Proforma for Registration of Subject For s3

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

Ms. MARITA JOSE FIRST YEAR M.Sc. NURSING CHILD HEALTH NURSING YEAR 2010 – 2012

VARALAKSHMI COLLEGE OF NURSING, No:19, KIADB ROAD, CHOKKASANDRA, T.DASARAHALLI, BENGALURU – 560 057.

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE, BANGALURU, KARNATAKA. 1 PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

MS. MARITA JOSE I YEAR M.SC.(NURSING) VARALAKSHMI COLLEGE OF 1. NAME OF THE CANDIDATE NURSING AND ADDRESS NO:19, KIADB ROAD, CHOKKA SANDRA, T.DASARAHALLI, BANGALORE – 560 057 Varalakshmi College of Nursing No:19, Kiadb road, 2. NAME OF THE INSTITUTE Chokka Sandra, T.Dasarahalli, Bangalore – 560 3. COURSE OF THE STUDY Ist Year MSc. Nursing AND SUBJECT Child Health Nursing 4. DATE OF ADMISSION TO THE COURSE 26-05-2010

5. Knowledge and Practice of Staff TITLE OF THE STUDY Nurses Regarding Care of Child With Central Venous Catheter.

6. BRIEF RESUME OF THE INTENDED WORK

6.1 INTRODUCTION:

2 A central venous catheter (CVC), also known as a central line, is long, soft, thin, hollow tube that is placed into a large vein (blood vessel). A central line is much like an intravenous (IV) catheter that is placed in a small vein in an arm, except that a central line is longer and is placed in a large vein leading to the heart in the neck, upper chest, leg, or arm. This type of catheter has special benefits in that it can deliver fluids into a larger vein, and that it can stay in the body for a much longer period of time than a usual, shorter IV.

Common reasons for having a central line include, to give IV medications over a long period of time, to deliver IV medications as an outpatient, to rapidly deliver large amounts of fluid or blood, to directly measure blood pressure in a large or central vein, take frequent blood samples, to deliver nutrition directly into the blood, to connect a person with kidney failure to a haemodialysis machine. Some of the possible risks of a central venous catheter are, Discomfort during placement, Bleeding, Infection, Blocking or kinking, pneumothorax.

In general, the tube will stay in as so long as it is needed and the catheter is not blocked or infected. This may be days or months. Anything that touches the catheter site and anything that goes into the catheter must be sterile the catheter may be infected if the patient has: redness, tenderness, or swelling where the catheter enters the skin Fever or chills. The catheter may be blocked if it is difficult or impossible to flush. The catheter may be coming out of the vein if the length of catheter outside the skin is getting longer1.

3 Central venous catheters are often mandatory devices when caring for critically ill children. They are required to deliver medications, nutrition, and blood products, as well as for monitoring hemodynamic status and drawing laboratory samples. Central venous catheters carry a particularly high risk of infection and these infections can be life threatening. Advanced practice nurses possess the power to influence catheter-related line infections in their critical care units. Understanding current recommendations for catheter material selection, site selection, site preparation, and site care can affect rates of catheter-related bloodstream infections2.

The exit site of central venous line is a potential site of infection, as it is a long term break in the skin’s integrity. As a potential source of infection, the exit site requires careful monitoring and scrupulous hygiene. Certain procedures should be followed to ensure that the exit site of all central lines are monitored and cared for meticulously and treated as necessary. All healthcare professionals are responsible for their own actions and must exercise their own professional judgment at all times3.

Catheter-related bloodstream infections, a type of hospital-acquired infection, are an important cause of increased length of stay, mortality, and cost among hospitalized patients. Patients with central venous access devices are at highest risk for CLABSIs for a variety of reasons, such as frequent manipulation of the catheter, access required for an extended period of time, and urgent placement of some catheters without regard to strict aseptic technique etc.

