Preventative Measures for CLABSI in the NICU

Abstract

CLABSI (central-line associated bloodstream infection) is a significant problem facing NICUs (neonatal intensive care units) within hospitals and medical settings. The problem is essentially that hospital staff are not watching what they are doing and adhering to the ethical standards of hygiene. This appears to be the central issue that has caused a spike in the number of infections nationwide, and even globally. It is essential that the medical arena face the problem head-on by educating the various stakeholders on the problem and coming up with a variety of ways to diminish, minimize and reduce the rates associated with CLABSI. To do this, there must be an understanding first of the problem specifically noting and stating to the stakeholders as to what CLABSI is.

Second, hospitals and medical settings must come together to form a collaborative network where the education on how to move forward accordingly in addressing the issue can begin. This means instituting an implementation plan consisting of the strategies that those within the network must take and then executing them properly. Third, understaffed NICUs are an issue and thus, the hospitals and medical settings should hire more staff. This will be done in accordance with current standards and policies associated with the nursing field and with the understanding that nurses and medical professionals hired will be educated on CLABSI and how it is a significant problem needing to be fixed.

Guiding this implementation plan is the system theory that will be the backbone of the collaborative network systematically tackling the problem. Within the strategies associated with the implementation plan will be evaluation tools - including two checklists that will be disseminated to hospital staff and enforced by management within the collaborative network, along with an educational handout that will further inform the stakeholders on how to prevent future infections. Finally, community involvement may be needed in the form of information dissemination, but more importantly, the stakeholders must know how to proceed in NICUs to prevent the rates of CLABSI from climbing any further than they have already.

Problem Description

Being understaffed is a major issue in Neonatal Intensive Care Units. As a result, this is considered a violation of both ethics codes and safety (Haley and Bregman, 1982, p.875). Due to the impact of understaffed Neonatal Intensive Care Units, the medical arena has noticed a significant rise in the amount of central-line associated bloodstream infections (CLABSI) in neonates. Reducing the rates of CLABSI presents a challenge. Therefore, it is important for the medical field to understand what must be done to correct and minimize the rising rates as quickly as possible.

Central line-associated bloodstream infections occur frequently in NICUs (Haley and Bregman, 1982, p.875). Marshall et al (2008) noted that nurses and medical professionals must be extremely careful when inserting catheters and dealing with patients due to this issue. The prevalence of CLABSI infection rates has essentially forced the medical arena to be on guard while handling patients. It is important and crucial for the staff in the NICU to be educated on proper hygiene and proper work ethics regarding patient handling (Marschall et al., 2008, p.522-524). The medical field hopes that the rates can be diminished with additional and supplementary educational discussions.

Without proper education, the staff remains ignorant of CLABSI prevalence and this essentially causes significantly more issues and problems within NICUs. Therefore, there is a responsibility on hospitals and medical clinics to fix the understaffing associated with NICUs. With the rising amount of CLABSI rates, understaffing presents both complex and major problems including higher volumes of patients with central line access and no nurses to assist in helping to change central line tubing. Nurses then, feel rushed and this cause notable issues pertaining to cleanliness and proper protocol.

To remove the complex issues pertaining to CLABSI rates, hospitals and medical settings as previously mentioned should hire more staff to correct the understaffing concern. This would then reduce the factors that have contributed to the prevalence of CLABSI in NICUs as it would allow patients to receive better care.

Schulman et al. (2011) performed a comparative study that examined 18 New York hospitals and found that CLABSI rates could be decreased with the use of maintenance checklists (Schulman et al., 2011, p.436-444). Burton et al. (2009) found that system updates and technological advances could also be something that hospitals and medical settings can implement to fix the growing epidemic that is CLABSI (Burton et al., 2009, p.727-730). Essentially, to reduce CLABSI rates, there needs to be an implementation plan put in place across multiple hospitals and medical arenas to reduce this growing problem.

Implementation Plan

As a result of the frequency of Central Line-Associated Blood Stream Infections that are taking place nationwide, collaborative efforts must be made in order to reduce them. This means that hospitals and medical clinics must work in conjunction with each other to reduce the continual infections taking place, in NICUs. To ensure that an effective routine is established, an implementation plan must be executed that will offer hospital settings preventative measures and systematic changes that will hopefully prevent or at a minimum minimize CLABSIs. In performing research on an implementation plan, one collaborative article by the Prevention Collaborative of New Mexico aimed at decreasing the prevalence of CLABSI. Additional research was examined to form an implementation plan that would be successful in getting approved.

