I had the pleasure of meeting the author of a paper I am about to comment on this week while at the 99 NICU conference in Stockholm. Dr. Ohlin from Orebro University in Sweden presented very interesting work on their unit’s “scrub the hub” campaign. As he pointed out, many places attempt to reduce coagulase negative staphylococcal infections by introducing central line bundles but seldom is there one thing that is changed in a bundle that allows for a before and after comparison like his team was able to do. I was so impressed by this work and at the same time concerned about another strategy to reduce infection that I felt compelled to make a comment here.
Scrub the hub!
Dr. Ohlin and the first author Dr. Bjorkman published Scrubbing the hub of intravenous catheters with an alcohol wipe for 15 sec reduced neonatal sepsis back in 2015. They compared a 16.5 month period in their unit when they rolled out a CLABI reduction bundle to a period of 8.5 months afterwards when they made one change. Nurses as is done in the units I work in were commonly scrubbing the hub before they injected the line with a medication but in the second epoch the standard changed to be a specified 15 second scrub instead of being left up to the individual nurse. With permission from Dr. Ohlin here is a picture of the hubs highlighting bacterial growth without scrubbing, then for a duration less than 15 seconds and then with 15 seconds.
In the first epoch they had 9 confirmed CLABSIs and 0 confirmed in the second after their intervention. The rate of CLABSI then in the first epoch was 1.5% vs 0% in the second group. As with any study looking at sepsis, definitions are important and while they didn’t do paired cultures to rule out contamination (one positive and one negative as is the definition in our hospitals) they did refer each patient to a senior Neonatologist to help determine whether each case should be considered a true positive or not. Given that they made no changes to practice or other definitions in diagnosing infections during that time perhaps the results were indeed real. Presumably if they had missed an infection and not treated it in the second epoch the patient would have declared themselves so I think it is reasonable to say that 8.5 months without a CLABSI after their intervention is a success. As Dr. Ohlin points out the scrub duration may also help due to the abrasion of the hub surface removing a bacterial film. Regardless of the reason, perhaps a 15 second scrub is a good idea for all?
The lazy person’s solution – the SwabCap
One way to get around human nature or people being distracted might be to cover each luer lock with a cap containing 70% isopropyl alcohol. In this way when you go to access the line there should be no bacteria or labour required to scrub anything since the entry of the line is bathed in alcohol already. This was the subject of a systematic review from the Netherlands entitled Antiseptic barrier cap effective in reducing central line-associated bloodstream infections: A systematic review and meta-analysis. The reviews ultimately examined 9 articles that met their inclusion criteria and found the following; use of the antiseptic barrier cap was effective in reducing CLABSIs (IRR = 0.59, 95% CI = 0.45–0.77, P < 0.001). Moreover, they concluded that this was an intervention worth adding to central-line maintenance bundles. Having said that, the studies were mostly adult and therefore the question of whether minute quantities of isopropyl alcohol might be injected with medications was not a concern when they made their conclusion.
What about using such caps in ELBW infants
Sauron et al in St. Justine Hospital in Montreal chose to look at these caps more carefully after they were implemented in their NICU. The reason for taking a look at them was due to several luer valves malfunctioning. The authors created an in-vitro model to answer this question by creating a closed system in which they could put a cap on the end of a line with a luer lock and then inject a flush, followed by a simulated medication (saline) and then a flush and collect the injected materials in a glass vial that was sealed to prevent evaporative loss of any isopropyl alcohol. They further estimated the safe amount of isopropyl alcohol from Pediatric studies would be 1% of the critical threshold of this alcohol and using a 500g infant’s volume of distribution came up with a threshold of 14 mmol/L. The study then compared using the SwabCap over two different valve leur lock systems they had in their units (SmartSite and CARESITE valves) vs. using the strategy of “scrub the hub”.
The results were quite concerning and are shown below.
|SwabCap on Smart Site Valve
||Incubator 35 degrees
|SwabCap on CARESITE valve
||Incubator 35 degrees
|Isopropyl alcohol pad on CARESITE Valve
Certainly, the Smart Site valve allowed considerable amounts of isopropyl alcohol to enter the line but the CARESITE while better still allowed entry compared to the control arm which allowed none. Beyond the introduction of the alcohol into the system in all cases considerable clouding of the valves occurred with repeated capping of the system with new caps as was done with each med injection since each was single use. In lines that were not accessed contact with the cap was left for 96 hours as per recommendations from the manufacturer and these changes occurred as well.
While a reduction in CLABSI is something we all need to strive to obtain, it is better to take the more difficult path and “scrub the hub” and by that for 15 seconds which incidentally is the same recommended duration for hand hygiene in both of our units. Perhaps in larger term infant’s seepage of isopropyl alcohol into the lines would not be as concerning as their larger volume of distribution would lead to lower levels but I would ask the question “should any isopropyl alcohol be injected into any baby?”. I think not and perhaps by reading this post you will ask the same thing if your unit is using these caps.
