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NICU guideline identifier

Central Line Care - bundle of care for the neonate

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Purpose of guideline

To ensure safe and efficient initiation, delivery and ongoing management of neonatal fluid and medications via centrally placed catheters and prevent infection.

Definition

Bundle of care - are groupings of best practice interventions, which individually improve care but when applied together, result in a significantly greater improvement.

Aseptic Non Touch Technique (ANTT) -involves the identification of 'key parts' of equipment and ensuring they do not touch any part of the field or hand at any time. Key parts include fluid giving set male and female luer ends and syringe male ports.

Central-line associated bacteraemia (CLAB) - has a significant impact on infant mortality and morbidity as well as increase hospital stay and associated costs. Therefore, CLAB is one of the most important measures in the fight against nosocomial infection in the NICU.

NB: For the purpose of this guideline the word 'STERILE' will be used to describe accessing of central lines.

Nursing implications

As the patient advocate, the nurse needs to be constantly aware of any changes in the infant's clinical condition during any procedures as well as have the ability to prevent CLAB during central line insertion and maintenance. This can be achieved by adequate monitoring of vital signs, being able to visualize the infants so breathing and color can be monitored, limiting the number of people at the bedside, closing doors, and preparing equipment carefully.

Fixing of Lines

Once X-ray confirms position, lines need to be secured for stability.

Long Line

Once the line is fixed and secured using steristrips and tegaderm by a doctor/NNS/NNP on insertion, assisting nurse is to ensure that tegaderm does not overlap around the limb as this may interfere with circulation.

Umbilical line

The umbilical catheter is initially secured using a suture by the doctor/NNS/NNP. This is reinforced by a 5cm length of Elastoplast, which will be attached to the catheter - close to the base as possible. In securing the catheter, the suture threads are positioned along the length of the catheter and double back against the Elastoplast.

Gate strapping using sleek plaster with duoderm as a base tape, must be used on all babies over 1500gms and on babies under 1500gms from day 4 (or earlier) if condition of cord is giving concern. Place duoderm base tapes lengthwise on the baby's abdomen, one on either side of the umbilicus, then apply sleek gates on top of duoderm. Size of gate should be relevant to the size of infant. A bridge/crossbar is made with sleek in which the tubing is coiled, ensuring no tension on the line.

Interruption of Lines

This greatly increases the risk of sepsis. In order to minimize interruption of central line, the following protocol will be required:

Every time the central line is accessed for dressing change, adjustment of line or infusion set change, it must be done in a sterile manner.

  1. A new CLAB form must be filled out for line adjustments or dressing changes.
  2. All fluids, tubing and filters must be changed as per NICU guidelines. Label all tubing and bags with baby's label, date and time.
  3. All fluids through a syringe driver, must have a designated label on them.
  4. Babies <1000gms will have Starter solution commenced in the first 2-3 days of life. This fluid runs at a maximum of 30ml/kg/day therefore must be accompanied by a bag of D10W with a burette to make up remainder of total daily volume. Due to high protein concentration, no additives are to be infused with Starter solution.
  5. Inspect central line insertion site hourly for signs of soiling, redness, swelling or local infection. Document catheter status on shift assessment sheet once per shift on the CLAB form. Longline dressing needs to be changed only if soiled or lifting and catheter is exposed. If there is suspicion of local or systemic infection, consider prompt removal of catheter after discussion with consultant in charge.
  6. Maintaining sterility is vital in preventing CLAB. Drawing up IV antibiotics/fluids/flushes is a two-person procedure at all times. If an infusion requires a flush, it must be drawn up with the medication in a sterile manner. It can then be attached via ANTT by the administering nurse. If the central line is changed from one site to another (i.e. UVC to longline) or removed and replaced, all fluids, drugs, lines, filters and connections must also be replaced.
  7. Blood sampling from a UVC or surgical line must be done in a sterile manner using 10ml syringes. First, remove 1 ml of fluid/blood to clear the line then withdraw required amount of blood using another 10ml syringe. The 1ml of blood/fluid withdrawn to clear the line can be returned through the line and then flushed with hep-saline.

Hand Hygiene prior to sterile procedure

Doctors and NNS/NNP (insertion of CVL and dressing change)

Surgical handwash up to the elbows for 3 minutes with 2% Chlorhexidine skin cleanser and water. Dry thoroughly with sterile towels.