Implementation Logistics

The initial implementation strategy that will be needed will be based on recommendations and guidelines suggested by the Centers for Disease Control and Prevention (CDC), the Society of Healthcare Epidemiologists of America (SHEA), the Infectious Disease Society of America (IDSA) and other organizations which stated that the following guidelines should be incorporated in any implementation plan for CLABSI prevention:

(Template omitted for preview. Available via download)

This particular implementation strategy will be incorporated into an overall plan and is based on the website "Agency for Healthcare Research and Quality," (2012). Since the goal and objectives are to diminish and prevent CLABSI rates in NICUs, there will need to be several elements included in the overall plan. The Prevention Collaborative of New Mexico acknowledged that objectives must be defined in any formal implementation plan. Therefore, the objectives and goals are outlined as follows:

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Obtaining Approval and Resources

The implementation plan will be executed within a period of 10 months with the hope of getting approval from stakeholders that this is the right plan for execution within the collaborative network of hospitals and medical clinics. Additionally, a communications strategy will have to be woven into the implementation plan so that key stakeholders know how the plan will be put into place. The stakeholders will be hospital and medical clinic administration, medical staff, nursing staff, physicians and support staff. The implementation plan must have an assessment of the total expenses that it will take to institute this particular change in how hospitals and medical clinics will assess and examine CLABSI rates. Dawson and Moureau (2013) analyzed data associated with CLABSI treatment and found that it is "estimated to be $32,254 per incident" (p.1). Therefore, the stakeholders will have to be presented data associated with the treatment of CLABSI as well as the costs associated with implementation. Presently, the implementation plan will cost the collaborative network anywhere between $500,000 to $1 million to implement. Additional costs may be assessed. The collaborative network (stakeholders) must understand the importance of CLABSI prevention and this will include training and continual monitoring of prevention efforts. In addition to presenting data associated with the costs of the implementation plans, the stakeholders will have to be made aware of the rising amount of CLABSI rates. The CDC noted that "an estimated 41,000 central line-associated bloodstream infections occur in U.S. hospitals each year. These infections are usually serious infections typically causing a prolongation of hospital stay and increased cost and risk of mortality" ("Central for Disease Control and Prevention," 2013).

Data such as this will be presented to the stakeholders to stress and highlight the importance of proper hygiene in NICUs to ensure that infections are prevented as much as possible. Evaluation tool consists of checklist documentation, questionnaires and handout will be provided to all stakeholders. This checklist documentation will be utilized every time the central line is being accessed. A total of 5 questions will assess the responses and react accordingly in terms of evaluating the reduction of CLABSI. Lastly handout stating, “Why is an implementation plan needed to prevent CLABSI.

Current Issue In Need of Change

Furuya et al. (2011) examined the prevalence of CLABSI throughout US intensive care units and sought to establish an effective means of prevention. To do this, they conducted a cross-sectional study with regard to the policies and characteristics of bundle components and the current ways hospital settings are complying with overall policy (p.1). From their study, it seemed that much of the underlying issues related to CLABSIs in any medical setting are related to compliance issues, therefore, it will be necessary for the changes noted in the implementation plan to highlight compliance with new measures.

Communication then is the centerpiece of ensuring the implementation plan is followed. Draper et al. (2008) stated that as hospitals and medical arenas make changes to improve the role nurses and medical staff play in preventative measures, there is a responsibility that must be adopted and that is striving to follow compliance measures. Hospitals and medical settings should be accountable for successfully engaging their staff to comply with the changes to certain routines and existing protocols. Improving quality is not a new concept, it just must have a rationale behind in to avoid any form of escalating pressure on hospital staff to participate (p.1-2). Essentially, the previously mentioned implementation plan must secure votes and positive feedback to avoid confusion and/or issues once implemented. While medical staff at hospitals and clinics typically comply with changes to internal policies, explaining the changes will be needed to avoid any form of pressure.

