To help improve the vital work of those infection preventionists, nurses, and physicians in the infection control field,

searches for interesting, supportive, and innovative products.  These are this month's picks.

ChloraPrep patient preoperative skin preparation is a tenacious, quick-acting, broad-spectrum antiseptic for a wide range of procedures. The ChloraPrep formulation is the only antiseptic formulation whose persistent antimicrobial power has been confirmed in more than 50 studies. For convenience and ease of use, it is available in 6 different applicators designed for various procedures ranging from peripheral IV insertion to major surgery. The active ingredients include chlorhexidine gluconate 2% weight by volume and isopropyl alcohol 70% volume per volume. Its FDA approval came in 2000.

Chlorhexidine gluconate is highly recommended by at least 18 orga­nizations and initiatives, including the Centers for Disease Control and Prevention’s (CDC’s) 2002 Guidelines for the Prevention of Intravascular Catheter-Related Infections, with 11 specifically supporting a 2% formulation. The CDC guidelines state that before inserting a central venous catheter or peripheral arterial catheter, the skin should be cleaned with a greater than 0.5% chlorhexidine preparation with alcohol. This preparation is classified as a category 1A recommendation for cutaneous antisepsis, which is the highest recommendation from the CDC.

The patented ChloraPrep Scrub Teal and Hi-Lite Orange tint process adds color as the solution enters the sponge pad. The tint eases visualization of the prepped area compared with brown, iodine-based preps as the ChloraPrep Scrub Teal and Hi-Lite Orange are easier to see on different skin tones. The dyes in Scrub Teal and Hi-Lite Orange tints—Food, Drug and Cosmetic (FD&C) Green 3 and Yellow 6 dyes—have been “generally recognized as safe” (GRAS) by the FDA. Extensive safety tests are conducted, reviewed, and accepted to achieve the GRAS rating. FD&C Green 3 is not uncommon in the health care field and is found in eye angiography, screening for ocular dryness, dye injec­tions, routine lab testing, and histological/cytological stains for cancer screening of tissues. 

Aesculap offers an extensive range of containers, baskets, and accessories to meet all your instrument sets and reprocess­ing requirements. Deliver the right instrument set to the right place on time with the Aesculap SterilContainer System.

With more than 10 Food and Drug Administration (FDA) clearances, Aesculap allows its customers to standardize with 1 brand of sterile containers. Using only 1-time sterile containers limits process variabil­ity, which can reduce costs and waste, simplify the documentation process, lessen employee stress from the operating room to sterile processing department because of increased efficiency, and lower the chance of errors, all of which leads to improved patient outcomes.

The Aesculap SterilContainer System comes in a wide range of container sizes and heights for all custom­ers’ instrument sets’ requirements. The construction is lightweight aluminum that is 15% to 20% lighter than the leading competition, meeting the Association for the Advancement of Medical Instrumentation 25-pound weight recommendation. 

Benefits of the SterilContainer System include a 90° stop handle that helps prevent finger injuries during handling, a single-motion latch design that secures the containers swiftly when time is key in the operating room and sterile processing departments, and a 1-step retention plate that has an audible click, so the customer knows the filter is in place, simplifying and improving processing time. Best of all, the Aesculap guarantees a 10+-year service life. 

The sterilization wraps from Key Surgical save time and improve proficient wrap practices. Sterilization wrap comes in 26 sizes, strengths, and weights varying from 100 to 600. 

The wrap is made of 2 sheets of non­woven Spunbond/melt blown/spunbond (SMS) material bonded together, which gives high tensile strength and flexibility for a top-performing sterile barrier. The sterilization wrap also has a unique dia­mond pattern with contrasting colors of blue and green, which aids workers in the operating room who must inspect the wraps for pinholes or defects.

Each sheet of the sterilization wrap is double-layer–bonded SMS material, and resists tears, punctures, and rips. Ease of use facilitates wrapping instrument trays, devices, and other surgical items. It is validated for steam, EtO sterilization, gas plasma, and vaporized hydrogen per­oxide sterilization efficacy. Key Surgical sterilization wrap supports sterilization and, thus, patients’ safety. The barrier wrap protects against microorganisms, including bacteria, viruses, and spores while allowing sterilization.

Articles

Infection Control Today's® Product Locator is a monthly column highlighting some of the latest advanced technology in the infection prevention field. 

Infection Control Today's® Product Locator for September 2022

According to the Centers for Disease Control and Prevention (CDC) in 2011, “Specialized teams have demonstrated unequivocal effectiveness in reducing infections, complications and cost of infusion therapy.”

 A Cochrane Review investigating vascular access specialist teams for device insertion and prevention of failure

 define these groups as any of the following: infusion teams, intravenous teams and individual specialists (nurse, doctor, respiratory therapist, radiological technologist, nurse practitioner, and physician assistant) who have knowledge and skills through formal training and who frequently insert or manage vascular access devices.

The Infusion Nurses Society infusion therapy standards of practice present practice criteria for an infusion team and include benchmarks for peripheral and central catheters, which include first-time insertion success, daily assessments, decrease in catheter-related bloodstream infections, increase in patient satisfaction, data collection for reporting quality outcomes, and impact on patient safety.

 The purpose and function of a vascular access specialist team (VAST) or trained individual may include the initial assessment and insertion and management of peripheral intravenous catheters (PIVCs), midlines, peripherally inserted central catheters, arterial catheters, and external and/or internal jugular, femoral, and subclavian catheters.

 Teams and individual specialist functions will vary and may exclude the insertion and maintenance of some of the devices and associated activities listed above. Other functions embraced by these specialists may include patient access for difficult blood draws, use of ultrasound guidance for any or all of the functions, dressing changes for central catheters, daily evaluation of catheter necessity, removal of unnecessary catheters, and monitoring of dressing and insertion site for complication identification. Additionally, they provide a professional point of care for education and resource of vascular access device (VAD) queries for device maintenance and management of complications.