Nurses (central line fluids and medications/dressing change)

  • Administering nurse: aseptic handwash up to the elbow for 1 minute with 2% Chlorhexidine skin cleanser or liquid soap and water. Dry thoroughly with sterile towels.
  • Assisting nurse can use alcohol gel.

Setting up and maintenance

UAC/ UVC/long lines: All the tubing, priming and solutions used, must be set up using sterile technique.

  1. UAC: Drawing up of blood and flushing of the tubing, from the UAC, is done with the ANTT technique.
  2. All hub cleaning; 30 seconds scrub and 30 seconds drying time
  3. Clean the skin with the disinfectant appropriate for the infant's gestation and age.  All skin preparation: 30 seconds drying time

Documentation

Documentation page 1  Documentation page 2

Insertion UVC/UAC/Long lines

Equipment

  • Hat and mask
  • Sterile gloves
  • Sterile gown
  • Sterile towels
  • Appropriate dressing pack
  • Appropriate skin disinfectant
  • Surface disinfectant/wipe
  • 10ml  syringes
  • Extra equipment
  • CLAB insertion form

Procedure

  • Baby is positioned and swaddled appropriately.
  • Clean trolley surface and bench top (where the sterile gown and gloves will go) with surface disinfectant/wipe. Ensure that it is dry before use.
  • Collect required equipment as above and arrange on side of trolley.
  • Dr/NNS/NNP dons hat and mask.
  • Dr/NNS/NNP performs surgical handwash up to the elbows for 3 minutes with 2% Chlorhexidine skin cleanser and water. Dry hands thoroughly with sterile towels.
  • Dr/NNS/NNP dons sterile gown and gloves.
  • Assistant dons hat and mask then handwashes or uses alcohol gel.
  • Assistant opens dressing pack and Dr/NNS/NNP takes it and opens it on the clean surface.
  • Assistant opens equipment one by one, allowing Dr/NNS/NNP to take the equipment and put it in the sterile field. The Dr/NNS/NNP arranges equipment onto the dressing pack.
  • Assistant opens incubator door or heat table side.
  • Dr/NNS/NNP commences and completes the procedure.
  • Dr/NNS/NNP completes the date, time, place and site of insertion as well as the catheter type and X-ray confirmation on the CLAB form.
  • Assistant settles the baby and fills in the CLAB insertion bundle checklist.
  • Both assistant and Dr/NNS/NNP signs the CLAB form.

Central Line Fluids and Additives (long lines/UVC/UAC) - Setting up and changes (by Nurses)

Equipment

  • Hat and mask
  • Sterile gloves
  • Sterile towel
  • Dressing pack
  • Appropriate disinfectant
  • Surface disinfectant/wipes
  • I.V. Solution &/drugs as prescribed
  • I.V. giving set/ extension sets, bungs, double lumen sets as required
  • Drawing up needles/filter needles and syringes
  • Fluid balance chart
  • CLAB maintenance form