Current Practice and Why Change Is Needed

Han, Liang, and Marschall (2010) documented that the current practice of central venous catheters is an invaluable tool, but prevention and management issues come into play because of their complex uses. Much of their findings added to existing research regarding CLABSI rates in that it did not reveal any potential mechanism for hospitals and medical settings to stop the use of those types of catheters. The authors reason that it is not so much a catheter issue, but more or less an educational measure or measures must be taken or instituted to ensure competency among health care professionals in lowering rates of CLABSI. In their assessment of a program/implementation plan that was done in several tertiary teaching hospitals, the rates associated with CLABSIs dropped notably from 11.2 to 8.9 infections over a period of 1000 catheter days (p.147-148), indicating that educational programs are effective or rather can be in ensuring hospital staff complies with prevention measures and new policies/guidelines.

Han, Liang, and Marschall (2010) also stressed the importance of sterile environments as being a crucial component of any hospital strategy (p.148). The previously mentioned implementation plan includes sterility and hygiene as core components needed in the prevention efforts of CLABSI. To ensure that healthcare professionals are complying with the identified preventative measures, monitoring with a checklist as well as set aside funding will be created. This will ensure that kits and carts comply with guidelines instituted by the collaborative network implementation plan. Moreover, this will be presented to the staff associated with the network so there is no miscommunication as to the expectations associated with the prevention of CLABSI in NICUs. Additionally, monitoring may take place in the actual insertion process of the catheter to ensure there are no issues. While isolated incidents can occur, the purposes of the implementation plan will be to make sure that problems associated with lack of cleanliness or improper insertion are lessened and/or negated by the new guidelines.

Finally, the hospital staff will have to be educated on the expansion of prevention activities which includes different ways to treat CLABSI should problems continue to persist. There are several types of treatments. Preventive measures have shown to have a notable effect on the rates of CLABSI and will undoubtedly be the standard that the collaborative network will take on in terms of proper understanding. The field of CLABSI prevention, however, is ever-evolving, so while the implementation plan will be a necessity for stakeholders to adapt and to resolve the issues pertaining to CLABSI, there will need to be continual studies and data uncovered about CLABSI infections. While the collaborative network will understand that this implementation plan will prove to be effective in minimizing and/or preventing CLABSI, which will not necessarily resolve future issues regarding the infection.

Hospital management will have to continue to assess and evaluate the field of prevention further and any new methods that arise with regard to infections. With this measure in place, the hospital staff will have to be educated on the new treatments. Also, there may be new ways of prevention that come as a result of the changing field. If this should occur, an updated implementation plan will have to be created that incorporates the changes efficiently. The hospitals and medical clinics associated with the network will then have to be educated properly to ensure that compliance measures are met sufficiently. Additionally, there will have to be additional costs put into the educational process. By doing this, the implementation plan will hopefully continue to be effective in ensuring that CLABSI rates in NICUs are prevented and/or minimized to the best of the abilities of the medical staff within the collaborative network. This is the only way to proceed in ensuring that the rising rates of Central Line-Associated Blood Stream Infections that are taking place nationwide are no longer a serious and grave problem with regard to mortality and costs associated with hospital settings due to lack of planning and improper education.

Incorporating Theory

The nursing field continually seeks to find ways to strengthen the validity of the profession and clinical practice relevance. Given the problematic aspects of certain effects of medical setting quality, there needs to be a significant examination and analysis of what can be done to prevent health risks such as CLABSIs. One theory that will assist the profession in getting ahold of the problems that undeniably occur with CLABSI is the system model.

The System Model was developed by Betty Newman and its main focus is to understand the client system response to environmental stressors and prevent additional problems as a result. Newman stressed that each client was specifically unique and while there was no usual response because of this, she proposed that a basic structure could be implemented that included prevention on primary, secondary and tertiary levels. Clinical assessment and intervention on the primary level, additional intervention on the noxious effects of stressors at the secondary level and maintenance at the tertiary level (Olin, 2011).

In viewing this theory from the perspective of CLABSI, education seems to be the driving factor behind both the patient's family (as the patient themselves are neonates in most instances) and the medical arena for which the infection is obtained (Pintar, 2013). Therefore, based on the System Model, hospitals and medical settings will need to cohesively put together effective procedures that assist in the speedy recovery of patients by anticipating issues that could potentially occur from CLABSI infections. Additionally, patient's families must be educated on the problems of CLABSI infection so they can anticipate neonatal needs and demands that pertain to prevent further complications.