Several strategies have been proposed to prevent CLABSIs including hand hygiene, aseptic technique, catheter securement devices, and antimicrobial impregnated catheters. Some of these interventions are costly and/or time consuming; however, hand hygiene is inexpensive and relatively

4 simple to implement. Nurses are often at the frontline of central line care, and the profession has the potential to significantly impact the reduction in CLABSIs by adopting these measures4.

A prospective study on staff training: a key factor in reducing intravascular catheter sepsis conducted in, Birmingham children's hospital, monitored the frequency of sepsis in central venous catheters used for administering parenteral nutrition. A total of 58 central venous catheters were studied for a period of 12 months, 26/58 (45%) of catheters were removed because of proved sepsis. The possible causes were examined. As a result protocols were modified and an intensive staff training programme implemented throughout the hospital. The catheter sepsis rate was significantly reduced with only 9/107 (8%) catheters becoming infected. These findings emphasise the key role that education of staff plays in controlling central venous catheter sepsis and the importance and cost effectiveness of special nursing staff in implementing such measures5.

An article on Prevention of central venous catheter-related infection in the intensive care unit states that, prevention of catheter-related infection involves several measures which should be used in combination, like use of a checklist to guide catheter insertion and maintenance; adequate training of the nursing staff involved in the management of vascular access and an adequate patient-to-nurse ratio; the use of maximal sterile barrier precautions during catheter insertion; preference for a chlorhexidine-based solution for skin antisepsis; cleaning hands with an alcohol-based hand rub solution before any manipulation of the infusion line; and removing any useless catheters. Healthcare workers caring for a patient with a central venous access device need to be adequately trained, and assessed as being competent in using CVCs and adhering to infection prevention practices6.

6.2 NEED FOR THE STUDY 5 Central venous catheterization (CVC) is necessary for a great number of inpatients, particularly children. Though indispensable, CVC is not without risk. The use of central venous catheters may be associated with adverse events, originated during or after insertion of the catheter. The literature shows that nurses knowledge and knowledge on practice have an important role in prevention of complications associated with CVC.

About 250 000 bloodstream infections related to central venous catheter (CVC) placement develop in patients in US hospitals annually7. Most catheter- related bloodstream infections (CR-BSIs) develop in patients in intensive care units (ICUs) and result in an estimated 90 000 deaths a year8.

Bloodstream infections are among the most common infections in PICUs and suggested that such infections are a significant source of morbidity for critically ill children. Reducing the occurrence of CR-BSIs in critically ill children is important to health care providers and organizations9.

Access to a vessel can be gained via percutaneous puncture or with use of open surgical techniniques. “Seldinger” percutaneous technique is the most frequently used. CVCs are inserted via the subclavian vein, internal and external jugular veins or umbilical vein in newborns. The tip of the catheter can be placed into the right atrium, superior or high inferior vena cavaWhen inserting CVC, the operator should be very experienced and cautious, given that possible complications are numerous and some of them can be very serious Percentage of known catheter-related complications range from 0.7 to 26%.

A retrospective study on use of central venous catheters in children conducted in Croatia. During the study period 1300 patients aged from 0 to 18 years were admitted to the PICU. A total of 352 CVCs were inserted in 300 children. Patient age ranged from 0 to 18 years. The average catheter insertion time was 12.88 days. they noted 66 (18.8%) of CVC-related complications. 6 Complications related to CVCs insertion were malposition of catheter (5.4%) and pneumothorax (0.9%). Occlusion of CVCs (4.3%), catheter related bloodstream infections (CRBI) (4.0%), dislodgment (3.7%) and catheter damage (0.6%) were complications associated with length of CVCs use. They conclude that central venous catheterization is a safe and efficient procedure with minimal complications in pediatric patients10.

A report of the study on Medium and long term central venous access in children, conducted in St. John’s Medical College Hospital, Bangalore, Karnataka, From September 2000 to August 2001, 104 central venous access devices (CVAD) were inserted in 91 children, governed by a uniform protocol. There were 12 insertion related complications-all of which were minor. The incidence of non-infectious complications was 20% (rate of 13.7/1000 line days) and was influenced by the child’s age and insertion site. Femoral route was the safest. Incidence of catheter associated infections (CAI) was 15.4% (rate of 11/1000 line days). There was no major complication, though more than 50% insertions were in neonates and infants. In our practice, use of CVAD is feasible and safe, especially in neonates and infants11.

