TODAY, INFECTIONS CONTRACTED in the hospital and other health care settings represent one of the greatest risks to the health and well-being of patients. Health care-associated infections (HAIs) occur throughout the world, affecting hundreds of millions of patients each year.1 The Centers for Disease Control and Prevention estimates that 5% to 10% of hospitalized patients develop an HAI.2 There were an estimated 1.7 million infections and 99 000 associated deaths in hospitals in 2002.3 Another estimated 1.6 million to 3.8 million infections occur in long-term care facilities each year.4

Recent evidence that HAIs are largely preventable has created new opportunities to implement relatively simple practices to reduce or even eliminate the burden associated with such infections. Central line-associated bloodstream infections (CLABSIs) are one such type of infection that appear to be largely avoidable with adherence to evidence-based preventative guidelines.5

BACKGROUND

Central venous catheters (CVCs) play an integral role in modern health care, allowing for the administration of intravenous fluids, blood products, medications, and parenteral nutrition, as well as providing hemodialysis access and hemodynamic monitoring. Their use, however, is associated with a risk of bloodstream infection caused by microorganisms colonizing the external surface of the device or the fluid pathway when the device is inserted or in the course of its use.6 Central venous catheters are the most frequent cause of health care-associated bloodstream infections.7 It has been estimated that 80 000 CLABSIs occur in intensive care units in the United States each year6; however, if patients outside intensive care units are also included, the estimate increases to 250 000 cases of CLABSI each year.7

A CLABSI is a laboratory-confirmed bloodstream infection related to the presence of a central line or umbilical catheter that is in place either at the time of or within the 48 hours before the onset of an infection; it is not related to an infection at another site.8 Signs and symptoms of CLABSI can include soreness or redness at the insertion site, fever, chills, and hypotension; infants and neonates may have fever, hypothermia, apnea, or bradycardia.8

PREVENTION OF CLABSI

Employing relatively simple, evidence-based practices to reduce, if not eliminate, CLABSIs seems to be within the reach of even resource-limited settings.9 Within this framework HAIs, and CLABSIs in particular, are more and more being viewed as "preventable" events. For example, Umscheid et al10 estimated that as many as 65% to 70% of CLABSIs may be preventable with the implementation of evidence-based strategies. Pronovost and colleagues,11 from the Johns Hopkins Quality and Safety Research Group, demonstrated initially in 103 intensive care units in Michigan that increased use of evidence-based interventions and an improved culture of patient safety could prevent CLABSIs. At the end of the 36-month study period, there was a 60% overall reduction in the baseline CLABSI rate.11 As a result, $200 million and an estimated 2000 lives were saved.12 The Pronovost model spawned a national effort in the United States, supported by the Agency for Healthcare Research and Quality, to implement the program in all US states.13

Efforts to track, report, and prevent bloodstream infections in the United States have also improved in recent years. As part of its Action Plan to Prevent HAIs,14 the US Department of Health and Human Services has set a national goal to reduce CLABSIs by 50% by 2013, as monitored through the National Healthcare Safety Network. The Joint Commission also includes CLABSI in its National Patient Safety Goals (NPSGs) for hospitals. The Joint Commission NPSG related to CLABSI requires organizations to institute a variety of preventive and educational initiatives.

THE JOINT COMMISSION REQUIREMENTS

Because education is a key component in preventing CLABSIs, the NPSG requires organizations to educate health care workers who are involved in central line-related procedures about CLABSIs and prevention strategies. This education occurs not only at hire but also on an annual basis and whenever central line-related procedures are added to an individual's job responsibilities. Patients and their families must also be educated about CLABSI prevention as part of the NPSG. In addition, organizations must conduct surveillance for CLABSIs. Periodic risk assessments must be conducted, infection rates measured, compliance with best practices monitored, and the effectiveness of prevention efforts evaluated. All of these measures then need to be communicated to key stakeholders, including leaders, licensed independent practitioners, nursing staff, and other clinicians.