Within this project, there will need to be an emphasis not only on data pertaining to the CLABSI infection problem, but preventative measures specifically adhered to the Newman nursing theory and how the System Model can hopefully combat future issues regarding neonatal infections via catheter insertion. Since the system model is based on interaction between both the internal and external environments, community involvement may be needed to reinforce the implementation plan presented. It can be reasoned that the community is a stakeholder in the prevalence of CLABSI rates and therefore, should be involved in the plan to keep rates to a minimum and curtail future rates.

The system model functions on keeping the structure of a system stable and preventing any disorganization (Olin, 2011). While it is expected with any plan that there will be variables that may set the implementation back, the model will hopefully prove to be a dynamic integration within the collaborative network structure - which will enforce and reinforce existing policies associated with prevention and the new strategies put forth by the plan.

Evaluation Plan

The nursing profession continues to develop and as a result of this progression, there is a need for evaluation from time to time. Marsland & Gissane (1992) argued that evaluation is a powerful tool that has tremendously benefited the field of nursing and that nursing standards on a professional level are raised when these are performed on a routine basis (Marsland & Gissane, 1992). In addition to this, when hospitals and medical settings seek to implement new processes and concepts to further improve themselves, the evaluation must be rigorous, and these implementations must be examined from a critical eye. Marsland & Gissane (1992) further stated that any area that is being neglected in medicine and/or nursing must be addressed and brought to the surface or spotlight and methodically analyzed (Marsland and Gissane, 1992, p.233-234). The evaluation will be essential to better understand the rising CLABSI rates - and will provide an indispensable tool for the quality of care that neonates in the NICUs are receiving.

When evaluating how the collaborative network is dealing with CLABSI rates, there will be two checklists used. The first will be a questionnaire asked to the nurses and staff within the collaborative network regarding what they know about CLABSI, the importance of hygiene and the frequency of cleanliness regarding catheter insertion. At the beginning of the evaluation of whether or not the nurses and medical professionals know about CLABSI or not, there will be a total of five questions, but more may be added following the execution of the implementation plan that will be distributed to the stakeholders.

The second tool will be a checklist that will be required to be completed with every line change in the NICU. The checklist will be in the form of yes/no questions but every question must be answered by hospital and medical professional staff in the NICU whether a catheter insertion took place or not.

It is expected that the collaborative network may have issues at the beginning of the implementation plan execution and because of this, a handout will be distributed and training may be required for the nurses and medical professionals to specifically understand the importance of hygiene in NICU, what CLABSI is and why there is need for continual maintenance to minimize rising rates. The handout will detail both why the implementation plan is needed and the steps to preventing CLABSI.

All stakeholders will be given the evaluation tools per management requirements after the implementation plan is executed. The evaluation tool (Appendix A) will consist of 5 questions at first. After a period of 6 months, additional questions may be added depending upon the success of the implementation plan. Hospital management will evaluate how effective the checklist (Appendix B) is being utilized during each NICU staff shift and make the determination also at the 6-month point if there need to be additional evaluation tools and/or discussions pertaining to the importance of reducing bloodstream infections. The implementation plan will take a period of 9-12 months to execute properly as the management within the collaborative network will want to ensure that all key points are monitored and any potential variables are addressed beforehand. Continual evaluation of the collaborative network will be required given the prevalence of CLABSI.

While it is expected that the implementation plan will be successful within the collaborative network, given the prevalence of CLABSI that has taken place thus far, there may be some obstacles faced in the plan’s execution including stakeholders not wanting to perform the necessary steps associated with preventing future CLABSIs, issues with training and/or discussions where the handouts can be distributed and lack of community support. The collaborative network will have to assess each variable that may halt or hinder the process of implementation plan execution at the particular time the variable arises.

(Appendices A & B omitted for preview. Available via download)

Dissemination Plan

It is critical that when hospitals and medical settings seek to implement changes that they ensure that there are data and evidence that they can present to back up what they are proposing. Schillinger (2010) described the importance of dissemination of information to hospitals, by adding that it is a step by step process that must include basic research, treatment development, efficacy, effectiveness and an adaptation to the general reality of the field itself. The goal of information dissemination in the research process is to provide new insight into an existing problem with the hope that the proposal of information will be applied to current practice (Schillinger, 2010, p.4).