A prospective , longitudinal study conducted in south western united states for Reducing central venous catheter-related blood stream infections in children with cancer .51 catheter hub cultures were obtained from 27 children with cancer, and 121 nurses participated in the educational intervention.CVC hub cultures were obtained prior to and three months after an educational intervention. A written pre- and post education assessment was used to evaluate the nurses learning.post-test mean score of 87% was significantly higher than the pre-test mean score of 72% prior to the education program, 57% of the hubs were culture positive, and after the educational program , the proportion of culture-positive hubs were reduced to 36%. A comprehensive educational program increases nurse’s knowledge of CVC care and reduces CVC hub

7 colonization and catheter related blood stream infections in children with cancer12.

From the above findings and from the researchers own experience while working in a pediatric intensive care unit several incidence of complications related to central venous catheter occurred in children from this researcher realized that nurses have a vital role in caring central venous lines for preventing complications in children that occur as a result of central venous line.

6.3 STATEMENT OF THE PROBLEM

8 A Study To Assess The Effectiveness of Self Instructional Module On Knowledge And Practice of Staff Nurses Regarding Care of Child with Central Venous Catheter in Selected Hospitals, Bengaluru.

6.4 OBJECTIVES OF THE STUDY

1. To assess the existing level of knowledge and practice of staff nurses regarding care of child with central venous Catheter.

2. To determine the effectiveness of self instructional module on the knowledge and practice of staff nurses regarding care of child with central venous Catheter.

3. To correlate the knowledge and practice of staff nurses regarding care of child with central venous Catheter.

4. To associate the pre test knowledge and practice of staff nurses with selected demographic variable.

6.5 OPERATIONAL DEFINITION

Effectiveness - It refers to the improvement of knowledge and level of practice of staff nurses adopted in care of child with central venous Catheter and determined by significant difference in pre-test and post test knowledge scores.

9 Self Instructional Module- It refers to self sufficient written information on central venous catheter regarding, definition, indication, uses, procedure for care and complications and its prevention.

Knowledge- It refers to correct response of staff nurses regarding care of child with central venous catheter and measured by structured knowledge questionnaire and expressed in terms of knowledge scores.

Practice- It refers to the ability of the staff nurses to do their care of central venous catheter by verbalize answer regarding central venous catheter care.

Staff nurses- Refers to the nurses who are registered in Karnataka Nursing Council and have the Diploma or Degree certificate and who are providing care for the child with central venous catheters in selected pediatric units.

Care of child- It refers to the nursing measures on routine care of child with central venous catheter between birth to eighteen years such as dressing the site daily using aseptic techniques, inspecting the site for any redness, checking the line for patency, monitoring the central venous pressure, so as to reduce the incidence of central line related complications like infection, occlusion, pneumothorax, damage of the catheter.

Central venous Catheter - It refers to the catheter placed into a large vein in the neck (internal jugular vein or external jugular vein), chest (subclavian vein) or groin (femoral vein),umbilical vein( neonates). It is used to administer medication or fluids and obtain blood tests for child who is critically ill.

6.6 ASSUMPTION a. Staff nurses may have some knowledge and practices in meeting the care of child with central venous lines.

10 b. Administration of self instructional module may help to update the new information regarding care of child with central venous catheter among staff nurses.

6.7 HYPOTHESIS

H1 -There will be a significant correlation between knowledge and practice of staff nurses regarding care of child with central venous catheter.

H2-There will be a significant association between knowledge and practice of staff nurses on care of child with central venous catheter with their selected demographic variables.

