CLABSI Prevention Strategies in the NICU

CLABSI Prevention in the NICU: More Than a Central Line Bundle

Central lines are essential in neonatal care. PICCs, UVCs, and UACs allow us to provide medications, parenteral nutrition, fluids, blood pressure monitoring, and blood sampling to babies who often have very limited vascular access.

But every central line also creates risk.

CLABSI prevention is sometimes taught as a list of tasks: clean the skin, maintain a sterile field, scrub the hub, assess the dressing, and remove the line when it is no longer needed. All of those things matter, but experienced NICU nurses begin to see the bigger picture.

Preventing infection means understanding why the line is needed, how the baby’s skin changes our approach, where contamination can occur, and what we can do each day to safely decrease the amount of time that line remains in place.

That makes CLABSI prevention much more than central line care.

Start With the Skin

Central line infection prevention begins before the catheter ever enters the baby.

Premature infants have an immature skin barrier, which means the same antiseptic approach used in an older child or adult cannot automatically be applied to every NICU patient. Gestational age, chronologic age, skin maturity, antiseptic product, concentration, and application technique all matter.

Chlorhexidine is an important example. It is highly effective for skin antisepsis, but chemical burns have been reported in premature infants. This is one reason neonatal policies often differentiate which products can be used based on the age and maturity of the baby.

Technique matters too.

Antiseptic solution should not pool underneath the infant or saturate linens and positioning devices. It also needs time to dry completely before the procedure continues.

The key takeaway:

Effective infection prevention should protect the bloodstream without causing avoidable injury to the skin.

Understanding why a particular antiseptic is being used is just as important as knowing how to apply it.

Central Line Insertion Is a Team Procedure

One of the most important components of safe central line insertion has very little to do with technical skill.

It is having another person in the room who is watching.

The nurse or provider inserting the line is concentrating on the vessel, catheter placement, equipment, and the procedure itself. They cannot realistically observe every edge of the sterile field at the same time.

That is why central line insertion should never be considered a one-person procedure.

Another team member should be actively watching the sterile field and prepared to speak up if contamination occurs. If a sterile glove touches something outside the field or equipment becomes contaminated, the safest response is to identify it immediately, replace what was contaminated, and continue safely.

This can feel uncomfortable, especially for a newer nurse working with someone more experienced.

But speaking up is not criticism...Speaking up is part of the procedure.

When teams build this expectation into their central line bundle, maintaining sterility becomes a shared responsibility rather than something placed entirely on the person inserting the catheter.

The Bigger Challenge Is Maintenance

Insertion may take minutes. A central line may remain in place for days or weeks.

That means most CLABSI prevention actually occurs during routine bedside care.

The line should be part of the nurse’s ongoing safety assessment. This includes more than looking at the insertion site. Nurses should assess the dressing, visible catheter, tubing, connections, securement, moisture, drainage, and any change from the previous assessment.

And the baby matters.

Consider two very different patients.

A 24-week infant may be relatively still in an incubator with minimal movement around the dressing. A 44-week corrected infant with bronchopulmonary dysplasia may be sweating, moving constantly, being held frequently, and pulling against tubing.

Both babies require the same infection-prevention principles, but their risks for dressing disruption may look very different.

This is where nursing assessment matters: Standardize the bundle, but individualize how you watch the baby.

A loose edge, damp dressing, blood underneath the dressing, changing external catheter length, or new tension on the tubing should never become something we simply “keep an eye on” until the next scheduled care time.

Every Access Should Have a Purpose

Cleaning the connector before access is an important component of CLABSI prevention. So is allowing the disinfectant adequate time to work and dry.

But another important question comes before that:

Why are we accessing the line?

Central lines should be used when they are needed, but unnecessary manipulation adds opportunities for contamination.

This is where nurses can look for ways to reduce repeated access:

• Can labs be bundled together?

• Does every laboratory test need to be obtained from the central line?

• Can medications or other care be coordinated?

• Is a closed blood-sampling system available for an umbilical catheter?

• Are passive disinfecting caps being used consistently if they are part of the unit’s practice?

The goal is not to make nurses hesitant to use central access when it is clinically necessary.

The goal is to make every access intentional.

A useful question at the bedside:

Can I accomplish what this baby needs with fewer breaks into the system?