However strong the evidence for specialized teams, professional application of empirical guidelines for teams within the acute care setting is limited.

 Whether through lack of awareness of guidelines and recommendations, changing administrative priorities, or perceived economic constraints, the hospital adoption and support of VAST has been erratic. Similar to specific services where a cardiologist is required for a particular cardiac problem to provide the best evidence-based care, it is logical that seeking the services of a trained vascular access clinician to initiate and maintain the most appropriate intravenous device is a worthy mandate. Given the growing complexity in patient needs, a unique specialist discipline, namely, the VAST, is surely needed to provide for patient needs. Specialty teams are also seen as models that not only improve patient safety and outcomes, but also can serve as a platform for clinical training of junior residents, medical students, and nursing clinicians. The evidence to date suggests that the highest-achieving system of initiating and delivering treatment to patients in acute care is inexplicably tied to a purpose-driven group of skilled individuals and the processes that guide their practices.

Evidence supports the value of a specialized infusion team for improved success with access, reduced insertion attempts, and reduced complications associated with intravenous or arterial device insertion. According to da Silva in 2010, use of a specialized team increased first-attempt success with only 16% of attempts requiring more than 1 attempt.

 Teams of specialized individuals performing insertion of PIVCs report increased first-time insertion success.

 Consistent across all VADs, peripheral and central, teams
historically represented the lowest levels of device-related complications.

 Adoption of a team approach for care and maintenance has resulted in reduction of central venous access device (CVAD)–associated infections.

Complications associated with VADs relate to the skill and knowledge of the operator for insertion

 and for postinsertion complications related to maintenance by clinicians and patient-specific risk factors.

 Specialized education has led to infection prevention practices that reduce complications.

Adverse vascular events are largely avoidable through specific practices of assessment and selection of the vascular access device with the lowest risk for the patient and their treatment. These practices are evidenced in a
variety of specific models, recommendations and guidelines such as the Society for Healthcare Epidemiology of America,

Vessel Health and Preservation: The Right Approach for Vascular Access

 MAGIC,26 Infusion Nurses Society Standards of Practice,

 the European Society for Clinical Nutrition and Metabolism,

 Evidence-based Guidelines for Preventing Healthcare-associated Infections,

 and the National Institute for Health and Care Excellence

 all recommending specific strategies to promote better clinical outcomes. Each of these organizations and publications focuses on the necessity of specialized training for inserters and those managing VADs that integrate infection prevention and practices that avoid complications. Despite these recommendations the majority of insertion attempts of VADs are performed by a diversity of clinical professional disciplines with little to no formalized education or current training on insertion, or the means to prevent complications. Emphasis is placed on the central line bundle and other practices that include device assessment for risk reduction as a key component.

Device selection and assessment are focused on indications specific to patient, treatment type, and duration factors that point to the type, size, and location of device insertion that best meets the need.

 Steps leading up to insertion of a VAD require the clinician to perform the initial patient assessment, which incorporates vein assessment, patient condition, and selection of the most appropriate site and device for the treatment, all leading to successful insertion, vein preservation, and positive patient outcomes throughout treatment. Performing a patient-individualized assessment provides valuable information necessary to select the most appropriate device with the lowest risk of infection, thrombosis, and overall complications that can most reliably allow the patient to complete therapy without interruption.

Advanced practice nurses and those receiving specialized training to perform insertions of all CVADs who work in collaboration with medical providers offer valuable contributions to the clinical care of acute and chronically ill patients in by performing insertions with low incidence of complications.

However, with respect to the quality and design of studies reporting that VAST positively impacts patients’ vascular access outcomes, there are no randomized, controlled trials to support or refute the role of the VAST. A Cochrane systematic review on VAST provides a glaring lack of any published interventional study to support this concept.

This is surely a wake-up call for associations committed to defining and growing the VAST concept, and perhaps the ambiguity on what constitutes best evidence when it comes to VAST would perhaps be resolved with interventional studies or, at minimum, prospective registered data sets.

 This lack of high-quality evidence may threaten the uptake and expansion of VAST and the reduction of complications related to the specialist role despite the CDC statements supporting specialized teams.

The purpose for the people, processes, and functions of a specialized team are to assess the patient for the most suitable VAD while providing (eg, inserting, recommending, assisting, and managing) reliable peripheral and/or central venous catheter access. Results of a cross-functional team demonstrated effectiveness in postinsertional care with statistically significant central line–associated bloodstream infection reduction with major economic impact.

 Clinical guidelines and standards describe how teams and such processes can deliver successful patient outcomes.

 However, such idealistic endeavors are often compromised by the lack of adherence and variety of clinicians responsible for assessment, device selection, insertion, and postinsertion management. All of this results in fragmentation of a service delivery leading to poor patient and clinical outcomes. Providing a consistent VAD assessment, insertion, and management service to patients in the pursuit of risk minimization involves health care personnel who have received special training. Patients indicate that the inadequate skill level of those performing these types of procedures is a source of great dissatisfaction.

 These occurrences were exposed in the qualitative study of patient and staff experience, indicating a need for vascular access specialist as a quality initiative.

 Because of this, device and vein selection processes, qualified inserters, effective management and evaluation of practices, and clinical outcomes are improved as reflected in the elimination or reduction of complications, prolonged dwell times, reduced length of stay, and improvements in patient satisfaction.

 Teams have the potential to effect improvements through both insertion and postinsertion care of patients. Providing dependable vascular access assessment, insertion techniques, and postinsertion care and management are necessary patient requirements to support modern health care treatment plans.