6.8 REVIEW OF LITERATURE

A review of literature related research and theory on a topic has become a standard and virtually essential activity of scientific research projects “literature review is a critical summary of research on a topic of interest , often prepared to put a research problem in contact or as the basis for an implementation project.’’ Review of literature was undertaken to gain in depth knowledge on various knowledge on various aspect of the problem under this study.13

In this study the relevant literature reviewed has been organized and presented under the following headings:

1. Literature related to knowledge of staff nurses regarding care of central venous lines. 2. Literature related to practice of staff nurses regarding care of central venous lines.

11 3. Literature related to complications of central venous lines in children.

1. Literature Related to Knowledge Of Staff Nurses Regarding Care Of Central Venous Lines.

An exploratory study for evaluating central venous catheter care in a pediatric intensive care unit. A convenience sample technique was used to collect data in 2 phases, including 30 days to establish baseline information and 30 days each during which patients received dressing care for a central venous catheter with a transparent dressing alone and with a transparent dressing plus a chlorhexidine-impregnated dressing. Nurses also participated in a survey of knowledge about infection control practices related to central catheters. Few differences were found between the transparent dressing alone and a chlorhexidine-impregnated dressing plus the transparent dressing. A serendipitous finding was the number of times that central catheters were accessed daily. The results of this project suggest that infection control efforts may be most appropriately focused on processes rather than on products.14

A literature review on Educational interventions to reduce the rate of central catheter related blood stream infections in the NICU states, Cost- effective and successful educational interventions aimed at nurses have been shown to decrease CR-BSIs with adults, but no such studies address neonatal nurses. This literature review examined how educational interventions could help neonatal nurses reduce infection rates in patients with central venous catheters. Four databases were searched: PubMed, CINAHL, Cochrane, and OVID. Of Ten studies that measured CR-BSIs before and after educational interventions, nine showed a post intervention reduction in the rate of CR-BSIs of 40 percent or greater, and the tenth reported a reduction rate of 21 percent. 12 All of the educational programs had additional intervention components, so it is not possible to ascribe all the success to the education, but this review suggests that this topic needs to be studied with the NICU population.15

A retrospective, interventional study on Systematic intervention to reduce central line-associated bloodstream infection rates in a pediatric cardiac intensive care unit , Boston using an interrupted time-series design to compare central line-associated bloodstream infection. Their goal was to determine whether an intervention involving staff education, increased awareness, and practice changes would decrease central line-associated bloodstream infection rates. The estimated mean pre intervention central line-associated bloodstream infection rate was 7.8 infections per 1000 catheter-days, which decreased to 4.7 infections per 1000 catheter-days in the partial intervention period and 2.3 infections per 1000 catheter-days in the full intervention period. A multidisciplinary, evidence-based initiative resulted in a significant reduction in central line-associated bloodstream infections in their pediatric cardiac ICU.16

2. Literature related to practice of staff nurses regarding care of central venous lines.

A cross-sectional, descriptive, self-report survey regarding hand washing practices surrounding central venous catheter (CVC) care. Nurses working in pediatric intensive care units were included in the survey. A total of 30 nurses from 7 hospitals completed the survey. When comparing nurses' clean hand washing practices to hospital policy, the percentage of nurses who performed according to policy ranged from 17% to 100%. For aseptic hand washing, performance in accordance with policy ranged from 10% to 100%.If 1 minute was required, there were 17% of nurses who reported washing for less time. If 2 minutes was required, 75% were noncompliant, and for 3 minutes, 100% were noncompliant.. The authors note the large amount of variation in the hand washing practices of these nurses, noting that healthcare-associated

13 infections are a cause of poor patient outcomes. They identify a need for standardized guidelines in pediatric intensive care units in17.

