Elsevier

The Lancet

Volume 355, Issue 9218, 27 May 2000, Pages 1864-1868
The Lancet

Articles
Impact of a prevention strategy targeted at vascular-access care on incidence of infections acquired in intensive care

https://doi.org/10.1016/S0140-6736(00)02291-1Get rights and content

Summary

Background

Intravascular devices are a leading cause of nosocomial infection. Specific prevention strategies and improved guidelines for the use of intravascular devices can decrease the rate of infection; however, the impact of a combination of these strategies on rates of vascular-access infection in intensive-care units (ICUs) is not known. We implemented a multiple-approach prevention programme to decrease the occurrence of vascular-access infection in an 18-bed medical ICU at a tertiary centre.

Methods

3154 critically ill patients, admitted between October, 1995, and November, 1997, were included in a cohort study with longitudinal assessment of an overall catheter-care policy targeted at the reduction of vascular-access infections and based on an educational campaign for vascular-access insertion and on device use and care. Incidence of ICU-acquired infections was measured by means of on-site surveillance.

Findings

613 infections occurred in 353 patients (19.4 infections per 100 admissions). The incidence density of exit-site catheter infection was 9.2 episodes per 1000 patient-days before the intervention, and 3.3 episodes per 1000 patient-days afterwards (relative risk 0.36 [95% Cl 0.20–0.63]). Corresponding rates for bloodstream infection were 11.3 and 3.8 episodes per 1000 patient-days, respectively (0.33 [0.20–0.56]) due to decreased rates of both microbiologically documented infections and clinical sepsis. Rates of respiratory and urinary-tract infections remained unchanged, whereas those of skin or mucous-membrane infections decreased from 11.4 to 7.0 episodes per 1000 patient-days (0.62 [0.41–0.93]). Overall, the incidence of nosocomial infections decreased from 52.4 to 34.0 episodes per 1000 patient-days (0.65 [0.54–0.78]).

Interpretation

A multiple-approach prevention strategy, targeted at the insertion and maintenance of vascular access, can decrease rates of vascular-access infections and can have a substantial impact on the overall incidence of ICU-acquired infections.

Introduction

Insertion of intravascular devices is among the main causes of nosocomial infections,1 which exacerbate morbidity and hospital costs in intensive-care units (ICUs).2, 3 Various strategies have been used to decrease the risk of vascular-access infections, including prevention efforts targeted at the materials from which catheters are made, and catheter care.4, 5, 6, 7 So far, only a few studies have used a multiple-strategy approach to decrease infection rates and to explore the possible benefits of the combined measures on rates of vascular-access infections.8, 9 Hitherto, no large-scale study has assessed the impact of an overall management approach in the adult critical-care setting.

We did a prospective cohort study, and implemented a multimodal, multidisciplinary prevention strategy to decrease rates of vascular-access infections and to assess the impact of the strategy on the incidence of ICU-acquired infections.

Section snippets

Patients

The University of Geneva Hospital is a 1500-bed primary-care and tertiary-care centre. An average of 1400 patients are admitted each year to the 18-bed medical ICU for a mean length of stay of 4 days. All adult patients admitted to the medical ICU for more than 48 h between October, 1995, and February, 1997 (control period), were prospectively surveyed for nosocomial infections by standard methods.10 The intervention programme was implemented in March, 1997, and its impact was measured during

Results

2104 patients were surveyed during the control period, and 1050 during the intervention period (a total of 13 200 patient-days). The groups were similar with respect to baseline characteristics, underlying disease, and intrinsic susceptibility to infection (table 2). A fifth of the patients required mechanical ventilation (similar proportions in both groups). The duration of ICU stay was similar among patients within the same disease categories. Monthly Project Research in Nursing scores were

Discussion

Our results demonstrate the impact of a multiple-approach intervention strategy on rates of bloodstream and catheter-related infection, as well as on the overall incidence of ICU-acquired infections. Although infection rates before the intervention (ie, 6·6 episodes of microbiologically documented bloodstream infections per 1000 CVC-days) were within the accepted limits,17, 18, 19 our experience shows that, as postulated,1 a large proportion of nosocomial infections related to extrinsic factors

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