Fluid change procedure

  1. Staff education. Ensure staff are familiar with correct procedure.
  2. Perform hand hygiene to minimize risk of infection.
  3. Clean trolley surface and bench top (where the towel and gloves will go) with surface disinfectant/wipe and allow to dry to prevent contamination of sterile equipment when pack and equipment opened
  4. Collect required equipment as above and arrange on side of trolley. Minimize contamination of sterile equipment when pack and equipment are opened.
  5. Two nurses throughout procedure to facilitate sterile technique.
  6. Check patient's identity - I.D. label matches patient's I.D. sticker on treatment sheet.
    Check fluids correspond with fluids prescribed on treatment sheet to ensure correct patient and fulfill ADHB management policy.
  7. Administering nurse and assistant to don hat and mask to minimize risk of contamination
  8. Administering nurse performs aseptic hand hygiene up to the elbow, with water and 2% chlorhexidine skin cleanser or liquid soap for one minute to minimise risk of contamination.
    1. Dry thoroughly.
    2. Administering nurse puts on sterile gloves.
    3. Assistant nurse can use alcohol gel.
  9. Assistant opens dressing pack and administering nurse takes it and opens it on the clean surface to maintain aseptic environment and ensure maximum area for sterile field.
    1. Assistant opens equipment one by one, allowing administering nurse to take the equipment and put it in the sterile field. The administering nurse arranges equipment onto the dressing pack.
    2. Assistant opens the 2% chlorhexidine 70% alcohol solution and pours into the sterile dish. Maintain aseptic environment and ensure maximum area for sterile field
  10. Assistant will hold bag of prescribed fluids and open blue tab. The administering nurse will hand the assistant the giving set end. Maintain line and fluid sterility.
    1. Assistant takes the end of the giving set, ensures sterility of key part then connects it firmly to the bag and hangs the bag on the pole.
  11. With the assistant holding solutions and drugs, the administering nurse draws up the required solutions and drugs into syringes, swabbing appropriate connections for 30 seconds and allowing 30 seconds drying time to prevent contamination.
    1. Discard used gauze outside of the sterile field.
  12. The administering nurse attaches all connecting and priming tubing, filters and ports slowly to avoid air bubbles and minimize potential for bacterial growth on line.
    1. The administering nurse ensures connections are secure and all surfaces of giving set and connector ports remain free of excess lipid or glucose solution. 
  13. When I.V. tubing has been primed, leave the tubing on the sterile field to maintain sterility of all line connections.
    1. Protect all key parts.
  14. Assistant opens the incubator door, detaches tubing if not needed and hold up connecting port. Maintain sterility of all line connections.
    1. The administering nurse puts the sterile guard under the hub, holds the required port with gauze and cleans it with Chlorhexidine for 30 seconds and 30 seconds drying time.
    2. When dry, the administering nurse connects the new tubing.
    3. Assistant removes the old tubing from the in incubator / heat table and discards accordingly. Maintain sterility of all line connections.
  15. Administering nurse and assistant to check all clamps are open and infusions running at correct rate. Check lines and ports are visible and close incubator door. Ensure no lines trapped in door or clamped which will delay medication fluid delivery.
  16. Dispose used equipment in the appropriate receptacles. Ensure adherence to ADHB protocols on sharps and rubbish disposal.
  17. Document fluids and line/filter change on recording sheet and medications. Write on appropriate labels and sign to ensure accurate record taking and identification of change.
  18. Perform hand hygiene to minimize risk of infection.
  19. Inspect central line insertion site hourly for signs of soiling, redness, swelling or local infection. Early detection of complications enables early interventions.
    1. Document catheter status on shift assessment sheet once per shift on the CLAB form. 

Central Line (UVC/UAC/Long lines) Medications

Equipment

  • Hat and mask
  • Sterile gloves
  • Sterile towel
  • Dressing pack
  • Appropriate disinfectant
  • Surface disinfectant/wipes
  • I.V. Solution &/drugs as prescribed
  • I.V. giving set/ extension sets, bungs, double lumen sets as required
  • Drawing up needles/ filter needles and syringes
  • Filter
  • Fluid balance chart
  • Drug chart