3. Literature related to complications of central venous lines in children

An observational study conducted in Italy about Central venous catheter-related complications in children with oncological/hematological disease. 418 central venous catheters were inserted in 368 children, overall, 234 complications were observed in 169 devices (40%). Four types of possible complication were defined, mechanical, thrombotic, malfunctioning and infectious. The overall complication rate was 2.2 (95%): it was 0.87 (n=93) for infectious complications; 0.78 (n=84) for malfunctioning; 0.45 (n=48) for mechanical complications; and 0.08 (n=9) for thrombotic complications. The main reason for developing complication is, type of central venous catheters, underlying disease and patient age being the three main factors that affect the incidence of CVC-related complications.18

A prospective surveillance study about Infectious complications of peripherally inserted central venous catheters in children was conducted in Israel. A total of 279 PICCs were inserted in 221 patients. Mean dwell time was 30 days. 177 (63%) of all PICC placements were free of complications. Twenty-six catheters (9.3%) were dislodged accidentally; 38 (13.6%) were removed for mechanical problems: tears in 5, leaks in 12, and obstructions in 21; 38 (13.6%) were removed for an infectious complication: phlebitis in 13 (4.6%), exit-site infection in 10 )(3.5%), PICC-associated bloodstream infection in 12 (4.3%), and PICC-related bloodstream infection in 4 (1.4%); 15 more were removed for presumed infection (5.3%).PICCs are safe and may be used for prolonged periods. Accidental dislodgement is not uncommon and may be prevented by use of sutures, occlusive dressing, and education of patients, families, and medical staff.19

14 Prospective cohort study on Central venous access via external jugular vein in children was conducted in USA. The study was conducted over a period of 15 days in a11- bed PICU, the patients who had CVC via external jugular vein were the sample. The catheters were used for an average of 7.5 days (range, 1-28 days). Catheter malfunction occurred in 4 (1.21/100 catheter- days), and catheter-related bloodstream infections occurred in 2 patients (6.04/1000catheter-days). No thrombotic complications were clinically detected. The external jugular vein is a viable site for central venous access with a low complication rate in pediatric patients.20

A descriptive study on Decreasing PICU catheter- associated blood stream infections conducted in Poland. The CVC complications were analyzed according to the CVC type, blood product transfusion (BT) and parenteral nutrition (TPN). A total of 566 CVCs were taken ranging from two days to 2583 days , 297 complications were observed: 81 catheter infections , 77 mechanical complications , 59 no aspiration events , 52 thrombotic occlusion and 28 tunnel infections. At the end of the study period 121 (28%) CVCs were prematurely removed . CVC's related complications were relatively rare. Most common were infections and concerned catheters and these complications were most frequent in patients receiving BP and TPN. Risk of mechanical complications was higher in catheters than ports.21

A multi-institutional, interrupted time-series study on Central venous catheters in children with cancer. Risk of complications, was conducted in 29 PICUs across the United States. Two central venous catheter-care practice bundles comprised their intervention: the insertion bundle of pediatric-tailored care elements and the maintenance bundle derived from the Centers for Disease Control and Prevention recommendations. They used comparable modeling to assess the relative importance of the insertion versus maintenance bundles; the

15 results showed that the only significant predictor of an infection-rate decrease was maintenance-bundle compliance (RR: 0.41 [95% CI: 0.20-0.85]; P = .017). Maximizing insertion-bundle compliance alone cannot help PICUs to eliminate CA-BSIs. The main drivers for additional reductions in pediatric CA-BSI rates are issues that surround daily maintenance care for central lines, as defined in their maintenance bundle. Additional research is needed to define the optimal maintenance bundle that will facilitate elimination of CA-BSIs for children22

A prospective study on Percutaneously inserted central catheters in the newborns conducted in turkey. They did a prospective collection and analysis of the data of all infants who underwent PICC placement. The success rate of PICC insertion was 88.5%. PICCs were removed electively for 72 times (54.1%) and due to catheter-related complications for 61 times (45.9%). The main complication rate was the mechanical occlusion (12.7%). There were no statistically significant differences in the number of complication rates according to the insertion site, the position of the catheter tip, or the size of the catheter. Mechanical complications were the common reason for removal and they did not see complications more serious.23

