Evaluating Central Venous Catheter Care in a Pediatric Intensive Care Unit
Evaluating Central Venous Catheter Care in a Pediatric Intensive Care Unit
Background Catheter-related bloodstream infection remains an important health problem for hospitalized children. Although placement of a central venous catheter is a life-saving intervention for critically ill children, these same central catheters are a potential source of infection.
Objectives Few studies that directly address care of central venous catheters for children in intensive care units have been reported. This evaluation was designed to describe the extent of evidence-based practices for care of insertion sites of central venous catheters in the pediatric intensive care unit of an urban tertiary care center. Another goal was to determine the influence of 2 different regimens for dressing changes on rates of catheter-related bloodstream infections and costs.
Methods A convenience sample and an exploratory design were used to collect data in 2 phases, including 30 days to establish baseline information and 30 days each during which patients received dressing care for a central venous catheter with a transparent dressing alone and with a transparent dressing plus a chlorhexidine-impregnated dressing. Nurses also participated in a survey of knowledge about infection control practices related to central catheters.
Results Few differences were found between the transparent dressing alone and a chlorhexidine-impregnated dressing plus the transparent dressing. A serendipitous finding was the number of times that central catheters were accessed daily.
Conclusions The results of this project suggest that infection control efforts may be most appropriately focused on processes rather than on products.
About 250000 bloodstream infections related to central venous catheter (CVC) placement develop in patients in US hospitals annually. Most catheter-related bloodstream infections (CR-BSIs) develop in patients in intensive care units (ICUs) and result in an estimated 90000 deaths a year. Acutely ill children of various ages, diagnoses, and underlying conditions who are admitted to pediatric intensive care units (PICUs) are particularly vulnerable to CR-BSIs. Richards and colleagues reported that bloodstream infections are among the most common infections in PICUs and suggested that such infections are a significant source of morbidity for critically ill children. Placement of CVCs can increase the risk of nosocomial bloodstream infections developing, with concomitant increases in the length of hospital stay and costs of care, estimated at nearly $40000 per episode. Clearly, reducing the occurrence of CR-BSIs in critically ill children is important to health care providers and organizations.
Although few reported studies directly address CVC care for PICU patients, studies of acutely ill adults have yielded findings that may apply. Among the effective strategies identified is use of chlorhexidine skin preparation solution. Materials and processes used in dressing changes also have been implicated in CR-BSI, with studies done to compare gauze versus transparent dressing, transparent hydro-colloid versus polyurethane dressing, and povidone-iodine ointment, gauze, and transparent dressing versus transparent dressing alone. In one of the few studies of pediatric patients, Garland et al conducted a multicenter, randomized trial of a chlorhexidine-impregnated dressing (Biopatch, Johnson & Johnson, Somerville, NJ) for neonates who needed a CVC for at least 48 hours. The investigators determined that use of the chlorhexidine-impregnated dressing, replaced weekly, was equal in effect to disinfection with povidone-iodine solution and replacement of a transparent dressing every 3 to 7 days. Although support exists for some prevention strategies, more information is needed.
Because available studies used various approaches and evaluated a variety of dressing types, little consistent information exists to guide nursing care. This inconsistency predisposes to errors and increases costs because of the need to maintain equipment and supplies for a variety of methods of site care. The project described in this article was designed to (1) document the extent of evidence-based practices for CVC site care in the PICU of an urban tertiary care center and (2) determine the influence of 2 different dressing change regimens on CR-BSI rates and costs. By developing and following guidelines for CVC site care, we intended to reduce the number of CR-BSIs and thus reduce hospital costs.
Abstract and Introduction
Abstract
Background Catheter-related bloodstream infection remains an important health problem for hospitalized children. Although placement of a central venous catheter is a life-saving intervention for critically ill children, these same central catheters are a potential source of infection.
Objectives Few studies that directly address care of central venous catheters for children in intensive care units have been reported. This evaluation was designed to describe the extent of evidence-based practices for care of insertion sites of central venous catheters in the pediatric intensive care unit of an urban tertiary care center. Another goal was to determine the influence of 2 different regimens for dressing changes on rates of catheter-related bloodstream infections and costs.
Methods A convenience sample and an exploratory design were used to collect data in 2 phases, including 30 days to establish baseline information and 30 days each during which patients received dressing care for a central venous catheter with a transparent dressing alone and with a transparent dressing plus a chlorhexidine-impregnated dressing. Nurses also participated in a survey of knowledge about infection control practices related to central catheters.
Results Few differences were found between the transparent dressing alone and a chlorhexidine-impregnated dressing plus the transparent dressing. A serendipitous finding was the number of times that central catheters were accessed daily.
Conclusions The results of this project suggest that infection control efforts may be most appropriately focused on processes rather than on products.
Introduction
About 250000 bloodstream infections related to central venous catheter (CVC) placement develop in patients in US hospitals annually. Most catheter-related bloodstream infections (CR-BSIs) develop in patients in intensive care units (ICUs) and result in an estimated 90000 deaths a year. Acutely ill children of various ages, diagnoses, and underlying conditions who are admitted to pediatric intensive care units (PICUs) are particularly vulnerable to CR-BSIs. Richards and colleagues reported that bloodstream infections are among the most common infections in PICUs and suggested that such infections are a significant source of morbidity for critically ill children. Placement of CVCs can increase the risk of nosocomial bloodstream infections developing, with concomitant increases in the length of hospital stay and costs of care, estimated at nearly $40000 per episode. Clearly, reducing the occurrence of CR-BSIs in critically ill children is important to health care providers and organizations.
Although few reported studies directly address CVC care for PICU patients, studies of acutely ill adults have yielded findings that may apply. Among the effective strategies identified is use of chlorhexidine skin preparation solution. Materials and processes used in dressing changes also have been implicated in CR-BSI, with studies done to compare gauze versus transparent dressing, transparent hydro-colloid versus polyurethane dressing, and povidone-iodine ointment, gauze, and transparent dressing versus transparent dressing alone. In one of the few studies of pediatric patients, Garland et al conducted a multicenter, randomized trial of a chlorhexidine-impregnated dressing (Biopatch, Johnson & Johnson, Somerville, NJ) for neonates who needed a CVC for at least 48 hours. The investigators determined that use of the chlorhexidine-impregnated dressing, replaced weekly, was equal in effect to disinfection with povidone-iodine solution and replacement of a transparent dressing every 3 to 7 days. Although support exists for some prevention strategies, more information is needed.
Because available studies used various approaches and evaluated a variety of dressing types, little consistent information exists to guide nursing care. This inconsistency predisposes to errors and increases costs because of the need to maintain equipment and supplies for a variety of methods of site care. The project described in this article was designed to (1) document the extent of evidence-based practices for CVC site care in the PICU of an urban tertiary care center and (2) determine the influence of 2 different dressing change regimens on CR-BSI rates and costs. By developing and following guidelines for CVC site care, we intended to reduce the number of CR-BSIs and thus reduce hospital costs.
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