Medication administration procedure

  1. Staff education. Ensure staff are familiar with correct procedure.
  2. Perform hand hygiene to minimize risk of infection.
  3. Clean trolley surface and bench top (where the towel and gloves will go) with surface disinfectant/wipe and allow to dry to prevent contamination of sterile equipment when pack and equipment opened
  4. Collect equipment as above and arrange on side of trolley. Prevent contamination of sterile equipment when pack and equipment are opened.
  5. Two nurses throughout procedure to facilitate sterile technique and to comply with ADHB medication safety requirements.
    1. Two nurses to check the correct drug, dose, route, time as per ADHB policies.
  6. Check patient's identity - I.D. label matches patient's I.D. sticker on treatment sheet.
    Check fluids correspond with fluids prescribed on treatment sheet to ensure correct patient and fulfill ADHB management policy.
  7. Administering nurse and assistant to don hat and mask to minimize risk of contamination
  8. Administering nurse performs aseptic hand hygiene up to the elbow, with water and 2% chlorhexidine skin cleanser or liquid soap for one minute to minimise risk of contamination.
    1. Dry thoroughly.
    2. Administering nurse puts on sterile gloves.
    3. Assistant nurse can use alcohol gel.
  9. Assistant opens dressing pack and administering nurse takes it and opens it on the clean surface to maintain aseptic environment and ensure maximum area for sterile field.
    1. Assistant opens equipment one by one, allowing administering nurse to take the equipment and put it in the sterile field. The administering nurse arranges equipment onto the dressing pack.
    2. Assistant opens the 2% chlorhexidine 70% alcohol solution and pours into the sterile dish Maintain aseptic environment and ensure maximum area for sterile field
  10. Assistant holds ampoule and administering nurse scrubs the top for 30 seconds and 30 seconds drying time. Discard used gauze outside of the sterile field. Minimise risk of contamination of key parts.
    1. With the assistant holding ampoule and other solutions, the administering nurse draws up the required medications and solutions into syringes.
    2. If normal saline flush is needed at the end of administering medication (i.e., amikacin), draw up the flush at the same time as the medication, then wrap it in a sterile drape and place outside the sterile field. When needed, attach the flush to the tubing using ANTT ensuring key parts are protected.
    3. If heparinized saline flush is needed, draw up the flush at the same time as the medication and leave it within the folded sterile field. When administering heparinized saline flush, the administering nurse uses the sterile technique ie. aseptic handwash, don hat, mask and sterile gloves. Assistant opens the folded sterile field and administering nurse gets the heparinized-saline flush. 
  11. Assistant opens incubator door or heat table side, clamps any tubing, and holds up required port to maintain a sterile working field and protect key parts of central line from contamination.
    1. The administering nurse puts the sterile guard under the hub, holds the required port with gauze and cleans it with chlorhexidine for 30 seconds and 30 second drying time. When dry, the administering nurse gives the medication and flushes the tubing accordingly.
  12. After administration of medication or solutions, open clamps and port to fluids to ensure correct delivery of prescribed fluids.
    1. Both nurses to check and recommence infusions as prescribed
  13. Document on drug administration record sheet to ensure accurate record taking and identification of change.
  14. Dispose of used equipment to appropriate receptacle and perform hand hygiene ensuring adherence to ADHB protocols on sharps and rubbish disposal.

ANTT Aseptic Non Touch Technique for peripheral lines

  1. Clean hands - an antiseptic 30 sec handwash with 4% chlorhexidine/liquid soap or handrub with alcohol gel.
  2. Wipe down trolley surface with surface disinfectant/wipe.
  3. Get equipment needed and put on side of trolley.
  4. Prepare infant if appropriate , i.e, swaddle.
  5. Clean hands - An antiseptic 30 sec handwash with 4% chlorhexidine/liquid soap or handrub with alcohol gel.
  6. Don non-sterile gloves.
  7. Open guard onto trolley top.
  8. Scrub medication tops with 2% Chlorhexidine wipes for 30 seconds and allow to dry for 30 seconds.
  9. Open each equipment, protecting key parts at all times and place on guard. Syringes must be attached to capped needles before placing on guard to ensure key parts are protected.
  10. Two nurses to check the correct patient, drug, dose, route and time as per ADHB policies.
  11. Draw up dilutions and mix with medications.
  12. Draw up drugs and fluids needed. Check dosages.
  13. Scrub top of bung with 2% Chlorhexidine wipes for 30 seconds and allow to dry for 30 seconds.
  14. Give medications
  15. Discard equipment accordingly.
  16. Clean hands.

Long Line catheter dressing change (by Dr/NNS/NNP only)

Correct dressing management is critical to preventing infection. The dressing protects the insertion site and cannulated vessel from trauma and keeps the side clean and dry.

Indications for changing dressing

  • Lifted and catheter is exposed.
  • Evidence of leakage around insertion site.
  • Impaired venous return and /or tissue oedema distal to site.
  • Restriction of circulation and/or movement.

Equipment

  • Hat and mask
  • Sterile gloves
  • Sterile gown
  • Sterile towels
  • Dressing pack
  • Appropriate disinfectant
  • Sterile scissors or scapel
  • Sterile SteriStrips
  • Transparent dressing (Tegaderm)
  • CLAB insertion form