A prospective study on Reduction of bloodstream infections associated with catheters in paediatric intensive care unit: stepwise approach, conducted in a 292 bed tertiary care children's hospital, Arkansas. Significant decreases in rates of infection occurred over the intervention period. These were sustained over the three year follow-up. Annual rates decreased from 9.7/1000 days with a central venous catheter in 1997 to 3.0/1000 days in 2005, which translates to a relative risk reduction of 75% (95% confidence interval 35% to 126%), an absolute risk reduction of 6% (2% to 10%). A stepwise introduction of interventions to reduce nosocomial infections can be implemented successfully. This requires a multidisciplinary team, support from hospital leadership, ongoing data collection, shared data interpretation, and introduction of evidence based interventions24 16 A Matched case-control study conducted in Children's Hospital Boston. To identify risk factors for central line-associated bloodstream infection (BSI) in patients receiving care in a pediatric cardiac intensive care unit. During the study period , 67 central line associated BSIs occurred in 61 patients. Unscheduled medical admissions, presence of noncardiac comorbidities, extended device utilization, and specific medical therapies are independent risk factors for central line-associated BSI in patients receiving care in a pediatric cardiac intensive care unit .25

A prospective study conducted in brazil to evaluate their experience and the complications from CVC placed percutaneously in children at a public hospital. During the study period, 155 central venous catheters were inserted into 127 patients over a nearly 8-month period were analyzed. There were 51 (32.9%) complications, of which 33 (21.3%) were mechanical and 18 (11.6%) suspected catheter-related infection. These complications were responsible for the removal of the catheter. Knowledge of anatomy and familiarity with seldinger technique highly increase the catheterization success rate, with few surgical complications. A better nursing care of CVC is emphasized. The available modern venous catheters have contributed to improve the quality of pediatric medical care. Nowadays, the percutaneous CVC is the preferred method in pediatric patients.26

17 7 MATERIALS AND METHODS

7.1 Source Of Data:

Data will be collected from the staff nurses working in selected pediatric unit who are providing care for child with central venous catheter.

7.2 METHOD OF DATA COLLECTION i) The Research Design

Non experimental descriptive correlational design.

ii) Research Variables

Dependent variable

The Knowledge and practice of staff nurses on care of child with central venous catheter.

Independent variable

Self instructional module regarding care of child with central venous catheter.

Demographic variable

The demographic variables of staff nurses such as age , gender, designation , qualification , working experience and previous exposure to any information. iii) Setting

The setting will be the pediatric units of the selected hospitals of Bengaluru.

18 iv) Population

In this study the population will be the staff nurses who are working in pediatric units of selected hospitals in Bengaluru.

V) Sample

The staff nurses who are fulfilling the inclusion criteria will be the sample. Sample size will be 60. vi) Criteria for sample selection

Inclusion criteria:

-Staff nurses who are working in the pediatric units in selected hospital Bengaluru.

-Both male and female nurses.

Exclusion criteria:

- Staff nurses who are on night duty during the time of data collection.

- Staff nurses who had attended in-service education or conference regarding care of child with central venous catheter. vii) Sampling technique.

Non probability purposive sampling technique. viii) Tool for data collection

19 Section A- Self administered structured questionnaire will be used to assess the demographic data such as age, gender, designation, qualification, working experience and previous exposure to any information.

Section B- Self administered structured questionnaire will be used to assess the knowledge of staff nurses regarding care of child with central venous catheter.

Section C- Self administered structured questionnaire will be used to assess the practice of staff nurses regarding care of child with central venous catheter

ix) Methods of data collection

Phase- I: Assess the existing knowledge and practice of staff nurses regarding care of child with central venous catheter with the help of structured questionnaire.

Phase-II: Administer self instructional module on care of central venous catheter

Phase-III: After a period of one week, post test will be conducted to assess the level of knowledge and practice of staff nurses by using same structured questionnaire.

Duration of data collection: 4 weeks

x) Plan for data analysis

20 Numerical data obtained from sample will be organised and analysed with the use of both descriptive and inferential statistics. Master coding sheet will be prepared based on the numerical data obtained from the sample.

Descriptive statistics

- Frequency and percentage will be used to study the demographic variables. - Mean, median, range and standard deviation will be used to determine the level of knowledge and practice regarding care of child with central venous catheter.

