Education, retraining reduce catheter-associated infections in ICUs

An education and retraining program that previously reduced catheter-associated infections in ICUs at Barnes-Jewish Hospital and Missouri Baptist Medical Center has been successfully exported to five other medical centers across the nation, clinicians report in the July issue of Infection Control and Hospital Epidemiology.

Scientists found the program reduced by 21 percent serious bloodstream infections associated with central venous catheters, tubes frequently inserted into major blood vessels in critical care patients. Clinicians use the large tubes to simultaneously administer multiple drugs and fluids.

Epidemiologists have identified the catheters as the most common source of hospital-acquired bloodstream infections, which include such pathogens as Staphylococcus aureus. These infections, which occur at a rate of approximately 2,000 cases per year in the United States, can lead to serious complications such as endocarditis, or infection of the heart valves, and death. But they more commonly result in increased hospital stays.

"The added days of hospitalization caused by these infections can result in additional attributable hospital costs in excess of $10,000 per patient," says lead author David K. Warren, M.D., assistant professor of medicine at Washington University School of Medicine in St. Louis. "That can have significant economic impact."

Warren and his colleagues' intervention begins with updating of ICU policies on catheter insertion and maintenance to align them with recent studies of the best ways to prevent catheter-associated infections. For ICU staff, they also produce brief training modules, leaflets and posters on minimizing catheter-associated infections.

"Clinicians are often very busy, and there's only so much time they can spend reviewing the latest research," Warren says. "This was a gadget-free, inexpensive way to ensure that they have the latest insights into how to prevent infections."

As an example of how research has improved methods for minimizing infection risk, Warren cites the choice between inserting catheters in the subclavian vein near the collarbone or in the femoral vein in the groin.

"A fraction of patients will always have to get femoral catheters, but in cases where an option exists, studies have shown that there's less risk of infection from catheters inserted into the subclavian vein," he notes.

Other practices that reduce incidence of infection include inserting the catheters with sterile techniques and equipment similar to those used in surgery and ensuring that dressings on insertion sites are regularly checked for tightness and cleanliness and changed when necessary.

When initially applied in ICUs at Barnes-Jewish and Missouri Baptist hospitals, the intervention produced infection reductions of 66 percent and 57 percent.

In the new study, researchers took the intervention to additional ICUs at Barnes-Jewish and at five other academic medical centers that were partners with Washington University in a collaborative Centers for Disease Control research grant known as a Prevention Epicenter Program. The grant funds research into prevention of hospital-acquired infections.

At the 13 participating ICUs, a total of 414 nurses and 276 physicians received the training modules. For 18 months, researchers monitored infection rates and other factors such as the percentage of catheter dressings that were dated, an indication of attention to proper dressing maintenance.

"The 21 percent infection reduction achieved at the other centers wasn't as dramatic as what we had here in St. Louis, but that points out the complexity of exporting these programs," Warren says. "And they do work--we estimated that these interventions prevented 131 serious bloodstream infections across all the ICUs and avoided more than 250 additional days of hospitalization."

Researchers did not perform a cost-benefit analysis, but Warren emphasizes that the intervention is a very low-cost investment.

"Basically, the biggest cost of this is the time nurses and physicians took to do the training modules, about 20 minutes," he notes. "Next is the review and updating of ICU policies and practices. We ran the modules off our own printers and had the brochures and posters professionally printed. Overall, it's a pretty inexpensive intervention considering the return that was produced."

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Besides Barnes-Jewish Hospital, the other participating medical centers were Memorial Sloan-Kettering Cancer Center, The Johns Hopkins Hospital, University of Iowa Hospital, Northwestern Memorial Hospital and Hunter Holmes McGuire Veterans Affairs Medical Center.

Warren DK, Cosgrove SE, Deikema DJ, Zuccotti G, Climo MW, Bolon MK, Tokars JI, Noskin GA, Wong ES, Sepkowitz KA, Herwaldt LA, Perl TM, Solomon SL, Fraser VJ. A multicenter intervention to prevent catheter-associated bloodstream infections. Infection Control and Hospital Epidemiology, July 2006. Funding from the Centers for Disease Control supported this research. Washington University School of Medicine's full-time and volunteer faculty physicians also are the medical staff of Barnes-Jewish and St. Louis Children's hospitals. The School of Medicine is one of the leading medical research, teaching and patient care institutions in the nation, currently ranked fourth in the nation by U.S. News & World Report. Through its affiliations with Barnes-Jewish and St. Louis Children's hospitals, the School of Medicine is linked to BJC HealthCare.


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