Therefore, for the purpose of the implementation plan for CLABSI prevention, there will need to be specific evidence that this new plan is needed. The stakeholders associated with the hospital and medical field (the collaborative network) will need to be presented with data that is precise. This data will include statistics about CLABSI and how it is currently being handled among the hospitals and medical clinics within the collaborative network. To prevent any potential issues that may occur because of the implementation plan that is presented, the research findings that will be done qualitatively must be assessed and examined thoroughly. The implementation plan, while straightforward may present some concerns among stakeholders who believe they are doing the right thing presently.

The implementation plan specifics will have to be set up in a document that addresses the projected costs and outcomes that will be executed in the collaborative network. The designer(s) of the implementation plan will have to evaluate what will be achievable and what elements will take time to execute. When looking at the implementation plan that was set up, there does not appear to be any issues with the collaborative network efficiently executing the plan. However, in any field - especially medical, there is always the potential for issues to occur. There must be a strategy with getting the stakeholders involved in the hospital management to employ it. The management at the various hospitals where CLABSI is prevalent must be presented with sufficient and effective information both on the epidemic and the necessary approach to minimize the problem.

Yuan et al. (2010) and Song et al. (2010) stated that there must be a blueprint of strategies when there is dissemination of information that will impact the quality of a hospital or medical setting. Yuan et al. (2010) took it a step further by stating that data must be simplified as much as possible, the implementation plan's process should be in line with the goals of the organizations associated with the network and that there should be an educational component in the campaign for any kind of proposed change (Yuan et al., 2010, p.5-8). This is why it will be important to have the information nicely presented and with minimal errors so that the importance of CLABSI prevention does not lose its credibility upon presentation. DeAngelis (2010) argued that research that is critical to healthcare must be organized systematically and then translated into practical and easy to understand discussion (DeAngelis, 2010, p.1). Essentially, the results of the issue of CLABSI will have to be organized according to how it is affected NICUs nationwide and worldwide.

There will be a need for collaborative network management to enforce training sessions and meetings on the research results that will be provided. This will ensure that everyone within the network (i.e. stakeholders such as nurses, doctors, and upper management) are kept abreast of what is happening with CLABSI rates in NICUs. The information on CLABSI rates will be distributed through handouts to the collaborative network that identify what CLABSI is, why it is important for CLABSI rates to be reduced and what can be done now by hospitals and medical settings to keep rates to a minimum in NICUs. Community participation may also be needed in order for the stakeholders to understand the seriousness of CLABSI and the need for the implementation plan to be executed properly. In gaining community participation, the collaborative network could potentially have an event in the general vicinity of the hospitals and medical settings that are in the collaborative network. This event would be an educational event that the collaborative network would gain sponsorship. It would be similar to an educational event on the importance of breast cancer or HIV, only for CLABSI, where the community would participate in events. It would be essential for the collaborative network to get the community involved so the medical professionals and nurses understand fully the importance of CLABSI prevention and reducing overall rates. In doing this, the research results from the qualitative study will be effective in ensuring that once the implementation plan is presented, it can be properly executed by the management at the hospitals and medical settings within the collaborative network – so that the rates of CLABSI can be minimized as much as possible.

Conclusion

It is expected that the mentioned implementation plan will be both effective and successful given the evaluation tools and the importance of educating the staff. Furthermore, hiring additional staff will also address the problem; but the main issue of concern with CLABSI rates is a lack of preventative measures within hospitals and medical settings. All stakeholders must understand what CLABSI is and how the rising rates as of late can be reduced. The evaluation tools (i.e. checklists and handout) will hopefully reinforce and emphasize the importance of why CLABSI must be dealt with, why proper adherence to policies and standards within the collaborative network must be followed and why there is need for more staff.

Moreover, with the system model integration into the framework of the plan, there will be both internal and external enforcement and reinforcement of how to best deal with the problem. Additional input and/or evaluation will be needed at 6, 9, 12 and 18-month intervals to ensure that the implementation plan is still sound and effective. Additional evaluation tools may be set up over the course of the plan’s implementation should a notable amount of variables hinder or halt the initial execution. It is the hope of the soundness of the plan, that the variables will be small other than a lack of education across the collaborative network of the statistical data pertaining to CLABSI and the need for proper hygiene when performing catheter insertion within the NICU. As a result of the implementation plan to diminish CLABSI rates in NICU, this will hopefully educate hospital and medical staff as well as keep neonates healthy and safe when they are in the NICU.