Accredited hospitals must use policies and practices that are aligned with evidence-based practices to reduce the risk of CLABSIs. These practices include performing hand hygiene, using an insertion checklist, following aseptic technique, using maximal sterile barrier precautions, prepping the skin with a chlorhexidine-based antiseptic, and using a supply cart or kit that contains all of the standardized materials that will be used to insert the CVC. The femoral vein is to be avoided unless other sites are unavailable. Once the central line is in place, hand hygiene must be performed before manipulating the CVC, and catheter hubs, connectors, and injection ports must be disinfected before accessing them. Finally, all CVCs must be routinely evaluated to determine whether they need to be continued, and all nonessential catheters should be removed.

PUTTING STRATEGIES INTO PRACTICE

As valuable as evidence-based practices may be, their availability alone does not necessarily result in directly changing the behavior of health care personnel.15-21 Common barriers to the implementation of best practices to reduce or eliminate CLABSIs include lack of leadership support, lack of a safety culture, unavailability of resources, issues with staffing such as suboptimal nurse-to-patient ratios, and the inadequate education, training, and competence of health care personnel.5

To bring best practices to the bedside level, improvement efforts must change practice patterns.22 Implementation strategies that are multifaceted and multidisciplinary, and that include sufficient resources and explicit support from organizational leaders, are most likely to be successful.20,23 The challenge comes in identifying which multifaceted approaches are likely to be most effective in a given organization, as there is no "one-size-fits-all" approach; instead, it is important that implementation strategies are customized to specific problem areas within a given organization in order to be most effective. As a first step, consider using a systematic approach to identify, prioritize, and remove local barriers that can diminish best practices.

The following is a brief overview of several internal and external factors that can affect the success of any improvement initiative that is designed to reduce or eliminate HAIs, including CLABSIs5:

* Leadership: This is broadly defined to include not only the executives, officers, and directors but also the clinical leaders and leaders of improvement teams or initiatives. Leaders communicate their vision to staff, provide human and fiscal resources to support CLABSI improvement initiatives, and work with staff to overcome barriers.

* Culture of safety: A culture of safety refers to an organization's commitment to safety across all levels of the organization and includes a blame-free environment that encourages staff to report error and near misses. Staff at all levels of the organization should seek solutions to patient safety issues.

* Multidisciplinary teams and teamwork: Teams create a balanced approach to improving patient care and safety. Such teams should include all staff members involved in CVC insertions and maintenance, clinical leaders and champions, managers, and infection preventionists. Health care personnel must not only be clinically competent but also be expert team members.

* Accountability of health care personnel: All members of the health care team must consistently carry out standardized protocols to prevent CLABSIs. Each individual is accountable for following evidence-based practices outlined in organizational policies and procedures.

* Empowerment: Health care personnel should have the ability to speak up, without fear of blame or intimidation, when unacceptable behaviors, errors, or near misses occur.

* Resource availability: Organizations need to ensure that necessary equipment and supplies are in place, along with education and training of staff on CLABSI prevention practices, competency assessments for staff, and trained epidemiologists and infection preventionists to oversee the CLABSI prevention program.

* Data collection and feedback of CLABSI rates: Surveillance for CLABSI and feedback of CLABSI rates to front-line staff can have a significant impact on CLABSI prevention efforts.

* Policies and procedures: Written policies and procedures that incorporate evidence-based practices should be available and their implementation should be monitored.

* Involvement of patients and families: Patients and their families should be educated on the steps they can take to reduce the risk of CLABSIs.

CONCLUSION

Central line-associated bloodstream infections are associated with high morbidity, mortality, and health care costs. There is growing recognition that many HAIs, including CLABSIs, are largely preventable when evidence-based practices are followed consistently. Progress that has been made in recent years in reducing CLABSIs points to their preventability, even in resource-limited countries.

Note. The Joint Commission monograph "Preventing Central Line-Associated Bloodstream Infections: A Global Challenge, A Global Perspective" is available for download free of charge at http://www.jointcommission.org/preventing_clabsi. The monograph includes information about CLABSI, clinical practice guidelines, prevention strategies, safety initiatives, surveillance and reporting information, and information about the economic aspects of CLABSI. The monograph was produced in partnership with infection prevention leaders from the Society for Hospital Epidemiology of America, Association for Professionals in Infection Control and Epidemiology, Inc, National Institutes of Health, Infectious Diseases Society of America, Association for Vascular Access, and International Nosocomial Infection Control Consortium. The monograph was supported in part by research grant provided by Baxter Healthcare Corporation.

REFERENCES