Procedure for dressing change

  1. Each shift, inspect insertion site for signs of infection/infiltration such as redness, swelling, tenderness, discharge or lifting of dressing to ensure early detection of complications. A swollen limb (or body part) near central line insertion may indicate:
    1. Displacement or extravasation of central line.
    2. Constriction due to tight dressing and/or tapes.
  2. Check that transparent dressing is completely sealed, free from drainage and non-restrictive. If no issues, leave dressing unchanged. Dressings of lines are NOT routine. Changing insertion site dressing may introduce bacteria into catheter and may inadvertently alter the position of the catheter tip.
  3. Evaluate appearance of catheter through insertion site. Observe that catheter is not stretched or pulled taut at its insertion into hub and that tape is not on too tightly. Catheter is very fragile and may break if pulled.
  4. Changing longline dressing is a sterile procedure using CLAB checklist to minimise risk of infection.
    1. Clean trolley and bench surface (where sterile towel and gloves are placed), with surface disinfectant/wipe and allow to dry to prevent contamination of sterile equipment when pack and equipment opened.
    2. Collect equipment as above and arrange on side of trolley.
  5. Dr/NNS/NNP dons hat and mask  to minimise risk of infection. 
    1. Dr/NNS/NNP performs surgical handwash up to the elbows for 3 minutes with 2% Chlorhexidine skin cleanser and water. Dry hands thoroughly with sterile towels.
    2. Dr/NNS/NNP dons sterile gown and gloves.
    3. Assistant dons hat and mask and performs hand hygiene.
    4. Assistant opens dressing pack and Dr/NNS/NNP takes it and opens it on the clean surface.
    5. Assistant opens equipment one by one, allowing Dr/NNS/NNP to take the equipment and put it in the sterile field. The Dr/NNS/NNP arranges equipment onto the dressing pack.
  6. Assistant to stabilize the longline hub and loosen the dressing toward the insertion site, avoiding tension on the catheter. Stretching the dressing can help loosen it. Maintain sterile principles to minimize contamination of line and insertion site, damage to catheter or cause migration.
  7. Dr/NNS/NNP to hold the limb with gauze and clean over old dressing. Remove loosened old dressing carefully and discard. Maintain sterile field and avoid contamination.
  8. Dr/NNS/NNP to inspect the insertion site for signs of infection/infiltration i.e. redness, swelling, tenderness or discharge to facilitate identification of complications. Remove line if any signs of infection/infiltration.
  9. Dr/NNS/NNP cleans skin with appropriate disinfectant, beginning at the insertion site and clean upward away from insertion site to catheter connection, taking special care not to pull on tubing. Allow solution to dry. This is to reduce surface debris and cleanse tubing, thereby reducing the risk of infection under new dressing, and to reduce skin flora present on catheter and around connection.
  10. Dr/NNS/NNP gently coils the excess silastic tubing and tapes to skin with steri-strip, leaving insertion site visible. 
    1. Dr/NNS/NNP places hub of longline on top of transparent dressing with small gauze or douderm under for comfort - ensuring no kinks in line.
    2. Dr/NNS/NNP covers long line and hub with transparent dressing to ensure all exposed line is protected.
    3. The transparent dressing allows easy visualization of the site and is changed only if it is no longer adherent. The gauze piece prevents the transparent dressing from sticking to the steri-strip, and dislodging the catheter when the dressing is being changed.
  11. Document dressing change and condition of insertion site in clinical notes and CLAB form to ensure accurate record taking and identification of change.
  12. Dispose of equipment into designated containers and perform hand hygiene to ensure adherence to ADHB protocols on sharps and rubbish disposal.

Surgically-placed Central Lines (Broviac,Hickman) Dressing change (by /Dr/NNS/NNP/Nurses)

  • Broviac dressing to be changed every 7 days or earlier if any signs of soiling, kinking or dressing lifting etc.
  • CLAB technique; 3 minute handwash and sterile gloves.

Equipment

  • Hat and mask
  • Sterile gloves
  • Sterile gown
  • Sterile towels
  • Dressing pack
  • Appropriate disinfectant
  • Sterile scissors or scapel
  • Sterile SteriStrips
  • Transparent dressing (Tegaderm)
  • CLAB insertion form