Review of Literature

Bueno, T., Diz, A., Cervera, P., Pérez-Rodríguez, J., & Quero, J. (2008). Peripheral insertion of double-lumen central venous catheter using the Seldinger technique in newborns. Journal of Perinatology, 28(4), 282-286.

The article assesses the risks associated with catheter insertion in neonates and the various complications that can arise as a result. The design of the study pertained to 61 newborns between the years spanning 2003 to 2006. The authors compared through analysis the indications and complications that can occur when catheters are taken out of the newborn. It seems from their outcome that placement is a very important metric that must be taken prior to insertion. In other words, medical staff must be careful where they insert the catheter as well as when they remove the catheter to avoid complications. This is an important article to practice because it reasons that education of where the insert the catheter is critical to preventing infections.

Center for Disease Control and Prevention (2011). Vital signs: central line--associated blood stream infections --- United States, 2001, 2008, and 2009. (2011). MMWR: Morbidity & Mortality Weekly Report, 60(8), 243-248.

This article seeks to understand the variations in infection rates associated with the years from 2001, 2008 and 2009. In order to study this article, collectedhealth informatics from the Centers for Disease Control and Prevention estimated data per three different settings: outpatient hemodialysis facilities, inpatient wards, and ICUs. Data was collected over a period of days and analyzed. In the outcome, the article reasons that infections decreased by 2009 when compared to 2001 in all three settings noting that more medical data and education were available. Hence, this provides clinical practice with useful information pertaining to minimizing infections and excessive healthcare costs.

Corzine, M., & Willett, L. (2010). Neonatal PICC: one unit's six-year experience with limiting catheter complications. Neonatal Network, 29(3), 161.

Corzine and Willett describe the varying complications that can result from central catheter insertion and the importance of safe dressing techniques. To better inform medical practice, the authors study the management and placement associated with 491 PICCs over a 6-year time frame. The authors add that certain complication rates associated with infections can be minimized with proper dressing techniques. The review in their outcomes is the particular complications that did indeed result from their study. They add that many of these complications could be prevented with proper maintaining and safety in hospital settings pertaining to neonates.

Franceschi, A., & da Cunha, M. (2010). Adverse events related to the use of central venous catheters in hospitalized newborns. Revista Latino-Americana De Enfermagem (RLAE), 18(2), 196-202. doi:S0104-11692010000200009

The article by Franceschi and Chollopetz da Cunha (2010) seeks to understand the risks associated with central venous catheter usage in newborns. To understand the adverse risks that can potentially occur, the authors perform a study of 167 newborns to quantitatively know the best ways to reduce risks associated with PICC insertions. The study was performed in Brazil at the Hospital de Clinicas at Porto Alegre. In their outcome, the authors describe that better handling of parenteral solutions and connections of the catheters can potentially prevent many complications. Moreover, additional data uncovered that most complications occur within 48 hours post-insertion. This article is important to research as it provided several measures for better insertion to lessen the potential risks of catheter insertion.

Garland, J., Alex, C., Uhing, M., Peterside, I., Rentz, A., & Harris, M. (2009). Pilot trial to compare tolerance of chlorhexidine gluconate to povidone-iodine antisepsis for central venous catheter placement in neonates. Journal of Perinatology, 29(12), 808-813. doi:10.1038/jp.2009.161

Garland et al.'s objective was to understand the rates associated with contact dermatitis with regard to central catheter placement in neonates. They note that catheter linked to bloodstream infection is one of the most complex, but also the most common complications of catheterization in neonates. To better understand this reasoning, the conducted pilots study at two community hospitals. They discovered that colonization was the primary outcome associated with bloodstream infection and that increased risk of dermatitis was not necessarily connected with cutaneous disinfection. This article provides a basis for infection issues in medical practice but additional information may be needed since it was a pilot study.

Holzmann-Pazgal, ,., Kubanda, ,., Davis,., Khan,., Brumley,., & Denson. (2012). Utilizing a line maintenance team to reduce central-line-associated bloodstream infections in a neonatal intensive care unit. Journal of Perinatology, 32(4), 281-286. doi:10.1038/jp.2011.91

Holzmann-Pazgal et al. (2012) provide a meaningful discussion on the importance of line maintenance to reduce central-line associated bloodstream infections in NICUs. To test their proposed measures of minimizing the risks associated with these infections, they quantitatively study a hospital with 240-beds in the NICU area that has 118 beds overall. With the implementation of line maintenance, the rates significantly dropped by a total of 65% which indicated that if certain precautions and post-maintenance occur that that will decrease the about of CLABSI infections substantially. The importance of this to clinical practice is that if hospitals start paying more attention to cleanliness in these NICUs, it will reduce the issues associated with infections.

