Central venous catheter (CVC)-related infections are a major cause of increased morbidity, mortality, and cost in healthcare.1-3 Patients in an intensive care unit (ICU) are at a greater risk for developing catheter-related bloodstream infections (CR-BSIs), due to numerous factors.1 Experts report 15 million CVC days in the United States occur in the ICU each year; the rate of infection is estimated to be 5.3 cases per 1,000 catheter days, resulting in approximately 80,000 CR-BSIs each year.3 The estimated cost per infection is $34,508 to $56,000 and the cost of caring for these patients ranges from $296 million to $2.3 billion.3 Although costly, these infections can be prevented through a multiprofessional approach to the problem.1
Assessing the situation
Baptist Hospital East (BHE), a 407-bed, not-for-profit community hospital in Louisville, Ky., has a 16-bed coronary care unit (CCU) and an 18-bed ICU. The CCU is a medical-surgical unit specializing in cardiac care, and the ICU is a medical-surgical unit specializing in neurologic care. Clinicians use CVCs frequently in both units. Recently, the CCU and ICU participated in a multiprofessional approach to decreasing CR-BSIs.
Each unit is routinely staffed with a nurse-to-patient ratio of 1:2. The CCU and ICU are open units, so any physician with admitting privileges can admit patients. The physicians that routinely insert CVCs within these units are private practice physicians, including pulmonary/critical care specialists, vascular surgeons, and general surgeons. The primary nurse of any patient receiving a CVC is typically present to assist the physician performing the insertion. Nurses change occlusive dressings on the insertion site every 7 days, unless they're soiled or dislodged.
The hospital's infection control department began tracking CR-BSIs in the ICU and CCU in January 2004, using definitions from the National Nosocomial Infection Surveillance Systems (NNIS). The rate is reported as the number of CR-BSIs per 1,000 patient days, as recommended by the NNIS.4 After 10 months of surveillance, unit managers, the director of nursing, and the director of infection control met to discuss the consistent rate above the national benchmark. At that time, BHE's ICU had a cumulative mean of 13 cases per 1,000 patient days. The CCU had a mean of 6.6 cases per 1,000 patient days. The national benchmark was 3.2 cases per 1,000 patient days.4
The group determined that nursing practice was inconsistent regarding the proper technique for changing occlusive dressings. Further, physicians didn't consistently use maximal barrier precautions. The group decided to perform a literature review on evidence-based practice and create an action plan to decrease CR-BSIs.
Evidence-based practice
The group reviewed several sources to compile the best information on evidence-based practice, CR-BSI-related costs, and benchmarks for comparing data. The group reviewed guidelines, endorsed by the Centers for Disease Control and Prevention (CDC), which were created to help healthcare practitioners prevent intravascular device-related infections.3 The guidelines include graded interventions based on the available studies and expert opinions. They recommended a multistep process to prevent CR-BSIs that includes:
* educating staff
* using maximal barrier precautions such as a sterile gown and gloves, mask, cap, and large sterile drape
* performing infection surveillance
* replacing occlusive dressing every 7 days or when needed.
Researchers reported a CR-BSI-associated mortality rate of 0% to 35%, with as many as 28,000 patients dying annually in ICUs.1 They also described the low-cost, five-step program administrators at Johns Hopkins Hospital initiated to decrease CR-BSIs. The five steps included:
* implementing education
* creating a CVC insertion cart
* asking physicians daily if CVC could be removed
* implementing a checklist for bedside nurses to complete
* empowering nurses to stop procedures if guidelines weren't followed.1
The group's literature review located a study describing several products clinicians could use to decrease CR-BSIs.2 Members also reviewed the NNIS-released CR-BSI benchmarks, which came out in October 2004. At the end of the review, the group determined that CR-BSIs can be prevented with low-cost techniques, noting that failure to prevent these infections could lead to poor patient outcomes and increased costs.
Plan implementation
The team modeled its action plan for decreasing CR-BSIs after the program established at Johns Hopkins Hospital. The group included interventions appropriate for BHE, namely:1
* educating the professionals involved in inserting CVCs, which included physicians and bedside nurses
* creating a kit to centrally house all related supplies, which would eliminate the need to search for supplies and help nurses use their time more efficiently
* asking physicians daily if the CVC was still necessary for the patient's care
* creating bedside tracking sheets for nurses to complete after assisting a physician with a CVC insertion.
For the first intervention, the group prepared an educational poster and displayed it in the physician lounge to draw attention to their role in decreasing CR-BSIs, namely, wearing maximal barriers such as a cap, mask, sterile gown, sterile gloves, and large sterile drape. Nursing staff attended mandatory in-services that included information about proper technique for changing occlusive dressings, evidence related to the importance of encouraging physicians to wear maximal barrier precautions, and education on the proper maintenance required to ensure optimal CVC operation.