The value of specialized teams for insertion and management of vascular access has been demonstrated through numerous publications and a variety of research designs. While there are currently no randomized, controlled clinical trials that support the benefits of VAST teams, the CDC continues to evaluate and recommend this practice as a method to reduce complications and infection associated with vascular access devices. Additionally, standards for infusion therapy call for establishing or maintaining a team for CVAD insertion, maintenance, and removal, and the practice criteria to adopt. The discussion and research represented in this article underscore the potential advantages of VAST for assessment, insertion, management, and education with VADs. Underpinned by the concepts of vessel health and preservation, the application of specialty teams for insertion and management of vascular access devices may significantly contribute to the pursuit of making VADs complications history.

O'Grady N, Alexander M, Burns L, et al. Centers for Disease Control and Prevention: Guidelines for the Prevention of Intravascular Catheter-related Infections. 

Carr P, Higgins N, Cooke M, Mihala G, Rickard C. Vascular access specialist teams for device insertion and prevention of failure. 

2018;3(3):CD011429. doi:10.1002/14651858.CD011429.pub2

Gorski L, Hadaway L, Hagle M, McGoldrick M, Orr M, Doellman D. Infusion Therapy: Standards of Practice. 

Simonov M, Pittiruti M, Rickard C, Chopra V. Navigating venous access: a guide for hospitalists. 

Flodgren G, Rojas-Reyes MX, Cole N, Foxcroft DR. Effectiveness of organisational infrastructures to promote evidence-based nursing practice. 

The Cochrane database of systematic reviews. 

Castro-Sanchez E, Charani E, Drumright L, Sevdalis N, Shah N, Holmes A. Fragmentation of care threatens patient safety in peripheral vascular catheter management in acute care--a qualitative study. 

2014;9(1):e86167. doi:10.1371/journal.pone.0086167

da Silva GA, Priebe S, Dias FN. Benefits of Establishing an Intravenous Team and the Standardization of Peripheral Intravenous Catheters. 

Tomford J, Hershey D, McLaren C, Porter D, Cohen D. Intravenous therapy team and peripheral venous catheter-associated complications.A prospective controlled study. 

Soifer N, Borzak S, Edlin B, Weinstein R. Prevention of Peripheral Venous Catheter Complications with an Intravenous Therapy Team:A Randomized Controlled Trial. 

Palefski S, Stoddard G. The Infusion Nurse and Patient Complication Rates of Peripheral Short Catheters. A Prospective Evaluation. 

Ramirez C, Mallock K, Agee C. Evaluation of Respiratory Care Practitioner Central Venous Catheter Insertion Program. 

Harnage S. Seven Years of Zero Central-line Associated Bloodstream Infections. 

British Journal of Nursing (IV Therapy Supplement). 

Brunelle D. Impact of a Dedicated Infusion Therapy Team on the Reduction of Catheter-related Nosocomial Infections. 

Fong N, Holtzman S, Bettmann M, Bettis S. Peripherally Inserted Central Catheters: Outcome as a Function of the Operator. 

Journal of Vascular & Interventional Radiology. 

McGee D, Gould M. Preventing Complications of Central Venous Catheterization. 

Lennon M, Zaw N, Pöpping D, Wenk M. Procedural Complications of Central Venous Catheter Insertion. 

Mourad M, Kohlwes J, Maselli J, Auerbach A. Supervising the Supervisors—Procedural Training and Supervision in Internal Medicine Residency. 

Gianino M, Brunt L, Eisenberg P. The impact of nutritional support team on the cost and management of multilumen central venous catheters. 

Scalley R, Van C, Cochran R. The impact of an IV team on the occurrence of intravenous-related phlebitis: a 30-month study. 

Maki D, Ringer M. Risk Factors for Infusion-Related Phlebitis with Small Peripheral Venous Catheters: A Randomized Controlled Trial. 

Coopersmith C, Rebmann T, Zack J, et al. Effect of an Education Program on Decreasing Catheter Related Bloodstream Infections in the Surgical Intensive Care Unit. 

Eggiman P, Harbarth S, Constantin M, Touveneau S, Chevrolet J, Pittet D. Impact of a Prevention Strategy Targeted at Vascular-access Care on Incidence of Infections Acquired in Intensive Care. 

Eggiman P, Pittet D. Overview of Catheter-related Infections with Special Emphasis on Prevention Based on Educational Programs 

Marschall J, Mermel L, Fakih M, et al. Strategies to Prevent Central Line–Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update. 

Infection Control and Hospital Epidemiology. 

Moureau N, Trick N, Nifong T, et al. Vessel Health and Preservation (Part 1): A New Evidence-Based Approach to Vascular Access Selection and Management. 

Chopra V, Flanders S, Saint S, et al. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method. 

Pittiruti M, Hamilton H, Biffi R, MacFie J, Pertkiewicz M. ESPEN Guidelines on Parenteral Nutrition: Central Venous Catheters (Access, Care, Diagnosis and Therapy of Complications). 

Moureau N, Lamperti M, Kelly L, et al. Evidence-based Consensus on the Insertion of Central Venous Access Devices: Definition of Minimal Requirements for Training. 

Loveday H, Wilson J, Pratt R, et al. EPIC3: National Evidence-based Guidelines for Preventing Healthcare-associated Infections in NHS Hospitals in England. 

National Institute for Clinical Excellence. NICE Technological Appraisal Guidance: Guidance on the use of ultrasound locating devices for placing central venous catheters. 

Pronovost P, Needham D, Berenholtz S, et al. An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU: Keystone Project. 

Alexandrou E, Murgo M, Calabria E, et al. Nurse-led Central Venous Catheter Insertion-procedural Characteristics and Outcomes of Three Intensive Care Placement Services. 