Kane, E., & Bretz, G. (2011). Reduction in coagulase-negative staphylococcus infection rates in the NICU using evidence-based research. Neonatal Network, 30(3), 165-174. doi:10.1891/0730-0832.30.3.165

Kane and Bretz (2011) focus mainly on CoNS (coagulase-negative Staphylococcus) bloodstream infection as being a predominant cause of sepsis in the NICU and the preventative measures that can be taken to diminish its effects on morbidity. The study incorporated several article searches for keywords associated with NICU issues such as hand hygiene, catheters, and premature infant. A variety of statistical data was studied in an effort to understand the issues of infection in NICU units between 1998 and 2003. The essential outcomes of this study were cleanliness and educational emphasis in hospital and medical settings. This article was very noteworthy as it offered a variety of clinical techniques and methods that medical settings can integrate into their practice.

Khattak, A., Ross, R., Ngo, T., & Shoemaker, C. (2010). A randomized controlled evaluation of absorption of silver with the use of silver alginate (Algidex) patches in very low birth weight (VLBW) infants with central lines. Journal of Perinatology, 30(5), 337-342. doi:10.1038/jp.2009.169

The article by Khattak et al. (2010) sought to assess the immersion of silver while using silver alginate dressings in VLBW (very low birth weight) neonates. The authors conducted a pilot study to determine the safety and obtained consent from the mother or both parents of each of the infants. This study was approved by the Baylor Research Institute Institutional Review Board. The participants in the study were infants whose birth weights ranged between 500 to 1500 g and they were enrolled within a 72-hour time frame. There is a minimal amount of literature that specifically speaks to the issue of silver toxicity in premature VLBW infants; however, the authors found that certain effects of silver in the study could be diminished by better preventative measures. However, the study was a preliminary evaluation on what to do with regard to silver dressings, and the authors note additional research is needed. This article allows hospital settings to understand the importance of the utilization of certain dressings in NICUs with an emphasis on the effects that improper dressings will have on VBLWs.

Newman, N., Issa, A., Greenberg, D., Kapelushnik, J., Cohen, Z., & Leibovitz, E. (2012). Central venous catheter-associated bloodstream infections. Pediatric Blood & Cancer, 59(2), 410-414. doi:10.1002/pbc.24135

Newman et al. (2012) investigate the issues that are by and large associated with CLABSI infections in children under the age of 18. Much of the basis of their study is researched through the use of Hickman and Port A Cath catheters, various types of insertion methods, the susceptibility of antibiotic data and certain pathological baselines that they obtained between 1998 and 2008 in a hemato-oncology unit. The study found statistically that pathogens could be reduced in certain types of catheter use and insertion sites. It would seem from this study that catheter selection and implementation is the primary reasoning behind the outcome. Therefore, nursing practice should understand the types of catheters they are using in order to prevent infections.

Paulson, P., & Miller, K. (2008). Neonatal peripherally inserted central catheters: recommendations for prevention of insertion and postinsertion complications. Neonatal Network, 27(4), 245.

Paulson and Miller (2008) state the importance of successful PICC placement in neonates in reducing any potential pain or problems that may happen in invasive procedures such as this. To better understand the importance, they perform a study identifying the best ways to insert PICC based on choosing the right vein. The authors add that most of the time, hospital staff do not know how to effectively and efficiently perform placement or ignore the various recommendations that are made. While care itself is individualized, the authors note that many of the issues that result from improper PICCs can be prevented with proper knowledge of the best ways to perform neonatal care. Quantitative data was collected over the years between 1998 and 2005 at a Level II-III NICU to understand the various reasons associated with PICC and proper practices of treatment completion. The outcomes of the study that the author’s state is a table that lists the ways in which medical staff can prevent complications that tend to happen in NICUs. This study was significant to medical practice because it will help other NICUs to know the best ways of handling care and performing proper preventative measures.

