Consistency between guidelines and reported practice for reducing the risk of catheter-related infection in British paediatric intensive care units
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Published on: July 13, 2019
Katie Harron1, Geethanjali Ramachandra, Quen Mok
1MRC Centre of Epidemiology and Child Health, UCL Institute of Child Health, London, UK.
Insights
Pediatric intensive care units (PICUs) often deviate from national guidelines for reducing catheter-related blood stream infections (CR-BSI) due to a lack of child-specific evidence. Guidelines need to address pediatric practice gaps, especially regarding catheter type and insertion site.
Area of Science:
- Pediatric critical care medicine
- Infection prevention and control
- Evidence-based practice
Background:
- Optimal strategies for reducing catheter-related blood stream infections (CR-BSI) vary between adult and pediatric populations.
- Existing national guidelines lack child-specific recommendations for CR-BSI prevention.
- Inconsistencies exist between current guidelines and reported practices in pediatric intensive care units (PICUs).
Purpose of the Study:
- To investigate the reasons behind discrepancies between CR-BSI reduction guidelines and actual practice in British PICUs.
- To determine if a lack of child-specific evidence explains these inconsistencies.
- To identify specific interventions where practice diverges from guidelines in pediatric critical care settings.
Main Methods:
- A survey was conducted across 25 British PICUs in 2009, assessing the implementation of eight CR-BSI reduction interventions.
- Interventions were categorized based on the need for child-specific evidence, generalizability to both adults and children, or as organizational recommendations.
- Response data from 24 PICUs were analyzed to compare reported practices against existing guidelines.
Main Results:
- Practice diverged from guidelines for child-specific interventions, such as insertion site selection, with femoral veins frequently used in PICUs.
- For generalizable interventions, some practices aligned with guidelines (e.g., administration set replacement), while others deviated (e.g., CVC asepsis maintenance).
- Reported practices also diverged for organizational interventions, including staff training in catheter care and bloodstream infection (BSI) rate monitoring.
Conclusions:
- Guidelines must explicitly address pediatric CR-BSI prevention, detailing evidence quality and recommendation strength.
- Organizations should prioritize training for healthcare workers on central venous catheter (CVC) insertion and invest in BSI surveillance systems.
- Significant evidence gaps remain concerning the optimal CVC type and insertion site for pediatric patients to reduce CR-BSI.
Purpose:
Optimal strategies for reducing catheter-related blood stream infection (CR-BSI) differ for adults and children. National guidelines do not make child-specific recommendations. We determined whether evidence explained the inconsistencies between guidelines and reported practice in paediatric intensive care units (PICUs).
Methods:
We conducted a survey of eight interventions for reducing CR-BSI in all 25 British PICUs in 2009. Interventions were categorised as requiring child-specific evidence, generalisable to adults and children, or organisational recommendations.
Results:
Twenty-four of the 25 PICUs responded. For child-specific interventions, practice diverged from guidelines for "Insert into subclavian/jugular veins" (18 PICUs frequently used femoral veins, supported by observational evidence for increased safety in children). Practice reflected guidelines for "Use standard but consider antimicrobial-impregnated central venous catheters (CVCs) for high-risk patients" (14 used standard only, 3 used standard and antimicrobial-impregnated despite no randomised controlled trial (RCT) evidence for antimicrobial-impregnated CVCs in children, 7 used heparin-bonded for some or all children); "Use 2% chlorhexidine for skin preparation" (20 PICUs); "Avoid routine CVC replacement" (20 PICUs). For generalisable interventions, practice was consistent with guidelines for "Administration set replacement" (21 PICUs) but deviated for "Maintenance of CVC asepsis" (11 PICUs used alcohol due to inconclusive evidence for chlorhexidine). Practice diverged from guidelines for organisational interventions: "Train healthcare workers in CVC care" (9 PICUs); "Monitor blood stream infection (BSI) rates" (8 PICUs).
Conclusions:
Guidelines should explicitly address paediatric practice and report the quality of evidence and strength of recommendations. Organisations should ensure doctors are trained in CVC insertion and invest in BSI monitoring, especially in PICUs. The type of CVC and insertion site are important gaps in evidence for children.
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