Newborn and premature critically ill infants in neonatal intensive care units face many challenges. Infants have delicate veins, so peripheral IVs usually last only a few days. A centrally inserted intravenous line is similar to a peripheral IV line, but lasts longer. It is difficult to insert these lines in newborn and premature infants and takes several attempts, thus making them more prone to infections, especially nosocomial infections which are very common in neonatal intensive care units. The most common infection is the central line associated blood stream infection (CLABSI). The risk is greater when the central intravenous line is in place for a longer duration, prolonged use of antibiotics, parental nutrition, low birth weight infants, low immune system, and lack of staff education. Inserting a central intravenous line is a sterile procedure so it is a nurse’s responsibility to minimize the risk of infections. Health care-associated infections increase the length of hospitalization, hospital cost, patient discomfort, and morbidity and mortality rates (O'Grady & Pearson, 2002). Thus, it is important for health care professionals to be responsible for knowing their roles and using maximum sterile barriers while placing and caring for central venous catheters. According to the Agency for Healthcare and Research Quality (AHRQ), there are many practices healthcare professionals should follow to prevent CLABSI (Marschall, 2008). The use of maximum sterile barriers are one of the essential practices observed in a patient care scenario that occurred in the neonatal intensive care unit.
Jenkins is a former 30 weeks-premature male infant born with respiratory distress and placed on a ventilator. He later developed bowel distention and could not tolerate formula. He was started on a course of antibiotics and was given nothing by mouth (NPO). Infant was then started on total parenteral nutrition (TPN) and intralipids (IL) via peripheral intravenous line. Upper gastrointestinal X-rays were done and showed bowel perforation, so a pediatric surgeon was consulted for bowel surgery. It was found that the infant had exploratory laparotomy and bowel resection. Thus, the infant remained on NPO and total parenteral nutrition and intralipids continued to be administered. Due to long term needs of intravenous fluids (IVF), it was difficult to maintain the intravenous site, so the infant needed a CVC. Initially, a peripheral inserted central catheter line was unsuccessfully attempted three times by a nurse practitioner. The pediatric surgeon was consulted for the second time to surgically place a CVC for long term IVF fluids replacement. Before the patient went for the procedure, all health care personnel were responsible in following the recommended AHRQ guidelines to prevent an infection from occurring. This would include the monitoring of central line insertion before and after central line management with ongoing maintenance care (Marschall, 2008).
Before Insertion:
All nurses would be educated on the risk factors of CLABSI and proper maintenance of the central line, such as administration of medication, IV tubing changes, and dressing changes, according to their hospital’s policies and protocols. Health care professionals’ competencies would be reviewed on an annual basis to make sure preventative measures are taken to bypass potential infections (Marschall, 2008). Parents would also be educated on how to use certain sterile techniques, such as cleaning hands with alcohol-based rub or soap and water, to prevent infections.
At Insertion:
A catheter checklist is utilized to make sure all measures are taken to prevent infection when the CVC is inserted. Proper sterile barriers are implemented: a mask prevents infection from any talking and coughing that may occur; a hat prevents hair from falling; and sterile gown and gloves keep any microorganisms that may be on your hands and clothes from crossing the sterile barrier (Raad, Hanna, & Maki, 2007). Gloves are used only after hands are washed with alcohol-based rub. A sterile drape should cover the patient to provide additional protection against possible infection. Traffic is reduced around the sterile field, and a designated nurse observes that aseptic techniques are maintained during the procedure, reporting any changes in the aseptic technique. Chlorhexidine is used on patients older than 32 weeks of age because further research is needed on the alternative effects on the skin. Povidine-iodine is used for patients under the age of 32 weeks. (Miller-Hoover & Small, 2009).
After Insertion:
The catheter needs to be reevaluated on a daily basis to prevent infection. Nurse must still use the aforementioned sterile maximum barriers when administering medication through the catheter injection port, changing IV tubing, and changing dressings.
Central venous catheters are usually cared and maintained by nurses, so nurses are accountable for following all the sterile technique measures when administering medications, changing IV tubing, and changing dressing (Sharpe, 2009). Nurses must assess the needs of the catheter on a routine basis to prevent CLABSI. Without proper care, a catheter can cause the development of sepsis, which leads to a spike in the mortality rate. Nurses are accountable for proper documentation of the central line site for skin integrity. In addition, nurses and other health care professionals must have good sanitary hygiene and create a sterile environment when interacting with patients. Preventing CLABSI all starts with proper care by healthcare professionals, but it also occurs as nurses educate the patients, their families, and their fellow peers on how to avoid infection.
In conclusion, central venous catheters are one of the leading causes of infection in hospitals. The AHRQ has published guidelines and regulations to help nurses in their responsibilities to treat patients. These guidelines include the use of a catheter checklist, sufficient training of the nursing staff, and most importantly, and the creation of a maximum sterile barrier for the patient. Using the correct antiseptic based on age of the infant and proper hygiene by health professionals can make a large difference in hospitals where patients are prone to infections. Overall, it is the nurse’s responsibility to prevent infection by maintaining a sterile environment with a mask, cap, patient drape, and other barriers. With proper care and diligence, patient safety becomes an utmost priority.