Ponnusamy, V., Venkatesh, V., Curley, A., Musonda, P., Brown, N., Tremlett, C., & Clarke, P. (2012). Segmental percutaneous central venous line cultures for diagnosis of catheter-related sepsis. Archives of Disease in Childhood -- Fetal & Neonatal Edition, 97(4), F273-8.

Ponnusamy et al. (2012) seek to understand whether or not certain proactive cultures in CV lines could prevent infections. The authors wanted to examine the colonization of PCVLS (percutaneous central venous line segments) in neonates. To do this, they analyzed the cultures in both the middle and proximal segments of the line as well as the tip of the line. Preterm infants were specifically examined. The outcome of the study was not conclusive despite the somewhat interesting data that proactive cultures did have an effect in preventing sepsis. This article provides a wealth of information despite the fact that further study is needed because all of the data collected was not sufficient to say that proactive cultures wholeheartedly prevent infections.

Stevens, T., & Schulman, J. (2012). Evidence-based approach to preventing central line-associated bloodstream infection in the NICU. Acta Paediatrica. Supplement, 101(464), 11-16. doi:10.1111/j.1651-2227.2011.02547.x

Stevens and Schulman (2012) review the existing practices and methodology that pertain to CLABSI reduction. They define first what CLABSI is and how it is basically a preventable complication, but necessary nevertheless in modern NICU care by today's medical standards. They identify that recent studies have demonstrated that certain care practices and bundle of practices can have a positive impact on routine clinical care. Their study was more of qualitative study in that they observed methodology and techniques from evidence-based approach. The amounts of techniques that they explored were transformational QI methods and the need for teamwork, for example. This particular article can have a positive effect on the research as it supports the proposed changes associated with how to minimize the rates of CLABSI infections. It seems that clinical practice can benefit tremendously from teamwork and paying more attention to how they handle catheters since they are based on the author's study, almost unavoidable in today's NICUs.

Wagner, M., Bonhoeffer, J., Erb, T., Glanzmann, R., Häcker, F., Paulussen, M., & ... Heininger, U. (2011). Prospective study on central venous line associated bloodstream infections. Archives of Disease In Childhood, 96(9), 827-831. doi:10.1136/adc.2010.208595

Wagner et al. (2011) diagnose the various characteristics associated with CLABSI in one particular institution and the best catheters to use. Their respective methodology with this study was done between April of 2008 to March of 2009 and the participants in the study, 152 neonates (88 of which were male), were heavily reviewed in terms of lab records and history. Additionally, the participants' parents were provided a questionnaire, which the authors stated to be standard practice. The outcome of the study showed the incidences were CLABSI was more than likely to occur in terms of catheter insertion time frame for neonates. This particular study assists in understanding the types of catheters that are best with regard to characteristics of neonates in NICUs.

Wirtschafter, D., Pettit, J., Kurtin, P., Dalsey, M., Chance, K., Morrow, H., & ... Kloman, S. (2010). A statewide quality improvement collaborative to reduce neonatal central line-associated blood stream infections. Journal of Perinatology,30(3), 170-181. doi:10.1038/jp.2009.172

Wirtschafter et al. (2010) discuss the risks associated with central line-associated bloodstream infections. The authors state the common prevention strategies associated with these infections and seek to understand better ways of reducing the morbidity rates of hospital patients. To do this, they set up an improvement program that included five different interventions: leadership commitments, potential best practices, collaborative process between members, audit and feedback process and quality improvement techniques. These intervention processes were done in 13 regional NICUs. The outcomes that were the result of these intervention programs reduced the rates of CLABSI infections and there ended up being a less amount of infections as a result. The significance of this to nursing/clinical practice is that hospitals can now implement these types of intervention programs that will hopefully continue to reduce the risks associated with central-line bloodstream infections.

Wu, J., & Mu, D. (2012). Vascular catheter-related complications in newborns. Journal Of Paediatrics & Child Health, 48(2), E91-5. doi:10.1111/j.1440-1754.2010.01934.x

Wu and Mu (2012)'s article discusses the invasive aspects associated with NICUs and how both central and peripheral vascular catheters can assist in serving many essential functions in the NICU. Additionally, they study the growing epidemic of risks associated with the improper insertion or extended catheter use in neonates. The study provides statistical data in order to present the need for awareness of proper handling when catheters are used in the NICU. This particular article provides additional information on the importance of education in clinical practice regarding catheter insertion.

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