By Kelly M. Pyrek
The Centers for Disease Control and Prevention (CDC) and its Healthcare Infection Control Practices Advisory Committee (HICPAC) have updated a guideline, "Guidelines for the Prevention of Intravascular Catheter-Related Infections," designed to help practitioners eliminate bloodstream infections in patients with intravenous catheters, considered to be deadly and costly healthcare-associated infections (HAIs).
"The updated CDC guidelines are rich with new recommendations that are based on additional scientific research that has emerged since the prior version was published," says APIC 2011 president Russell N. Olmsted, MPH, CIC. "This is an important resource to support efforts toward the elimination of catheter-related bloodstream infections (CRBSIs)."
Another expert, William Jarvis, MD, president of Jason and Jarvis Associates, agrees that infection preventionists must be able to successfully translate science into practice. "I think all the data supporting recommendations in each CDC/HICPAC guideline should be in the room during discussions, everyone should be familiar with them and during discussions these data (the evidence) should be examined," Jarvis says.
As the guidelines note, "The goal of an effective prevention program should be the elimination of CRBSI from all patient-care areas. Although this is challenging, programs have demonstrated success, but sustained elimination requires continued effort. The goal of the measures discussed in this document is to reduce the rate to as low as feasible given the specific patient population being served, the universal presence of microorganisms in the human environment, and the limitations of current strategies and technologies."
In recent years, a reinvigorated patient safety movement has spawned new study results demonstrating significant success in reducing and eliminating HAIs like CRBSIs. Specifically, the Keystone ICU Project, a federally funded program led by patient safety expert Peter Pronovost, MD, PhD, FCCM, involving intensive care units in Michigan hospitals, demonstrated the potential for the elimination of CRBSIs. The Michigan collaborative reduced the incidence of CRBSIs by two-thirds, saving more than 1,500 lives and $200 million in the first 18 months. Similarly organized initiatives in other states and countries have also reported similar degrees of success. The critical underlying foundation for these successes has been use of five key prevention strategies from the 2002 version of CDC's guidelines that were based on published, scientific evidence.
The combination of national and local focus on preventing CRBSIs, and specifically central line-associated bloodstream infections (CLABSIs), has proven to be effective in improving patient safety. A recent CDC report showed a 58 percent decrease in CLABSIs among hospital ICU patients in 2009, compared to 2001. In 2009 alone, reducing these infections saved about 3,000 to 6,000 lives and about $414 million in extra medical costs, compared with 2001. However, infections still occur in healthcare settings, and diligent prevention efforts must continue.
Jarvis says it’s time for any hospitals still not implementing evidence-based practices such as those in the updated guideline to understand the importance of compliance with proven methods. "The data for use of an insertion and a maintenance bundle (similar to SHEA's basic and special approaches in the SHEA Compendium) should be mandated for all ICUs today," Jarvis emphasizes. "We have at least six to 10 studies showing that when such bundles are used that the majority of CLABSIs in ICU patients are preventable. Unfortunately, many hospitals are not fully implementing these recommendations, but rather pick and chose on the basis of cost. We need the goal to be zero, not ‘our rate is low.’"
The many drivers of compliance, including public reporting, CMS pay-for-performance mandates and a call for HAI elimination in the Department of Health and Human Services (HHS) Healthcare-Associated Infection (HAI) Action Plan, are applying added pressure to doing what’s right for improved patient outcomes.
"The timing for this updated guideline is perfect because starting this year hospitals that accept Medicare patients are required to report their central line-associated bloodstream infections to the Centers for Medicare & Medicaid Services, or risk losing 2 percent of their Medicare payments," Olmsted says.
"More and more pressure will be put on hospitals to fully implement these bundles, as public reporting of their rates occurs," Jarvis says. "There was a major article in The Tennessean a couple of weeks ago criticizing a couple of hospitals in Nashville (including a major teaching hospital) about their high CLABSI rates in their ICU patients. This type of activity will force hospital administrators to implement insertion and maintenance bundles and to enforce clinician accountability."