Feeding Progression Can Be an Infection-Prevention Strategy

One of the most interesting parts of central line stewardship is recognizing how decisions that seem unrelated to the catheter can influence CLABSI risk.

Feeding advancement is a good example.

Imagine a premature infant receiving parenteral nutrition through a PICC. Feeds were fortified yesterday, and today the providers order another feeding increase.

At first, that can feel like a nutrition decision alone.

But when an infant safely advances enteral feeds, parenteral nutrition can often decrease. Eventually IV fluids may no longer be necessary, and the PICC can be removed.

That means feeding progression may also decrease central line days.

This does not mean feeds should be advanced faster than an infant can safely tolerate simply to remove a catheter. The feeding plan still needs to reflect the baby’s clinical condition.

It does mean nurses should connect the two plans.

During rounds, instead of asking only whether feeds are increasing, consider asking:

“At what feeding volume will this baby no longer need the central line?”

That question turns feeding advancement, IV nutrition, and infection prevention into one clinical conversation.

Daily Line Necessity Should Be Part of Rounds

One of the simplest CLABSI-prevention strategies is also one of the easiest to overlook.

Ask whether the line is still needed...every single day, every single rounds.

Daily line necessity should be part of rounds because nurses often see opportunities to reduce central access that may not be obvious when each part of the plan is discussed separately.

Could feeds advance?

Can a medication move to another route?

Are frequent laboratory draws still necessary?

Is the baby maintaining glucose and hydration without as much IV support?

The goal is not just to care for the line well.

The goal is to safely reach the point where the baby no longer needs it.

Fewer line days mean fewer days of exposure to central line complications, including infection.

The Bundle Has to Live in the Workflow

Most NICUs have a central line policy or bundle.

The more important question is whether the team can reliably follow it.

A useful central line workflow should make the major components of care easy to identify and document. Ideally, the electronic health record supports at least three distinct checkpoints:

At placement: Was the insertion bundle completed? Was the skin prepared appropriately? Was sterility maintained, and were any breaks identified and corrected?

Hourly: Is the dressing intact? Is the catheter secure? Are the tubing and connections appropriate? Has anything changed?

Daily: Has someone with central line expertise reviewed the line, dressing, ongoing indication, and plan for removal?

Documentation itself does not prevent CLABSI. But a well-designed EHR can reinforce the bundle, make missed elements easier to recognize, and give teams meaningful data for quality improvement.

The same is true for relatively simple tools such as passive disinfecting caps. If a unit has them available but they are inconsistently used, the issue may not be a lack of evidence or education. It may be a reliability problem.

Sometimes a strong quality-improvement question is simply:

Are we actually doing every part of our bundle, every time?

Parents Are Part of the Safety Team

Central lines can be intimidating for NICU families. Parents may worry that holding, touching, or participating in care will somehow disturb the catheter.

They need to hear that having a central line does not take away their role as the parent.

With appropriate support, many babies with central lines can still be held, comforted, repositioned, and participate in skin-to-skin care.

Parents can also help with safety by performing good hand hygiene and telling the nurse if they notice a dressing that looks wet, loose, lifted, or different, or if tubing suddenly does not look right.

They are not responsible for managing the catheter.

But parents spend hours looking at their baby, and sometimes they notice a change first.

The message for families:

You do not have to manage the central line, but you are absolutely part of your baby’s safety team.

Thinking Like an Experienced NICU Nurse

CLABSI prevention becomes more meaningful when we stop thinking about it as a collection of isolated tasks.

The experienced nurse connects the pieces.

The skin antiseptic used during insertion matters because premature skin is vulnerable.

The second person at the bedside matters because someone has to actively protect the sterile field.

The hourly line check matters because dressing integrity can change quickly.

A feeding increase matters because progressing enteral nutrition may help decrease central line days.

Rounds matter because somebody needs to ask whether the baby still needs the catheter.

And the central line bundle matters because these individual practices only protect the baby when they happen reliably together.

So instead of asking only:

“Did I complete the central line care?”

Ask the bigger questions:

Is the skin protected? Is the line protected? Are we limiting unnecessary exposure? And what can we safely do today to move this baby closer to not needing the line at all?

That is the bigger picture of CLABSI prevention in the NICU.