Inferential statistics

- Correlation coefficient will be used to find out the correlation between knowledge and practice of staff nurses. - -Chi-square test will be used to associate knowledge and practice with selected demographic variables. - Level of significance will be set at 0.05to interpret the hypothesis and findings. - Analysed data will be represented in the form of tables graphs and figures. xi) Projected outcome

The investigator will assess the existing knowledge of staff nurses regarding care of child with central venous catheter. The investigator will assess the effectiveness of self instructional module in improving the knowledge and practices of staff nurse regarding care of child with central venous lines.

7.3 Does The Study Require Any Investigations Or Intervention To The Patients Or Other Human Beings Or Animals?

21 Yes, with prior consent from sample the study will be conducted in selected hospital Bengaluru. The study requires minimum Investigation in the form of self administered structured questionnaire on care of child with central venous catheter. No other investigation which cause any harm will be done for the subjects.

7.4 Has ethical permission clearance obtained from your institution?

The permission will be obtained from

- Research committee of Varalakshmi College of Nursing.

- The selected hospital authorities

Privacy, confidentiality and anonymity will be guarded.

22 8. LIST OF REFERANCES:

1. Bonnie Fah, Marianna Sockrider.ATS Patient information series central venous catheter [Internet].American thoracic society; 2007. Available from: http://patients.thoracic.org

2. Kline AM. Pediatric catheter-related bloodstream infections: latest strategies to decrease risk. AACN Clin Issues. 2005 Apr-Jun;16(2):185- 98.

3. Claire Molloy.Procedure for the care of central venous line exit site for children[Internet]. Solihull care trust ;2009 nov. Available from: http://www.solihull.nhs.uk/getmedia/1b42311d-6215-4a11-bbea- 0bf26f94a69d/SCT(C)067v2.2009Procedure For The Care- OfCentralVenousLineExitSiteForChildren.aspx.uk/getmedia/1b42311d

4. Amy .E. lodolce. Prevention of Central Line-Associated Bloodstream Infections:The Role of Hand Hygiene and Hub Care[Internet].2010 [cited2010 sep 23]. Available from: http://www.proce.com/hai_css/pdf/Module%202_Hand%20Hygiene.pdf 23 5. J W Puntis, C E Holden, S Smallman, Y Finkel, R H George, and I W Booth. Staff training: a key factor in reducing intravascular catheter sepsis. Arch Dis Child. 1991 March; 66(3): 335–337.

6. Denis Frasca, Claire Dahyot-Fizelier ,Olivier Mimoz. Prevention of central venous catheter-related infection in the intensive care unit [Internet] 2010 [cited 2010 mar 9 ] . Available from: http://ccforum.com/content/14/2/212

7. Centers for Disease Control and Prevention. Intravascular Catheter- Associated Bloodstream Infections. 2005. Available from: http://www.cdc.gov/ncidod/dhqp/dpac_iv.html

8. Centers for Disease Control and Prevention. Guidelines for the prevention of intravascular catheter-related infections. MMWR. 2002;51(RR10):11–12.

9. Richards MJ, Edwards JR, Culver DH, Gaynes RP. Nosocomial infections in pediatric intensive care units in the United States. Pediatrics. 1999;103(4):e39.

10. Julije Mestrovic, Tanja Kovacevic, Ivanka Ercegovic, Branka Polic, Luka Stricevic, Ante Omazic, et el. Use of central venous catheters in children. SIGNA VITAE 2006; 1(1): 20 – 24.

11. S. Rao, A. Alladi, K. Das, A.J. Cruz. Medium and long term central venous access in children. Indian Pediatrics. 2003 Jan; 40(1):41-4.

24 12. Horvath B , Norvillie R, Lee D, Hyde A, hockenberry M,Gregurich M, Reducing central venous catheter-related bloodstream infections in children with cancer. oncol Nurs Forum.2009 Mar;36(2):232-8.

13. Polit D F ,Beck C T. Nursing research principles and methods .7 thed. New Delhi :Wolters kluwer health (India)Pvt LTD ;2007:p88-89.

