Elsevier

American Journal of Infection Control

Volume 36, Issue 10, December 2008, Pages S171.e1-S171.e5
American Journal of Infection Control

Brief report
Interventions to decrease catheter-related bloodstream infections in the ICU: The Keystone Intensive Care Unit Project

https://doi.org/10.1016/j.ajic.2008.10.008Get rights and content

Background

A quality improvement initiative that included rigorous measurement, feasible interventions, and cultural change was shown to nearly eliminate catheter-related bloodstream infections (CR-BSIs) in patients in a surgical intensive care unit (ICU). To build on this research, a statewide collaborative cohort study was conducted using the same evidence-based interventions.

Methods

Interventions included handwashing, using full barrier precautions during the insertion of central venous catheters, cleaning the skin with chlorhexidine, avoiding the femoral site if possible, and removing unnecessary catheters. Both technical and adaptive (cultural) aspects of implementing the intervention were addressed through engagement, education, execution, and rigorous evaluation. A “team checkup tool” was developed to help senior leaders assess their role in ensuring compliance.

Results

Of 108 ICUs in the study, 103 reported data. Analysis included data from 1981 ICU-months and 375,757 catheter-days. The regression model showed a significant decrease in CR-BSI rates from baseline, with incidence-rate ratios decreasing from 0.62 at zero to 3 months after implementing the intervention to 0.34 at 16 to 18 months. Preliminary analysis suggested CR-BSI rates were sustained 4 years after implementation of the intervention.

Conclusion

Results suggest that this program model can be generalized and be implemented on a large scale in the United States or the world to significantly reduce the rate of CR-BSIs and their associated morbidities, mortalities, and costs of care.

Section snippets

Evidence-based interventions

In developing an intervention model (Table 1), the evidence from published studies was reviewed, the interventions with a potential to improve outcomes were identified, the 5 interventions that had the strongest evidence and the lowest barriers to implementation were selected, and the interventions were transformed into specific behaviors.5 The goal was to design a system that increased the possibility of patients receiving these interventions5:

  • Wash hands;

  • use full barrier precautions during the

Comprehensive unit-based safety program

When implementing research in a clinical setting it is important to address both technical and adaptive (cultural) aspects to gain a willingness to comply and ultimately sustain use of the 5 procedures. The Comprehensive Unit-Based Safety Program (CUSP)6, 7 was designed to improve safety culture, including communication and teamwork in working together toward the common goal of eliminating CR-BSIs. The Comprehensive Unit-Based Safety Program is coupled with a strategy to translate evidence into

Importance of addressing technical and adaptive work

Ron Heifetz, a renowned leadership expert at Harvard, in one of his models separates problems into technical problems (problems for which scientific evidence exists) and adaptive problems (problems that require changes in values, attitudes and beliefs, culture change). A major mistake is to treat adaptive problems as though they were technical problems. Technical work summarizes the evidence, defines the measures, and standardizes these across all hospitals. Adaptive work implements the

High reporting rates

The very high reporting rate for the ICUs was remarkable. When the grant application was submitted, a letter was sent asking for participants, and 35 hospitals volunteered. Within a month, well over one hundred ICUs from 77 hospitals had agreed to participate—almost all the hospitals in the state. There were 3 reasons for this participation: (1) the procedures were evidence based, (2) rigorous evaluation was wanted to demonstrate that the procedures worked, and (3) the project was based on the

Results

The results of the 18-month study showed a 95.4% reporting rate (Table 2). The analysis included data from 1981 ICU-months and 375,757 catheter-days. The regression model showed a significant decrease in CR-BSI rates from baseline, with incidence-rate ratios decreasing from 0.62 at zero to 3 months after implementing the intervention to 0.34 at 16 to 18 months.4

. Comprehensive, sustained approach to reducing CR-BSIs3

• Implemented unit-based safety culture and daily goal sheet—3 months
• CR-BSI

Future directions

The QSRG research team is embarking on a national program to eliminate CR-BSIs across the United States. This is a large task and will require many partners. The team seeks to achieve this by replicating the collaborative undertaken in Michigan in other states. The Agency for Healthcare Research Quality has awarded the Heath Research and Educational Trust, and QSRG researchers at Johns Hopkins a grant to replicate this collaborative program in 10 states. In addition, the QSRG has received

Conclusion

Targeted, evidence-based safety improvement efforts that have a centralized research group to manage the technical work and a culture program to adapt it to local units can eradicate CR-BSIs as effectively as polio.4 In the mid-1980s, polio was killing approximately 350,000 people worldwide every year. Today, the death toll is less than a thousand, with almost all originating in one small region in Africa. Successful eradication happened because there was a focused effort on one problem.

Safety

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There are more references available in the full text version of this article.

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    Surgical site-infection (SSI) is considered the most common and costly HAI, accounting for ∼20% of all HAIs in hospitalized patients and seven to 11 additional postoperative days of hospital stay [3–6]. In addition to SSIs, catheter-related bloodstream infections (CRBSIs) make up ∼10–20% of HAIs, with ∼80,000 annual cases in intensive care units, extending hospital length of stay by ∼2–20 days [7–13]. Whereas a mature, intact epidermis is an effective barrier in preventing infection, surgery and other invasive procedures break the skin's barrier, allowing migration of skin-dwelling and environmental microorganisms into the wound, increasing the risk of local or systemic infection.

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Disclosures: Dr. Pronovost received an honorarium for participating in the symposium and writing this article.

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