International Journal of Nursing Studies. 

Alexandrou E, Spencer T, Frost S, Mifflin N, Davidson P, Hillman K. Central Venous Catheter Placement by Advanced Practice Nurses Demonstrate Low Procedural Complication and Infection Rates -- A Report From 13 Years of Service*. 

Cotogni P, Barbero C, Garrino C, et al. Peripherally Inserted Central Catheters in Non-hospitalized Cancer Patients: 5-year Results of a Prospective Study. 

Galloway M. Insertion and Placement of Central Catheters in the Oncology Patient. Paper presented at: Seminars in Oncology Nursing 2010.

Pittiruti M, Emoli A, Porta P. A New Area of Competence for the Vascular Access Nurse: The PICC Port. 

Journal of the Association for Vascular Access. 

Curto-García N, García-Suárez J, Chavarria MC, et al. A team-based multidisciplinary approach to managing peripherally inserted central catheter complications in high-risk haematological patients: a prospective study. 

Carr PJ, Higgins NS, Cooke ML, Rippey J, Rickard CM. tools, Clinical Prediction Rules, and Algorithms for the Insertion of Peripheral Intravenous Catheters in Adult Hospitalized Patients: A Systematic Scoping Review of Literature. 

Chan M-C, Chang C-M, Chiu Y-H, Huang T-F, Wang C-C. Effectiveness analysis of cross-functional team to implement central venous catheter care bundle. 

Journal of Microbiology, Immunology and Infection. 

Kelly L. The experience of patients living with a vascular access device [Internet]: IVUPDATE; 2017. Podcast. Available from: 

https://us.ivoox.com/en/the-experience-of-patients-living-with-a-vascular-audios-mp3_rf_20838415_1.html

Barton AJ, Danek G, Johns P, Coons M. Improving patient outcomes through CQI: vascular access planning. 

Kokotis K. Cost Containment and Infusion Services. 

AVATAR. The High Five Campaign: Making Vascular Access Complications History. 2017; 

h ttp://www.avatargroup.org.au/the-high-five-campaign.html

The purpose and function of a vascular access specialist team or trained individual may include the initial assessment and insertion and management of peripheral intravenous catheters, midlines, peripherally inserted central catheters, arterial catheters, and external and/or internal jugular, femoral, and subclavian catheters.

Value and Evidence for Vascular Access Specialist Teams

Infection Prevention in the NICU From the Physician's Point of View

The neonatal intensive care unit (NICU) in a children’s hospital contains some of the most medically fragile patients in the hospital. Many neonates should also be considered immunocompromised because of incompletely developed immune systems or congenital defects.

 As a result of their immature immune systems, babies in NICUs may develop health care–associated infections (HAIs). The most common HAIs for these neonates are linked to specific indwelling devices, such as central line–associated bloodstream infections (CLABSIs) and pediatric ventilator-associated events (PedVAEs). In a comprehensive study of critically ill children in US hospitals from 2013 to 2018, CLABSI infections in NICU neonates were principally caused by 

 and coagulase-negative staphylococci, with other CLABSI infections caused by 

Because of the immunocompromised nature of these infants, the NICU team must focus on prevention of disease as any infection in a neonate can cause
significant long-term morbidity and possible mortality. Preventing infections in the NICU relies on every member of the NICU team effectively doing their part. Infection preventionists (IPs) assist in leading the multidisciplinary care teams to reduce the threat of infection. These teams include physicians, advanced practice registered nurses, registered nurses, respiratory therapists, and others. According to the American Association of Post-Acute Care Nursing, IPs must establish a program that provides a “safe, sanitary, and comfortable environment” that will help prevent “transmission of communicable diseases and infections” in any hospital unit.

 In the NICU, IPs will help develop protocols to minimize potential transfer of pathogens to neonates. This will include precautions to prevent spread of infections, written standards detailing surveillance of the unit for diseases, and how infections are to be reported. These protocols should include how infected neonates should be isolated to prevent further spread of disease in the unit. IPs will also maintain detailed records of the incidence and type of disease in the unit. They will work with the unit’s medical director to help evaluate the effectiveness of the infection prevention protocols in place, producing periodic reports on the efficacy of the program. Through established methods of quality improvement such as “plan-do-study-act” cycles, IPs will help determine the effectiveness of current practices and how they should be modified to help reduce levels of infection.

In the NICU, the IP will help develop educational materials that will keep unit personnel up-to-date on hand hygiene, cleaning and disinfection procedures, specific procedures to ensure safe use of devices unique to the unit, how to use personal protective equipment, environmental cleaning and disinfection, and verification of staff immunizations.

 When new information on emerging pathogens (eg, multidrug–resistant organisms or novel pathogens) or new environmental disinfectants becomes available, the IP should help disseminate it to the NICU team.

 While helping keep NICU staff knowledgeable about new pathogens or new procedures relevant to the unit, the IP must also be knowledgeable about the changing landscape of federal (eg, OSHA), state, and local laws and regulations that have bearing on the operation of the unit. In theory, if the IP has adequate resources and works proactively with physicians, nurses, and other staff in the unit, development of HAIs in the unit should be kept to a minimum. However, as noted above, HAIs in NICUs continue to be a problem.

One interesting dilemma related to infection prevention in NICUs and other hospital units has been how to deal with pathogens found on environmental surfaces. During the 1970s, as advocated by both the US Centers for Disease Control and Prevention (CDC) and the American Hospital Association, general monitoring of pathogens on surfaces in health care facilities was discontinued because of a perception that HAI rates did not correlate with environmental contamination.

 As a result, between 1970 and 1975 it was estimated that 25% of hospitals in the US reduced their routine environmental culturing.