- Thank you to Örebro University Hospital for their permission in using the photo for the post
Look around you. Technology is increasingly becoming pervasive in our everyday lives both at home and at work. The promise of technology in the home is to make our lives easier. Automating tasks such as when the lights turn on or what music plays while you eat dinner (all scripted) are offered by several competitors. In the workplace, technology offers hopes of reducing medical error and thereby enhancing safety and accuracy of patient care. The electronic health record while being a nuisance to some does offer protection against incorrect order writing since the algorithms embedded in the software warn you any time you stray. What follows is a bit of a story if you will of an emerging technology that has caught my eye and starts like many tales as a creative idea for one purpose that may actually have benefits in other situations.
In 2012 students in Australia rose to the challenge and designed a digital stethoscope that could be paired with a smartphone. The stethoscope was able to send the audio it was receiving to the smartphone for analysis and provide an interpretation. The goal here was to help diagnose childhood pneumonia with a stethoscope that would be affordable to the masses, even “Dr. Mom” as the following video documents. Imagine before calling your health line in your city having this $20 tool in your hands that had already told you your child had breath sounds compatible with pneumonia. Might help with moving you up the triage queue in your local emergency department.
Shifting the goal to helping with newborns
Of course breath sounds are not the only audio captured in a stethoscope. Heart sounds are captured as well and the speed of the beats could offer another method of confirming the heart is actually beating. Now we have ECG, pulse oximetry, auscultation and palpation of the umbilical stump to utilize as well so why do you need another tool? It comes down to accuracy. When our own heart rates are running high, how confident are we in what we feel at the stump (is that our own pulse we are feeling?). In a review on measurement of HR by Phillipos E et al from Edmonton, Alberta, auscultation was found to take an average of 17 seconds to produce a number and in 1/3 of situations was incorrect. The error in many cases would have led to changes in management during resuscitation. Palpation of the umbilical cord is far worse. In one study “cord pulsations were impalpable at the time of assessment in 5 (19%) infants, and clinical assessment underestimated the ECG HR with a mean (SD) difference between auscultation and palpation and ECG HR of − 14 (21) and − 21 (21) beats min –1″. In another study, 55% of the time providers were incorrect when they thought the HR was under 100 BPM. This leaves the door open for something else. Might that something be the digital stethoscope?
How does the digital stethoscope fare?
Kevac AC et al decided to look at the use of the Stethocloud to measure HR after birth in infants >26 weeks gestational age at birth. The opted to use the ECG leads as the gold standard which arguably is the most accurate method we have for detecting HR. The good news was that the time to signal acquisition was pretty impressive. The median time to first heart rate with the stethoscope was 2 secs (IQR 1-7 seconds). In comparison the time for a pulse oximeter to pick up HR is variable but may be as long as one minute. In low perfusion states it may be even longer or unable to pick up a good signal. The bad news was the accuracy as shown in the Bland Altman plot. The tendency of the stethoscope was to underestimate the EKG HR by about 7 BPM. Two standard deviations though had it underestimate by almost 60 BPM or overestimate by about 50 BPM. For the purposes of resuscitation, this range is far to great. The mean is acceptable but the precision around that mean is to wide. The other issue noted was the frequent missing data from loss of contact with the patient. Could you imagine for example having a baby who has a heart rate of 50 by the stethoscope but by EKG 100? Big difference in approach, especially if you didn’t have EKG leads on to confirm. The authors note that the accuracy is not sufficient and felt that an improvement in the software algorithms might help.
Another go at it
So as suggested, the same group after having a new version with improved software decided to go at it again. This time Gaertner VD et al restricted the study to term infants. Forty four infants went through the same process again with the stethoscope output being compared to EKG lead results. This time around the results are far more impressive. There was virtually no difference between the ECG and the stethoscope with a 95% confidence interval as shown in the graphs with A being for all recordings and B being those without crying (which would interfere with the acquiring of HR). A maximal difference of +/- 18 BPM for all infants is better than what one gets with auscultation or palpation in terms of accuracy and let’s not forget the 2 second acquisition time!
Should you buy one?
I think this story is evolving and it wouldn’t surprise me if we do see something like this in our future. It certainly removes the element of human error from measuring. It is faster to get a signal than even the time it takes to get your leads on. Where I think it may have a role though is for the patient who has truly no pulse. In such a case you can have an EKG HR but the patient could be in pulseless electrical activity. Typically in this case people struggle to feel a pulse with the accuracy being poor in such situations. Using a device that relies on an actual heart contraction to make a sound provides the team with real information. Concurrent with this technology is also the rise of point of care ultrasound which could look at actual cardiac contractions but this requires training that makes it less generalizable. Putting a stethoscope on a chest is something we all learn to do regardless of our training background.
