TO DECREASE CATHETER-ASSOCIATED BLOODSTREAM INFECTIONS IN NEWBORNS : AN INTEGRATIVE REVIEW

Objective: to perform an integrative review of strategies presented in care bundles to decrease central catheter-associated bloodstream infection among newborns. Method: a search was conducted of the Cochrane Library, IBECS, PubMed, Lilacs, Medline and Scielo catalogues, using the terms “bundle”, “catheter-related infection”, “infection control”, “prevention”, “evidence-based nursing”,” evidence-based medicine” and” central venous catheter”. Inclusion criteria were: papers published from 2009 to April 2014; written in Portuguese, English or Spanish; addressing both neonatal and pediatric populations or just neonatal populations; describing the use and/or assessing care bundles or protocols to control central catheter-associated infection. Results: fifteen studies published between 2009 and 2013 were selected. The main information extracted from the studies was systematized as: 1) measures adopted to prevent central catheter-associated bloodstream infection according to level of scientific evidence, and 2) strategies used to implement evidence into health practice. Conclusion: there was a variety of practices adopted, some of which are consistent with scientific evidence and some of which are not. Systematization conducted in this study is expected to contribute to practice, facilitating the use of the best evidence in each context, and research indicating gaps in knowledge to be explored in future studies. DESCRIPTORS: Catheter-related infections. Evidence-based nursing. Neonatal nursing. Patient care bundles. Catheters. http://dx.doi.org/10.1590/0104-07072017005130015


INTRODUCTION
Primary bloodstream infections (BSI) are among the most common healthcare-associated infections.Approximately 60% of bacteremia existing in hospital settings are estimated to be associated with some intravascular device. 1 Even though central venous catheters (CVC) are an essential resource to enable necessary therapy, they are also known to be one of the primary risk factors for BSI. 1 Central venous catheter-associated blood stream infections (CVC-BSI) occur when a microorganism that is present in the site of insertion reaches the blood stream, resulting in bacteremia, which when not contained, causes infection with sepsis, severely compromising a patient's clinical state. 1 The etiology of infection should be attributed to the catheter when there is no apparent primary infectious focus and when cultures of blood and the catheter tip, collected after 48 hours of hospitalization, result in the growth of the same infectious agent. 1 If association between catheter and blood infection is not confirmed by laboratorial tests, but a CVC is the most probable cause of infection, it is defined as CVC-BSI. 1 CVCs are an integral part of the care provided in Neonatal Intensive Care Units (NICU), as they enable hemodynamic monitoring, hydration, and the administration of medication.Central lines, however, break the skin's integrity so that there is the risk of infections caused by bacteria and/or fungi. 2 Healthcare-associated infections are one of the primary problems faced among newborns under intensive care -a population with characteristics that are not observed in any group of patients in the different periods of life.The increased susceptibility of newborns to infection is related to the immunological system's deficiencies and fragile skin and mucosa barriers. 1tudies report that mortality caused by BSI range from 15% to 35% in both ill adults and newborns, from 24% in the pre-surfactant era and 11% in the post-surfactant era. 3 Given the negative impact of mortality and morbidity related to these infections and the cost caused by them, the clinical and scientific community has sought strategies to change this context by developing and disseminating protocols, guidelines and, more recently, care bundles in order to systematize the best-known practices to prevent CVC-BSI.The Institute for Healthcare Improvement developed the concept of care bundles, a package composed of a small set of practices that arguably improved the outcomes of healthcare, considering that, these practices lead to better outcomes when concomitantly implemented than when implemented individually. 4ven though the efficacy of care bundles is increasingly supported by various studies [4][5][6][7][8][9][10][11][12][13][14][15][16][17] and by the Centers for Disease Control and Prevention (CDC), 2 it is important to stress that the involvement of the entire multi-disciplinary team is key for successful actions and improved quality of care delivery.In this sense, the successful implementation of these actions, as well as the process of quality improvement as a whole, requires the entire staff to be engaged. 4iven the particularities of the neonatal population and the specific care required by those using CVCs, this study's aim was to perform an integrative literature review concerning the strategies presented in care bundles to decrease CVC-BSI among newborns.