 Eventually, the CDC established 4 conditions where environmental sampling would be warranted in hospital units. 

One situation in which sampling has been encouraged is to help with outbreaks of disease in a unit when epidemiological evidence points to possible environmental links. This is a situation where a NICU IP would need to obtain new data based on swab sampling of specific sites within the unit. In 1 such study of a NICU, in response to sporadic increases of methicillin-resistant 

 (MRSA) infections in neonates, microbiologists from the University of Tennessee at Chattanooga’s Clinical Infectious Disease Control Research Unit (CIDC) sampled nearly 50 different NICU environmental surfaces and found widespread contamination. In that NICU, the 2 most MRSA-contaminated sites were the return air ducts, which were contaminated with dust, and unit floors.

 By having data to help focus cleaning and disinfecting in the NICU, the IP and medical director were able to reduce the problem that dust plays in the unit, while floor contamination with MRSA remains a continuing problem.1 Additional studies of staphylococcal contamination within this NICU have indicated that other sites, including locations within Isolettes where neonates sleep, have viable MRSA present. Of Isolette sample sites, 25.7% of suction Yankauers swabbed had high levels of viable MRSA (

 This suggests that the work of the IP and the CIDC had not been completed in this NICU. As suggested in CDC guidelines, routine environmental sampling for pathogens in health care facilities is warranted as part of an ongoing process focused on reducing the threat of patient infection.

Henry G. Spratt, Jr, PhD, is the senior microbiologist and professor in the Department of Biology, Geology, and Environmental Science at the University of Tennessee at Chattanooga. His microbial ecologically based research, which now focuses on the presence of viable pathogens in clinic environments, has resulted in over 110 presentations at conferences and over 25 publications.

David Levine, PhD, DPT is a professor and the Walter M. Cline Chair of Excellence in Physical Therapy at the University of Tennessee at Chattanooga. His research includes public health epidemiology, control of clinical infectious disease, and Ehlers-Danlos syndrome. He has presented at over 100 conferences and has over 120 published works.

Silvia Weiss-Reed, MT (ASCP), CIC, is a board-certified infection preventionist at Erlanger Health System and Children’s Hospital with 17 years’ experience. She has a bachelor of science degree in medical technology from Southern Adventist University and served as president of the Greater Chattanooga Area Chapter of the Association for Professionals in Infection Control and Epidemiology in 2012 and 2018. Her previous roles include clinical microbiologist and microbiology supervisor.

Anuj Sinha, DO, is a fellowship-trained neonatologist who serves as neonatology/NICU medical director for Children’s Hospital at Erlanger. Working with the NICU infection preventionist, he has focused on quality improvements aimed at reducing patient infections in the unit.

Infection Prevention in the NICU From the Infection Preventionist's Point of View

Our smallest and often most fragile patients are in the neonatal intensive care unit (NICU). It’s a special place where these patients often face tremendous challenges under the care of dedicated health care workers. As an infection preventionist (IP), I am honored to work alongside the nurses, physicians, and other clinicians in the NICU. I have worked for over 8 years at Presbyterian/St. Luke’s Medical Center and Rocky Mountain Hospital for Children. Our hospital is a regional center for high-risk obstetrics and houses over 70 NICU beds, including 34 beds in the level IV NICU.

Neonates are vulnerable and susceptible to infection, making infection prevention in the NICU a top priority. Three important lessons come to mind as I recall my years helping oversee our NICU patients. Caring for patients in the NICU is a team sport. Physicians, nurses, and all health care workers must collaborate to reduce the risk of infection in the NICU. When we have encountered outbreaks or increases in hospital-acquired infections in our NICU, the entire team comes together to form a plan to prevent infections. We all work constantly to maintain that plan. I often receive after-hours calls when patients are admitted with unusual infections, and we must act quickly to implement the most recent guidelines to prevent the spread of a transmissible disease. As IPs, we rely on clinicians to help us understand the care of NICU patients. Clinicians rely on the IP team to notify the NICU of any important public health alerts, present updates from the latest evidence-based guidelines, and share the results of any new infection prevention studies from other NICUs. This means communication and team buy-in are critical. IPs need to make sure their voices are heard and that they understand the concerns of all. It is important that IPs form trusting relationships with clinicians and that it is easy for doctors and nurses to contact IPs with questions. At my facility we always have an IP on call so that on nights, weekends, or holidays an IP can jump in, answer questions, and support the team.

Complex care means thinking outside the box, and as IPs, we love to take best practices from 1 unit and share the lessons learned across the hospital. But not every infection prevention tactic can be implemented in the NICU the same way it can be in an adult care unit, or even pediatric units. Early in my IP career, I spent the day shadowing 1 of the most experienced NICU nurses at our hospital. I learned so much that day. We looked at many central lines and I was amazed that peripherally inserted central catheter lines could be placed in babies who were so tiny, some just 700 g in weight. I was also introduced to umbilical lines, a special type of central line placed in the umbilicus at birth. Today, I round in the NICUs frequently, but it still amazes me how tiny these patients are. For example, we love products that help stabilize central venous catheters for adult patients, but those products are often too large to use on a neonate, so instead we must make sure that our dressings are able to stabilize catheters or change the way we dress a central line to reduce the risk of dislodgement. Another important consideration in the NICU is that the skin of very premature neonates may be more permeable to topical agents. So when looking at products used in bathing or skin disinfection, it is sometimes pertinent to understand at what gestational age it is safe to use a particular product. As I think through NICU care, I always keep in mind that the products and policies we know and love elsewhere in the hospital may not be appropriate in the NICU.

