(B5) Part 1. Management of CVAD-Associated Skin Impairment in Pediatric Patients: Utilization of an Evidence-Based Algorithm Part 2. Securement Solutions for Children and Neonates with Central Venous Access Devices

Part 1.

Central line-associated bloodstream infections (CLABSIs) are a common source of hospital-acquired infections that are linked to increased morbidity, mortality, financial costs, and lengths of stay. While most literature stresses the importance of the standardization of central line insertion and maintenance practices in an effort to prevent CLABSIs, most research and consensuses have stemmed from adult populations. With that said, critically ill pediatric patients require the frequent use of central venous access devices (CVADs) for a multitude of reasons, and often those devices must be maintained under sub-optimal conditions due to limited anatomical access sites and restricted vessel size. As there is little evidence in the literature surrounding best practices in regard to the management of skin breakdown around CVAD insertion sites, our institution sought to adopt an established clinical decision-making algorithm created by the World Congress of Vascular Access that was published in 2017. The algorithm was tailored to fit the resources and products available at our institution and was trialed on pediatric cardiac patients of varying acuities.

Alterations in skin integrity are prevalent in pediatric cardiac patients in relation to altered tissue perfusion, chronic hypoxia, the frequent use of cardiopulmonary bypass and/or mechanical circulatory support devices, and frequent dependance on vasopressors, steroids, and anticoagulants. As this complex patient population has extremely limited anatomical sites for vascular access and severely altered responses to infection, it is essential that CVAD insertion sites are assessed often and multidisciplinary efforts are taken to prevent the incidence of CLABSI, as this promotes optimal hemodynamic stability as well as successful medical and surgical management. Outcomes measured in this QI project were incidence of CLABSI with documented skin alterations, incidence of skin alterations with Central Line Insertion Site Assessment (CLISA) scores of 2 or 3, total number of patients who met criteria to utilize the CASI algorithm, and descriptive statistics of eligible patients. Data was collected from February of 2021 to December of 2022 utilizing a convenience sample of patients admitted to either the Cardiac Intensive Care Unit (CICU) or the acuity-adaptable cardiac unit. Presentation of the results of this evidence-based QI project can have substantial benefits to patient outcomes and the development of pediatric-specific protocols surrounding central line care and maintenance practices. Participants who attend this presentation will be able to visualize the algorithm we created, see examples of skin alterations that we have experienced and managed successfully, and gain a greater understanding of how to prevent CLABSIs when patient-specific factors require alterations in standardization. As the original variation of this algorithm was highlighted as a new essential in The INS Infusion Therapy Standards of Practice (2021), the dissemination of these results could contribute to the development of a new standard of care. In addition, the results of this initiative emphasize the importance of multidisciplinary collaboration in the prevention of healthcare-acquired infections and enable nurses to function autonomously and innovatively at the bedside.

Part 2.

Peripherally inserted central catheters (PICCs) are common in children and neonates. In some children and neonates, the peripheral vein might be too small to accommodate a catheter that is large enough with adequate lumens to provide the necessary treatment. In this situation, the same long thin tube is used, however rather than the insertion beginning in a peripheral vein, the insertion begins in a larger central vein (jugular or brachiocephalic) and is tunnelled to the anterior chest wall; commonly known as a tunnelled non-cuffed central venous catheter (tnc-CVC). Adequate dressing and securement is difficult in such young patients, and complications such as dislodgement is common, often requiring device replacement. In patients with altered skin integrity, providing adequate dressing and securement is even more difficult. In this presentation we will describe various securement conundrums, and potential solutions. And finally we will present the clinical and economical outcomes of the results of this world first multi-site randomised controlled trial comparing sutureless securement to subcutaneous anchor securement, stratified by PICC and tnc-CVC.

This is the first fully powered randomized controlled trial comparing standard practice (sutureless securement device) to subcutaneous anchor securement system. This is a multi-site trial. Primary outcome was any dislodgement (partial and complete) that required device replacement due to non-central position. We also undertook a health economics evaluation, collected skin outcomes and patient and parent satisfaction to ensure patient and healthcare outcomes. This trial was completely unfunded, and although unable to blind clinicians to study arm, statistician, infection disease physician and radiologist were blinded when assessing trial outcomes and determining infection and thrombosis outcomes.