Infection Prevention Part 2

Last month’s blog addressed the concept of care bundles to decrease infection rates, particularly central line and infusion related infections.  In that blog, port access and care was addressed.  This month, we will address IV tubing changes.

While there are some randomized controlled trials demonstrating that the decreased frequency with which IV tubing is changed does not increase risk of infection, this seems to be an area where neonatal practitioners are hesitant to make that change.¹  In a recent article, neonatal intensive care units were polled for various practices related to PICC care and decreasing complications, including infection.²  This poll revealed that the majority of respondents continue to change tubing infusing non-lipid containing fluids at more frequent intervals than the recommended 96 hours.  The majority continue to change this tubing at every 24 hour intervals with the next frequency most reported at 72 hours.  Only 8.8% of the respondents changed non-lipid containing tubing at the recommended interval of every 96 hours.

A frequent point of discussion in my own practice has been the advisability of less frequent tubing changes for infants who are receiving intralipids which are not part of the main fluid i.e. mixed with parenteral nutrition.  Most NICUs administer intralipids through a Y-site set up which is Y-d into the main infusing fluid and then to the patient.  Many NICUs who do change tubing less often  will change the tubing to the intralipid solution every 24 hours but main line tubing is changed every 72 or 96 hours.  A study by Matlow et al out of Canada looked at the contamination rate of intralipid infusate at 24 hours compared to 72 hours.³  Prior to the study, the practice in this group of NICUs was to change tubing at the 72 hour frequency for both solutions.  The study protocol required that lines be randomized to be changed at 72 hour or 24 hour intervals and the infusate was sampled when the tubing was changed.  Both fluids were sampled above the Y-connector.  This study revealed that growth was higher, particularly of yeast organisms like Malassezia furfur and candida in the lipid solution at 72 hours vs 24 hours.  However, they also followed rates of positive blood cultures in both groups of patients and found no statistically significant difference in rates of positive blood cultures.  They postulate that the increased frequency of changing tubing may impact infection rates as much as the longer hang time.   This group decided to change tubing at 48 hour intervals after this study.  While this study is an important contribution, it raises many questions and opportunities for further research.  The method of tubing change may be as important as hang time as experience has shown a low rate of infection with longer tubing change times, even with intralipid solutions infusing via Y-site infusion.  Also important is the method of changing only the intralipid tubing and solution, if this practice is done.  Arranging tubing so that this can be done in a closed method may provide a safer way to change only a part of the tubing at more frequent intervals.

There is much to consider in the tubing change process that alone may impact infection rates and would be very difficult to pinpoint as a cause of the infection.  Adequate handwashing, use of clean or sterile gloves and cleansing of connection sites are other considerations.  Various methods of tubing changes are common.  The frequency of “sterile” tubing change has increased recently.  There is no evidence to demonstrate that a “sterile” tubing change is more effective than an aseptic tubing change.  However, in order to maintain a strict sterile environment during a tubing change, more than one person is required.  By creating a protocol where two people are required to change IV tubing, there is a double-check system put into place.  Simply having another person present who can observe and remind when lapses in protocol occur may improve compliance to the protocol.  However, depending on unit resources, requiring a two-person approach to IV tubing change may not be practical and therefore, not adhered to.

At the very least, creation of a sterile field in preparation for IV tubing change is helpful.  This allows the practitioner to place tubing on this field without contamination and prepare for assembly.  An approach that minimizes connections made helps to decrease infection and make the assembly of IV tubing consistent for each type of device and across devices when possible.  Whenever possible, purchasing tubing that is pre-assembled in the package is helpful and prevents one more opportunity for error or contamination.

When implementing any new practice it is important to ensure consistency.  No matter how much evidence is present, many of the practices we intend to implement in the neonatal population is not from a randomized-controlled trial and therefore, not based on strong research, particularly in our population.  The evidence must be replicated in our own environment and outcomes followed to ensure we are getting the outcome expected.  In order to accomplish this, two steps are critical.  First and foremost, care providers must be aware of changes made and practice changes desired.  Eggimann et al presented an infection prevention project in an adult medical intensive care population.⁴  They discussed the educational portion which included a 30-minute slide show and practical demonstrations for all staff, including fellows, residents, nurses and nursing assistants.  Other approaches might be poster presentations, discussion in one-minute shift reports or overviews or computerized training modules.  In many cases, a combination of approaches works best as not every person learns well with a single approach and multiple avenues of learning also serve to reinforce the information.

Auditing critical practices helps ensure that what is intended in the protocol is actually happening.  No amount of education can ensure that the intended practice occurs as intended.  Sacar et al observed hand washing practices and glove use during venipuncture.⁵  They observed 45.1% of the healthcare personnel washed their hands both before and after venipuncture and 23.1% washed their hands only after performing the venipuncture in spite of the fact that education had been done and all were knowledgeable that hand hygiene was required before and after venipuncture.  Often, particularly when new practices are started, habit does not change unless reinforced more than once.  Part of the audit process should also include reminders along the way and results of audits.

References:

1. Gillies D, Wallen MM, Morrison AL, Rankin K, Nagy SA, O’Riordan E. Optimal timing for intravenous administration set replacement. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD003588. DOI: 10.1002/14651858.CD003588.pub2

2. Sharpe E, Pettit J, Ellsbury DL.  A national survey of neonatal peripherally inserted central catheter (PICC) practices.  Advances in Neonatal Care, 2013; 13(1):55-74

3. Matlow AG, Kitai I, Kirpalani H, Chapman NH, Corey M, Perlman M, Pencharz P, Jewell S, Phillips-Gordon C, Summerbell R, Ford-Jones L.  A randomized trial of 72-versus 24-hour intravenous tubing set changes in newborns receiving lipid therapy.  Infection Control and Hospital Epidemiology.  1999;20(7):487-493.

4. Eggimann P, Harbarth S, Constantin M-N, Touveneau S, Chevrolet J-C, Pettit D.  Impact of a prevention strategy targeted at vascular-access care on incidence of infections acquired in intensive care.  The Lancet.  2000;355:1864-68.

5. Sacar S, Turgut H, Kaleli I, Cevahir N, Asan A, Sacar M, & Tekin K. Poor hospital infection control practice in hand hygiene, glove utilization, and usage of tourniquets. American journal of infection control, 2006;34(9):606-609.