It is always important to include the patient and their family in the care plan. In the NICU, parents/caregivers play an especially important role in helping ensure infection prevention practices are followed. At our hospital, when a patient in the NICU is identified as infected or colonized with an organism of concern, the IP team meets with the patient’s caregivers. We share how organisms are spread and answer any questions the caregivers have. We demonstrate how to properly wash hands and discuss why transmission-based precautions are important in the hospital to protect all patients. We also spend time talking to parents about central lines or other invasive devices and why it is so important to keep devices secure and ensure dressings are clean to reduce the risk of infection. We believe that caregivers play an important role in reducing the risk of infection.

What I love the most about working in the NICU is that I learn something new every day. I am grateful for the experienced NICU clinicians who have shared their knowledge with me through the years, and I am proud to be a part of the team that serves these patients. We all celebrate every time any of our NICU miracle babies leaves the hospital ready for their new life at home with their family, and know that the hard, smart, and timely work of an IP probably contributed to their success.

Emma Waymire, MPH, CIC, is the director of infection prevention at Presbyterian/St. Luke’s Medical Center and Rocky Mountain Hospital for Children, which serves many specialty populations including adult and pediatric bone marrow transplant programs, high-risk obstetrics, and a level IV NICU. Waymire is passionate about helping protect vulnerable patients from preventable infections.

The smallest hospital patients need extra care to be protected from infectious disease. This article series examines the NICU from both a physician and infection preventionist perspective. 

Infection Prevention Is Key in a Neonatal Intensive Care Unit

Infection prevention (IP) practices must evolve with advancing technology. To follow the dictum “first, do no harm,” hospital leaders must remain vigilant in their prioritization of patient safety and seek new technologies in order to align with the Hippocratic oath. Some recent developments in IP technologies include electronic hand hygiene monitoring systems, antimicrobial textiles, ultraviolet C (UV-C) devices, and the optimization of electronic medical records (EMRs) to include decision-support tools and predictive analytics using machine learning to prevent health care–associated infections (HAIs).

Electronic Hand Hygiene Monitoring Systems

Electronic hand hygiene monitoring systems (EHHMSs) offer hospitals large data sets of hand hygiene (HH) compliance among health care workers (HCWs) who wear their badges. Though the World Health Organization recommends direct observation of hand hygiene practices,

 and though that remains the gold standard,

 it is labor intensive, can be biased by the Hawthorne effect, and yields a much smaller denominator than EHHMSs provide. Limitations are inherent in all HH monitoring programs; however, the volume of data that EHHMs offers is of value to many IP programs. In addition to giving IP programs larger data sets of HH compliance, studies show that EHHMSs can increase HH compliance.

Despite the benefits of EHHMSs, barriers exist to widespread adoptability, including negative perceptions of the systems among HCWs,

 variability among the different types of systems,

 and an absence of studies demonstrating improvement in HAI outcomes with EHHMSs.

 Though HCWs routinely recognize the importance of HH and are generally positive about interventions to help improve compliance, Kelly et al found many HCWs worry about the accuracy of the data6 and may feel anxiety about the systems.

 In 2021 Knudsen et al found a statistically significant decrease in health care–associated bloodstream infections with improved HH in their small study,

 and Kovacs-Litman et al reported that hospital outbreaks occurred more often in units with lower HH compliance.

 These studies are encouraging and may lead to greater adoptability, particularly if future studies can reproduce similar results.

Despite mixed results in published studies, antimicrobial textiles (ATs) are
a promising technology for infection prevention. ATs uniquely decrease surface bioburden.

 Although little debate exists on the antimicrobial properties of copper and silver, the HAI prevention impact of impregnating fabrics or surfaces with these metals remains poorly defined.

Fan et al conducted a systematic review and meta-analysis in 2020 of 6 studies and did not find conclusive evidence that copper-impregnated linens decreased HAIs.

 Albarqouni et al conducted an additional systematic review and meta-analysis of 7 studies in 2020 and found the same lack of evidence.

 On a more promising note, Hesselvig et al demonstrated that iodine-impregnated incision drapes did reduce the contamination rate during primary knee arthroplasty compared with using no drape.

 This study does not answer the question of whether intraoperative contamination leads to a subsequent infection and, to date, no studies show a correlation. Madden et al found no decrease in HAIs following the introduction of copper-infused linens.

 However, Butler detected a statistically significant decrease in hospital-onset 

infections in 2018 among patients in 6 different hospitals.

An important consideration in the adoption of antimicrobial linens is wastewater management. These linens are more expensive than traditional hospital linens, so investigators must continue to study whether the savings hospitals may realize through reduction of HAIs through antimicrobial linens is worth the cost of purchasing them.

Much of the recent literature regarding UV-C robots discusses UV-C disinfection and SARS-CoV-2. In January 2022, Viana Martins et al reviewed 60 recent studies and found that UV-C devices inactivated airborne SARS-CoV-2, an important finding in the current fight against the COVID-19 pandemic.

 Although current rates of SARS-CoV-2 infections remain elevated as of this writing, focusing on preventing COVID-19 infections is crucial. Nonetheless, UV-C disinfection remains an important part of preventing many other infections in health care settings. The seminal study, the Benefits of Enhanced Terminal Room (BETR) Disinfection Study—a large, randomized 2016 control trial—found that “patients admitted to rooms previously occupied by patients harboring a multidrug-resistant organism or 

 were [10% to 30%] less likely to acquire the same organism if the room was terminally disinfected using an enhanced strategy,” with the largest risk reduction occurring when a UV-C device was a part of the disinfection strategy.

 This study demonstrated that UV-C light could be used as part of the standard of care for disinfection in rooms where discharged patients have multidrug-resistant organism infections or 

 infections, leading to a change in many health care facilities’ disinfection practices. In 2021, Rock et al found that UV-C disinfection did not decrease vancomycin-resistant enterococcus or 

 infections in immunocompromised patients.

