Catheter-Related Bloodstream Infections Can Be

¶ … catheter-related bloodstream infections can be eliminated in the intensive care unity. The sections are followed by description of my article of choice and rationale for that preference

Catheter-related bloodstream infections (CR-BSIs) are associated with significant death, disease, and expense. This is particularly the case with patients in ICU wards where many of them are hooked up to catheters that are more likely to transmit infection. Certain guidelines apply, but not always are these guidelines followed. Berenholtz et al. (2004) calculated that approximately 28,000 patients in an ICU ward die of CR-BSIs in the U.S.A. each year. Therefore, repeated attempts to prevent and eliminate the problem have been implemented with numerous articles appearing on the subject. The following is a synopsis of four studies that have devised and tested interventions to deal with CR-BSI.

Study1: Berenholtz, SM et al. (2004) Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med Vol. 32, No. 10, 2014-2020

This was a quantitative experiment. The objective was to investigate whether a multi-faceted integrated program would eliminate catheter-related bloodstream infections (CR-BSIs).

The design was a prospective cohort study in a surgical intensive care unit in John Hopkins Hospital with a control ICU. The addressed population was all patients who had received a central venuous catheter in the ICU.

A quality improvement team effected 5 interventions: they trained the staff; created a catheter insertion cart; asked providers daily whether catheters could be removed; structured a checklist to ensure adherence of evidence-based guidelines to preventing CR-BSIs; and finally directed nurses to stop the catheter insertion procedure were nurses to suspect violation of the evidence-based guidelines.

The researchers measured success of their study according to two outcome variables: (a) the rate of CR-BSIs from January 1, 1998 to December 31, 2002 (1000 catheter days). (b) Adherence to evidence-based guidelines to preventing CR-BSIs during the procedure.

The results were positive. Researchers had found as baseline measures that before implementation of this program, physicians had followed infection control guidelines only 62% of the time. In comparison, during the period of the study, researchers discovered that the evidence-based guidelines to preventing rate of occurrence of CR-BSI decreased from 11.3 per 10000 catheter days in the first quarter of 1998 to 0 per 10000 catheter days in the fourth quarter of 2002. Researchers estimated that these results prevented 8 deaths, 43 evidence-based guidelines to preventing CR-BSIs from occurring, and prevention of an expense of $1,945,922.

The authors advocate that similar multi-faceted programs that adhere to evidence-based control guidelines for preventing infection be instituted in every medical institution and ward where patients receive central venuous catheters.

Study 2: Pronovost,, P. et al. (2006) An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU N. Engl J. Med 355;26, 2725-2732

The objective of this quantitative study was to devise a method that would reduce the incidence of CR-BSIs. Researchers conducted a collaborative cohort study (n=103) primarily in ICUs in Michigan. Five evidence-based control guidelines were used for reducing the incidence of CR-BSIs (hand-washing, using full-barrier precautions during the insertion of central venuous catheters, cleaning the skin with chlohexidine; avoiding the femoral site if possible, and removing unnecessary catheters). Clinicians received education about the program; hospitals implemented a daily goals sheet to improve inter-clinician communications within the ICU, as well as a comprehensive unit-based safety program to ensure general safety of the environment. Multilevel Poisson regression modeling was employed to compare baseline infection rates with rates of CR-BSI during and after intervention. The rates of infection per 1000 days were measured at 3-month intervals, according to the guidelines of the National Nosocomial Infections

Surveillance System.

Researchers discovered that the average rate of CR-BSIs decreased from 2.7 infections at baseline to 0 at 3 months after the implementation of the study and the mean rate of CR-BSIs from baseline to 16-18 months after follow-up of study decreased from 7.7 to 1.4. The regression model showed significant results. In fact, a reduction of 66% of CR-BSIs. Was maintained and sustained throughout the study.

Researchers concluded that evidence-based guidelines, if scrupulously followed, help prevent a large number of CR-BSIs from occurring

Study 3. Coopersmith CM et al. (2002). Effect of an education program on decreasing catheter-related bloodstream infections in the surgical intensive care unit Crit Care Med Vol. 30, No. 1, 59-64

The objective of this quantitative study was to assess whether an education program could reduce incidence of CR-BSIs from occurring by improving clinician's care to inserting central venuous catheter and motivating them to take more care during the procedures. This was a pre- and post-observation study conducted on 4,283 patients in an 18-bed surgical/burn/trauma IVU in an urban hospital.

The program was generated towards registered nurses (n=49) and developed by a multidisciplinary task force for the purpose of teaching correct practices of inserting the central venuous catheter. The program itself consisted of a 10-page self -study module on risk factors involved in CR-BSIs. The topics were: epidemiology and scope of the problem; risk factors; etiology; definition; and methods to decrease risk. Each participant took a pre-test before completing the study module and completed the same pre-test upon completion of the study module. Fact sheets and posters summarizing the information found in the module were posted throughout the ICU. Concurrent lectures (not the program itself) were also given to a subset of physicians, fellows, and a single group of residents.

Results discovered that 74 CR-BSIs from occurring had occurred in 6874 catheter days in the 18 months preceding the intervention in contrast to only 26 CR-BSIs from occurring in 7044 days following the intervention. This was a decrease of 66%. Predicted cost in savings was between $185,000 to $2.808 million.

Researchers concluded that a focused training program for ICU nursing staff could lead to a dramatic increase in the incidence of CR-BSIs.

Study 4: Bleasdale, SB et al. (2007)Effectiveness of Chlorhexidine Bathing to Reduce Catheter-Associated Bloodstream Infections in Medical Intensive Care Unit Patients Arch Intern Med.;167(19):2073-2079

The objective of this study is to determine whether patients who bathed daily with chlorhexidine glconate (CHG) experience fewer CR-BSIs compared to patients who simply bathed with soap and water.

The experiment was a 52-week, 2-group crossover study (quantitative) continuing control and experimental group. The study occurred in the 22-bed ICU of the John H. Stroeger J (Cook County) Hospital in Illinois with 836 patients participating.

During the first 28 weeks, one hospital unit was randomly selected to serve as the experimental unit where patients were bathed daily with 2% CHG-suffused washcloths. At the same time, patients in the control unit were bathed with soap and water. There was a 2-week gap and then the units were reversed for 24 more weeks.

The primary outcome measures that were used to assess success of the intervention included assessment of incidences of CR-BSIs and clinical sepsis as well as incidences of other infections.

Researchers discovered that the patients in the CHG experimental group were significantly less likely to acquire CR-BSIs as they were also less likely to acquire other infections. In fact, effect of the method was noted after a minimal of 5 days in the MICU.

Researchers concluded that daily cleaning of MICU patients with CHG could go a long way in reducing the incidence of CR-BSIs.

Evaluation of the studies and my preference