I think they could be on to something here but perhaps a little more evidence and in particular a study in the preterm infant would be helpful to demonstrate similar accuracy.
Throughout my career one thing has been consistently true. That is that wherever I was working and regardless of the role I have been an educator. I imagine the blog to a great extent is related to my interest in this aspect of my work. In the last few years much has been said about care by parents whether it be a general approach for family centred care or in formalized approaches such as FiCare which has also been formally studied in the research setting. When we speak of family centred care, one thing that I am constantly reminded of is that the focus of all of our efforts must be on the family and the patient. As I said recently to a colleague when discussing what was presented as a difficult discussion with another colleague due to a disagreement about the direction of management, when you put the patient first the discussion really isn’t difficult at all. It’s not about you or a colleagues ego but about the patient and if the management is not up to par then change direction and worry about managing egos later.
What We Know And What They Know
Another aspect that needs to be addressed is the difference in power that we have through knowledge. I am not talking about us exerting authority over families but from the perspective of us having the knowledge from years of experience in the field as to what is significant and what is not in terms of events in the NICU. The evidence for example with respect to neurodevelopmental outcome from apnea and bradycardia should give us reason to be optimistic the majority of the time. While in Edmonton I learned a great deal from one of my colleagues who was the lead author in a paper entitled Early childhood neurodevelopment in very low birth weight infants with predischarge apnea. While frequent apnea may be associated with mild motor impairments in their paper, the predictive value of these predischarge recordings is very limited when you take away those kids without severe IVH. I think about all of the parents we see who have their eyes glued to the monitors while they attend at the bedside and what they must be thinking. To us it is just a matter of time but I wonder for them how agonizing a time it really is! It isn’t just those infants who are nearing discharge and having apnea either as the CAP study at 5 years of age showed no difference in survival without disability in those infants who received caffeine vs those who did not. More frequent events may not be that detrimental after all. I am not suggesting we not treat patients as one never knows where the threshold lies to cause injury but these preemies are certainly made of some tough stuff.
Identifying Stress and Preparing Parents For it
The first step in dealing with this issue is to know it is there. Recognizing this, Melnyk and others performed an educational intervention targeting behaviour of families in their study Reducing premature infants’ length of stay and improving parents’ mental health outcomes with the Creating Opportunities for Parent Empowerment (COPE) neonatal intensive care unit program: a randomized, controlled trial. The group of parents who went through the program had better mental health outcomes compared to the control groups. The issue here and really is at the crux of the goal in writing all of this is that the stress that parents feel may not be overtly present. The squeaky wheel as the saying goes gets the grease and the parents that are demonstrating signs of poor coping are the first to draw the referrals to social work or engage in a deeper conversation with nursing at the bedside. All parents experience stress at least to a certain degree and it is all of our jobs to tease it out. On the other hand employing standardized approaches such as the COPE program for all parents might be another way of helping those who are in need but not clearly wearing a sign on their foreheads that say “help me”.
Don’t Underestimate the Power of Reassurance
So we know that much of what we see on the monitors will not lead to long term harm, transient central cyanosis during feeds will not damage the brain and apnea of prematurity is a distinct entity from SIDS. The parents on the other hand commonly make these links and additionally in case no one has mentioned it to you, those babies with TTN may one day develop asthma and those with hypoglycemia may have diabetes (we know both not to be true but I have been asked about this many times). This is why I believe it is our duty to explain why we are not worried about things that come up in the unit. Saying “don’t worry” or “that is normal preterm behaviour” may not be enough. Ask a parent what it is they are worried about and you may be surprised to find out the links that they have made in their heads, some of which may be valid but some completely false. I am not meaning to trivialize their concerns but rather validate them as real worries. If we have the knowledge and it is power as I said before then shouldn’t we use that power to help reduce their stress?
Engaging Families Can Reap Huge Dividends
The movement towards family centred care and more specifically care by parent will have a dramatic impact on this issue. As more and more centres move to engaging families to be part of rounds and not just listen and then ask questions but to take some degree of control and provide some of the reporting stress will be reduced. It is only logical. The more a family comes to understand what is significant and what is not in terms of reporting concerns the more confident they will be. Moreover, spending more time at the bedside leads to more skin to skin care and with that shorter hospital stays due to better cardiorespiratory stability. We aren’t there yet but we are headed in the right direction. In the meantime, take the time to ask a simple question “what are you worried about” to parents no matter how confident and strong they appear and you may find yourself with an opportunity to harness the power of education you have a make a real difference to a family in need.
Nineteen seventy two was notable for many things aside from the year of my birth. Canada defeated the Soviets in the summer series, the Watergate scandal took down a Presidency, The GodFather was released and for the purposes of this post breastfeeding rates in the US reached an all time low of 22%. For an excellent review of the history of breastfeeding the article by AL Wright is excellent.