METHOD
This is an integrative literature review, a design that permits bringing scientific evidence to clinical practice and includes studies with different designs. 18The following stages were adopted: identification of topic; establishment of guiding question; establishment of inclusion and exclusion criteria; definition of information to be extracted from the selected studies; critical assessment of studies; and interpretation of results. 18e search was conducted from March to April 2014, in the Cochrane Library, IBECS, PubMed, Lilacs, Medline and SciELO databases, using the terms "bundle", "catheter-related infections", "infection control", "prevention", evidence-based nursing", "evidencebased medicine" and "central venous catheter".
In the first stage, we adopted the strategy of using each descriptor in isolation, associating each to filters available in the Virtual Health Library, such as year of publication and language.The titles of papers, respective abstracts and keywords were read in order to select the ones that indicated the use and/or assessment of strategies to control CVC-BSI.The following exclusion criteria were adopted: diagnostic studies; studies addressing adults; experiments with skin antisepsis agents; and studies addressing hemodialysis catheters.Papers that were unavailable otherwise were requested from the authors and, after accessing the initially unavailable papers, the snowball method was used, through which another five papers that met inclusion criteria were selected.After this first selection, papers that did not address neonatal populations, that is, those papers that exclusively assessed pediatric patients, were excluded.
Finally, inclusion criteria were: papers published from 2009 to April 2014; available online or provided by authors after request; written in Portuguese, English or Spanish; studies addressing neonatal population or both pediatric and neonatal populations; describing the use and/or assessing care bundles or protocols to control CVC-BSI and evidencing it in the title, abstract and/or descriptors; regardless of study design.
The flowchart (Figure 1) presents the search stages and number of selected papers.
In terms of design, before and after interventions 19,24,[29][30] (26.6%) and reviews [21][22][23]28 (26.6%) predominated, representing 53.2% of the sample. Thre were also three cohort studies, [9][10]27 two timeseries studies, 11,26 one retrospective intervention study, 20 and one exploratory study.25 The main information extracted from the studies is distributed between: 1) measures adopted to prevent CVC-BSI according to level of evidence (Tables 1 and 2); and 2) strategies used to implement evidence into care practice (Table 3).22,[24][25] --Use of glove procedure every time catheter is manipulated 20,23 --Use sterile glove and mask to change sterile dressing [23][24] --Use double or three-lumen catheters to ensure there is one that is exclusive to parenteral nutrition 24 --Promote enteral nutrition to remove the central venous catheter early on 27 --Avoid the use of dyed/colored solutions on stumps that may received a catheter later 10 --Insert umbilical catheters in pairs to checklist the catheter insertion 10 --Not placing patients with umbilical catheter in the prone positon 10 --Changes of fluids and infusions of umbilical catheters made by a medical staff 10 --Dressings: use preassembled dressing kits 20 --Flush syringes are single use only 23 --Use clean gloves to check the system if not using a closed system 26 --Use sterile gloves to setup a closed system and at least clean gloves to install it 26 --Use flush syringes previously aspired by the manufacturer or in the pharmacy using sterile technique 26 --Comply with diagnostic criteria and measurement standards for nosocomial infections 27 --Identify the catheter with date of insertion and infusion system and connections with the date they were changed 30 --Avoid femoral site if possible/standardize the insertion sites 10,19,29 ≠ Clean the stump or site of the peripherally inserted central catheter with iodine-based solution 10 ≠ Dressing: change transparent dressings every seven days or before if dirty, wet or loose 22 ≠ Change infusion systems within an interval between 72 and 96 hours, or before if there is blood or suspicion of infection 30 ≠ --: Non-evidence-based intervention; ≠: Intervention disagrees with evidence-based recommendation.