The second intervention included creating kits to encourage nurses to use the correct supplies. Baptist Hospital East uses a computerized supply cabinet, which allows each area to create a custom kit. In this case, green LED indicator lights flash to alert the nurse of the supplies he or she would need for CVC insertion, which included an antimicrobial-coated CVC (including large sterile drape), physician barrier kit (including a gown, mask, and cap), sterile gloves, chlorhexidine for skin antisepsis and a chlorhexidine-impregnated topical patch to place around the catheter after insertion, and a central line dressing change kit. All nurses received education on how to access the kit function of the computerized supply cabinet. They performed return demonstrations to ensure that the education was effective.
The third intervention, which required bedside nurses to inquire daily whether the CVC was still required for the treatment of the patient, aimed to decrease patient exposure to CVC and help decrease CR-BSI rates.
For the final intervention, the nurse assisting with CVC insertion observed the physician and documented whether the proper barriers were offered and used. The hospital uses a computerized database to house all forms, so the group created a packet within the database to include education forms, consent forms, and the tracking sheet. This put the form in the hands of the nurses as they obtained consent for the CVC. Once completed, the nurse forwards the form to the director of infection control, where statistics are being kept on each individual inserting CVCs at BHE. These statistics will be reviewed quarterly for trends in physician practice and infection rates.
These four interventions went into effect January 2005. The group held monthly meetings to monitor progress toward goals.
Driving down rates
The CR-BSI rate in the CCU for December 2004 was 16.7 cases per 1,000 patient days, with a cumulative mean of 6.6 cases per 1,000 patient days. The ICU rate was 8.5 cases per 1,000 patient days, with a cumulative mean of 13 cases per 1,000 patient days. Interventions began in January 2005 with all education completed in February 2005. The rate dropped in both units in the following months. Data from March 2005 revealed 0 cases per 1,000 patient days for both the CCU and ICU, with cumulative means of 6.4 and 11.6, respectively. Though these results are positive, the data will continue to be monitored on an ongoing basis to ensure improvement over a longer period of time. To join the national focus on decreasing CR-BSIs, the organization joined the Institute for Healthcare Improvement's (IHI) 100,000 Lives Campaign in August 2005.
Taking its lead from the IHI, the team set three goals for BHE:
1. 100% hand hygiene compliance
2. 100% maximal barrier usage
3. Decrease central line infections to rates below the national benchmark.5 (See Complying with the central line bundle.)
Consequently, these interventions are implemented wherever clinicians insert CVCs. Nurses and physicians across the entire hospital have received education to gain support for the initiative.
Experts estimated the cost of CR-BSI to be $34,508 to $56,000.3 At BHE, the group estimated that the combined CCU and ICU efforts saved the hospital $226,270 in a period of 3 months.
Future considerations
The group will continually monitor CR-BSI rates to assess the interventions' efficacy. Though all parties aren't completely complying, the group did see a significant decrease in the infection rates in a short amount of time. Of course, the data are preliminary and will continue to be collected and reviewed to determine the interventions' continued efficacy. Physicians' compliance with wearing appropriate barrier precautions is still an obstacle. Other challenges include maintaining the competency level of nursing staff and keeping them aware of progress toward the goal of zero CR-BSI cases.
Catheter-related bloodstream infections are costly in financial terms and human terms, but can be prevented with a concerted effort by the multiprofessional team of healthcare providers. Preventing these infections is a win-win situation for all involved. Patients have better outcomes, leading to lower costs and increased patient satisfaction. Preventing these infections can also lead to nurse and physician satisfaction, because they're seeing the results of their efforts. Regardless of what steps are taken, the key to preventing CR-BSIs relies on a multiprofessional, evidence-based practice approach.
Complying with the central line bundle
One goal of the Institute for Healthcare Improvement's 100,000 Lives Campaign is to reduce the number of catheter-related bloodstream infections from central lines. The five components of the central line bundle are:
1. Performing hand hygiene
* before and after palpating catheter insertion site
* before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter
* when hands are soiled
* before and after invasive procedures
* between patients
* before donning and after removing gloves
* after using the bathroom
2. Using maximal barrier precautions when inserting central lines, which include:
* cap
* mask
* sterile gown
* sterile gloves
* covering patient with large sterile drape
3. Chlorhexidine skin antisepsis
4. Optimal catheter site selection
* Whenever possible and not contraindicated, the subclavian line site should be preferred over the jugular and femoral sites for nontunneled catheters in adult patients.
5. Daily review of central line necessity, with prompt removal of unnecessary lines.
Source: Institute for Heathcare Improvement. Getting started kit: Prevent central line infections. Accessed at: http://www.ihi.org/NR/rdonlyres/of4cc102-CS64-4436-AC3A-OC57B1202872/o/Centralli.
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