 Although this does not disprove the BETR study’s findings, Rock’s findings suggest that more research about the efficacy of UV-C disinfection in special populations is warranted.

Although UV-C devices can play a critical role in infection prevention programs, for them to provide optimum patient outcomes, health care facilities need a clear strategy for when the devices should be deployed. Like that of EHHMSs, the upfront cost of UV-C devices is significant, so a clear deployment plan helps to ensure the devices are used with consistency.

Optimization of the Electronic Medical Record for Infection Prevention Practices

As EMRs continue to become tools not just for clinician documentation, but also as data collection tools, harnessing the power of EMRs to prevent HAIs becomes increasingly important. Two innovative ways EMRs are being used in this capacity are decision-support tools, helping guide clinicians to make decisions to prevent HAIs; and predictive modeling via machine learning, aiding clinicians and infection programs in targeting patients at greatest risk of developing an HAI.

Decision-support tools are electronic nudges or hard stops that either direct clinicians away from choosing an intervention that may increase the risk of an HAI or disallow a clinician to make that choice at all (typically with an override from a hospital epidemiologist or other hospital leader). Recent studies continue to affirm that electronic nudges improve patient safety by decreasing inappropriate 

 and decreasing inappropriate antibiotic prescribing.

 However, decision-support tools are most likely to be effective when they feel easy to use, useful for decision-making, and reliable.

Preventing infections in hospitalized patients via predictive modeling using machine learning (ML) is still a novel field, but teams of investigators, clinicians, and information technologists are working to create tools that can be broadly adapted to help identify patients who are at greatest risk of developing an HAI. Multiple recent studies demonstrate promising results of a variety of predictive tools to assess who is at greatest risk of a central line–associated bloodstream infection,

 and catheter-associated urinary tract infections.

 Two of these studies found that the models they created outperformed more traditional regression models.

 However, Frondelius et al found fewer positive results in their systematic review of the literature looking at predictive modeling tools and their ability to prevent VAP.

 A limitation to these tools being used regularly and as part of standard infection prevention practice is their newness. More testing and validation must be done before ML can be used to predict at-risk patients consistently and reliably, especially on a large scale. What works at 1 facility must be further validated for other facilities to use the same tool. Extracting correct data from the EMR remains an ongoing challenge at many health care facilities.

Advances in infection prevention generally increase patient safety and decrease hospital costs. The role of infection prevention technologies is evolving. Future studies are required to explore the integration of infection prevention technologies into everyday practice. These investigations should focus on the validation of current technologies, particularly focusing on patient-centered outcomes such as HAI risk reduction. In addition, cost-benefit analyses are required for a better understanding of the potential impact of these technologies on the patient safety mission.

Rachel Pryor, RN, MPH, is a nurse specializing in health care data analytics and research for the Health Care Infection Prevention Program at Virginia Commonwealth University Medical Center.

Gonzalo Bearman, MD, MPH, is an epidemiologist, chief of infectious diseases at Virginia Commonwealth University, and editor in chief of Antimicrobial Stewardship & Healthcare Epidemiology (ASHE) from the Society for Healthcare Epidemiology of America.

World Health Organization. WHO guidelines on hand hygiene in health care. January 15, 2009. Accessed July 21, 2022. https://www.who.int/publications/i/item/9789241597906

Stewardson and Pittet, 2014. Hand hygiene G.M. Bearman, M. Stevens, M.B. Edmond, R.P. Wenzel (Eds.), A guide to infection control in the hospital (5th ed.), International Society for Infectious Diseases, Brookline, MA (2014), pp. 22-30

World Health Organization. Systematic literature review of automated/electronic systems for hand hygiene monitoring. preliminary results. Accessed June 30, 2022. 

https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/hand-hygiene/automated-hand-hygiene-monitoring.pdf?sfvrsn=d1db267a_5&Status=Master

Lin TY, Lin CT, Chen KM, Hsu HF. Information technology on hand hygiene compliance among health care professionals: a systematic review and meta-analysis. 

. 2021;29(6):1857-1868. doi:10.1111/jonm.13316

Druckerman DG, Appelbaum N, Armstrong-Novak JD, Masroor N, Cooper K, Stevens MP, Godbout E, Bearman G, Doll ME. Health care worker perceptions of hand hygiene monitoring technologies: Does technology performance matter? Infect Control Hosp Epidemiol. 2021 Dec;42(12):1519-1520. doi: 10.1017/ice.2021.286

Kelly D, Purssell E, Wigglesworth N, Gould DJ. Electronic hand hygiene monitoring systems can be well-tolerated by health workers: Findings of a qualitative study. J Infect Prev. 2021;22(6):246-251. doi:10.1177/17571774211012781

Knudsen AR, Kolle S, Hansen MB, Møller JK. Effectiveness of an electronic hand hygiene monitoring system in increasing compliance and reducing health care-associated infections. J Hosp Infect. 2021 Sep;115:71-74. doi: 10.1016/j.jhin.2021.05.011. Epub 2021 May 29. PMID: 34058262.

Cawthorne KR, Cooke RPD. A survey of commercially available electronic hand hygiene monitoring systems and their impact on reducing health care-associated infections. J Hosp Infect. 2021 May;111:40-46. doi: 10.1016/j.jhin.2021.03.009. Epub 2021 Mar 19. PMID: 33753120.

Kovacs-Litman A, Muller MP, Powis JE, Ricciuto D, McGeer A, Williams V, Kiss A, Leis JA. Association Between Hospital Outbreaks and Hand Hygiene: Insights from Electronic Monitoring. Clin Infect Dis. 2021 Dec 6;73(11):e3656-e3660. doi: 10.1093/cid/ciaa1405. PMID: 32936910.