Table 3 -Strategies to implement evidence into central venous catheter-associated blood stream infections prevention among children and newborns published between 2009 and 2014. Londrina, Paraná, Brazil, 2014
Strategies Education/training/workshops on the central venous catheter-associated blood stream infections concept 9-10,19,23-24,26-27-29 Meetings with the staff/teleconferences 9,[19][20]23,26,[28][29] Discussing infection rates in the unit [19][20]24,26,[28][29] Daily checklists to verify bundles compliance 9 -10,20,23,28 Feedback to the team concerning performance of bundles [19][20][23][24][28][29] Use of posters/reminders [19][20][23][24][28][29] Establish one or more leaders to prevent central venous catheter-associated blood stream infections 19,[23][24]29 Goals to decrease infection rates and improve adherence to bundles 20,26 Autonomy to interrupt the insertion procedure if the team fails to observe any of a bundle's items 11,26 Anonymous and random nursing auditing 24 Applying tests or quizzes for the team 20 Provide training to workers 20 Ensure there is one antisepsis dispenser in every bed 24 Prohibit accessories below elbow, including sleeves and long nails 24 Establish a competition among employees to encourage their participation in the process 24 Promote commemorative celebrations on the project's aniversaries 24 Update practices by email and provide printed copies to staff 24 Visit facilities with good practices and rates 23 Involve other sectors that also use catheters (e.g., anesthesiology and radiology) 23 Disseminate guidelines and tools 27

DISCUSSION
The use of evidence-based practice can be encouraged.Up to 70% of the four million children who die every year who are still in the neonatal period could be saved if evidence-based practice were used, especially in the delivery of nursing care. 31n theory, care bundles intended to improve care delivery propose the adoption of the best evidence-based practices.In this review, however, even though most of the interventions employing care bundles were based on evidence-based practices, non-evidence-based recommendations were also found, while some of these recommendations diverge from already established evidence.
The 20 recommendations identified in care bundles not categorized with any level of evidence, presented in Table 2, in general represent particular measures adopted to decrease infection rates in diverse services.When not diverging from the already scientifically established evidence, they are not inappropriate per se, however they do not fit the bundle concept, i.e., a package of measures, the efficiency of which in improving practice is related to the rigor with which evidence was selected. 4][21][22][23][24][25][26][27] Fourteen examples of evidence were included in the bundles presented in the papers in regard to the maintenance of catheters, the most frequent being: hand hygiene; the use of sterile, transparent and semipermeable dressing or sterile gauze; daily assessing the need to the keep the catheter; daily examining for signs of infection at the site of insertion and also the aspect of the dressing; changing the dressing if dirty, wet or loose; standardizing the aseptic insertion and change infusion systems; and using a closed infusion system.
The recommendation to use a sponge impregnated with chlorhexidine on the insertion site whenever dressings are changed is classified by CDC as evidence level IB 2 and was observed in two studies. 20,22It is, however, a procedure to be implemented in patients older than two months of age, if CVC-BSI is not receding with the adoption of basic preventive measures. 2One of the two studies reporting adherence to this recommendation 20 was correct because care bundles were implemented both in neonatal and pediatric units.The other study, 22 however, recommended this procedure only in NICUs, which is inappropriate for this population.
In terms of gaps in knowledge, the time necessary for letting antisepsis agents dry on the skin has not yet been investigated, therefore, recommendations establishing such an interval of time, which in the studies ranged between 15 seconds and 1 minute, were considered as having "no level of evidence". 10,20ikewise, there is no scientific evidence establishing what length of time spent rubbing is sufficient or ideal to sterilize catheters' lateral injectors or connections, though the recommendation to rub with alcohol at 70% or alcoholic chlorhexidine, without an established period of time, is acknowledged as evidence level IA. 2 Another gap is the type of chlorhexidine solution to be used with extremely preterm newborns, a population vulnerable to skin lesions, especially when alcoholic solutions are used.Since 2012, the Food and Drug Administration (FDA) reported increased chlorhexidine experience and safety concerns and recommends caution when using it on infants younger than two months of age, 13 but does not mention whether alcoholic or aqueous means would be recommended.
There were four recommendations diverging from what have been already scientifically established. Finally, another disagreement was found in regard to the frequency with which infusion systems should be changed.The standardized recommendation is 96 hours, 2,15,25 but one of the studies 30 established an "interval between 72 and 96 hours".
Much effort has been expended to encourage health workers to commit to evidence-based practice, with the acknowledgement that the de-velopment and mere dissemination of systematic reviews and guidelines is not sufficient to ensure its implementation.
In view of this, another factor observed in these studies were the strategies described to implement these care bundles.According to the science of implementation, verifying the effectiveness of each type of strategy is essential 28 to supporting efforts to improve care practices.Twenty different strategies to implement and maintain care bundles were mentioned in the studies under analysis.The ones most frequently mentioned were educational interventions and trainings, meetings with the staff/ teleconferences, discussing infection rates in the unit, daily use of checklists, feedback to the staff concerning compliance with bundles, and the use of posters and reminders.
The various different practices related to the prevention of CVC-BSI became apparent.Some bundles even proposed measures that diverged from recommendations, the efficacy of which had already been established and acknowledged by the scientific community.Hence, institutions need to appropriate better evidence, standardizing their practices according to what has been established as efficacious in CVC-BSI prevention.
There is a large number of terms used in the literature to name the process of applying knowledge to practice, including "use of knowledge", "knowledge transfer", "evidence-based practice", and "diffusion of innovation". 31Some factors seem to favor this process, such as: facilitating roles that actively promote the use of research in an institution; establishing bonds with researchers and trendsetters outside of the organization; developing a technical infrastructure that enables access to scientific evidence, such as databases and libraries; and maintaining training programs to promote the staff's constant improvement and the updating of their training. 32The fact is that, even though there are many and different interventions for implementation, there are no evidence-based recommendations regarding the use of a specific intervention to support implementation in a given setting. 31esides the selection of high-level evidence to compose bundles and the adoption of implementation strategies that are efficacious and appropriate for each context of care delivery, there is a need to carefully assess results.The use of clinical indicators of quality in CVC care protocols favors the identification not only of indices concerning compliance and performance of such care, but also the identification of concrete situations interfering in the results, enabling direct and specific interventions to improve them. 30,33Even though clinical indicators of performance related to CVCs were not the object of analysis in this study, they should be considered an important tool to assess and support the use of care bundles to prevent CVC-BSI.