Rates of breastfeeding began a steady decline in the 1960s as more and more women entered the workforce and seemingly had to choose between employment and breastfeeding. This was a time when it was not seen as being acceptable to breastfeed in public (although that is not the case in many places still to this day) and the workplace was not as conducive to supporting women as in current times (think onsite daycares). Add to this that the 1970s also saw a backlash of sorts in the appeal of breastfeeding due to science “perfecting” a better source of nutrition in formula and we had the low rates that we did. In fact through discussions with parents from that generation, mother’s who chose to breastfeed may have been viewed by some as being silly for not using something like formula that could let the whole family in on the experience. Mom, Dad, kids and grandparents could all take part in the wonderful act of feeding. Why be so selfish?
Following this period as research began to demonstrate improved outcomes with breastfeeding including reductions in atopic disease, less hospital admissions and more recently positive impacts on intelligence and your microbiome the trend reversed. In fact, as the above graph demonstrates, rates approximating 70% were reached by the late 1990s. Since that time the CDC has shown that initiation rates have continued to rise and currently are at the highest documented levels in history.
Looking at the CDC data though reveals some very important information. While the rates of any breastfeeding reach 80%, the rates at 6 months hover around 50%. This means that a significant portion of US women are using some formula when they come home and from the graph on the right about 35% by three months are exclusively breastfeeding. This number is far short of the goal the WHO has set to encourage exclusive breastfeeding for the first 6 months however it is a remarkable achievement for infant health.
A recent trend on social media and print media has been the Brelfie. As you may know, this involves taking a picture of yourself breastfeeding your baby and posting it in one forum or another. This has been popularized by many celebrities and made it’s way onto the cover of Elle magazine this month.
So called Lactavists have been overjoyed to see such public acceptance and promotion of breastfeeding. As a Neonatologist I am delighted to see such high rates of breastfeeding and with it the beneficial effects that it brings.
Curiously, though all of this attention and promotion of breastfeeding has created a culture that is now being called bressure. This is defined as pressure to breastfeed and was the subject of a recent survey by Channel Mum in the UK. The highlights of the survey that went out to 2,075 mums showed:
– 16 per cent of bottle-feeding mums have been on the receiving end of cruel comments from other mothers they know
– one in 20 being attacked on social media
– 69 per cent of bottle-feeding mums said they had been judged negatively
– 41 per cent made to feel they have ‘failed as a mum and failed their child’ by not breastfeeding
– 15 per cent of mums have even lied to cover up their bottle-feeding and appear to be ‘better’ mums.
This so called bressure has led to a public campaign to increase awareness of the harassment that some mothers feel which involves taking selfies with cards having one word describing what breastfeeding meant for them. A video from Channel Mum can be seen here
Channel Mum Video Response to Brelfies
While I am all for breastfeeding, I find it peculiar that the experience that breastfeeding mothers (all 22% of them) had in 1972 is now being felt by a larger percentage in 2015 who are bottle feeding. It is unfortunate that assumptions are being made of many of these women who put a bottle in the mouths of their infants. How many times does one conclude that the mother simply chose not to breastfeed because they were worried about the way their breasts would be affected cosmetically or that they simply chose to go back to work and breastfeeding would just get in the way. I suspect in most cases the truth is much different. Many of these mothers have tried to breastfeed but couldn’t produce enough. Others may have suffered from cracked nipples, mastitis, abscesses or due to prior surgery were unable to produce milk. Many such mothers have agonized over their “failure” to do something that they hear “everyone can do”. While they are told it takes some work for many that is a huge understatement. Is it not bad enough that these women have suffered the feeling of failure? To be looked at or spoken to in a disapproving way does nothing to support them. Add to this that by 3 months of age at least in the US 65% of mothers are providing some formula and it seems silly to take the “high and mighty” approach in the first couple of months and assume the worst of these women. Many of the “breastfeeders” will soon enough join the ranks of those using some formula.
Maybe the better option is to try and help. Many of the above problems whether it be producing enough quantity or pain related to breastfeeding can be addressed through tips on technique. While I am not an expert in this, hospitals would do well to increase staffing of on site lactation consultants to help mothers who wish to breastfeed get off on the right foot so to speak. A larger working force of midwives in North America in particular could certainly provide help in this regard. What I can say is that if a woman suffers a bad experience with breastfeeding in their first pregnancy the likelihood they will try again the next time is lower especially if we as a society make them feel like a failure.
Yes we need to promote breastfeeding and we should do what we can to follow the WHO recommendations and minimize the use of formula when possible. While bressure may have been intended to yield something good we need to be sensitive. Perhaps a better strategy next time a friend says they are going to use formula is to ask if they are having trouble with breastfeeding and if they need some help. Not having the discussion will ensure that nothing changes and a chance to do something will be lost due to misdirected bressure.