Procedure for Surgically inserted Central Line dressing change

  1. Dressing change is a sterile procedure using CLAB checklist to minimize risk of infection
  2. Clean trolley and bench surface (where sterile towel and gloves are placed), with surface disinfectant/wipe and allow to dry to prevent contamination of sterile equipment.
    1. Collect equipment as above and arrange on side of trolley.
  3. Dr/NNS/NNP/Nurse dons hat and mask  to minimise risk of infection.
    1. Dr/NNS/NNP/Nurse performs surgical handwash up to the elbows for 3 minutes with 2% Chlorhexidine skin cleanser and water. Dry hands thoroughly with sterile towels.
    2. Dr/NNS/NNP/Nurse dons sterile gown and gloves.
    3. Assistant dons hat and mask and performs hand hygiene.
    4. Assistant opens dressing pack and Dr/NNS/NNP/nurse takes it and opens it on the clean surface.
    5. Assistant opens equipment one by one, allowing Dr/NNS/NNP/nurse to take the equipment and put it in the sterile field. The Dr/NNS/NNP/nurse arranges equipment onto the dressing pack.
  4. Assistant to stabilize the Broviac/Hickman hub and loosen the dressing toward the insertion site, avoiding tension on the catheter. Stretching the dressing can help loosen it. Maintain sterile principles to minimize contamination of line and insertion site, damage to catheter or cause migration.
  5. Dr/NNS/NNPS/Nurse to clean over old dressing to maintain sterile field and avoid contamination. Remove loosened old dressing carefully and discard. 
  6. Inspect the sutures and insertion site for signs of infection/infiltration i.e. redness, swelling, tenderness or discharge for identification of complications. Remove line if any signs of infection/infiltration.
  7. Dr/NNS/NNP/Nurse cleans skin with appropriate disinfectant, beginning at the insertion site and clean upward away from insertion site to catheter connection, taking special care not to pull on tubing. Allow solution to dry.Minimize risk of infection and reduce skin flora present on catheter and around connection.
  8. Dr/NNS/NNP/Nurse to cut out duoderm base to fit under flange only, to prevent pressure on skin. Coil or loop catheter tubing (as necessary) and secure with steristrips 
  9. Dr/NNS/NNP/Nurse to cover area with transparent dressing  to provide secure transparent aseptic cover over insertion site.
    1. Secure catheter outside dressing to skin with steristrips
    2. Exit line from side or bottom of dressing if possible 
    3. Minimize access to hands/fingers.
  10. Document dressing change and condition of site in clinical notes and CLAB form to ensure accurate record taking and identification of change.
  11. Dispose of equipment into designated containers and perform hand hygiene to ensure adherence to ADHB protocols on sharps and rubbish disposal.

Removal of Long Lines/umbilical catheters (Dr/NNS/NNP/Nurse)

Indications

It is recommended that UVC is removed and changed to long line at 7 days to prevent risk of infection.

A longline is removed when infant condition no longer necessitates its use or if complications require its removal.

Procedure for removal of long lines/umbilical catheters

  1. Staff education. Ensure staff are familiar with correct procedure.
  2. Perform hand hygiene to minimize risk of infection. Don non-sterile gloves.
  3. Keep infusion running  to prevent clot formation.
    1. Long line:
      Dr/NNS/NNP/Nurse to loosen transparent dressing on long line toward the insertion site, avoiding tension on the catheter. Stretching the dressing can help loosen it. Avoids excess tension on the line during withdrawal.
      Once the dressing is off, slowly draw out the catheter. Secure the site with gauze and tape if needed. Any  excess pressure application during attempts to move catheter may result in catheter tearing or snapping inside vessel.
    2. UVC/UAC:
      Dr/NNS/NNP/Nurse to cut stitches between catheter and knot of purse string.
      Remove catheter from bridging sleek.
      Pull catheter from vessel slowly, over 5 minutes.
      Draw back the catheter until 3cm left. Retape onto bridging sleek. Turn 3-way tap off to catheter.
      Leave for 30 minutes to allow clotting.
      Slowly remove the rest of the catheter. Secure wound with gauze and tape.
      N.B.Have sterile gauze handy to apply pressure if bleeding occurs.
    3. UVC site is left uncovered - do not nurse infant prone for minimum of 4 hours post removal. Check frequently for ooze.
  4. Inspect catheter tips to ensure catheter is complete. Ensure entire length has been removed.
    1. This is a two-person check and should be documented on the CLAB form. 
  5. Dispose of equipment into designated containers and perform hand hygiene to ensure adherence to ADHB protocols on sharps and rubbish disposal.
  6. Document removal of catheter in medical notes and CLAB form  to ensure accurate record taking and identification of change.

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Document Control

  • Date last published: 08 October 2018
  • Document type: Clinical Guideline
  • Services responsible: Neonatology
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years