The guidelines suggest that healthcare institutions can reduce infection rates to as low as feasible given the specific patient population being served, and Jarvis says the data show this is possible. "The surgical ICU at Johns Hopkins reduced their CLABSI rate from 11.4 to zero and others can do this as well," Jarvis says. "The Keystone ICU Project showed we can markedly reduce our CLABSI rates and sustain this after the funding and personnel go away. It is a change in culture from it is inevitable to it is preventable and should not happen."
The guidelines also examine the significance of the universal presence of microorganisms in the human environment related to catheter placement, maintenance, and Jarvis notes that "The insertion and maintenance bundles reduce the risk of CLABSI associated with these organisms."
The guidelines also explore the limitations of current strategies and technologies.
"We need to document the efficacy of the insertion and maintenance bundles outside of ICUs, although a hospital in ca has zero CLABs for four years now," Jarvis says. "Some populations (oncology, hemodialysis, etc.) may need additional interventions. When we move these interventions outside of ICUs, we will need IV teams (one cannot control hundreds or thousands of nurses and physicians)."
As director of the Hospital Infections Program at the CDC for more than 20 years, Jarvis is qualified to provide some unique insights relating to the guidelines process and makes several observations: "First, all those in infection control should read and comment on these CDC guidelines (only about 350 people submitted comments for this guideline and one-third were industry members commenting on their product and of the remainder, less than 10 read all the document, the references, and commented on the entire document). The infection control community must become more actively involved in this process," Jarvis says. "Second, we should all require that the data for each recommendation be specified (so we can review the papers and decide if we agree. Third, if all the studies documenting the efficacy of a product are all on one product (see CHG-impregnated sponge dressing), CDC and HICPAC should not be afraid to name the product. Data should be the determinant of the recommendation and the more specific the better. Following this example, CDC recommended use of the CHG-impregnated sponge disk instead of the Biopatch. Now, another company, Guardiva, has come out with a CHG-impregnated dressing with a hemostatic agent in it. It meets the CDC recommendation criteria, yet the package insert says not for prevention of CLABSIs (required by the FDA). This leads to confusion."
Jarvis continues, "A fourth observation is that all CDC and HICPAC personnel should be required to read the entire guideline and the references and then to sign that they agree with the final result. Fifth, the criteria for the level of recommendation should be stated and consistently applied from guideline to guideline and from recommendation to recommendation. For example, the Biopatch has 12 to 14 randomized controlled trials and is rated a category 1B. The CHG/silver-impregnated catheter (second generation) and minocycine-rifampin impregnated catheter together have fewer than 10 randomized controlled trials -- all either in ICU or cancer patients -- yet it is a category 1A recommendation. Science should be politically blind and totally based on the data."
The guidance document, "Guidelines for the Prevention of Intravascular Catheter-Related Infections" replaces guidelines published in 2002, and was developed by a working group led by the Society of Critical Care Medicine, in collaboration with the Infectious Diseases Society of America, Society for Healthcare Epidemiology of America, Surgical Infection Society, American College of Chest Physicians, American Thoracic Society, American Society of Critical Care Anesthesiologists, Association for Professionals in Infection Control and Epidemiology (APIC), Infusion Nurses Society, Oncology Nursing Society, American Society for Parenteral and Enteral Nutrition, Society of Interventional Radiology, American Academy of Pediatrics, Pediatric Infectious Diseases Society, the Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee.
The document will be published in its entirety in a special supplement to the American Journal of Infection Control. The journal will also present a video roundtable that features perspectives of healthcare professionals on the impact of this new guideline on infection prevention practices. To access the complete guidelines, visit: www.cdc.gov/hicpac. The guidelines also appear in the journal Clinical Infectious Diseases, http://cid.oxfordjournals.org/.
