1. Prevention of Central Line-Related Bloodstream Infections (CRBSI) on NNU Wales Neonatal Audit and Outcomes Day Cardiff, 07/10/2015 Sandar S, Ratcliffe C, Abelian A, Wrexham Maelor Hospital, BCUHB

2. Timeline Jan 2010 – Jan 2011 prospective Audit showed high rate of CRBSI; Jan 2013 – CRBSI prevention guideline introduced; Jun 2013 – June 2014 – prospective re-Audit; Aug 2014 – Aug 2015 – second prospective re-Audit.

3. CRBSI Prevention Guideline Based on the 2011 Centers for Disease Control (CDC; USA) recommendations:  Maximal barrier precautions;  Use of Hydrex ® pink (0.5% chlorhexidine in 70% alcohol);  Check and do list for clinicians;  Bundled supplies;  Staff education and nurse empowerment to stop non-urgent insertions if proper procedures weren’t followed.

4. Objectives Compare CRBSI rates pre- and post- Guideline; Compare CRBSI rates to those reported by CDC; Describe factors leading to CRBSI; Describe CRBSI-related morbidity.

5. Methods Prospective data collection; Definition of CRBSI: growth of the same organism in blood and tip cultures obtained within 48 hrs of each other (CDC 2011 criteria); Primary outcome measure: number of central line days per one CRBSI; Secondary outcome measure: length of central line stay before removal (days).

6. RESULTS

7. Pre- guideline Post-guideline 2010 - 20112013 - 20142014 - 2015 Central lines, n41 (long lines only) 9070 Central line days, n179530379 Average time line in situ, days (range) 4.4 (0-17)5.8 (0-32)5.4 (1-16) CRBSI, n1032 CL days per one CRBSI, n17.9176190 Average gestation (SD; range), weeks 30.2 (4.0; 24- 38) 32.6 (4.4; 23- 40) 32.5 (4.6; 27- 41) Average weight (SD), gramNo data1828 (1129)2003 (983) Table 1. Pre – and post-guideline data.

8. Pre-guideline 2010 – 2011 (12 months) Post-guideline 2013 – 2015 (24 months) Significance (p) Central lines, n41 (long lines only) 160n/a* Central line days, n179909n/a Average time line in situ, days (range) 4.4 (0-17)5.7 (0-32)<0.0001 CRBSI, n105 CL days per one CRBSI, n17.9181.8<0.0001 Average gestation (SD; range), weeks 30.2 (4.0; 24- 38) 32.6 (4.5; 23- 41) 0.001 Table 2. Data analysis (all central lines)

9. Pre-guideline 2010 – 2011 (12 months) Post-guideline 2013 – 2015 (24 months)Significance (p) Long lines, n4150n/a* Long line days, n179349n/a Average time line in situ, days (range) 4.4 (0-17)7 (1-32)<0.0001 CRBSI, n101 CL days per one CRBSI, n17.9349<0.0001 Average gestation (SD; range), weeks 30.2 (4.0; 24- 38) 31.2 (4.7; 23- 41) 0.123 Table 3. Data analysis (long lines only)

10. Conclusion Clear and sustained improvement in CRBSI rate since the implementation of the prevention measures; No additional costs; Rate of CRBSI comparable to that reported by CDC (4-10 per 1000 central line days).

11. Recommendations Continue to engage medical and nursing staff in ensuring adherence to the Guideline; Continue ongoing audit of CRBSI; Establish audit of CRBSI in other units across Wales - is there scope for an All- Wales guideline?

12. Questions?

13. Morbidity and Mortality 2010-112013-142014-15 CRBSI-related deaths, n 310 CRBSI –related significant morbidity (recovery >48 hrs), n 311

14. Case 1 Case 2 29/40 Prolonged TPN LL in situ 15/7 BC + and LL tip + Staph Epidermidis Full recovery in 72 hours 28/40 UAC and UVC inserted day 1 UAC removed day 3 Respiratory distress day 5  UVC removed BC + and line tip + Staph Epidermidis Recovery within 48 hours Cases 2014-12015

15. Infection no 1. 26-weeker, passed away. Gestation 26 +4, birth weight 930g; UAC in-situ for 21 days removed due to occlusion; New UAC inserted into the same artery immediately; Passed away on day 25: blood cultures (x3) grown Staphylococcus epidermidis; Learning point: do not re-insert umbilical lines.

16. Infection no 2; full recovery after 7 days Gestation 32, birth weight 1670g; UVC in situ since birth; Became clinically unwell needing CPAP on day 4; CRP went from 2.6 on day 4 to 46 on day 5; Tretated with co-amoxiclav and gentamicin until day 6; Rapid improvement following introduction of teicoplanin on day 7 (when CRP rose to 76); Required increased respiratory support (CPAP) and increased nutritional support at 48 hours; Full recovery of symptoms after 7 days of treatment; Staph epidermis in blood culture and UVC tip cultures.; Learning point: use anti-Staph epi antibiotic early in an unwell baby with a central line in situ.

17. Infection no 3; full recovery in 48 hrs Gestation 34, birth weight 2055g; Day 5 of life; UVC inserted after multiple attempts to insert a long line; Day 7 of life clinically deteriorated, Staph epi growth in blood culture and from UVC tip; Treated with Teicoplanin with full recovery of symptoms by 48h; Learning point: prolonged procedure increases infection risk.