Beyond Bundles, HAI Prevention “Plus Measures” Toolkit Updated 2018

© 2016 Sue Barnes, RN, CIC, FAPICNICU Catheter Related Bloodstream Infection (CRBSI) Prevention,

Necrotizing Enterocolitis (NEC) and Late Onset Sepsis Prevention (LOS) Chapter

Document posted here: www.zeroinfections.orgOverview: This toolkit was designed for IPs (Infection Prevention professionals) and other clinicians as a resource/reference to support efforts to amplify/enhance infection prevention and control bundles. In the absence of sustained zero preventable infections of any type, and in the absence of risk to patients, products and practices supported by less than category 1 level evidence (i.e. “Plus Measures”) are often employed to amplify/enhance IP bundles. The “Plus Measures” contained within this toolkit are most commonly supported by what CDC considers category II level evidence (see page 3 for evidence categories). Within this toolkit evidence summaries are provided for each plus measure, in order to reduce the time required for literature searching by IPs, and are updated every two years. These “Plus Measures” including products, have been identified by the author during review of peer reviewed journals, attendance of professional conferences, continuing education courses, networking with clinical experts and industry partners. Consequently, the set of plus measures (including products), represented in this document is not all inclusive or exhaustive. I welcome any suggested additions from colleagues and industry partners (sueabarnes@gmail.com).

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This document was developed by Sue Barnes. Please feel free to use and reproduce this document in the spirit of patient safety, and please retain this note for appropriate recognition.

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CDC Evidence Categories (https://www.cdc.gov/violenceprevention/pdf/understanding_evidence-a.pdf): Category IA. Strongly recommended for implementation and strongly supported by well-designed

experimental, clinical, or epidemiologic studies. Category IB. Strongly recommended for implementation and supported by some experimental,

clinical, or epidemiologic studies and a strong theoretical rationale; or an accepted practice (e.g., aseptic technique) supported by limited evidence.

Category IC. Required by state or federal regulations, rules, or standards. Category II. Suggested for implementation and supported by suggestive clinical or epidemiologic

studies or a theoretical rationale. Unresolved issue. Represents an unresolved issue for which evidence is insufficient or no consensus

regarding efficacy exists.

https://ebbp.org/training/searchforevidence

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NICU Catheter Related Bloodstream Infection (CRBSI) Prevention, Necrotizing Enterocolitis (NEC) and Late Onset Sepsis Prevention (LOS)

The following category level 1 prevention measures are supported by CDC: 1. Allow only trained personnel to insert and care for central lines. 2. Checklist for insertion3. Daily review of line necessity, with prompt removal of unnecessary lines, and minimum number of

lumens4. Hand hygiene5. Maximal barrier precautions during line insertion6. Optimal catheter site selection e.g. peripherally inserted central catheter (PICC) line in peripheral

vein vs. femoral7. Use “bundled” interventions for central line insertion and maintenance as part of a single or multiple

facility quality improvement effort to reduce rates of CLABSIs. Bundled interventions should include staff education and efforts to promote adherence to recommended practices (e.g., checklist).

If zero preventable infections have not been achieved and/or sustained, consideration might be given to adding one or more of the following “PLUS” prevention measures to your NICU infection

prevention bundle(s):

DOUBLE CLICK ON ICONS IN TABLE BELOW TO OPEN EMBEDDED DOCUMENTS – COPY & PASTE LINKS INTO BROWSER

Plus Measures References

Product order info

Tools

CRBSI Prevention – Additional considerations Antimicrobial locks (consider) Bare arms to elbows – no watches or jewelry,

remove lab coats prior to contact with neonates CHG bathing CHG impregnated site dressing applied at time of

insertion (not 24 hours later), and when switching from umbilical to central site at 14 days

CVC dressing change only PRN due to dislodgement risk

Chlorhexidine skin prep without alcohol Exidine: https://www.medline.com/product/Exidine-4-Preop-Prep-Solution-by-BD/Z05-PF27687

Insertion checklists:

Insertion observation tool:

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CVC line cart or insertion kit – standard

NICU CRBSI continued, NEC AND LOS Prevention Plus Measures Reference

sProduct order info Tools

CRBSI Prevention continued CVC removal when enteral feedings

reach 120 ml/kg per day Glove up for all vascular access IV tubing – keep it outside of bed/

incubator – sterile technique for changing tubing

Minimize the number of times line is accessed for blood sampling

Nasal decolonization Participation in a collaborative Port protectors plus scrub the hub Post days between infections in NICU Simulation training for central line

inserters Skin antisepsis prior to line insertion

with CHG 2% solution with trace (non-therapeutic) alcohol for neonates only after first week of life. Remove any antiseptic applied to neonatal skin with sterile water.

Train ancillary departments where neonates travel in line and dressing care

Tunneled catheter removal after 7 weeks (consider)

Two-person CVC dressing change

See above CHG vascular insertion site dressing: Biopatch

http://www.biopatch.com/ Silverlon silver plated nylon

dressing IV http://www.silverlon.com/catheter-dressings

Bard https://www.bardaccess.com/products/procedural/guardiva

Disinfecting IV caps Curos Swabcap Dualcap PureHub

Prevantics device swab and strip: https://pdihc.com/products/interventional-care/prevantics-device-swab-strip

Instructions CHG dressing:

CPQCC: http://www.cpqcc.org/qi-projects/cpqccccs-collaboratives

NICU CLABSI Prevention Presentation:

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NICU NEC AND LOS Prevention continuedPlus Measures References Product order

infoTools

NICU NEC and LOS prevention measures CHG or PVI for umbilical cord cleaning Decolonize parents via CHG bathing and nasal

antiseptic (alcohol or PVI) or mupirocin Disinfect parent cell phones prior to entry Early enteral nutrition initiation (<24 hours) Human milk feedings (more effective

compared with formula for protection against neonatal sepsis, and can reduce duration of CVC)

Lactoferrin (an iron-binding protein that supports healthy modulation of gut microflora) to reduce the incidence of NEC, late onset sepsis, HAI, and infection-related mortality

Prebiotics and probiotics Skin to Skin or “Kangaroo mother care” Skin cleansing of parent prior to Skin to Skin

Care

PhoneSoap UV-C disinfection device for tablets and cell phones: www.phonesoap.com

Patient info on infection prevention:http://www.safecarecampaign.org/infection-topics.html

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