Dear Dr

We would like to find out more about current practice regarding central venous lines (CVLs) in paediatric intensive care units (PICUs) to reduce healthcare associated infections. We are asking you to complete this questionnaire on behalf of your PICU. Where necessary, we would ask you to approach other members of staff for information to complete the questionnaire. If you feel that you are not the appropriate person to coordinate completion of this questionnaire please could you pass it onto someone who can and fill in the details on the tear off slip at the end of this questionnaire.

Background

PICU has one of the highest rates of nosocomial blood stream infection, much of which is related to central venous catheters. There has been a major national initiative led by the Department of Health (DH) working with the Institute for Healthcare Improvement (in the USA) to reduce healthcare acquired infections and particularly CVL related infections. Not much is known about how these recommendations have been implemented locally and for some of the recommendations, there is uncertainty about their applicability to children.

For example, one of the areas where paediatric practice appears to diverge from current recommendations is in relation to impregnated CVL. The DH document ‘Saving Lives’ currently recommends that antimicrobial impregnated CVLs should be used for patients at high risk of CVL infection. However, some PICUs already use heparin coated CVLs and a recent systematic review of 37 randomised controlled trials found the two best options compared with standard CVLs were antibiotic impregnated (minocycline and rifampicin) or heparin coated CVLs. No trials have yet been done to directly compare these two types. Moreover, none of the trials comparing antibiotic impregnated with standard CVLs involved children

Why do this survey now?

There are two reasons for conducting this survey now. Firstly, to determine the extent of variation in routine care of CVLs in PICUs across the country. This will help identify areas of innovative practice, questions for research, areas where specific paediatric guidelines are needed and scope for improvements in practice.

Secondly, the survey will help uswith background information before starting the trial which aims to compare heparin coated, antibiotic impregnated and standard CVLs in children admitted to PICU.

Thank you very much for your help with this survey. Please return the completed questionnaire in the self addressed envelop provided. Response from the individual units will be keptanonymous. If you would like further information about the survey or the trial please contact Dr Quen Mok

Quen Mok- Consultant Intensivist, GOSH PICU ()

Geethanjali Ramachandra- SpR, GOSH PICU()

a)Name of the intensive care unit:…………………………………………......

b)Your name:………………………………………………………………………......

c)Your designation:......

d)Date form completed:……………………………………………………......

Please base your answers on practice in the last 3 months. The first 2 sections (A and B) allow for different answers for emergency admission and in those admitted from theatre. If necessary, please enlist the help of anaesthetists for the post-op patients. Sections A and B relate to polyurethane CVLs.

