Bloodstream infections caused by improper procedures, during insertion and removal of central catheters in the ICU, occur too often and are potentially lethal. Implementation of simple patient safety measures, such as hand washing and avoiding femoral insertion sites, can significantly reduce the incidence of these infections. This essay examines a recent study that investigated the efficacy of these and other interventions in the majority of Michigan hospital ICUs.
¶ … Catheter-Related Infections
Central Catheter-related ICU Infections
Central Catheter-Related Infections in ICUs
Reducing Central Catheter-Related ICU Infections in Michigan
Reducing Central Catheter-Related ICU Infections in Michigan
Teams of clinicians at five hospitals across Michigan reported their efforts to reduce the frequency of catheter-related bloodstream infections in intensive care units (ICUs) through the implementation of five patient safety measures: (1) hand washing, (2) full barrier precautions during insertion of central venous catheters, (3) use of chlorhexidine to clean the insertion site, (4) avoid using a femoral site for catheter insertion, and (5) never leaving unnecessary catheters in the patient (Pronovost et al., 2006). The intervention was based on the published research findings from five research groups: Berenholtz et al., 2004; Cohran et al., 1996; Eggimann et al., 2000; Warren et al., 2004; and Warren et al., 2006. Three of these studies investigated the efficacy of interventions on catheter-related bloodstream infections in an ICU setting, while the other two evaluated the effect of interventions more generally. All emphasized clinician education in the prevention of these infections and together this group of studies represented the evidence base upon which Pronovost and colleagues (2006) designed the intervention they tested.
The study design involved designating ICU team leaders, consisting of a physician and nurse, who would be trained in the intervention strategies (Pronovost et al., 2006). Through a partnership with hospital-based infection-control professionals, the team leaders implemented the intervention and collected infection data. In addition to the five patient safety measures, a number of other measures were implemented, which included checklists, the creation of a central-line cart with all necessary supplies, best practice procedures preventing clinicians not adhering to guidelines from continuing, and reminders and feedback at daily rounds and meetings. The independent variable in this study was the intervention and the dependent variable (outcome) the incidence of central catheter-related ICU infections occurring over time. The study period was between March 2004 and September 2005, a full 18 months, and took place in 103 ICUs in 67 Michigan hospitals. About half of the ICUs, however, did not contribute to baseline data.
Central catheter-related infections were defined according to National Nosocomial Infections Surveillance (NNIS) guidelines (Pronovost et al., 2006). Infections were determined by culture and validated by hospital infection-control officers. The data was collected by these officers and submitted to researchers once a month. One catheter day was based on the use of one or more central lines per patient per day. For the purpose of data analysis, three months of sequential data was grouped to form quarterly data. Statistical analysis was based on calculations of median values and interquartile ranges, because the distribution of the data was non-normal. In other words, the data did not form a bell-shaped curve necessary for the use of more common and powerful statistical tools. Significance between baseline and outcome data was determined using a two-sample Wilcoxon rank-sum test and was based on a two-sided alpha of 0.05. Possible interactions between hospital status as teaching or non-teaching, bed size, and geographic location were explored using a generalized linear latent and mixed model with a Poisson distribution.
The conclusion that their new program was successful was based on data representing 375,757 catheter days (Pronovost et al., 2006). The outcomes they reported included the overall baseline data, implementation period data, and post-implementation data. The overall median infection rate was 2.7 (0.6-4.8) central catheter-related bloodstream infections per 1,000 catheter days. This was reduced to 1.6 (0-4.4) during implementation of the intervention and to near zero after implementation was completed. The overall mean infection rate declined from 7.7 to 1.4 by the end of the study period. Teaching hospitals and hospitals with 200 beds or less took longer to achieve a zero median rate; however, smaller hospitals were more effective in implementing the safety measures. Overall, the difference between baseline and post-implementation data was statistically significant (p ? 0.002). Analysis using the multilevel Poisson distribution reached the same conclusion, with the incidence rate declining by 66% by the end of the study period.
Based on the data presented five conclusions can be made. First, central catheter-related infections rates can be significantly reduced by implementing patient safety measures that promote sterile procedures. Second, these improvements are realized almost immediately and can be sustained over the long-term. Third, large and small, teaching and non-teaching, hospitals will benefit to the same degree. Fourth, given the direct care costs associated with infections, over eight million dollars annually for the participating ICUs, substantial savings can be realized. Fifth, the congressionally-mandated NNIS infrastructure was essential for implementation of the intervention and ongoing surveilance.
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