Madden GR, Heon BE, Sifri CD. Effect of copper-impregnated linens on multidrug-resistant organism acquisition and Clostridium difficile infection at a long-term acute-care hospital. Infect Control Hosp Epidemiol. 2018 Nov;39(11):1384-1386. doi: 10.1017/ice.2018.196. Epub 2018 Sep 20. PMID: 30231949; PMCID: PMC7063582.

Fan T, Shao L, Wang X, Ren P. Efficacy of copper-impregnated hospital linen in reducing health care-associated infections: A systematic review and meta-analysis. PLoS One. 2020 Jul 20;15(7):e0236184. doi: 10.1371/journal.pone.0236184. PMID: 32687517; PMCID: PMC7371175.

Albarqouni L, Byambasuren O, Clark J, Scott AM, Looke D, Glasziou P. Does copper treatment of commonly touched surfaces reduce health care-acquired infections? A systematic review and meta-analysis. J Hosp Infect. 2020 Dec;106(4):765-773. doi: 10.1016/j.jhin.2020.09.005. Epub 2020 Sep 9. PMID: 32916212; PMCID: PMC7480678.

Hesselvig AB, Arpi M, Madsen F, Bjarnsholt T, Odgaard A; ICON Study Group. Does an Antimicrobial Incision Drape Prevent Intraoperative Contamination? A Randomized Controlled Trial of 1187 Patients. Clin Orthop Relat Res. 2020 May;478(5):1007-1015. doi: 10.1097/CORR.0000000000001142. PMID: 32011378; PMCID: PMC7170680.

Butler JP. Effect of copper-impregnated composite bed linens and patient gowns on health care-associated infection rates in six hospitals. J Hosp Infect. 2018 Nov;100(3):e130-e134. doi: 10.1016/j.jhin.2018.05.013. Epub 2018 May 24. PMID: 29803808.

Direct Supply. What You Need to Know About Health care Antimicrobial Textiles. 2020 Apr 27. Accessed 2022 July 1. 

https://www.directsupply.com/blog/what-to-know-about-antimicrobial-textiles/

Viana Martins CP, Xavier CSF, Cobrado L. Disinfection methods against SARS-CoV-2: a systematic review. J Hosp Infect. 2022;119:84-117. doi:10.1016/j.jhin.2021.07.014

Anderson DJ, Chen LF, Weber DJ, Moehring RW, Lewis SS, Triplett PF, Blocker M, Becherer P, Schwab JC, Knelson LP, Lokhnygina Y, Rutala WA, Kanamori H, Gergen MF, Sexton DJ; CDC Prevention Epicenters Program. Enhanced terminal room disinfection and acquisition and infection caused by multidrug-resistant organisms and Clostridium difficile (the Benefits of Enhanced Terminal Room Disinfection study): a cluster-randomised, multicentre, crossover study. Lancet. 2017 Feb 25;389(10071):805-814. doi: 10.1016/S0140-6736(16)31588-4. Epub 2017 Jan 17. PMID: 28104287; PMCID: PMC5935446.

Rock C, Hsu YJ, Curless MS, Carroll KC, Howard TR, Carson KA, Cummings S, Anderson M, Milstone AM, Maragakis LL. Ultraviolet-C Light Evaluation as Adjunct Disinfection to Remove Multi-Drug Resistant Organisms. Clin Infect Dis. 2021 Oct 12:ciab896. doi: 10.1093/cid/ciab896. Epub ahead of print. PMID: 34636853.

Howard-Anderson JR, Sexton ME, Robichaux C, Wiley Z, Varkey JB, Suchindran S, Albrecht B, Ashley Jones K, Fridkin SK, Jacob JT. The impact of an electronic medical record nudge on reducing testing for hospital-onset Clostridioides difficile infection. Infect Control Hosp Epidemiol. 2020 Apr;41(4):411-417. doi: 10.1017/ice.2020.12. Epub 2020 Feb 10. PMID: 32036798; PMCID: PMC7909614.

Wu T, Davis SL, Church B, Alangaden GJ, Kenney RM. Outcomes of clinical decision support for outpatient management of Clostridioides difficile infection. Infect Control Hosp Epidemiol. 2021 Sep 29:1-4. doi: 10.1017/ice.2021.397. Epub ahead of print. PMID: 34583800.

May A, Hester A, Quairoli K, Wong JR, Kandiah S. Impact of Clinical Decision Support on Azithromycin Prescribing in Primary Care Clinics. J Gen Intern Med. 2021 Aug;36(8):2267-2273. doi: 10.1007/s11606-020-06546-y. Epub 2021 Feb 25. PMID: 33634383; PMCID: PMC8342651.

Souza-Pereira L, Ouhbi S, Pombo N. A process model for quality in use evaluation of clinical decision support systems. J Biomed Inform. 2021 Nov;123:103917. doi: 10.1016/j.jbi.2021.103917. Epub 2021 Sep 24. PMID: 34563692.

Programs seeking to implement advances in health care epidemiology must critically evaluate their impact on infection prevention processes, patient safety, and cost prior to wholesale adoption. 

Infection Control Today, September 2022, (Vol. 26, No. 7)

Infection Control Today's® Product Locator for September 2022

Value and Evidence for Vascular Access Specialist Teams

Infection Prevention Is Key in a Neonatal Intensive Care Unit

Latest Advancements in Infection Prevention Technology

Give Sterile Processing Team, Profession the Recognition They Deserve

The 3 C’s: Connection

Racial and Gender Differences Noted in Community-Associated Carbapenem-Resistant Enterobacterales Cases

Terminal Cleaning, Including UV Sterilization, Effectiveness in Mitigating Pathogen Transmission

Is Dry Heating or UV Disinfection Safe and Effective for Reusing N95 Respirators?