A. Type of CVL (Polyurethane not Silastic)
Please circle approximate answers / Emergency Admissions / Post op admissions
1. What percentage of children admitted to PICU require a polyurethane CVL / a) 0-25%
b) 26-50%
c) 51-75%.
d) 76-100%. / a) 0-25%.
b) 26-50%.
c) 51-75%
d) 76-100%
2. Type of CVL used in your PICU
Please circle all types used / a) Standard
b) Minocycline/ Rifampicin
c) Heparin
d) Chlorhexidine /
Silversulpahdiazine / a) Standard
b) Minocycline / Rifampicin
c) Heparin
d) Chlorhexidine /
Silversulpahdiazine
B.CVL Insertion
Please circle appropriate response / Emergency Admissions / Post op admissions
3. Is there a written protocol governing CVL insertion? If yes, please enclose a copy. / a) Yes, copy enclosed
b) Yes, but copy not
enclosed.
c) No
d) Don’t’ know / a) Yes, copy enclosed
b) Yes, but copy not
enclosed
c) No
d) Don’t’ know
4. Has compliance with the protocol been audited in the last year? / a) Yes.
b) No
c) Don’t’ know / a) Yes
b) No
c) Don’t’ know
B.CVL Insertion (continued)
Please circle/complete appropriate response / Emergency Admissions / Post op admissions
5. Are there specific training sessions for the doctors regarding CVL insertion? / a) Yes
b) No
c) Don’t’ know / a) Yes.
b) No
c) Don’t’ know
6. Site of CVL insertion
a) Subclavian
b) Internal jugular
c) Femoral
d) Other / 0%: a, b, c, d
1--25%: a, b ,c, d
26-50%: a, b ,c, d
51-75%: a, b, c, d
75-100%: a, b, c, d / 0%: a, b, c, d
1--25%: a, b ,c, d
26-50%: a, b ,c, d
51-75%: a, b, c, d
75-100%: a, b, c, d
7. Which solution is usually used for skin preparation prior to insertion? / a) Alcohol
b) 0.5%Chlorhexidine in
alcohol
c) Povidine iodine
d) 2% chlorhexidine in
alcohol
e) Any other ......
...... / a) Alcohol
b) 0.5%Chlorhexidine in
alcohol
c) Povidine iodine
d) 2% chlorhexidine in
alcohol
e) Any other ......
......
C. Ongoing CVL Care in PICU
Please circle/complete appropriate response / Care of CVL in PICU
8. Are there specific training sessions for the nurses regarding CVL care? / a) Yes
b) No
c) Don’t’ know
9. What method is usually used to clean the CVL hubprior to drug or fluid administration / a) Alcohol
b) 0.5%Chlorhexidine in alcohol
c) 2% chlorhexidine in alcohol
d) Any other…………….
10. How often do you routinely change administration sets for fluids and medications / a) Every 24 h
b) Every 48 h
c) Every 72 h
d) Routinely but less often than every 72h
e) No routine changing
11. How often do you routinely change administration sets for total parenteral nutrition? / a) Every 24 h
b) Every 48 h
c) Every 72 h
d) Routinely but less often than every 72h
e) No routine changing
12. Do you routinely replace a CVL after so many days? / a) Yes b) No
If yes, state number of days allowed before replacement......
C. Ongoing CVL Care in PICU (continued)
Please circle/complete appropriate response / Care of CVL in PICU
13. If no to Q12, what would be your indication for changing CVL? / a) ......
b) ......
c) ......
14. Do you have a system on PICU for daily recording the need for keeping CVL ? / a) Yes
b) No
  1. Bloodstream infections in patients with a CVL

Please circle/complete approximate answers / Care of CVL in PICU
15. What is the rate of nosocomial bacteraemia in PICU (please give all results available) Nosocomial means bacteraemia >48 hours after admission. If nosocomial rate not available please report all bacteraemia). / a) Per patient admitted......
b) Per patient days of stay......
c) Per catheter days......
c) Do not know......
Approximate data collection period......
16. Do you think the rate of nosocomial bacteraemia is higher or lower in your PICU now than 2 years ago / a) Lower
b) Higher
c) About the same
d) Don’t know
17. If lower please list any factors that you consider helped to lower the rate of bacteraemia. / a)……………………………………………...... b)……………………………………………......
c)……………......
18. Are there any other aspects of infection control within your unit that you consider have had, or are likely to have, a significant impact on blood stream infections in patients with a CVL? / …………………………………………......
……………………………………………......
……………………………………………......
……………………………………………......
E. Sampling procedures
Please circle/complete appropriate answers / Care of CVL in PICU
19. Are separate blood culture samples taken from each CVL lumen? (ie separate bottles) / a) Yes, separate sample from each lumen
b) No, only 1 lumen sampled
20. In which circumstances would you take a peripheral blood culture in a patient with a functioning CVL in situ? / a) Routinely for all blood cultures
b) Whenever infection is suspected clinically.
c) If CVL culture is positive
d) Other(please describe)
……………….………………………………......
Any other Comments: Please feel free to add any other comments here that might be relevant to the survey

Please complete this tear off slip if you are not the appropriate person to complete this questionnaire. Let us know to whom you have passed the questionnaire.Please return to

Dr Q Mok.

Your name: …………………………………Place of work: ……………………….....

The appropriate person to contact to coordinate completion of this questionnaire is:

Name: …………………………………………………………………………

Contact telephone number………………………………………………….

Email address:…………………………………………………………………...