers, providing direct patient care, cannot or will not eliminate ritualistic practices, even after scientific data present a better practice. Adding to this problem is the dissemination of new information to health care workers, especially those with many years of practice. For example, the majority of practicing nurses are 40⫹ years old and finished nursing school before much of the information on current infection control was known. There is a shared responsibility between the bedside health care workers and the hospital’s education de-

partment to maintain awareness of current evidence-based practice guidelines.35

Conclusion

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n summary, the incidence of nosocomial infections and their attendant morbidity and mortality is increasing as tinier infants occupy NICU bed spaces. It is imperative that a multidisciplinary team within the individual NICU culture identifies risk factors and subsequent strategies to decrease nosocomial infection rates in their unit. Future efforts should focus on unit-based procedures and their effect on nosocomial infections. Small changes may have great impact.

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Prevention of Nosocomial Infections in the NICU

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