14. Carol Halter, Linda Buckwal, Zoraida Salas-Allison, Cathleen Murphy- Taylor. Evaluating Central Venous Catheter Care in a Pediatric Intensive Care Unit. American journal of critical care. 2009 Nov; Vol (18):514- 520.

15. Semelsberger CF. Educational interventions to reduce the rate of central catheter-related bloodstream infections in the NICU: a review of the research literature. Neonatal Netw.2009 Nov-Dec;28(6):391-5.Also available from http://www.ncbi.nlm.nih.gov/pubmed/19892637

16. Costello JM, Morrow DF, Graham DA, Potter-Bynoe G, Sandora TJ, Lausen PC. Systematic intervention to reduce central line-associated bloodstream infection rates in a pediatric cardiac intensive care unit. Pediatrics. 2008 May;121(5) :915-923.

17. Valerie S. Eschiti. Hand washing practice and policy variability when caring for central venous catheters in paediatric intensive care. Dimensions of critical care nursing. 2007 July/Aug;26(4):168-169.

18. G. Fratino, A. C. Molinari, S. Parodi, S. Longo, P. Saracco, E. Castagnola et.el. Central venous catheter-related complications in children with oncological/hematological diseases.Ann Oncol.2005 Apr; 16 (4): 648-654. doi: 10.1093/annonc/mdi111.08028370294

25 19. Levy I, Bendet M, Samra Z, Shalit I, Katz J. Infectious complications of peripherally inserted central venous catheters in children. Pediatr Infect Dis J. 2010 May;29(5):426-9.

20. Tecklenburg FW, Cochran JB, Webb SA, Habib DM, Losek JD. Central venous access via external jugular vein in children. Pediatr Emerg Care. 2010 Aug;26(8):554-7.

21. Miller MR, Griswold M, Harris JM , Yenokyan G, Huskins WC, Moss M, Rice TB, et.el. Decreasing PICU catheter-associated bloodstream infections: NACHRI's quality transformation efforts. Pediatrics. 2010 Feb;125(2):206-13.

22. Perek D, Kowalewska E, Czajnska A, Polnik D, Drogosiewicz M, Stefanowicz M. Central venous catheters in children with cancer, Risk of complications.One centre experience. Med Wieku Rozwoj. 2006 Jul- Sep;10 (3 Pt 1):757-65.

23. Bulbul A, Okan F, Nuhoglu A. Percutaneously inserted central catheters in the newborns: a center's experience in Turkey,J Matern Fetal Neonatal Med. 2010 Jun;23(6):529-35.

24. Adnan Bhutta,Craig Gilliam,Michele Honeycutt, Stephen Schexnayder, Jerril Green, K J S Anand et el. Reduction of bloodstream infections associated with catheters in paediatric intensive care unit: stepwise approach. BMJ 2007. Vol 334, Number 7589.

25. John M. Costell, Dionne A. Graham, Debra Forbes Morrow, Gail Potter- Bynoe, Thomas J. Sandora, et el. Risk Factors for Central Line- associated Bloodstream Infection in a Pediatric Cardiac Intensive Care Unit. Pediatr Crit Care Med. 2009;10(4):453-459. 26 26. Paulo Custo´ dio F. Cruzeiro Paulo Augusto M. Camargos Marcelo E. Miranda. Central venous catheter placement in children: a prospective study of complications in a Brazilian public hospital. Pediatr Surg Int .- 2006 JUN 01; 22(6): 536-40.

9. Signature of the Candidate :

10. Remarks of the Guide : The Synopsis of the present study is appropriate to update the nurses knowledge and the study is genuine, relevant, feasible and individually benefiting.

11. Name and Designation : Mrs. Indira S 11.1 Guide Associate Professor

11.2 Signature :

11.3 Head of the Department : Mrs. Indira S Associate Professor 11.4 Signature :

27 11.5 Remarks of Principal : The study is relevant feasible and appropriate for the speciality chosen.

11.6 Signature :