The following terms are defined as:
• Antimicrobial lock therapy: involves instillation of a highly concentrated antibiotic solution into an intravascular catheter lumen for the purpose of sterilization in order to treat catheter-related bloodstream infections (CRBSIs), minimize associated complications, and avoid catheter removal (Girand, 2018)
• Central venous catheter: are thin, flexible tubes that are inserted through the skin into a large vein, often in the arm or chest. The tube can then be used to give fluids, medicine and nutrition to chronically and critically ill patients (Lai, Lai, O’Riordan, Chaiyakunapruk, Taylor, Tan, 2016).
• CLABSI: is a serious infection that occurs when germs (usually bacteria or viruses) enter the bloodstream through the central line. (CDC, 2011)
Identify the Question
In hospitalized pediatric patients less than 12 years old, does use of central line antimicrobial locks compared to usual care reduce the occurrence of CLABSI? Central lines are used for various reasons and are direct lines into the body, making it a portal of entry for susceptible infections. Pediatric patients under the age of 12 years old who have CVC (central venous catheters) are at a higher risk for developing a central line infection due to impaired immune systems and the direct line the CVC has to the heart. “The catheter provides a prime pathway for exposure to infection. As a result of the vulnerability, prudent care and maintenance of CVCs must be provided; however, despite the best care of CVCs, infections still occur.” (Pitts, Bergamo, Cartaya, Gore, 2014). It is very important for the nurses to identify infection; early symptoms include fever, chills, edema, redness at insertion site headaches and general malaise, etc. (Ignatavicius, Workman, Rebar, Heimgartner, 2018 p.221).
Literature Search
Medline and CINAHL Database with full text were used to find articles. Using the CINAHL heading search, the keywords used for the search included: Central line antimicrobial locks, Bloodstream infections, Central line or central venous catheters, and Catheter Care; Vascular. Boolean operators used were “And/or”. Limiters with the advanced search were: 2013-now, peer reviewed, non-gender specific, Full text, all child, special interest: pediatric care. The articles found included studies based on meta-analysis, case studies, randomized control trials and quasi-experimental.
The current practice of central venous catheters includes proper hand hygiene, sterile technique upon insertion and changing of the dressing, skin asepsis, gloves, masks and assistance from another nurse to ensure there is minimal exposure to infection. (Ignatavicius, Workman, Rebar, Heimgartner, 2018 p. 206). “ALT (Antimicrobial lock therapy) involves the installation of a highly concentrated antimicrobial” (Bookstaver, Rokas, Noris, Edwards, Sheretz, 2013). This therapy is becoming more widely used as a prophylaxis to prevent the risks of infections. With this therapy, it can help to keep CVC in longer and reduce the chances of having to re-administer the line. “An occlusion can lead to interruption in therapy, risk for catheter related infection and increased healthcare cost” (Davis, 2013). According to (Zemeles and Flannery 2018), the article speaks upon the indication for antimicrobial lock therapy, stating that it is used for patients who catheter salvage is a goal or priority. The use of antimicrobial locks, should grant an extended period allowing the catheter to remain stable and decrease the changes of solutions and locks; even though it is known that the sooner the line is removed, the less of the chance to acquire an infection. Education is top priority with patients and their families, from how to clean the area and who should clean it and what to use.
“There is a higher incidence of infection in newborn infants, especially in very preterm and very low birth weight infants, as their immature immune systems and thin, immature skin increase susceptibility (Borghesi 2008) Finally, the consequences of infection in newborn infants are different and more serious than in older children and adults” (Balan, Oddie, McGuire, 2015). Neonatal patients with CLABSI, can develop neurodevelopmental issues, including auditory and visual disability. Given they are not fully developed and have an immature immune system. Therefore, the importance of reducing the incidence of CLABSI is critical, regardless of whether the patient is pediatric or geriatric.
Action Plan
To implement the changes and interventions, the study will be done over a span of one year. Over the course of the year, two groups will be evaluated for the rates of CLABSI, one group will be the control group while the other is the experimental group. The control group will be using the standard of care for CVC, while the experimental group will be using the antimicrobial locks. The current practice for pediatric CVC management is proper flushing technique, dressing changes in intervals and utilizing sterile technique and use of antiseptic wipes. (Davis, M. B. H. 2013). Each group will be given the same number of pediatric patients. With the experimental group, they may need educational resources on what the antimicrobial locks are and how to use them. This will guide nurses and other health care workers to understand and implement the use of antimicrobial locks in the experimental group. Nurse administration in both groups will need to keep a record of the patients who have CVC and the incidence of infection, as well as their other health conditions. In the end, the committee can evaluate and understand what could have influenced the infections. Nurses must document the techniques they used in the patient’s charts.
After one year, the results will be evaluated. If antimicrobial locks are seen to make an impact on decreasing central line associated bloodstream infections, they will also need to look at the incidence of infections during the infections and determine what group they were categorized in. The committee will need to look at the statistics from CLABSI prior to the intervention compared to the implementation of the intervention. Moving forward the nurses and staff will be given extensive educational courses to implement the antimicrobial locks for nurses who care for pediatric patients with CVC. Nurse educators and administration must be up to date and prepared to make the changes. Changes will not be over night, but over the span of a few months. Education and understanding is crucial in the nursing field, making sure health care professionals know the proper techniques and the evidence to show that antimicrobial locks are seen to decrease the risks in central line infections.
Follow-up and Evaluation Plan
Once the staff has been informed and implementing the changes the hospital/ organization will need to be reevaluated as to the rates of CLABSI to determine whether the numbers have decreased or not. Facilities will be given approximately a year to make the changes and get accustomed to the changes. Older staff who have been working for 20+ years are less likely to make the changes. It may take them more since they have been doing it a certain way for many years. The committee will need to look at new CVC infections, what caused them and what went wrong, looking at the statistics from CLABSI prior to the intervention compared to the implementation of the intervention.
Conclusions/ Special Considerations
In regards to special considerations, while no patient is being harmed, pediatric patients are seen to be a vulnerable population especially with the CVC and a suppressed immune system causing a higher risk for developing a CVC infection or CLABSI. Nurses must be able to note the symptoms of infection. Although, the subjects being studied are pediatrics under 12, an informed consent will need to be obtained from the parents or guardians. To conclude, the use of antimicrobial locks compared to usual care of central venous line have been more effective in reducing the incidence of CLABSI.