CONCLUSION
This review's results present the existence of strong evidence to base care related to the insertion and maintenance of CVCs in newborns.On the other hand, the findings also reveal different practices that have been adopted in bundles and protocols, some of which even disagree with established scientific evidence.
There are a large number of strategies intended to engage and ensure collective participation of the staff, but a considerable gap of knowledge still persists regarding what is the most efficient and best strategy for each context, considering that it is a very complex task.Filling in the gap between what scientific research has proven to be efficacious and what care practice has actually provided to patients seems to be a considerable challenge.
This integrative review indicates gaps of knowledge to be explored in future studies and is also expected to contribute to the systematization of evidence and facilitate the use of the best evidence for each context.

Figure 1 -
Figure 1 -Flowchart concerning the selection of papers Evidence found in the studies categorized according to the CDC's guidelines: 2 -Category IA: strongly recommended for implementation and strongly supported by welldesigned experiments, clinical or epidemiological studies.-Category IB: strongly recommended for implementation and supported by experiments, clinical or epidemiological studies with strong theoretical foundation; or accepted practice, though supported by limited evidence.-Category IC: required by state or federal regulation, rules or standards.-Category II: suggested for implementation supported by the clinical experience of experts in the field, epidemiological studies or theoretical foundation.

Table 2 -Non-evidence-based recommendations to prevent central venous catheter-associated blood stream infections among children and newborns published between 2009 and 2013. Londrina, Paraná, Brazil. 2014 Intervention Level Rub
the injector with chlorhexidine for different durations established for rubbing and drying